educational session abstract 2010 ashp midyear clinical ... · 2010 ashp midyear clinical meeting...

EDUCATIONAL SESSION ABSTRACT 2010 ASHP Midyear Clinical Meeting

Anaheim, California

258 Emergency Medicine Pearls 2010 Hays, D. University Medical Center, 1501 North Campbell Ave, Department of Pharmacy, PO Box 245009, Tucson, AZ 85724, USA. Email: [email protected] This session is designed for practitioners in emergency medicine or for other practitioners with an interest in emergency medicine. Seasoned practitioners will describe how to apply clinical pharmacotherapy to unique circumstances and clinical presentations in the Emergency Department. Learning Objectives:

1. Describe a practical process that increases total pharmacy coverage hours in the Emergency Department using a Pharmacy Resident On‐Call Program

2. Discuss the clinical significance of accidental digital epinephrine injection with an autoinjector device.

3. Discuss therapeutic options to prevent or treat digital ischemia following local epinephrine injection.

4. Identify the dose of rFVIIa appropriate for use in warfarin induced ICH. 5. Describe the role of thrombolytics in cardiac arrest with pulmonary

embolism 6. Understand the pros and cons of succinylcholine compared to a long‐acting

neuromuscular blocker for rapid sequence intubation. 7. Identify the appropriate agent(s) for tetanus immunization in ED patients as

part of wound management. 8. Identify two methods of providing guidelines and education to emergency

department staff to standardize the management of potential acute ischemic stroke patients

9. Describe the appropriate indications and methods of administration for rabies prophylaxis.

10. Identify three ways to reduce errors and improve communication when using intramuscular methotrexate for the treatment of ectopic pregnancy in the Emergency Department

11. Describe the pharmacological management of acutely agitated patients in the ED.

12. List agents that can be deadly to children with a single ingestion of a single pill or sip.

13. Define the pathophysiology of ischemic priapism and why it is considered a urologic emergency

14. Identify pharmacologic treatment options for priapism 15. Describe how to use antacids for the treatment of capsaicin‐induced

dermatitis.


Anaheim, California

16. Review the general principles of hyponatremia 17. Describe the role of vasopressin in hyponatremia 18. Describe the steps in the management of hyponatremia 19. Identify medication and patient‐specific factors that guide appropriate dose

selection of weight‐based medications in the pregnant patient. 20. Discuss the proper use, preparation, and administration of intranasal

sedation and analgesia in the ED. 21. Describe the advantages of intranasal administration of sedation and

analgesia in key patient populations. 22. Describe the role of pyridoxine in .‐Aminobutyric Acid (GABA) production 23. Discuss the proper use, preparation, and administration of intranasal

sedation and analgesia in the ED. 24. Describe the advantages of intranasal administration of sedation and

analgesia in key patient populations. 25. Provide local anesthetic options for patients that have a history of ester or

amide "caine" allergies. 26. Evaluate evidence surrounding the utilization of lidocaine pretreatment for

patients with traumatic brain injuries that require emergent intubation. SelfAssessment Questions:

1. (True or False) Allowing pharmacy residents to respond to medical codes and trauma situations in the Emergency Department can provide valuable resident learning experiences.

2. (True or False) The Pharmacy Resident On‐Call is a substitute for routine clinical pharmacy services in the Emergency Department.

3. (True or False) All epinephrine autoinjector accidents require a trip to the emergency department for evaluation.

4. (True or False) Nitroglycerin paste can be used to prevent or treat complications from accidental digital injection of epinephrine.

5. (True or False) The dose of rFVIIa necessary for warfarin induced ICH is 90 mcg/kg.

6. rFVIIa time to onset is: a. 15 minutes b. 60 minutes c. 6 hours

7. (True or False) rtPA has been proven to be the most effective thrombolytic agent for pulmonary embolism.

8. (True or False) CPR should be stopped 15 minutes after thrombolytic administration.


Anaheim, California

9. (True or False) The literature reports that patients are generally

administered adequate anxiolysis after the use of a long‐acting neuromuscular blocker.

10. (True or False) Based on the available literature and expert clinical opinion, succinylcholine should remain the drug of choice in the emergency department for rapid sequence intubation.

11. (True or False) Tdap should be administered to all adult ED patients who require tetanus toxoid‐containing vaccine as part of wound management

12. Tetanus immune globulin (TIG) should be administered as part of wound management if the person's vaccination history is either unknown / incomplete:

a. For all wounds b. For all but clean minor wounds

13. (True or False) Developing an operational methods sheet demonstrating the admixture of alteplase for acute ischemic stroke can be a useful resource for emergency department nursing staff during times when a pharmacist is not available.

14. (True or False) Development of pre‐printed ordersets can help standardize the care of potential acute ischemic stroke patients in the emergency department.

15. (True or False) Rabies Vaccine should be given in the gluteal muscle due to the vaccine's large volume.

16. (True or False) Immune globulin and Rabies vaccine could be mixed in the same syringe to decrease the needle burden to the patient.

17. (True or False) Creating a standard process for methotrexate dose calculation and ordering can help reduce potential medication errors

18. When creating guidelines for the treatment of ectopic pregnancy in the Emergency Department, which of the following departments should be included in the development process?

a. Emergency Department and OB/GYN Department b. Emergency Department and Pharma c. Emergency Department only... it's their department d. Emergency Department, OB/GYN Department and Pharmacy

Department 19. (True or False) Ketamine is the preferred agent for managing all acutely

agitated patients in the ED. 20. (True or False) A single pill of glipizide can be life threatening to a child?


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21. (True or False) A single pill of suboxone(R) is only requires 6‐12 hours of

monitoring for an asymptomatic child. 22. (True or False) A blood gas of a corporal aspirate in ischemic priapism will

show a low PO2 and a high PCO2. 23. (True or False) Dilute vasoactive medications like phenylephrine are a

potential treatment option for priapism. 24. Topical antacids relieve capsaicin‐induced dermatitis by:

a. Increasing activation of noicieptors by lowering the extracellular pH b. Altering the ion‐mediated release of substance P due to the presence

of divalent cations c. Removing capsaicin residue from the skin

25. (True or False) The safety profile, cost, and availability of liquid antacids in the ED makes them a reasonable treatment option for capsaicin‐induced dermatitis.

26. Which of the following is the most common cause of euvolemic hyponatremia:

a. Hypothyroidism b. Glucocorticoid deficiency c. Nephrotic syndrome d. SIADH or Syndrome of Inappropriate Antidiuretic Hormone

27. All of the following agents are selective oral V2 receptor antagonists except: a. Tolvaptan b. Conivaptan c. Lixivaptan d. Satavaptan

28. (True or False) Maternal physiologic changes (i.e., increased plasma volume and glomerular filtration rate) and pharmacokinetic drug properties (i.e., volume of distribution and placental transfer of drug to the fetus) are factors to consider in determining

29. (True or False) Patients are less likely to experience adverse drug effects from intranasally administered products than intravenously administered products.

30. Which of the following is an advantage of intranasal administration of analgesia and sedation?

a. Drugs are absorbed directly into the bloodstream b. It is painless, fast, and requires little skill c. It is inexpensive


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d. All of the above

31. (True or False) Chronic ethanol consumption can down regulate the production of GABA receptors.

32. (True or False) Pyridoxine supplementation can be used to ensure normal GABA receptor function.

33. (True or False) Patients are less likely to experience adverse drug effects from intranasally administered products than intravenously administered products.

34. Which of the following is an advantage of intranasal administration of analgesia and sedation?

a. Drugs are absorbed directly into the bloodstream b. It is painless, fast, and requires little skill c. It is inexpensive d. All of the above

35. (True or False) There is cross reactivity between ester local anesthetics 36. (True or False) Diphenhydramine has a longer onset of action compared to

lidocaine. 37. (True or False) 1 mg of lidocaine is an appropriate pretreatment dose for RSI

in preventing increases in ICP (intracranial pressure) for those patients with head trauma

Answers: 1. (T); 2. (F); 3. (F); 4. (T); 5. (F); 6. a; 7. (F); 8. (F); 9. (F); 10. (T); 11. (T); 12. b; 13. (T); 14. (T); 15. (F); 16. (F); 17. (T); 18. d; 19. (F); 20. (T); 21. (F); 22. (T); 23. (T); 24. b; 25. (T); 26. d; 27. b; 28. (T); 29. (F); 30. d; 31. (T); 32. (T); 33. (F); 34. d; 35. (T); 36. (T); 37. (F)

Wednesday, December 8, 20108:00 AM – 9:45 AM

The Program Chair and presenters for this continuing pharmacy education activity report no relevant financial relationships.

Karalea Jasiak, PharmDPGY2 Emergency Medicine

University of Arizona

Noxious chemical in the Capsicum plants AKA: Chili peppers

Used in:Used in: Cooking/flavoring agents

Personal protection sprays

Animal repellants

Topical ointments

Nociceptor Activation

Exposure to Capsaicin

Burning, Irritation, Erythema, Swelling, Pain

Vasodilation, Vascular Leakage, Inflammation

Substance P Release

2010 ASHP Midyear Clinical Meeting Supplemental Handout

© 2010 American Society of Health-System Pharmacists Page 1 of 28

Ice water Milk Vinegar

V t bl il Vegetable oil Local anesthetics Antacids solutions/suspensions

Cheap

Readily available

Relatively safe

Efficacy?

2.5

3

3.5

4

4.5

Sco

re

*

**

Lee DC, Ryan JR. Magnesium-aluminum hydroxide suspension for treatment of dermal capsaicin exposures. Acad Emerge Med 2003;10:688-90.

0

0.5

1

1.5

2

Pai

n S

10 20 30 60 90 120

Time (minutes)

AntacidSaline

* P<0.05

Increasing the concentration of divalent cations may alter the ion-mediated release of substance P

Increasing the extracellular pH may decrease nociceptor sensitivity to capsaicin

The application of antacid solutions is a reasonable treatment option for capsaicin-induced dermatitis

Philippe MentlerEmergency Medicine Pharmacist

Durham Regional Hospital Durham, NC



A viral disease

Invariably fatal once symptoms develop 99.99999999999999% death rate

~50% of rabid bites cause active infection if not prophylaxed

MMWR. May 23, 2008 / Vol. 57 / No. RR-3

“I kicked my girlfriend’s dog and it bit me” 10 day quarantine

“I f d b t i tti ” “I found bat guano in my attic”

“I found a dead bat in my baby’s room this morning”

“I was randomly attacked by a fox while waiting for the bus”

“A rabid donkey was licking my open wounds”

Standard wound care Clean wound thoroughly

Rabies immune globulin

Rabies vaccine

MMWR. May 23, 2008 / Vol. 57 / No. RR-3

Dose 20 IU/kg administered one time

How to give it Administer most/all RIG in and around wound

when possible

Remainder via IM injection



What if RIG wasn’t given on day 0 ? May be given through day 7

What if they’ve been previously accinated for rabies ?vaccinated for rabies ? Generally, No RIG needed

What if the patient just got a live vaccine (eg. MMR) ? Repeat live vaccine 4 months after RIG

MMWR. May 23, 2008 / Vol. 57 / No. RR-3

The rabies vaccines HDCV – Imovax (human diploid)

PCECV – Rabavert (chick embryo)

How to give them 1 ml IM injection to the DELTOID ONLY

N Engl J Med 2004;351:2626-35.

What if the person develops a local or systemic reaction ? Give the vaccine

What if we start with one vaccine brand but run out ? You can switch mid-course

MMWR. May 23, 2008 / Vol. 57 / No. RR-3

What if a person is late for follow-up vaccination ? Adjust schedule

What if the person is pregnant ? Just do it®

MMWR. May 23, 2008 / Vol. 57 / No. RR-3

What if they were previously vaccinated for rabies ?

No immune globulin No immune globulin

Vaccine on days 0 and 3 only

MMWR. May 23, 2008 / Vol. 57 / No. RR-3

Vaccine schedule is now days 0, 3, 7,14

Immune-compromised to continue through p gday 28

MMWR. March 19, 2010 / Vol. 59 / No. RR-2



NEVER MIX VACCINE AND RIG IN SAME SYRINGE

NEVER GIVE RIG IN SAME SITE AS VACCINE

Who is my Local Contact? http://www.cdc.gov/rabies/resources/contacts.h

tml

1-800-CDC-INFO. They will likely tell you to call your local officer

Ask for a case or reference number

Recombinant Factor VIIa: Recombinant Factor VIIa: How Low Can You Go? How Low Can You Go?

Amanda V. Woloszyn, PharmDAmanda V. Woloszyn, PharmDPGY2PGY2--Emergency Medicine Pharmacy ResidentEmergency Medicine Pharmacy ResidentMayo Clinic, Rochester MNMayo Clinic, Rochester MNDisclosures: NoneDisclosures: None

ObjectiveObjective

•• Identify the dose of rFVIIa Identify the dose of rFVIIa appropriate for use in oral appropriate for use in oral anticoagulation (OAC) induced ICHanticoagulation (OAC) induced ICH

Patient CasePatient Case

•• 78 yo F presenting to ED from home 78 yo F presenting to ED from home with altered mental status per familywith altered mental status per family

•• PMH: HTN, CAD, CHF, afib, CVAPMH: HTN, CAD, CHF, afib, CVA

•• M d L li t f di tiM d L li t f di ti•• Meds: Long list of medications, Meds: Long list of medications, includes warfarin (INR from 1 week includes warfarin (INR from 1 week ago 2.4)ago 2.4)

•• Vitals: BP 192/87, HR 72, 02stat 90%Vitals: BP 192/87, HR 72, 02stat 90%

•• Labs: INR 4.2, all others WNL Labs: INR 4.2, all others WNL

Oral Anticoagulation Induced ICHOral Anticoagulation Induced ICH

Used with permission from Mayo Clinic



Search of Drug Database RevealsSearch of Drug Database Reveals

•• 7070--90 mcg/kg90 mcg/kg

•• Who is this dose for?Who is this dose for?•• Factor VII deficient and hemophilia Factor VII deficient and hemophilia

patientspatientspatients patients

•• Why it works to reverse INR?Why it works to reverse INR?•• Bypasses most of the clotting Bypasses most of the clotting

cascadecascade•• Directly binds to tissue factor to Directly binds to tissue factor to

activate thrombinactivate thrombin

What are the risks of giving this What are the risks of giving this dose?dose?

ThrombosisThrombosis

•• Deep vein thrombosisDeep vein thrombosis

•• Myocardial infarctionMyocardial infarction•• Myocardial infarctionMyocardial infarction

•• Cerebral infarctionCerebral infarction

•• Worsen the patient’s conditionWorsen the patient’s condition

Morgenstern LB, et al. Morgenstern LB, et al. StrokeStroke. 2010;41:00. 2010;41:00--00. Online at 00. Online at http://stroke.ahajournals.orghttp://stroke.ahajournals.orgDiringer MN, et al. Diringer MN, et al. StrokeStroke. 2010;41:48. 2010;41:48--53.53.Robinson MT, et al. Robinson MT, et al. Stroke. Stroke. 2010;41:14592010;41:1459--63.63.

Is this dose appropriate for Is this dose appropriate for reversal of OAC?reversal of OAC?

•• Probably notProbably not

•• Higher doses increased risk of Higher doses increased risk of thrombosisthrombosisthrombosisthrombosis

•• Lower doses in nonLower doses in non--hemophilicshemophilicsmay workmay work

Diringer MN, et al. Stroke. 2010;41:48-53.Robinson MT, et al. Stroke. 2010;41:1459-63.

What dose should you use?What dose should you use?

•• 1010--40 mcg/kg40 mcg/kg

•• Some have gone as low at Some have gone as low at 5 mcg/kg5 mcg/kgg gg g

•• Trials showed lower doses Trials showed lower doses efficaciousefficacious

•• Administer over 1Administer over 1--2 minutes slow IV 2 minutes slow IV bolusbolus

Sorensen B, et al. Sorensen B, et al. Blood CoagulFibrinolysisBlood CoagulFibrinolysis. 2003;12:469. 2003;12:469--477.477.Freeman WD, et al. Freeman WD, et al. Mayo Clin Proc.Mayo Clin Proc. 2004;79:14952004;79:1495--1500.1500.Mayer SA, et al. N Engl J Med.Mayer SA, et al. N Engl J Med. 2005;352:7772005;352:777--785.785.

LOWER IS BETTER!!!LOWER IS BETTER!!!

•• 1010--40 mcg/kg 40 mcg/kg

•• Efficacious in reversal of OAC Efficacious in reversal of OAC induced ICH induced ICH

•• Lower doses decreased risk of Lower doses decreased risk of thrombosis thrombosis

•• No longer recommended by the No longer recommended by the AHA/ASA guidelines AHA/ASA guidelines

Morgenstern LB, et al. Morgenstern LB, et al. StrokeStroke. 2010;41:00. 2010;41:00--00. Online at 00. Online at http://stroke.ahajournals.orghttp://stroke.ahajournals.org

Christopher R. Shaw, PharmDPGY2 Emergency Medicine Resident



Describe a practical process that increases total pharmacy coverage hours in the Emergency Department using a Pharmacy Resident On-Call ProgramPharmacy Resident On Call Program

Level I trauma center Regional pediatric trauma referral center Maryland eye trauma center Adult ED- 58 000 patient visits annuallyAdult ED 58,000 patient visits annually Pediatric ED- 24,000 patient visits

annually

Primary goal- Enhance resident’s clinical experiences

Coverage Hours Weekdays: 1600 to 2300 Weekdays: 1600 to 2300

Weekends/Holidays: 1100 to 2300 Responsibilities Includes medical code and trauma coverage

Development of clinical autonomy Experience being primary clinical

reference Meet residency learning system (RLS)Meet residency learning system (RLS)

goals Participate in the management of medical

emergencies

July 1, 2009 to June 30, 2010 1,241 documented code/trauma

responses by ROC 1 006 responses to ED1,006 responses to ED 429 requiring ROC intervention

Median of 40 minutes if interventions required Range: 10 to 240 minutes

True or False: Allowing pharmacy residents to respond to medical codes and trauma situations in the Emergency Department can provide valuable residentDepartment can provide valuable resident learning experiences.

True or False: The Pharmacy Resident On-Call is a substitute for routine clinical pharmacy services in the Emergency Department.



Christopher R. Shaw, PharmDPGY2 Emergency Medicine Resident

The Johns Hopkins Hospital

DTaP or Tdap from the ADC: The Alphabet Soup of Tetanus

Immunization in the EDImmunization in the ED

Maria I. Rudis, PharmD, DABAT, FCCMMaria I. Rudis, PharmD, DABAT, FCCMClinical Pharmacy Specialist Clinical Pharmacy Specialist –– Emergency MedicineEmergency Medicine

Mayo Clinic, Rochester MNMayo Clinic, Rochester MN

Disclosures: NoneDisclosures: None

Learning Objective

•• Identify the appropriate agent(s) for Identify the appropriate agent(s) for tetanus immunization in ED patients as tetanus immunization in ED patients as part of wound managementpart of wound management

In other words,In other words,

•• What are all these products? What are all these products?

•• Who gets what? Who gets what?

•• What should I stock in the ED ADC?What should I stock in the ED ADC?

Mortality and Incidence Rates of Tetanus Reported in the US (1900-2005)

Reported Cases of Tetanus, Survival Status and Average Annual Incidence Rates by Age Group in US (2001-2005)

Tetanus Trends in the US

• Tetanus is rare in the US • Reemerging in: • Areas• Specific populations – age, risk groups

From the Manual for the Surveillance of Vaccine-Preventable Diseases4th Edition at: http://www.cdc.gov/vaccines/pubs/surv-manual/chpt16-tetanus.pdf

Number of Tetanus Cases Reported Among Persons With Diabetes or Injection-Drug

Use (IDU), by Age Group

Pascual FB, et al. Tetanus surveillance--United States, 1998--2000.MMWR Surveill Summ. 2003 Jun 20; 52(3):1-8

Alphabet Soup: The BasicsDTAP*, Tdap**, DT*, Td**, TIG

• Diphtheria, Tetanus, and Pertussis Vaccines• Four combination vaccines to prevent

diphtheria, tetanus and pertussis

• Upper case letters• Full strength doses• Full-strength doses

• Lower-case “d” and “p”• Reduced doses; “a” = “acellular”

• * (DTaP and DT): age < 7 yrs• ** (Tdap and Td) for older kids and adults• TIG – tetanus immune globulin (human)



…Alphabet Soup: The BasicsDTAP*, Tdap**, DT*, Td**, TIG

• Td: adult tetanus-diphtheria vaccine adsorbed • Min age: 7 yrs• Booster q10 years; or after an exposure to tetanus

• Tdap - tetanus-diphtheria-acellular pertussis• Similar to Td but also contains protection vs pertussis• Single dose at age 11-12; or instead of one Td booster in older

adolescents & adults (19-64)• Boostrix (GSK): 10-18 yrs (FDA 12/08: now to 64 yrs)• Adacel (Sanofi Pasteur): 11-64 yrs

• DT ≠ pertussis; substitute for DTaP for children who cannot tolerate pertussis vaccine

• TT – tetanus toxoid (single antigen)• Only if severe allergic reaction Td

CDC Recommended adult immunization schedule—United States, 2009

• Approved by the ACIP, AAFP, ACOG, ACP

MMWR 2008;57(53)

Wound Management

Vaccination History

Clean Minor Wounds

All Other Wounds

*Unknown or < 3 doses

Td or Tdap(Tdap preferred for ages 11-18)

Td or Tdap (Tdap preferred for ages 11-18) + tetanus immune globulin (TIG)

Doses ≥ 3 and:

• Last dose ≤5 yrs

• Last dose 6-10 yrs Td or Tdap (Tdap preferred for ages 11-18)

• Last dose >10 yrs Td or Tdap(Tdap preferred for ages 11-18)

Td or Tdap (Tdap preferred for ages 11-18)

www.cdc.gov

*If need full series of 3 vaccines, then Tdap can substitute for Td for any one of the 3 doses in the series.

Why Tdap instead of Td?

• It’s all about the ‘p’ –Pertussis – “Whooping Cough”

• Pertussis• Poorly controlled

vaccine preventable

Pre Tdap: Reported Pertussis Casesby Year in US: 1922-2005

vaccine-preventable bacterial disease

• Outbreaks common• Vaccinate groups at

risk or those caring for them

MMWR 2008; 57 (May 14) (Early Release): 1MMWR 2008; 57 (May 14) (Early Release): 1--4747http://www.cdc.gov/mmwr/preview/mmwrhtml/rr57e0514a1.htm?s_cid=rr57e0514a1_e#tab11

Tetanus Vaccination: Pre and Post TdapNational Health Interview Survey (NHIS)

• Self-reported vaccination tetanus vaccination coverage in preceding 10 yrs

• No change in tetanus vaccination in 2008 vs. 1999• 61.6% versus 60.4%; p=0.07

• Coverage suboptimal with Tdap (2008)• Adults (18–64): 5.9%• HCP: 15.9%• Infant contact: 5.0%

Miller BL, et al. MMWR 2010; 59(40): 1302-1306.

Interval Between Most Recent Td and Tdap

• Standard is 5 yrs

• Can be as short as 2 yrs• Local injection pain and inflammation• If risk for transmitting / acquiring pertussis

• Outbreaks / Pertussis activity in communityOutbreaks / Pertussis activity in community• Health-care workers• Those who care for infants (<12mos)



…Tetanus Vaccination– Special Situations

• Pregnancy:• Default is Td (2nd / 3rd trimester) • Tdap immediate post-partum (pre D/C home). • No interval b/w Td and Tdap

Ad l d 6• Adults aged >65 years:• Tdap is not licensed (safety and immunogenicity?)

but off label OK• Default is Td q 10 yrs

Who Should NOT Get Vaccinated with DTap, DT, Td or Tdap?

• Life-threatening /severe allergic reaction after DTP, DTaP, DT, or Td

• Encephalopathy within 7 days after a dose of pertussis-containing vaccine

• No Tdap or Dtap but Td OK

• Consider….Defer DTap in kids if progressive neuro disorder… until stable

• Epilepsy• Severe swelling or severe pain after a previous dose

of DTP, DTaP, DT, Td, or Tdap• Guillain Barré Syndrome (GBS)

http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-td-tdap.pdf

Who Needs Tetanus Immune Globulin (TIG)? Tetanus Prone Wounds

If vaccination status unknown / incomplete:

• Wound >6 hours old

• Wound >1 cm deep

Type / mechanism of injury (any)• Type / mechanism of injury (any)• Complex soft tissue injury

• Missile, crush, burn, frostbite

• Devitalized tissues

• Contaminants: dirt, feces, soil, saliva, etc.

• Denervated, ischemic

• Early infection

Tetanus Immune Globulin (TIG)

• Dose 250-500 Units IM in opposite extremity to tetanus toxoid

• When?• If vaccination Hx unknown or incomplete

• ASAP s/p injury (Yes, in the ED)

• How late is too late for TIG?• Vaccinated but not up to date: ≤ 7ds• Not vaccinated / unknown: 3 wks (21 ds)

*Incomplete: less than full series of 3 doses Td

Which Product Should I carry in the ED Automated Dispensing Cabinet (ADC)?

Product Stock in ED ADC?Td Yes

TIG Yes

Tdap Yes (ideally)

*If need full series of 3 vaccines, then Tdap can substitute for Td for any one of the 3 doses in the series.

• Store in fridge at 2°C-8°C

Key points to remember

• No clear history + tetanus prone wound Tetanus immune globulin (TIG) + Td

• Tdap preferred in none previously• Increase vaccination rate• Prevent transmission of pertussisp

• Think about risk factors• In general, many not up-to-date• Many lack / loose immunity

• Age, women > 55, diabetics, IVDU

• In ED ADC, stock Td, TIG and Tdap

http://emergency.cdc.gov/disasters/disease/tetanus.asp



Accidental Digital Injection of Epinephrine

Christopher J. Edwards, PharmD, BCPSClinical Staff Pharmacist

Emergency MedicineUniversity Medical Center

Tucson, Arizona

Describe the possible adverse effects of accidental digital injection of epinephrine

Describe at least two treatment modalities that can be used following digital injectionthat can be used following digital injection of epinephrine

Epinephrine autoinjector first approved in December 1987

First case report of accidental digital injection in July 1989injection in July 1989

Epinephrine causes vasoconstriction Alpha-1 agonist

Vasoconstriction of small vessels leads to decreased blood flowdecreased blood flow

Decreased blood flow leads to ischemia Ischemia leads to necrosis Necrosis leads to it falling off

16% of physicians accidentally self injected during a simulated training session 100% read the instructions prior to session 100% read the instructions prior to session

Several approaches Wait and watch

Warm water

Nitroglycerin ointment Nitroglycerin ointment

Phentolamine



Poison Control Centers recommend soaking in warm water and waiting Retrospective cohort of 213 patients

All called poison control with accidental digital All called poison control with accidental digital injection of epinephrine

Most had complete resolution within 2 hours

All eventually had complete resolution of symptoms

No digits fell off (or required surgery)

Local vasodilation Limited success in the literature 1 gram of 2% nitroglycerin ointment Potential adverse effectsPotential adverse effects Hypotension

Headache

Local infiltration with phentolamine Blocks alpha-1 effect of epinephrine

Immediate reversal of symptoms

Painful!!! Painful!!! Dilute 1 mg of phentolamine with 1 ml of

2% lidocaine Slowly inject subcutaneously until pallor

resolves

It will not fall off (probably) If treatment is needed Nitroglycerin▪ Less invasiveLess invasive

▪ Efficacy questionable

Phentolamine▪ Painful, but definitive

Accidental Digital Injection of Epinephrine

Christopher J. Edwards, PharmD, BCPSClinical Staff Pharmacist

Emergency MedicineUniversity Medical Center

Tucson, Arizona

Nicole M. Acquisto, Pharm.D., BCPSEmergency Medicine Clinical Pharmacy Specialist, Dept. of Pharmacy

Senior Instructor, Dept. of Emergency MedicineUniversity of Rochester, Rochester, [email protected]



Describe the mechanism of action of neuromuscular blocking agents

Understand the pros and cons of psuccinylcholine compared to a non-depolarizing neuromuscular blocker for rapid sequence intubation

Facilitate intubation Protect against

physiologic response from

Time Zero minus 3 minutesPre-induction agents

Time Zero minus 5 minutesPre-oxygenate with 100% O2

response from laryngoscopy and intubation Increase ICP

Minimize aspiration

Time ZeroInduction agent and NMBA

Time Zero plus 20 secondsCricoid pressure

Time Zero plus 45-60 secondsIntubate

Action potential

Ca2+

Motor end plateNa+

K+

Ca+ release from sarcoplasmic reticulum

ACh

ACh receptors

Depolarizing

Persistent depolarization of the muscle fiber

Non-Depolarizing

Competitively inhibits the binding of Ach to receptors

resistant to Ach Succinylcholine▪ 1-1.5 mg/kg IV

Onset 30-60 seconds Duration 5-10 minutes

p Rocuronium▪ 0.6-1.2 mg/kg IV

Vecuronium

Atracurium

Cisatracurium Onset 1-3 minutes Duration 30-60 minutes

Fasciculations Increases ICP/IOP

Post-paralysis pain Hyperkalemia Subacute or chronic denervation syndromes

(myopathies, muscle atrophy, etc.)

Crush injury > 24-48 hrs

Sepsis > 7 days

Severe burns (> 20-30%) > 24 hours Bradycardia, myalgias, malignant hyperthermia

16 randomized, controlled trials (n = 1362) Succinylcholine compared to rocuronium

17.7% (95% CI = 13 to 22) increase in frequency of excellent intubating conditions

5.1% (95% CI = -7.3 to -2.9) decrease in frequency of unacceptable intubating conditions

Independent of low vs. high dose 37 studies combined for analysis (n = 2690) Succinylcholine superior intubating conditions vs.

rocuronium, RR = 0.86 (95% CI, 0.8 to 0.92)

Karcioglu, et al. International J of Clin Practice 2006;60:1638-1646Perry, et al. Cochrane Database of Systematic Reviews, 2008



Does not have intubating conditions identical to succinylcholine

Inability to re-examine the patient for 30-60 minutes

Support ventilation if failed airway Concern for post-paralysis sedation 23.8% - ≤ 15 minutes

63.1% - > 15 minutes

13.1% - No additional sedative

Mallon, et al. J Emerg Med 2009;183-88Kendrick, et al. Ped Emerg Care 2009;25:393-96

Succinylcholine Remains the drug f h i f idof choice for rapid

sequence intubation unless contraindicated

Leah Hatfield, PharmD, BCPSEmergency Medicine Clinical Pharmacist

Children’s Healthcare of Atlanta Atlanta, GA

Oral Slow onset

Intake restricted

Intravenous Pain and anxiety

Resource use

Patient refuses

Vomits or spits out

Needle stick risk

Experienced providers



Highly vascularized mucosa Rapid access to bloodstream and brain

Avoid first pass metabolism

Painless and fast delivery Painless and fast delivery Inexpensive Skilled training not necessary

Minimize drug volume Less than 1mL per nostril

Maximize drug concentration Use both nostrils Use both nostrils Doubles surface area for absorption

Use atomization device

Suction nostrils before administration Secure patient’s head Place atomizer securely in nostril Point toward ear on the same sidePoint toward ear on the same side Rapidly deliver half contents of syringe Repeat in other nostril with remaining drug

SUBTITLE Analgesia Fracture care

Large abrasions

B

SUBTITLE Sedation MRI and CT scans

Laceration repair

D i h Burns

Dressing changes

Dressing changes

Port access

Short procedures

Subtitle SubtitleIndication Medication Dose Comments

Analgesia Fentanyl 1.5-2mcg/kgMax 100mcg

Use 50mcg/mLTitrate Q 10-15 min

SedationAnxiolysis

Midazolam 0.2-0.4mg/kgMax 10mg

Use 5mg/mLBurning sensation

Leah Hatfield, PharmD, BCPSClinical Pharmacist, Emergency Medicine

Children’s Healthcare of Atlanta Atlanta, GA



Managing Priapism in the ED: Managing Priapism in the ED: It Doesn’t Have to Be HardIt Doesn’t Have to Be HardIt Doesn’t Have to Be Hard It Doesn’t Have to Be Hard

Ryan Attwood PharmD, BCPSRyan Attwood PharmD, BCPS

ED Clinical PharmacistED Clinical Pharmacist

Mayo Clinic, Rochester, MNMayo Clinic, Rochester, MN

Objectives Objectives

•• Describe pathophysiology of priapismDescribe pathophysiology of priapism•• IschemicIschemic vs non ischemic vs non ischemic •• Highlight implicated medicationsHighlight implicated medications

•• Describe management of ischemic priapism Describe management of ischemic priapism •• Treatment algorithm Treatment algorithm •• Role of vasoactive medicationsRole of vasoactive medications•• Method of administrationMethod of administration

Priapism Priapism

•• Erection > 4 hours after or unrelated Erection > 4 hours after or unrelated to sexual stimulationto sexual stimulation

•• Overall incidence 1.5 cases / 100,000 Overall incidence 1.5 cases / 100,000 person yearsperson years

•• Relevant to ED pharmacists???Relevant to ED pharmacists???•• Drugs can cause it Drugs can cause it •• Drugs used to treat itDrugs used to treat it

Eland IA , et al. Urology 2001;57:970-972

Ischemic Ischemic vsvs NonischemicNonischemic PriapismPriapism

Ischemic Ischemic PriapismPriapism•• Inadequate perfusion Inadequate perfusion

•• Painful full erectionPainful full erection

•• Urologic emergencyUrologic emergency

NonischemicNonischemic PriapismPriapism•• Normal perfusion Normal perfusion

•• Non painful, semi erect Non painful, semi erect

•• Not emergentNot emergentUrologic emergency Urologic emergency

•• Various causesVarious causes

•• Sample blood gas: Sample blood gas: PaO2 < 30 PCO2 > 60, PaO2 < 30 PCO2 > 60, pH< 7.25 pH< 7.25

•• Treatment: Medications, Treatment: Medications, surgery surgery

Not emergentNot emergent

•• Results from traumaResults from trauma

•• Sample blood gas PaO2 Sample blood gas PaO2 > 50 PCO2 < 40 pH > 7.30> 50 PCO2 < 40 pH > 7.30

•• Treatment: Cooling, Treatment: Cooling, surgery surgery

Causes of Ischemic PriapismCauses of Ischemic Priapism

•• IdiopathicIdiopathic

•• Drug induced / associatedDrug induced / associated

•• Sickle cell disease: 29%Sickle cell disease: 29%--42% chance42% chanceSickle cell disease: 29%Sickle cell disease: 29%--42% chance 42% chance of developing in lifetime of developing in lifetime

•• Others Others

Pohl J, et al. Br J Urol 1986;58:113Emond AM, et al. Arch Intern Med 1980;140:1437-7

Drugs Implicated in Ischemic Drugs Implicated in Ischemic PriapismPriapism

•• Alpha blockersAlpha blockers

•• AnticoagulantsAnticoagulants

•• Antidepressants Antidepressants

•• Injections and Injections and suppositories for ED suppositories for ED treatment treatment

•• LithiumLithium•• AntihypertensivesAntihypertensives

•• AntipsychoticsAntipsychotics

•• Alcohol Alcohol

•• Baclofen Baclofen

•• CocaineCocaine

LithiumLithium

•• Marijuana Marijuana

•• PhosphodiesterasePhosphodiesteraseinhibitors inhibitors

•• PropofolPropofol

•• Testosterone Testosterone



Ischemic Priapism: Time Is TissueIschemic Priapism: Time Is Tissue Ischemic Ischemic PriapismPriapism Treatment AlgorithmTreatment Algorithm

Decompression by blood aspiration

Intercavernosal injection of sympathomimetics

Surgical intervention

SympathomimeticsSympathomimetics for for PriapismPriapism

•• MOA: vasoconstrictionMOA: vasoconstriction

•• Injected into the Injected into the corpora corpora cavernosaecavernosae

•• Variety of agents triedVariety of agents triedVariety of agents triedVariety of agents tried

•• PhenylephrinePhenylephrine: most : most commonly commonly recommendedrecommended

PhenylephrinePhenylephrine for for PriapismPriapism•• Variety of doses / dilutions usedVariety of doses / dilutions used

•• Recent guidelinesRecent guidelines•• 200 µg / ml X 0.5200 µg / ml X 0.5--1 1 mLmL Q 5 min until Q 5 min until

resolutionresolution•• Dilution: 1 ml 1% Dilution: 1 ml 1% phenylephrinephenylephrine in 49 in 49 p y pp y p

ml NSml NS

•• Efficacy: 81%Efficacy: 81%

•• High dose High dose phenylephrinephenylephrine (1000 µg / dose)(1000 µg / dose)•• Theoretical, but no clinical differenceTheoretical, but no clinical difference

Broderick GA, et al. J Sex Med 2010;7:476-500 Munarriz R, et al. J Sex Med 2006;3:918-922Montague DK, et al. J Urol 2003;170:1318-1324

PhenylephrinePhenylephrine for for PriapismPriapism

•• Max dosage Max dosage -- 1 mg? 1 mg?

•• Monitoring: same as other Monitoring: same as other vasoactivevasoactivemedicationsmedications

•• Continuous BPContinuous BPCC•• Consider EKG? Consider EKG?

•• Few reported AEsFew reported AEs•• Severe hypertension / SAH post 2 mg Severe hypertension / SAH post 2 mg

(n=1 case)(n=1 case)

Davila HH, et al. J Sex Med 2008;5:1025-8

ConclusionsConclusions•• Ischemic Ischemic priapismpriapism = Urologic Emergency= Urologic Emergency

•• Condition is relatively common Condition is relatively common

•• ED pharmacists have a role to play ED pharmacists have a role to play •• Identify agents that may cause it Identify agents that may cause it •• Help recommend appropriate treatmentHelp recommend appropriate treatmentHelp recommend appropriate treatment Help recommend appropriate treatment •• Assure safe administration of Assure safe administration of

phenylephrinephenylephrine

•• 200 µg / ml 200 µg / ml phenylephrinephenylephrine: made by diluting 1 : made by diluting 1 ml of 1% ml of 1% phenylephrinephenylephrine in 49 ml NSin 49 ml NS

•• 0.5 0.5 –– 1 ml dose q 5 min until resolution 1 ml dose q 5 min until resolution



Julie Hoover, PharmD, BCPSClinical Pharmacist – Emergency Department

Legacy Emanuel Hospital, Portland. OR

Help! My patient is allergic to penicillin, sulfa, morphine,

cephalexin, codeine, lidocaine,cephalexin, codeine, lidocaine,ibuprofen, lisinopril, phenytoin, ketorolac,paroxetine, aspirin, tramadol, naproxen, prednisone,

red dye, metoprolol, haloperidol, amoxicillin, valproate, latex, metformin…

Adverse reaction Tachycardia, headache, nausea, palpitations,

syncope, diaphoresis

Allergy Urticaria, pruritis, hypotension, laryngeal

edema

RARE!

Lid iB i

Esters Amides

Lidocaine Bupivicaine Mepivacaine Prilocaine your

content here

Benzocaine Procaine Tetracaine Chloroprocaineur

content here

Ester anesthetics produce PABA metabolites highly antigenic!

Methylparaben commonly used asMethylparaben commonly used as preservative, similar in structure to PABA

Gather details about allergy Skin testing? Anesthetics are cross-sensitive within

groupgroup Allergy to procaine try preservative free

lidocaine Diphenhydramine?



May be used when conventional anesthetics cannot

1% diphenhydramine vs. 1% lidocaine produced similar anesthesia for local placeration repair2

0.5% diphenhydramine associated with less injection site pain3

1% diphenhydramine = 1 mL 50mg/mL diphenhydramine + 4 mL NS

Longer onset of action, shorter duration

Add image here1. Eggleston ST, Lush LW: Understanding allergic reactions

to local anesthetics. Ann Pharmacother 1996; 30:851-857.

2. Ernst AA, Anand P, Nick T, et al: Lidocaine versus diphenhydramine for local anesthesia in minor skin lacerations J Trauma 1993; 34:354-357lacerations. J Trauma 1993; 34:354-357.

3. Ernst AA, Marvez-Valls E, Mall G, et al: 1% Lidocaine versus 0.5% diphenhydramine for local anesthesia in minor laceration repair. Ann Emerg Med 1994; 23:1328-1332.

4. Green SM, Rothrock SG, Gorchynski J: Validation of diphenhydramine as a dermal local anesthetic. Ann Emerg Med 1994;23:1284-1289.

Pamela Walker, Pharm.D., BCPSClinical Coordinator – Emergency Department Pharmacy ServicesAdjunct Clinical Assistant ProfessorUniversity of Michigan Hospitals and Health Centers

Intubation can set off a chain reaction Coughs

Dysrhythmias

Hypertension Hypertension

Increase intracranial pressure

Increase intraocular pressure

Tachycardia Potential hemodynamic changes tend to

be overlooked

Reflex circulatory changes Mean arterial pressure can increase by 25-28

torr

Heart rate can increase by 11-28 beats/minHeart rate can increase by 11 28 beats/min

Typically lasts </= 5 mins Upper respiratory tact undergoes

mechanical stimulation via laryngoscope Reflex sympathetic response Atropine failure

Other agents have failed Alpha adrenergic blockers, beta blockers,

cocaine + tetracaine topically, nitroprusside, fentanyl, etcy ,

1960 – Wycoff 1ST successful blunting of the CVS response

to intubation with lidocaine



Attenuation CVS response

Increased intracranial pressure

Increased intraocular pressure Increased intraocular pressure Cough suppression No significant harmful effects with

respect to hemodynamics or respiratory system

Bedford, et al 20 pts with CNS neoplasms

Transient increases with both groups▪ Lidocaine group – avg. 12 mmHg smaller increase

< 0 05 p< 0.05

Donegan, et al 10 pts with closed-head injuries

Evaluated ICP changes due to endotracheal suctioning▪ Lidocaine group – 7 mmHg decrease in ICP ▪ p<0.5

Grover, et al Dosing 1 – 2 mg/kg of lidocaine▪ Schedule VP shunt surgery

▪ Maximal decrease seen within 2 mins (p<0.001)a a dec ease see s (p 0 00 )

▪ Decrease in ICP seen greater in those with higher dosing

▪ No adverse changes in HR

▪ Decrease in arterial pressure in those dosed at 2 mg/kg (p <0.05)

Robinson and Clancy Meta-analysis

Conclusion based on 6 papers▪ No evidence that pretreating with lidocaine▪ No evidence that pretreating with lidocaine

decreased ICPs or that pretreatment improve patient outcomes for patients undergoing RSI due to acute TBI

Potential for harm?

EM residency survey ~87% utilize pre-treatment with lidocaine for

head trauma No direct evidenceNo direct evidence Decreases in mean arterial pressure But is it balanced by an equal ICP decrease or

not Time delay required to use IV lidocaine

maybe detrimental to the patient

Lev R, Rosen P. Prophylactic Lidocaine use Preintubation: A Review. J Emerg Med. 1994;12(4):499-506

Donegan MF. Bedford RF. Intravenously administered lidocaine prevents intracranial hypertension during endotracheal suctionings. Anesthesiology 1980; 52:516-518

Mower WR, Knopp RK. Clinical Controversies: Lidocaine Administration Before Rapid Sequence Intubation in Patients with Traumatic Brain Injuries. Ann Emerg Med. 2007;49(1):84-87

Robinson N. Clancy M. In patients with head injury undergoing rapid sequence intubation, does pretreatment with intravenous lignocaine/lidocaine lead to an improved neurological outcome? A review of the literature. Emergency Medicine Journal. 2001;18(6):453-457



Grover VK, Reddy GM, Kak VK, Singh S. Intracranial pressure changes with different doses of lignocaine under general anaesthesia. Neurol India 1999;47:118

Silber SH. Rapid Sequence Intubation in Adults with Elevated Intracranial Pressure: A Survey of Emergency Medicine Residency Programs Am J Emerg Med 1997;15(3):263 267Programs. Am J Emerg Med. 1997;15(3):263-267

Melinda J Ortmann, PharmD, BCPSClinical Pharmacy Specialist- Emergency Medicine

The Johns Hopkins HospitalBaltimore, MD

Identify three ways to reduce errors and improve communication when using intramuscular (IM) methotrexate for theintramuscular (IM) methotrexate for the treatment of ectopic pregnancy in the Emergency Department

Inconsistent processes Unclear orders The error that started it all…. Non-validated medical calculatorNon validated medical calculator

Define provider roles in the process Standardize calculation process Maximizing available resources Electronic order entry system

Validated web calculator

On-line access to Methotrexate Policy and patient information

OB/GYN provider responsibilities ED provider responsibilities Pharmacy role In the EDIn the ED

In the satellite Nursing responsibilities



True or False?

Creating a standard process for th t t d l l ti dmethotrexate dose calculation and

ordering can help reduce potential medication errors

When creating guidelines for the treatment of ectopic pregnancy in the ED, which of the following departments should be included in the development process?

A. ED and OB/GYN Department

B. ED and Pharmacy Department

C. ED only... it's their department

D. ED, OB/GYN Department and Pharmacy Dept

Weighing You Weighing Your Options:Appropriate Dose Selection in the Pregnant Patient

Weighing Your Options:Appropriate Dose Selection

i th P t P ti t

Adrienne Bell, Pharm.D., BCPSEmergency Department Pharmacist

University of Michigan Health System

in the Pregnant Patient

Clinical Scenario: 36yo pregnant female (34 weeks gestation)

presents w/ likely HSV encephalitis

You’re the clinical pharmaciston duty in the ED and…

p y p

The team would like to initiate acyclovir

Question: Should I use the patient’s pre-pregnancy

weight or actual body weight?

Variety of weights to

choose from

Physiologicchanges

in pregnancy

Pharmacokinetic properties of drug

Pre-pregnancyIBW

Adj BWActual BW

↑ body fat↑ TBW

↑ plasma volume↑ GFR

VdRenal elimination

Placental tx of drug

Relevant factors in pregnancy

Dosing weight to consider

Acyclovir3,4 - Renal elimination - Large Vd (0.8 L/kg)

Crosses placenta

Actual BW

- Crosses placenta

Alteplase5,8 - Vd @ ss = 2x plasma vol.- Does NOT cross placenta

Pre-pregnancy or

Adj BW

AMGs6,7 - Renal elimination- Vd (0.4L/kg in 3rd Tri)- Crosses placenta

Adjusted BWor

Actual BW



Relevant factors in pregnancy

Dosing weight to consider

LMWH8-10 - Renal elimination Actual BW- Vd = intravascular space- Does NOT cross placenta

UFH8 - Vd = blood volume- Does NOT cross placenta- Altered PB

Adjusted BWor

Actual BW

1. McCarter-Spaulding DE. Medications in Pregnancy and Lactation. MCN. 2005;30(1):10-17.

2. Dundas K. Obstetrics – the physiologic changes. Hospital Pharmacist. 2003;10:242-254.

3. Lockwood C.J. & Lemons J.A. (Eds.) (2007). Guidelines for Perinatal Care (6th Ed). Elk Grove, IA: American Academy of Pediatrics and The American College of Obstetricians andPediatrics and The American College of Obstetricians and Gynecologists.

4. Malm G. Neonatal herpes simplex virus infection. Seminars in Fetal & Neonatal Medicine. 2009;14:204-208.

5. Murugappan A, Coplin WM, Al-Sadat AN, et al. Thrombolytic therapy of acute ischemic stroke during pregnancy. Neurology.2006;66:768-770.

6. Ward K, Theiler RN. Once-daily Dosing of Gentamicin in Obstetrics and Gynecology. Clin Obstet Gynecol.2008;51(3):498-506.

7. Lyell DJ, Pullen K, Fuh K, et al. Daily Compared With 8-Hour Gentamicin for the Treatment of Intrapartum Chorioamnionitis. Obstet Gynecol. 2010;115:344-9.

8. Bates SM, Greer IA, Pabinger I. Venous Thromboembolism, Thrombophilia, Antithrombotic Therapy, and Pregnancy: American College of Chest Physicians Evidence-Based Clinical Practice g yGuidelines (8th Edition). Chest. 2008;133:844S-886S.

9. Patel JP, Hunt BJ. Where do we go now with low molecular weight heparin use in obstetric care? Journal of Thrombosis and Haemostasis. 2008;6:1461-1467.

10. Royal College of Obstetricians and Gynaecologists. Thromboembolic Disease in Pregnancy and the Peurperium: Acute Management. Guideline no.28 Update. London: RCOG Press, 2007. Available at http://www.rcog.org.uk.

Gillian H. Pineda, Pharm.D., BCPSEmergency Medicine Clinical Pharmacist

Community Regional Medical CenterFresno, California

JM, 33 y.o. male, found down in the gutter by FPD and BIBA for AMS

Ht: 5’8”, Wt: 80 kg PMH: Unk; SH: Unk PMH: Unk; SH: Unk

On arrival to the ED, JM became extremely agitated and combative Non-pharmacological measures proved to be futile Pharmacological agents to consider for rapid tranquillization?



A state of motor restlessness accompanied by mental tension

Pathophysiologyp y gy Increase in dopamine and norepinephrine Decrease in gamma-aminobutyric acid (GABA) Hyper- and hyposerotonergic states

Battaglia, J. Drugs 2005;65(9):1207-1222.

Possible Causes Medical Psychiatric Medications

Goals of therapy To calm the patient Patient safety

▪ Prevent harmMedications Substance-related ▪ Medical evaluation and

treatment

Staff safety

Rapid tranquillization, aka chemical restraint Assertive use of medication to calm severely

agitated patients, prevent harm, and treat underlying clinical condition

Barriers to therapy Etiology typically unclear PMH unknown Medical/physical exam and vital signs difficult to

obtain

Battaglia, J. Drugs 2005;65(9):1207-1222.

Ideal agent Fast-acting Non-sedating Low adverse effect profile Intramuscular (IM) administration

IM Formulations Benzodiazepines Antipsychotics Dissociative anesthetic

Zimbroff, DL. CNS Drugs 2008;22(3):199-212.

Binds to GABA receptors and facilitates GABA neurotransmission

Points to consider Reduces agitation without causing movement disordersReduces agitation without causing movement disorders Fails to address underlying psychiatric disorder

Examples Midazolam Lorazepam Diazepam

Typical Blocks dopamine-2

receptors Points to consider

▪ Adverse effect profile of

Atypical Blocks dopamine-2 and

serotonin-2 receptors Points to consider

▪ Better tolerability and ▪ Adverse effect profile of individual agents

Examples▪ Haloperidol▪ Droperidol

▪ Better tolerability and safety profile vs typicals

▪ Easier transition to oral formulation

Examples▪ Ziprasidone▪ Olanzapine▪ Aripiprazole



Dissociative anesthetic

PK and Dose Onset: 3 – 4 min Duration of action: ~30 min

Adverse effects Laryngospasm, excessive

salivation, emergence reactions, hypertension, tachycardia

Duration of action: 30 min Dose: 4 – 6 mg/kg IM x 1

Strengths 10mg/ml, 50mg/ml, 100mg/ml

Points to consider Most commonly used

anesthetic in the world Does not decrease airway

protective reflexes

Benzodiazepines alone or in combo with typical antipsychotics continue to be the mainstay for the management of undifferentiated acute agitation

Antipsychotics are preferred for the treatment of acute p y pagitation in persons with known psychiatric illnesses

Ketamine IM may be considered in patients with undifferentiated form of agitation AND life-threatening, uncontrollable behavior

Allen MH, Currier GW, Carpenter D, et al. J Psychiatr Pract. 2005;11(Suppl 1):5-108.Roberts JR and Geeting GK. J Trauma 2001;51:1008-1010.

Umbreen I. Murtaza, PharmD, BCPSClinical Pharmacy Specialist - Emergency Medicine

The Johns Hopkins HospitalBaltimore, MD

Identify two methods of providing guidelines and education to emergency department staff to standardize the management ofstaff to standardize the management of potential acute ischemic stroke patients

BAT Packet Preliminary order set

Lab requisition

CT requisition CT requisition

NIHSS

Contraindications check list

Alteplase order set

Documentation flow sheet Operational Methods Sheet

Collaborative effort Emergency Department (ED)

Neurology

Pharmacy Pharmacy



Administer intravenous alteplase (tPA):

Reconstitute per package insert instructions with provided 100 ml sterile water (swirl, do not shake vial).

Final concentration of alteplase solution is 1 mg/ml.

Total dose (0.9 mg/kg)= _______ mg (round to nearest whole mgMaximum dose 90 mg)

Total dose volume = mg x 1 ml/mg = mlo a dose o u e _____ g / g _____

Withdraw and discard excess alteplase from vial:[100 ml – total dose (_____ml) = excess (waste)_____ ml]

Calculate bolus dose (10% total volume) = _____ mlAdminister bolus over 1 minute by Alaris pump

Infuse remainder of dose (90% total volume)=_____ml ascontinuous IV infusion over 60 min (must use infusion pump)

An instruction sheet that outlines a workflow using graphics and simple, concise textconcise text

How To Reconstitute Alteplase

Use aseptic technique

AlteplaseRemove flip caps from

Alteplase and Sterile Water for Injection (SWFI) vials. Remove transfer device

from packagingKeeping vial of SWFI upright, insert pin

vertically into center of the SWFI vial stopper

Holding the vial of Alteplase upside down, pierce the other end of the pin

vertically into the center of the Alteplase vial stopper

SWFI

How to Reconstitute Alteplase

Alteplase

SWFI

Invert the vials Allow entireInvert the vials. Allow entire contents of vial of SWFI to flow

into Alteplase vial (Approximately 2 minutes)

Remove empty SWFI vial and transfer pin from Alteplase vial and

swirl gently

REMEMBER: When withdrawing the

waste, hold the vial horizontally and draw out the excess medication. If you hold the vial vertically, the liquid will drip and leak out of the puncture hole.

True or False?Developing an operational methods sheet demonstrating the admixture of alteplase for acute ischemic strokealteplase for acute ischemic stroke can be a useful resource for ED nursing staff during times when a pharmacist is not available.

True or False?

Development of pre-printed order sets can help standardize the care of potentialhelp standardize the care of potential acute ischemic stroke patients in the emergency department.



Is It Really Water Intoxication?

Mona Shah, Pharm.D, BCPSClinical Specialist, Emergency Medicine

Inova Fairfax Hospital, VADecember 8, 2010

MCM 2010 Clinical Pearls

Severe if serum Na < 115 mEq/L

S/Sx: disorientation → coma, seizures

Considered a medical emergency

Acute vs. chronic

Pathophysiology

Inability to suppress ADH or ↑H2O intake

H2O shifts from ECF to ICF

Max rate of correction:10-12 mEq/L/24 hrs

Isotonic saline Hypovolemia; Maintenance

Slow ↑PNa; requires large volume

Hypertonic saline

Acute and symptomatic

Overcorrection can cause ODS. Infusion rate calculations??

Fluid restriction Hypervolemia, l i

Helps prevent further decrease in P f bleuvolemia PNa; not enforceable

Diuretics May worsen hyponatremia –↓Na+

and H20

Demeclocycline SIADH (not FDA appr.)

Takes days for effect, risk of nephrotoxicity in cirrhosis and HF

Vaptans SIADH, CHF, cirrhosis

No ∆ [Na+], ↓ H20

ODS = Osmotic demyelination Syndrome

Mr. Jones is 62 y/o M BIBAircare w/ tremors, vomiting, weakness, ∆MS. Pt was found unconscious on bathroom floor. Pt consumed +70 beers over last 4 days per family

VS: 180/106, 120, 24 (intubated in the ED) PE: No focal deficit, PERRLA CT (Head) - No acute intracranial abnormality

EtOH:103, BUN <2, Na 113, SCr 0.7, BG 234

1. Calculate total body water (TBW) Men: 0.6 x lean body weight (kg) Women: 0.5 x lean BW (kg)

2. Estimate the change in serum sodium needed ∆PNa (mEq/L) = 10-12 mEq/L/24 hours

OR

∆PNa (mEq/L) = (120 – patient’s serum Na) = _____ mEq/L3. Calculate the amount of sodium (Na) needed

Amount of Na (mEq) = ∆PNa (mEq/L) x TBW (L)4. Calculate the volume of infusate (3%) needed Vol of 3% saline = [Amt Na (mEq)/ 513 (mEq/L)] x 1000 = ____ mL

5. Calculate the rate of correction Volume (mL) / ___ hrs = ______ mL/hr

6. Check serum Na every 2-4 hours when infusing 3% saline

Step 1: Calculate TBW (use IBW) TBW = 0.6 x 68 kg = 40.8 L

Step 2: Max ∆P per 24 hrs is 12 mEq/L Step 2: Max ∆PNa per 24 hrs is 12 mEq/L Step 3: Calculate amount of sodium

needed to achieve the above ∆PNa

Amt of Na needed = ∆PNa x TBW= 12 mEq/L x 40.8L = 490mEq

490 mEq is the total amount of Na needed to increase serum Na by 12 mEq/L/24 hours



Step 4: Calculate volume of 3% saline 3% (mL) = 490/513 x 1000 = 960 mL/24 hrs

Step 5: Calculate rate of administration May correct rapidly over 4-6 hrs to achieve a

‘safe’ serum sodium of 120 mEq/L quicker Administer 50% (480 mL) over 4-6 hrs, and

the rest (480 mL) over the next 18-20 hrs 1st infusion rate = 480 mL/6 hrs = 80 mL/hr

▪ May ↓ rate when Sx resolve and/or Na 120mEq/L

2nd infusion rate = 480 mL/18 hrs = 25 mL/hr

Step 6: Recheck sodium level q 2-4 hrs when infusing hypertonic saline

Decrease rate when symptoms resolveDecrease rate when symptoms resolve and/or serum Na reaches 120 mEq/L

Do not correct more than 12 mEq/L/day

Severe hyponatremia is considered a medical emergency and may require rapid correction of serum sodium with 3% saline

Overcorrection of serum sodium can cause osmotic demyelination syndrome

Max rate of correction <12 mEq/L/24 hrs



SUPPLEMENTAL HANDOUT 2010 Midyear Clinical Meeting

Anaheim, California

**Materials not provided by presenter in time to meet publication deadline** Emergency Medicine Pearls 2010 Planned in cooperation with the ASHP Section of Clinical Specialists & Scientists ACPE Activity #204-000-10-258-L01P 1.75 Contact Hours / Knowledge-based Moderator: Daniel Hays, Clinical Pharmacist, University Medical Center Presentation: The Clot Stops Here Laura E. Celmins, PharmD Speaker Contact Information: Laura E. Celmins, PharmD 2630 West Armitage Avenue, Apt 2 Chicago, IL 60647 Email: [email protected]

mailto:[email protected]�

SUPPLEMENTAL HANDOUT 2010 Midyear Clinical Meeting

Anaheim, California

**Materials not provided by presenter in time to meet publication deadline** Emergency Medicine Pearls 2010 Planned in cooperation with the ASHP Section of Clinical Specialists & Scientists ACPE Activity #204-000-10-258-L01P 1.75 Contact Hours / Knowledge-based Moderator: Daniel Hays, Clinical Pharmacist, University Medical Center Presentation: Deadly in a Dose, Pediatric Poisons Deborah J. Larison, PharmD, BCPS Speaker Contact Information: Deborah J. Larison, PharmD, BCPS Sarasota Memorial Hospital Department of Pharmacy 1700 S. Tamiami Trl Sarasota, FL 34239 Email: [email protected]

mailto:[email protected]�

educational session abstract 2010 ashp midyear clinical ... · 2010 ashp midyear clinical meeting...

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