“And I realized that they could never hurt me more than they had just hurt me that night, and

that out of chaos like this had to come confidence and skill. Something had

happened . . . ., and I didn’t know what, but I knew that from taking the risks and learning

and remembering Fats, I had pinned down my terror and exploded it to bits. From that night

on, I might be everything else, but I’d never again be panicked in the House of God.”

Dr. Samuel ShemTHE HOUSE OF GOD (p. 140)

EMERGENCYPHARMACOLOGY

Clinical Applications

Terry Mengert, MDTerry Mengert, MD

Frank Vincenzi, PhDFrank Vincenzi, PhDUniversity of Washington

School of Medicine

CREDITS

The black and white photo-graphs in this presentation are from this source (published in 1989).

“Time is but the stream I go a-fishing in.”

Henry David Thoreau (1817-1862)

Why arewe here?

Emerg Pharm: OBJECTIVES • HAVE FUN ?

• Make DRUGS Alive!

• Approach to Emergencies

• Manage Patients• Acute MI• Anaphylaxis• COPD Exacerbation• Septic Shock• Ventricular Fibrillation

• Learn by DOING

DRUGSare TOOLS

Quick ADRENERGIC Receptor Review

• Alpha 1: contraction or constriction• Alpha 2: pre-synaptic stimulation INHIBITS

norepinephrine release

• Beta 1: mostly heart – chronotropic & inotropic

• Beta 2: relaxation of smooth muscle (bronchial walls, blood vessels, GI tract, bladder wall, & pregnant uterus)

• Beta 3: adipose tissue

Adrenergic Agonist Classification;

From

Stringer JL: BASIC CONCEPTS IN PHARMACOLOGY

3rd edition

TRADITIONALMedical Approach

• History

• Physical Examination

• Differential Diagnosis

• Working Diagnosis

• Additional Studies

• Therapy

TIME MATTERS

• Pulseless VTach / VFib

• Acute Myocardial Infarction

• Acute Cerebrovascular Accident

• Bacterial Meningitis

Initial CRITICAL / EMERGENCY Care

• Primary Survey & Resuscitation• Airway with C-Spine Control• Breathing & Ventilation• Circulation & Hemorrhage Control• Deficits & “DON’T” Regimen• Expose & Environmental Control

• Secondary Survey

• Definitive Care

CONCEPT“The Safety Net”

O2 – IV’s – Monitor 2

3 “Pillars” of EMERGENCY CARE at the Bedside

• SAFETY NET

– Oxygen– IV Access– Monitors

• VITAL SIGNS

– Pulse– BP– RR– T– Mental

Status– Others

• PRIMARY SURVEY

-- A-- B-- C-- D-- E

The DON’T Regimen for Altered Mentation

•D = Dextrose

•O = Oxygen

•N = Naloxone

•T = Thiamine

Our FIRST Patient !

CLINICAL CASEThis 58-year-old man presents to the ED with 2 hr of chest pressure. He has vomited twice and is diaphoretic.

Risks: age, cigarette use

Meds: ibuprofen, multivitamins

All: penicillin (anaphylaxis)

VS: P 80 (irregular), BP 150/100, RR 22,

T 37 C.

Begin Caring for HIM Now!

ACS: Initial Care• Three Pillars

– O2 – IV’s – Monitors– Vital Signs (“added” ones)– Primary Survey: A, B, C, D, & E

• Working & Differential Diagnosis

• ACS: Emergency Drug Care: M O N A B + H

(“To Cath or not to cath, that is the question.”)

ACUTE CORONARY SYNDROMEQuestions

• Name 4 life-threatening causes of acute Chest Pain.

• What are the 3 Acute Coronary Syndromes?

• What does the ECG show?

Acute Coronary Syndrome: Questions (continued)

• CORNERSTONE INITIAL THERAPY• Morphine• Oxygen• Nitroglycerin• Aspirin (what if they are aspirin allergic?)• Beta Blocker• Heparin

Acute Coronary Syndrome: Questions (continued)

• Our patient’s initial blood pressure was 150/100 (“praise the Lord”). But what would you do if his initial blood pressure was 85/50, and

– Lungs are clear

– Patient is dyspneic and in pulmonary edema (prominent pulmonary crackles)

Color Atlas & Text of Clinical Medicine, 3rd Edition, Mosby, 2003, p. 223.

CHF Concepts: Positive Inotropes in CHF

• Dobutamine

• Dopamine (dose dependent)– dopaminergic receptors– beta receptors– alpha receptors

• Additional Teaching Point:

Why NOT Norepinephrine?

Acute Coronary Syndrome: Questions (continued)

• Our patient survives! What medications should he eventually leave the hospital taking?

Acute Coronary Syndrome: Hospital Care

• A: aspirin, other anti-platelet drugs (clopidogrel, glycoprotein IIb/IIIa inhibitors), anticoagulation (heparin), ACE inhibitors

• B: beta blockers, blood pressure control

• C: cholesterol measurement & control, cigarette smoking cessation

• D: diet, diabetes management

• E: education, exercise

CLINICAL CASE

This 32-year-old RN arrives emergently from the hospital cafeteria. She is allergic to peanuts and inadvertently ate one on her salad.

She presents with lip edema, diffuse pruritis, generalized urticaria, and moderate dyspnea with wheezing.

Meds: oral contraceptives

All: penicillin (anaphylaxis)

VS: P 130, BP 120/70, RR 34, T 37.5 C.

ANAPHYLAXIS: Initial Care

• Three Pillars– O2 – IV’s – Monitors– Vital Signs– Primary Survey: A, B, C, D, & E

• Working & Differential Diagnosis

• Anaphylaxis: CORE DRUGS

ANAPHYLAXIS: Questions

• Clinical findings?

• Why do people die?

• Why is epinephrine the “drug of choice?”

Anaphylaxis: PHARMACOLOGY•Oxygen

• IV Crystalloid

•Epinephrine

•Albuterol

•Diphenhydramine

•Prednisone

•Others– H2 Blockers– Racemic Epinephrine– Glucagon

REVIEW:Acute MI – Visualization Exercise

• Rest, relax, take some deep breaths

• Clear your minds . . .

• Picture the following: “It is 2.5 years from now and it is your first night on call . . .”

CLINICAL CASEThis 75-year-old man is well known to the UWMC. He has a long history of severe COPD. This afternoon he presents to the ED in an acute COPD exacerbation in the setting of a respiratory tract infection.

Meds: multiple

All: NKDA

VS: P 120 (regular), BP 170/105, RR 32,

T 38.3 C.

Patient is awake, alert, diaphoretic, using accessory muscles, dyspneic, wheezing, with bibasilar coarse crackles.

COPD: Initial Care

• Three Pillars– O2 – IV’s – Monitors– Vital Signs (“additional” ones)– Primary Survey: A, B, C, D, & E

• Working & Differential Diagnosis

• COPD Exacerbation: CORE DRUGS

COPD: Questions• Definition

• Leading Cause

• Emergency Drugs– Oxygen (use judiciously)– Beta agonist (albuterol, ? terbutaline)– Ipratropium bromide (Atrovent)– Corticosteroids– Others: antibiotics, diuretics

Pause -- COMPASS READING: Where are we any way?

• Drugs are TOOLS

• Approach in Emergency Medicine

• Cases Thus Far– Acute Myocardial Infarction– Anaphylaxis– COPD Exacerbation– Acute Congestive Heart Failure

CLINICAL CASESeattle Paramedics bring to the ED a 35-year-old woman who is comatose and was intubated in the field. The lady has a history of injection drug use, and, according to family, has been ill for 5 days with a fever and cough. The family found the patient unconscious this morning.

Meds: uncertain

All: Aspirin (stomach upset)

VS: P 130 (regular), BP 70/40, RR 22 (being bag ventilated), T 39.5 °C.

OUTLINE YOUR CARE OF THIS PATIENT

Intubated & HYPOTENSIVE: Initial Care

• Three Pillars– O2 – IV’s – Monitors– Vital Signs (“additional” ones)– Primary Survey: A (confirm correct ET tube

placement), B, C, D, & E

• Working & Differential Diagnosis

• HYPOTENSIVE PATIENT: Core Care

Our Patient’s Care• ET Tube Confirmation

• The DON’T regimen

• IV fluids: NS wide open

• Admission Labs + Cultures

• Vasopressor for BP support: norepinephrine vs dopamine

• Antibiotics

• Considerations for adrenal gland support

Concept: Goal-Directed Therapy in Septic Shock

• Basic A – B – C’s + Emergency Diagnosis

• Volume Resuscitation + Antibiotics

• Vasopressor Therapy

• Central Mixed Venous Oxygen Saturation Monitoring (Transfuse to Hct > 30 if CVO2 < 70%; if still < 70%, add dobutamine

• Adjunctive Therapies: glucocorticoids, drotrecogin alfa, intensive insulin therapy

CLINICAL CASE

Remember our 58-year-old man with the acute anterior MI from the first hour?

The Cardiac Cath lab calls, and we are preparing to transport him for emergent catheterization and coronary artery stent placement. He is pain free, but he suddenly loses not only consciousness, but also his pulse!

LET’S RESUSCITATE HIM !

“The undiscover’d country,

from whose bourn

No traveller returns -- . . .”

Hamlet

Acute Cardiac Arrest: Questions• What do you do when you encounter an unresponsive

patient?

• What are the 3 Arrest Algorithms?

• CORNERSTONE INITIAL THERAPY• C--A--C• CPR until defibrillator arrives• SHOCK (If VFib / pulseless VTach) – then immediate return of

CPR (5 cycles)• IV placement -- Epinephrine-Shock• Advanced Interventions (Intubate-Confirm-Secure)• Amiodarone-Shock

CARDIAC ARREST—Again !

• VOLUNTEERS NEEDED (5 people)– Chest compressions– Breathing/Ventilation (two people)– Defibrillator Manager– Medication Delivery (“Drug pusher”)– Code Captain (“The Class”)

CLINICAL CASEYou are on your ICM II hospital visit. You go in to see a 52-year-old male who was admitted the night before to a cardiac monitored bed with recurrent chest pain. The patient’s cardiac enzymes are all normal.

You walk in to introduce yourself to the patient. They take one look at you, their eyes roll up, and they become unresponsive ! (Definition: Bad Karma)

Pulseless VTACH & VFIB

• Primary Survey until Defibrillator arrives

• 200 J (bi-phasic; 360 J if monophasic)

• Resume CPR for 5 cycles + place IV

• Reassess: still in VFIB?

• Epinephrine (1 mg IV push) then SHOCK

• Intubate + Tube Confirmation + Secure

• Anti-Arrhythmics & SHOCK• Amiodarone: 300 mg IV push• Lidocaine: 1.5 mg/kg IV push, may repeat• Magnesium: 2 grams slow push

Emerg Pharm: OBJECTIVES • HAVE FUN ?

• Make DRUGS Alive!

• Approach to Emergencies

• Manage Patients• Acute MI• Anaphylaxis• COPD Exacerbation• Septic Shock• Ventricular Fibrillation

• Learn by DOING