emerggyency medicine attack of the killer migraine! pearls
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Emergency Medicine g yPearls
Attack of the Killer Migraine! gDroperidol to the Rescue!
Megan Musselman, PharmD, BCPSEmergency Medicine Clinical Pharmacist
The University of Kansas Hospital
Megan Musselman, PharmD, BCPSEmergency Medicine Clinical Pharmacist
The University of Kansas Hospital
Disclosure
Megan Musselman reports no relevant financial relationships.
Acute Migraine
- Headache lasting 4-72 hours with at least 2 characteristics:- Unilateral location - Photophobia
- Pulsating quality - Phonophobia
- Moderate-to-severe intensity - Nausea/Vomiting
- Aggravated by routine activityAggravated by routine activity
- Have experienced 5 attacks in lifetime without a known secondary cause
Kelley NE, et al. Headache. 2012;52:114‐28.
General Management in the ED
- Headaches are the 4th most common reason for emergency department visits- > 1.5 million visits/year
- Affecting women > men
- Approach to treatment:- Replace volume depletion
- Blood pressure management
- Serum magnesium replacement
- Assessment of preferential route of treatment
- Onset of action
Kelley NE, et al. Headache. 2012;52:114‐28.
Treatment Options in the EDDrug Class Agents Indication
Analgesics/Opioids/Non‐steroidal anti‐inflammatorydrugs
Acetaminophen/hydrocodone, morphine, meperidine/ibuprofen, naproxen sodium, ketorolac
‐ First line treatment option
‐ Caffeine as an adjunct
A i i M l id Fi li f iAnti‐emetics Metoclopramide,prochlorperazine, droperidol
‐ First line for patients experiencing nausea and vomiting
Non‐selective 5‐hydroxytryptamine receptor agonists
Ergotamine ‐ Second line treatment option
Selective 5‐hydroxytryptamine receptor agonists
Sumatriptan, Zolmitriptan ‐ Second line treatment option
Kelley NE, et al. Headache. 2012;52:114‐28.
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 1 of 32
Droperidol (Inapsine®)
Studied in the 1950’s as an alternative for morphine Class:
• Butyrophenone
Mechanism of action: • Potent dopamine2 receptor antagonist and alpha1 receptorPotent dopamine2 receptor antagonist and alpha1 receptor
antagonist
Onset of Action:• IM/IV- peak serum levels in 1 hour• Half-life: 2 hours
Adverse events:• QT prolongation, extrapyramidal side effects (drug-induced
parkinsonism), tachycardia, orthostatic hypotension
Richards JR, et al. J Emerg Med. 2003;24:441‐7.
Evidence
Study Comparison DroperidolResults
Side Effects
Silberstein, et al.
Droperidol (0.1‐8.25 mg) IM versus placebo
Greater pain relief at 2 hours; P < 0.01
‐ Sedation and anxiety
‐ 30% of patientsreceiving > 2 75 mgreceiving > 2.75 mg
Miner, et al. Droperidol 5 mg IM versus prochlorperazine10 mg IM/IV
Greater pain reduction at 1 hour; P < 0.001
‐ No difference‐ Most common
sedation
Weaver et al. Droperidol 2.5 mg IV versus prochlorperazine10 mg IV
Pain‐free at 30 minutes; P < 0.01
‐ No difference‐ Most common
akathisia
Richman, et al.
Droperidol 2.5 mg IM versus meperidine 1.5 mg/kg IM
Similar pain reduction; P=0.33
‐ Drop > akathisia‐ Meperidine >
sedation
Kelley NE, et al. Headache. 2012;52:292‐306.
Management of Side Effects
Torsades de pointes• 9 cases have been reported in the last 30 years
• Only occurred in patients receiving doses > 5 mg
Drug induced parkinsonism Drug-induced parkinsonism• Administration of concomitant anticholinergic medication
Orthostatic hypotension• Pretreat with a normal saline bolus
Kelley NE, et al. Headache. 2012;52:292‐306.
Take Home Points
Droperidol 0.625-2.5 mg IV/IM for acute migraine attacks is an efficacious option with minimal side effects
Only need to obtain a baseline QTc prior to administration• Routine cardiac monitoring not necessary
Most patients experience pain-relief in 2 hours or less
Short half-life allowing quick ED discharge
Pharmacists can play a role in reducing the occurrence of drug-related side effects• Home medication histories• Pre-medication agents
Silberstein SD, et al. Neuro. 2003;60:315‐21.
Pediatric Intranasal MidazolamPediatric Intranasal Midazolam
Kimberly Glasoe, PharmDEmergency Medicine Clinical Pharmacist
Mercy Hospital – Allina HealthCoon Rapids, MN
Kimberly Glasoe, PharmDEmergency Medicine Clinical Pharmacist
Mercy Hospital – Allina HealthCoon Rapids, MN
Disclosure
Kimberly Glasoe reports no relevant financial relationships.
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 2 of 32
Objective
Identify scenarios where intranasal midazolam would be appropriate for mild to moderate pediatric sedation
Nasal Atomizer and AdministrationMAD Nasal™ - Intranasal mucosal atomization device
Intranasal Midazolam Dosing
Midazolam 0.2-0.5 mg/kg
Lower end dose 0.2 mg/kg• Imaging studies
• Positioning
Hi h d d 0 5 /k Higher end dose 0.5 mg/kg• Laceration repair
• Ortho procedures
• IV line placement
Maximum 10 mg/dose or repeat administration
Pharmacokinetics
Onset~ 4 - 6 minutes
Peak~ 10 - 14 minutes
• 55% bioavailable compared to IV
0 utes
Duration~ 45 - 60 minutes
Additional Information
Midazolam concentration 5 mg/ml
Maximum volume per nare – 1 ml
Burning with administration – few/no patients reported memory of pain
Monotherapy – shows no significant respiratory depression
Others in literature – fentanyl, sufentanyl, naloxone, ketamine
Conclusion
Intranasal midazolam allows for a rapid, non-invasive & reliable method for mild to moderate pediatric sedation
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 3 of 32
References
Acworth, J.P., D. Purdie, and R.C. Clark, Intravenous ketamine plus midazolam is superior to intranasal midazolam for emergency paediatric procedural sedation. Emerg Med J. 2001;18(1):39-45.
Bates, B.A., S.A. Schutzman, and G.R. Fleisher, A comparison of intranasal sufentanil and midazolam to intramuscular meperidine, promethazine, and chlorpromazine for conscious sedation in children. Ann Emerg Med.1994;24(4):646-51.
Chiaretti, A., G. Barone, et al. Intranasal lidocaine and midazolam for procedural , , , psedation in children. Arch Dis Child. 2011 Feb;96(2):160-3.
Gilchrist, F., A.M. Cairns, and J.A. Leitch, The use of intranasal midazolam in the treatment of paediatric dental patients. Anaesthesia. 2007;62(12):1262-5.
Knoester, P.D, et al. Pharmacokinetics and pharmacodynamics of midazolam administered as a concentrated intranasal spray. A study in healthy volunteers.British Journal of Clinical Pharmacology. 2002;53(5):501-7.
Yealy, D.M., et al., Intranasal midazolam as a sedative for children during laceration repair. Am J Emerg Med. 1992;10(6):584-7.
Wermeling, D.P. et al., Bioavailability and pharmacokinetics of lorazepam after intranasal, intravenous, and intramuscular administration. J Clin Pharmacol.2001;41(11):1225-31.
[Don’t] Take My Breath Away: The Role of Glucagon in Acute AsthmaThe Role of Glucagon in Acute Asthma
ExacerbationNadia Awad, Pharm.D.
PGY‐2 Emergency Medicine Pharmacy Resident
Robert Wood Johnson University Hospital
New Brunswick, New Jersey
Nadia Awad, Pharm.D.
PGY‐2 Emergency Medicine Pharmacy Resident
Robert Wood Johnson University Hospital
New Brunswick, New Jersey
Disclosure
Nadia Awad reports no relevant financial relationships
Learning Objective
Describe the various doses and routes of administration for glucagon in the management of acute asthma exacerbation
Clinical Vignette
SH is a 42‐year‐old female who presents to the emergency department with the following chief complaint:
“It’s happening again…I just need to be intubated.”
Clinical Vignette (cont’d.)
Has she been here before?• SH has been in the ER more than a dozen times in the past 3 months
• Previous visits related to acute exacerbations of• Previous visits related to acute exacerbations of asthma secondary to ethanol abuse
• Non‐compliant with medications
• Has been intubated several times and required admission to the intensive care unit
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 4 of 32
Clinical Vignette (cont’d.)
SH presents with tachypnea and acute shortness of breath with audible wheezing
Physical exam:
• HR 115 bpm; RR 43 bpm with signs of accessoryHR 115 bpm; RR 43 bpm with signs of accessory muscle use; 88% O2 saturation on room air
• Decreased breath sounds bilaterally with inspiratory and expiratory wheezing
Readings from peak flow meter are consistently in the red zone between 150 and 160 L/min
“Run of the Mill”
Oxygen therapy
Nebulized solution of albuterol 2.5 mg and ipratropium 0.5 mg q20 minutes x 3 doses
Methylprednisolone 125 mg IV x 1Methylprednisolone 125 mg IV x 1
SH is not showing any signs of improvement
• Treatment with continuous nebulized albuterol is started at a rate of 10 mg/hr
“Kitchen Sink”
Terbutaline 0.25 mg SQ x 1 dose
Magnesium sulfate 2 g IV x 1 dose
Still no improvement
• Loading dose of aminophylline 400 mg IV is ordered• Loading dose of aminophylline 400 mg IV is ordered
The ED attending physician asks:
“Can we try glucagon in this patient?”
Rationale
Glucagon is a 29‐amino acid polypeptide hormone
• Produced and secreted by the α‐cells of the islets of Langerhans in the pancreasof Langerhans in the pancreas
Mechanism of action:
• Causes relaxation of the bronchial smooth muscles
• Stimulates adenyl cyclase to activate the synthesis of cyclic adenosine monophosphate (cAMP)
Give Me Proof
Study Design Population Intervention Results
(1) Open‐label,non‐blinded, non‐controlled study
n = 14
• ED adult patients • Mild to moderately
severe asthma exacerbation
Glucagon 1 mg IV over 1 minute
8/14 (57%) achieved a mean increase in PEFR of ≥ 60 mL/min after
10 minutes
( ) d d l(2) Randomized,double‐blind, placebo‐
controlled study
n = 46
• Adult ED patients• Asthma exacerbation• Peak expiratory flow
rate (PEFR) < 350 mL/min at presentation
Glucagon 0.03 mg/kg IV over 2
minutes
Placebo: equivalentvolume of normal saline solution
Improvement in PEFR of ≥ 60 mL/min after
10 minutes:
Glucagon: 2/21 (9.5%)Placebo: 3/25 (12%)
1Wilson et al. J Emerg Med 1990; 8:127‐130.2Wilber et al. Ann Emerg Med 2000; 36:427‐431.
Switching It Up
Nebulized Glucagon for Bronchospasm in Asthmatic Patients
Study Design Randomized, double‐blind, placebo‐controlled, crossover study in pulmonary function lab
Populationand Methods
• History of chronic stable asthma (n = 10)• Methacholine challenge administered to the point at which baseline forced expiratory volume in one second (FEV1) decreased by at least 20%
Intervention • Glucagon 2 mg administered via nebulization and effects on FEV1 were compared to nebulized normal saline
• Nebulized albuterol 2.5 mg given after administration of either treatment • Patients returned one week later to receive alternative solution (nebulized glucagon or normal saline)
Results Improvement in FEV1 after 15 minutes:• Nebulized glucagon: 58% ± 15% • Nebulized normal saline: 36% ± 7%
Melanson et al. Am J Emerg Med 1998; 16:272‐275.
p < 0.05
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 5 of 32
Take Home Message
Effects of glucagon in treating bronchospasm associated with acute asthma exacerbation has mixed results
Anecdotally, intravenous glucagon at a dose of 2 mg has been administered at RWJUH to select patients with bronchospasm with positive results
Can be considered as a last‐line option if patients with acute asthma exacerbation do not show improvement with standard therapy
The Use of Richmond Agitation Sedation Scale (RASS) for Alcohol Withdrawal in the(RASS) for Alcohol Withdrawal in the
Emergency Department
Lauren King, PharmD
PGY‐2 Emergency Medicine Pharmacy Resident
The Johns Hopkins Hospital
Lauren King, PharmD
PGY‐2 Emergency Medicine Pharmacy Resident
The Johns Hopkins Hospital
Disclosure
Lauren King reports no relevant financial relationships.
Objective
Describe the benefits of using RASS for the assessment of acute alcohol withdrawal in an adult emergency department
Acute Withdrawal Disorder
Pathophysiology
• Reduced transmission of GABAA pathway
• Enhanced neurotransmission in glutamate pathway
Symptoms y p
• May occur within hours of the last drink• Typically do not develop until 48 – 72 hours after last drink
• Agitation
• Tachycardia
• Fever
• Diaphoresis
• Hypertension
Arch Intern Med. 2004;164:1405‐12.
How do healthcare professionalstitrate therapy?py
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
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Scales Used to Titrate Therapy
Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA‐Ar)
Alcohol Withdrawal Syndrome (AWS) Type Indicator
Minnesota Detoxification Scale (MINDS)
Subjective Clinical Assessment
Scale name Description Advantages Disadvantages
CIWA – Ar • 10 symptoms categories including nausea and vomiting,tactile, auditory, and visual disturbances, tremor, paroxysmal sweats, anxiety, headache, agitation, orientation and clouding of sensorium
• Considers variety of symptoms
• Simple scoring system
• Vital signs not accounted for in scoring
• Specific verbiage necessary for accurate assessment
• Time to perform assessment
AWS Type Indicator • 3 categories of symptoms including CNS excitation
• Considers variety of symptoms and
• Complex assessment and documentationincluding CNS excitation,
adrenergic hyperactivity and delirium
• Treatment dictated by symptoms present
symptoms and treatment directed to specific symptomatology
• Simple scoring system• Accounts for vital signs
and documentation• Time to perform
assessment
MINDS • 9 symptom categories including pulse, diastolic blood pressure, tremor, sweat, hallucinations, agitation, orientation, delusions, seizures
• Considers variety of symptoms
• Accounts for vital signs
• Complex scoring system
• Time to performassessment
• Not validated
The Addition Research Foundation Clinical Institute Withdrawal Assessment for Alcohol, revised ScalePharmacotherapy. 2005;25(8):1073‐83.Pharmacotherapy. 2007;27(4):510 – 8.
Institution Guidelines
Provider orders nurse‐driven alcohol withdrawal protocol and assesses patient’s baseline RASS
Nurse titrates medication administration to a goal RASS of ‐1 b d id li th t d li ht lbased upon guidelines that recommend light somnolence as the recommended therapeutic endpoint
Arch Intern Med. 2004;164:1405‐12.
AWS Guidelines compared to RASS
Light somnolence
• State in which patient is awake but tends to fall asleep unless stimulated or is sleeping but easily aroused
RASS of ‐1
• Patient responds to verbal stimuli by opening his/her eyes and maintain eye contact for >10 seconds
Arch Intern Med. 2004;164:1405‐12.
Richmond Agitation‐Sedation Score (RASS)Score Term Description
+4 Combative Overly combative, violent, immediate danger to staff
+3 Very agitated Pulls or removes tubes or catheters; aggressive
+2 Agitated Frequent non‐purposeful movement, fights ventilator
+1 Restless Anxious, but movements are not aggressive or vigorous
0 Alert and calm
‐1 Drowsy Not fully alert, but has sustained awakening (eye opening and eye contact) to voice (greater than or equal to 10 seconds)
Verbal stimulation
‐2 Light sedation Briefly awakens with eye contact to voice (<10 seconds)
Verbal stimulation
‐3 Moderate sedation Movement or eye opening to voice (but no eye contact)
Verbal stimulation
‐4 Deep sedation No response to voice, but has movement or eye opening to physical stimulation
Physical stimulation
‐5 Unarousable No response to voice or physical stimulation Physical stimulation
RASS Procedure
Observe the patient. Is patient alert and calm? (score 0)
Does the patient have behavior that is consistent with restlessness or agitation • Score +1 to +4 using the criteria
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 7 of 32
RASS Procedure (cont’d)
If the patient is not alert, in a loud speaking voice state patient’s name and direct patient to open eyes and look at speaker. Repeat if necessary. Can prompt patient to continue looking at speaker.
• Score 1 to 3 using criteria• Score ‐1 to ‐3 using criteria
If patient does not response to voice, physically stimulate patient by shaking shoulder then perform sternal rub if necessary.• Score ‐4 to ‐5 using criteria
Advantages to RASS
Validated tool for sedation
Less symptoms to assess compared to other tools for alcohol withdrawal leading to quick nursing assessment
Well known to health care professionals
Disadvantages to RASS
Potential for inter‐rater variability
Not specific to alcohol withdrawal
Summary
Goal of managing alcohol withdrawal in the emergency department is rapid titration of benzodiazepines in short
frequency to gain adequate symptom controlHeart to Heart: Recognizing Undiagnosed
Congenital Heart Disease in the EDCongenital Heart Disease in the ED
Leah Hatfield, PharmD, BCPSClinical Pharmacist Specialist, UNC Healthcare
Assistant Clinical Professor, UNC Eshelman School of Pharmacylhatfiel@unch.unc.edu
Leah Hatfield, PharmD, BCPSClinical Pharmacist Specialist, UNC Healthcare
Assistant Clinical Professor, UNC Eshelman School of Pharmacylhatfiel@unch.unc.edu
Disclosure
Leah Hatfield reports no relevant financial relationships
It’s NOT Just Another Sick Baby!
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 8 of 32
Presentation to the ED
A 3 week old infant presents to the ED and the parents note the following complaints:• Poor sleep• Poor feeding toleranceg• Persistent fussiness and irritability
DON’T always assume the obvious:• Normal newborn• Neonatal sepsis or infection• Colic or GERD
Symptoms of CHD at Presentation
Easy to Recognize
Congestive heart failure
Cyanosis
Shock
A Little More Tricky
Feeding difficulty
Tachypnea
Fussiness or agitation Shock
Diaphoresis
Murmur
Abnormal heart rate
Fussiness or agitation
Coughing and wheezing
Lethargy
Poor weight gain
Asymptomatic
Types of Lesions: Ductal Dependent
Left Sided
HLHS
Aortic stenosis
Coarctation of the aorta
Right Sided
Tetralogy of Fallot
Pulmonary atresia
Coarctation of the aorta
Interrupted aortic arch
Types of Lesions: Non-Ductal Dependent
Atrial septal defect
Ventricular septal defect
ALCAPA
Congenital cardiomyopathy
The Ductus Arteriosus
PDA
Definitive Diagnosis
Assess BP and pulses in all four extremities
Pulse oximetry
Chest radiography
Hyperoxia test Hyperoxia test
Echocardiogram
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 9 of 32
Acute Management
ABC’s, not as easy as 1-2-3• Oxygen may help or harm
• Fluid should be used judiciously to improve perfusionp
Access• Upper extremity or scalp IV
• Avoid IO in patients with poor peripheral pulse or perfusion
Acute Management: Alprostadil
Initiate immediately for suspected ductal dependent lesion• Rule out sepsis prior to initiation
• 0.05-0.1mcg/kg/min, titrate to clinical effect
• Decrease dose once ductus reopens
Monitor for expected adverse effects• Apnea
• Nonpathologic hyperthermia
• Decreased SVR
Thank You Think, Pair, Share!
From the Pearls you just heard, discuss with someone near you…
What is something you can apply in your setting?
What are challenges you would encounter?
Alternative Dosing of Adenosine:Does Size Really Matter?Does Size Really Matter?
Daniel Jarrell, PharmDPGY2 Emergency Medicine Resident
University of Arizona
Daniel Jarrell, PharmDPGY2 Emergency Medicine Resident
University of Arizona
Disclosure
Daniel Jarrell reports no relevant financial relationships.
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 10 of 32
What should you do?
60 year old male with heart palpitations• EKG reveals supraventricular tachycardia
• Heart rate – 165 beats per minute
• Past medical history• Appendectomy 2 months agoAppendectomy 2 months ago
• Access – intraosseous
• Weight – 85kg
Attending physician would like to chemically cardiovertwith adenosine
Objective
At the end of this pearl, the listener will be able to…• Choose appropriate dosing of adenosine for alternative vascular
access
Adenosine
Depress sinus node rate and transient atrioventricular (AV) nodal block
Diagnostic and therapeutic use
Extremely short duration of action
Rankin et al. Am Heart J. 1990.DiMarco et al. J Am Coll Cardiol. 1985.
2010 ACLS Guidelines
Recommend initial dose of 6mg given peripherally• May repeat with 12mg if ineffective
• 0.1mg/kg – 0.3mg/kg for pediatrics
Reduce initial dose to 3mg Reduce initial dose to 3mg…• Post-cardiac transplant patients
• Concomitant use of dipyridamole or carbamazepine
• Administration through a central vein
Increased dose may be necessary when…• Significant blood concentrations of theophylline or caffeine
presentNeumar et al. ACLS Guidelines. Circulation. 2010.
Central vs Peripheral
Route of administration influenced efficacy
Mean effective dose (p < 0.005)• Central (femoral vein): 3.8mg
P i h l ( t bit l f i ) 8 4• Peripheral (antecubital fossa vein): 8.4mg
Rankin et al. Am Heart J. 1990.
Central vs Peripheral
Mean dose required (p < 0.0001)• Central: 3.8 1.6mg
• Peripheral: 6.3 3.3mg
Time from dose to termination of SVT (p < 0.0001)• Central: 12 7 5 1 seconds• Central: 12.7 5.1 seconds
• Peripheral: 19.2 7.9 seconds
No difference in total frequency of adverse effects
Lower doses of adenosine more effective after central vs peripheral administration• Initial dose via central vascular access should be 3mg
McIntosh‐Yellin et al. J Am Coll Cardiol. 1993.
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 11 of 32
Intraosseous
Animal model to determine effective dose via peripheral, central, and intraosseous routes• Central: 0.087mg/kg
• Peripheral: 0.159mg/kg
• Intraosseous: 0 127mg/kgIntraosseous: 0.127mg/kg• p = 0.006 (central vs peripheral)
• p < 0.03 (central vs peripheral vs IO)
• p = non-signficant (central vs IO or peripheral vs IO)
Conclude intraosseous route effective for adenosine administration• Effective dose between peripheral and central dosing
Getschman et al. Arch Pediatr Adolesc Med. 1994.
Intraosseous
Case report demonstrating successful intraosseous administration of adenosine to terminate SVT
11-day-old female presented to ED with SVT• History of SVT on day of birth converted with IV adenosine
• IV access difficult to obtain IO access initiated• IV access difficult to obtain, IO access initiated
• 0.1mg/kg adenosine via IO converted to NSR• Reverted to SVT but converted with additional 0.1mg/kg dose
Friedman. Ann Emerg Med. 1996.
Intraosseous
Case reports of unreliable termination of SVT 2 month old with previous cases of SVT responsive to IV
adenosine• 0.05mg/kg, 0.15mg/kg, 0.25mg/kg all via IO with no resolution
• No transient asystole
• 0.1mg/kg given through peripheral IV terminated SVT
4 month old with previous case of SVT responsive to IV adenosine• 0.1mg/kg, 0.2mg/kg both IO with no resolution
• No transient asystole
• 0.1mg/kg, 0.2mg/kg central (femoral) IV caused transient asystole, conversion to NSR, then return to SVT
Goodman et al. Pediatr Emer Care. 2012.
What should you do?
60-year-old male with heart palpitations• EKG reveals supraventricular tachycardia
• Heart rate – 165 beats per minute
• Past medical history• Appendectomy 2 months agoppe decto y o t s ago
• Access – intraosseous
• Weight – 85kg
Attending physician would like to chemically cardiovertwith adenosine
4-5mg initial dose followed by 8-10mg if necessary
References
Babuty D, Aupart M, Cosnay P et al. Electrocardiographic and Electrophysiologic Properties of Cardiac Allografts. J Cardiovasc Electrophysiol. 1994;5:1053-63.
Delacretaz E. Supraventricular Tachycardia. N Engl J Med. 2006;354:1039-51. DiMarco JP, Sellers TD, Lerman BB et al. Diagnostic and Therapeutic Use of Adenosine in Patients With Supraventricular
Tachyarrhythmias. J Am Coll Cardiol. 1985;6(2):417-25. Ellenbogen KA, Thames MD, DiMarco JP et al. Electrophysiological Effects of Adenosine in the Transplanted Human Heart:
Evidence of Supersensitivity. Circulation. 1990;81:821-8. Friedman FD. Intraosseous Adenosine for the Termination of Supraventricular Tachycardia in an Infant. Ann Emerg Med.
1996;28:356-8. Getschman SJ, Dietrich AM, Franklin WH et al. Intraosseous Adenosine: As Effective as Peripheral or Central Venous
Administration? Arch Pediatr Adolesc Med 1994;148:616 9Administration? Arch Pediatr Adolesc Med. 1994;148:616-9. Goodman IS, Lu CJ. Intraosseous Infusion is Unreliable for Adenosine Delivery in the Treatment of Supraventricular
Tachycardia. Pediatr Emer Care. 2012;28:47-8. Manole MD, Saladino RA. Emergency Department Management of the Pediatric Patient with Supraventricular Tachycardia.
Pediatric Emergency Care. 2007;23:176-89. McIntosh-Yellin NL, Drew BJ, Scheinman MM. Safety and Efficacy of Central Intravenous Bolus Administration of Adenosine
for Termination of Supraventricular Tachycardia. J Am Coll Cardiol. 1993;22:741-5. Neumar RW, Otto CW, Link MS et al. Part 8: Adult Advanced Cardiovascular Life Support: 2010 American Heart Association
Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S729-67. O’Nunain S, Jennison S, Bashir Y et al. Effects of Adenosine on Atrial Repolarization in the Transplanted Human Heart. Am
J Cardiol. 1993;71:248-51. Overholt ED, Rheuban KS, Gutgesell HP et al. Usefulness of Adenosine for Arrhythmias in Infants and Children. Am J
Cardiol. 1988;61:336-40. Rankin AC, Oldroyd KG, Chong E et al. Adenosine or Adenosine Triphosphate for Supraventricular Tachycardias?
Comparative Double-Blind Randomized Study in Patients with Spontaneous or Inducible Arrhythmias. American Heart Journal. 1990;119:316-23.
Propofol for Alcohol Withdrawal Syndrome:Imitation is the Sincerest Form of FlatteryImitation is the Sincerest Form of Flattery
Darrel W. Hughes, Pharm.D., BCPSClinical Specialist, Emergency Medicine
University Health SystemUniversity of Texas Health Science Center San Antonio
Darrel W. Hughes, Pharm.D., BCPSClinical Specialist, Emergency Medicine
University Health SystemUniversity of Texas Health Science Center San Antonio
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 12 of 32
Disclosure
Darrel W. Hughes reports no relevant financial relationships.
Why Should We Care?
Alcohol most widely abused drug in the world
8-31% of hospitalized patients develop alcohol withdrawal (AWD)withdrawal (AWD)
AWD may increase mortality 300%
Diagnostic Criteria
Cessation or reduction in heavy or prolonged alcohol use
Diagnostic Criteria
Two or more of the following developing hours to days after cessation or reduction• Autonomic hyperactivity
• Increased hand tremor
• Insomnia
• Nausea or vomiting
• Visual, tactile or auditory hallucinations or illusions
• Psychomotor agitation
• Anxiety
• Grand mal seizures
Diagnostic Criteria
Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioningfunctioning
Diagnostic Criteria
Symptoms are not due to a general condition and are not better accounted for by another mental disorder
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 13 of 32
Neurophysiology
Chronic ingestion of alcohol• Decreases GABA-A1 receptor function
• Increases NMDA2 receptor function
D i ithd l f l h l During withdrawal of alcohol• NMDA overload
• Delirium, hallucinations and seizures
• Decreased GABA • Tremors, diaphoresis, tachycardia, anxiety and
seizures
1 Gamma‐amino‐butyric acid type A2 N‐methyl‐D‐aspartate
Benzodiazepine
Bind GABA-A receptors
Control agitation
Reduce• Mortality
• Duration of AWD symptoms
• Treatment complications
GABA receptor down regulation…• Saturation → refractoriness
Benzodiazepine Refractory Withdrawal
What to do?• More benzodiazepine…
• Waste of good benzodiazepine
• No added control of agitation• No added control of agitation
• q10 minute orders make nurses angry!!!
Give propofol a try!
Propofol for Alcohol Withdrawal
Dose dependent hypnotic effects (5-80 mcg/kg/min)
• Activates GABA-A receptors AND…
• Inhibits NMDA at glutamate receptor
Effective for benzodiazepine resistancep
Case series level of evidence• Clinical data soon???
Short t1/2 and predictable metabolism
SE: hypotension, hypertriglyceridemia and PRIS
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 14 of 32
Take Home Points
Alcohol withdrawal • Too much NDMA and not enough GABA
Benzodiazepine• Only affect GABA receptors
• Saturated GABA receptors → refractoriness
Propofol• Hits both GABA and NMDA receptors
• Imitates neuro-biochemistry of alcohol
Thank You!
“Everybody has to believe in something.....I believe I'll have another drink.”
-W. C. Fields
Ebbing the flow in trauma-induced gcoagulopathy
Brittany R. Traylor, PharmDUC Davis Medical Center
Sacramento, CA
Brittany R. Traylor, PharmDUC Davis Medical Center
Sacramento, CA
Disclosure
Brittany R. Traylor reports no relevant financial relationships.
Trauma-induced coagulopathy (TIC)
Exsanguination is the leading cause of preventable death among injured patients – up to 1/3 presenting with coagulopathy
TIC i t d ith 3 f ld i i t lit TIC associated with a 3-fold increase in mortality among injured patients
Coagulopathic patients with identical Injury Severity Scores (ISS) have doubled rates of mortality
Causes of Trauma-induced Coagulopathy
Loss coagulopathy
Dilutional coagulopathy
Consumption
Hyperfibrinolysis
Anemia
Hypothermia*
Acidosis*
Electrolyte disturbances
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 15 of 32
XIIaXIIa
XIaXIa
IXaIXa
VIIIaVIIIaVIIaVIIa
Va, VIIIa, Va, VIIIa,
Extrinsic Pathway – Activated by tissue factor in injured subendothelium. Measured by PT/INR
Intrinsic Pathway – Contact activated by platelets. Measured by aPTT
XaXa
Thrombin (IIa)
Thrombin (IIa)
Fibrin (Ia)Fibrin (Ia)
Degradation products
Degradation products
XaXa
Plasminogen Plasmin
XaXa
Fibrinogen (I)
Prothrombin (II)
Heparins/LMWHstPA
XIIIaXIIIa
University of Arizona Medical Center
Prothrombin Complex Concentrate (PCC) – replaces deficient clotting factors (II, IX, and X). These factors will still require activation in plasma
T i id (TXA) f ibl l Tranexamic acid (TXA) – forms a reversible complex that displaces plasminogen from fibrin resulting in inhibition of fibrinolysis
In vitro study
Results: • aPCC shortened clotting time from 11.8 to 7 minutes
• TXA increased clot lysis time from 6.0 to 16 or 37 minutes
• Combination shortened clotting time AND increased clot lysis time
The combination appears to improve clot stability
University of California, Davis Medical Center
Anti-inhibitor Coagulant Complex (FEIBA) – replaces deficient clotting factors in their active form (IIa, IXa, and Xa)
Recombinant Factor VIIa (rFVIIa) – replaces deficient ti t d l ti f t VIIactivated coagulation factor VII
Tranexamic acid (TXA) – inhibits fibrinolysis
Conclusion
May begin to see combinations of these products (PCC + TXA) being used
Some benefits over fresh frozen plasma (FFP)
More studies may help elucidate benefits and risks of these coagulation factor concentrates
Uncommon Pediatric Treatments in Traumas -Avoiding the "I wish I had known that" moment
Shannon Manzi, PharmD
Boston Children’s Hospital
Shannon Manzi, PharmD
Boston Children’s Hospital
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 16 of 32
Disclosure
Shannon Manzi reports no relevant financial relationships.
Objectives
Describe two situations more prevalent in pediatric trauma
Outline the use case for and against high dose steroids i di t i i l d tin pediatric spinal cord trauma
She swallowed what??!
Button batteries and magnets
Serious ingestion, surgical intervention often necessary
Button batteries• Corrosion of the battery lodged in the esophagus can result in fistulas,
strictures, and erosions• Although some are made of mercury oxide, g y
mercury poisoning is unlikely due to poor GIabsorption
• One case report using PEG – not routinely recommended – removal must occur within 2 hours, required higher than usual volume
Magnets• Attract each other through intestinal wall, creating fistulas, erosions, acute
abdomen, etc
That must have hurt….
Methylene Blue for Joint Injuries Suspected open joint injuries – Extravasation is highly indicative of
open joint injury
1. 1% Lidocaine infiltration first (max 0.6 mL/kg). Additionally analgesia may be necessary.
2. 1 mL methylene blue in 500 mL NS instilled into the joint space. A large volume may be required.
Adverse effects• Injection of methylene blue into joint space has resulted in effusion in the treated
j i tjoint.
Contraindications:• Known hypersensitivity to the drug • Severe renal impairment • Glucose-6-phosphate dehydrogenase deficiency • Methemoglobinemia
Topical skin discoloration can be removed with a dilute solution of bleach if necessary.
Good reference with great pictures:• p://emedicine.medscape.com/article/114453-treatment
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 17 of 32
SCIWORA
SCIWORA – Spinal Cord Injury WithOut Radiographic Abnormality
Over 65% of cases occur in children < 8 years old Immediate transient deficits may be followed by severe deficits
hours later Some may resolve for 24 hours and return with severe deficits Some may resolve for 24 hours and return with severe deficits High dose methylprednisolone is NOT routinely recommended for
spinal cord injuries in children• NASCIS II trial – found benefit only in post hoc analysis, many questioned
methods, excluded kids < 12 years• NASCIS III trial – found benefit in 48 hr regimen, not 24 hr• Several others found no benefit, risks of severe GI bleed, infections
Fluid resuscitation and pressor therapy – alpha agonists such as norepinephrine or phenylephrine
Picture from /www.elearningdigital.com
Before you cut that…
Tissue entrapment by zipper
Before getting out the wire cutters – which freak out grown men let alone a 5 year old…
Try liberally applying mineral oil to the trapped area and iti 5 10 i t Oft th ti ill lid twaiting 5-10 minutes. Often the tissue will slide out
easily.
If not, a dose of intranasal midazolam before
using the wire cutters might be a good idea!
Not necessarily trauma, but good to know……
SVC syndrome
Superior Vena Cava (SVC) syndrome• Encircled by lymph nodes responsible for draining thoracic cavity
Most often seen in kids with Hodgkins or non-Hodgkinslymphoma• Massive adenopathy obstructs SVC, resulting in dilated chest and
neck veins, facial edema, drowsiness, stupor
All intravenous therapy must be via the lower extremities• SVC obstruction results in poor circulation in the upper extremities
and torso • Drug distribution is restricted and there is an increased risk of
thrombus formation.
When the Pain is Skin DeepTopical Analgesia in the EDTopical Analgesia in the ED
Courtney B. McKinney, PharmD, BCPSCritical Care Clinical Pharmacist
Intermountain Medical CenterSalt Lake City, Utah
Courtney B. McKinney, PharmD, BCPSCritical Care Clinical Pharmacist
Intermountain Medical CenterSalt Lake City, Utah
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 18 of 32
Disclosure
Courtney McKinney reports no relevant financial relationships.
Indications for Topical Analgesia
Things we DO in the ED
Venipuncture
Laceration or abrasion
Questions ASKED in the ED
Tattoos
Tattoo removaldebridement
First-degree burns Cosmetic procedures
Product Selection
Topical analgesia = topical anesthesia• Most commonly lidocaine based
Many available preparations/formulations• AerosolsAerosols
• Creams
• Gels
• Ointments
• Solutions for injection
• Compounded products
Product Selection
The product depends on the procedure
Key considerations in product selection• Is the skin broken or intact
• What is the surface area of the area involved
• What is your timeframe and setting
Three common products• Lidocaine 2.5%, Prilocaine 2.5% oil-in-water eutectic mixture
• Lidocaine 4% liposomal cream
• L.E.T solution or gel
Lidocaine/Prilocaine Eutectic Mixture
Dose: 1-2 gm/cm2 (max: 5 mg/kg lidocaine)
Application: intact skin only, occlusive dressing required, depth of penetration time dependent
Onset: 45-60 min
Duration: 2 hrs after removal
Pros: long lasting, ok to use on mucous membranes, studied in neonates
Cons: long onset, occlusive dressing required
Bottom line: consider for planned dermal procedures
EMLA®: package insert. APP Pharmaceuticals, 2008
Lidocaine 4% Liposomal Cream
Dose: 1-2 gm/cm2 (max: 5 mg/kg lidocaine)
Application: intact skin only, do not wash skin prior to application, occlusive dressing not required (recommended)
O t 30 i Onset: 30 min
Duration: 60 min
Pros: shorter onset, available OTC
Cons: No safety data in kids <2 yrs
Bottom line: good for minor burns or planned/non-emergent dermal procedures
LMX®: package insert. Ferndale Laboratories 2011
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 19 of 32
L.E.T Gel
Lidocaine 4%, epinephrine 0.05%, tetracaine 0.5% sterile compounded product
Dose: 1-3 ml (max: 5 mg/kg lidocaine)
Application: apply directly to open laceration/wound
Onset: 20 min
Duration: 45-60 min
Pros: ok to use on open skin, epinephrine may reduce systemic absorption and bleeding
Cons: epinephrine may cause vascular compromise
Bottom line: product of choice for open wounds
Schilling et al. Ann Emerg Med 1995;25:203‐8.
Large Surface Area Wounds
Otherwise known as “road rash”
Tends to cover more surface area than is practical or safe for the previously mentioned products
Make your own “Lido-Lube”Lid i 3 4 /k ( 1 2% l ti f i j ti )• Lidocaine 3-4 mg/kg (as 1 or 2% solution for injection)
• Large tube of sterile surgical lubricant
• Small emesis basin
• Mix in lubricant until the consistency is a thin gel
• Slather, wait 20 min, then scrub
Think, Pair, Share!
From the Pearls you just heard, discuss with someone near you…
What is something you can apply in your setting?
What are challenges you would encounter?
Wilderness Medicine:High Altitude Medicine ConcernsHigh Altitude Medicine Concerns
HAPE and HACE
Pam Walker, Pharm.D., BCPSClinical Coordinator- Emergency Medicine
Adjunct Clinical Assistant ProfessorUniversity of Michigan College of Pharmacy
University of Michigan Health Systems
Pam Walker, Pharm.D., BCPSClinical Coordinator- Emergency Medicine
Adjunct Clinical Assistant ProfessorUniversity of Michigan College of Pharmacy
University of Michigan Health Systems
Disclosure
Pamela Walker reports no relevant financial relationships.
Why High Altitude Sickness
Approximately 35 million people are travelling to altitudes greater than 3000 m• Nepal treks alone increased by 450% from 1994-2000
If not acclimated incidence of AMS is seen at altitudes of 2000 – 2500 m
Typical signs and symptoms include:• HA, nausea, vomiting, fatigue, insomnia, dizziness and anorexia
Pathophysiology not 100% understood• Current theory related to swelling of the brain
Generally self-limiting but can develop into high altitude pulmonary edema (HAPE) and/or cerebral edema (HACE)
Dumont L. et al. Travel Medicine and Infectious Disease (2005)3, 183‐188
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 20 of 32
Potential medical problems
Hypoxia High-altitude headache Acute Mountain sickness High-altitude cerebral
edema
High-altitude pulmonary edema (HAPE)
Organic brain syndrome Peripheral edema Retinopathyedema
Cerebrovascular syndromes
Retinopathy
Auerbach P. Wilderness Medicine 4th Ed
When is this a concern
Climbers/hikers that get to elevations > 2350 m (8000 ft.) are at risk for one of 3 forms of high altitude illness• Acute Mountain Sickness (AMS), HAPE and HACE
Best way to avoid is ensuring no overly rapid ascents• Published plans call for those > 2000 m to not increase their• Published plans call for those > 2000 m to not increase their
sleeping elevations by > 300 – 500 m and rest every 3rd to 4th
day
Definitions
High altitude = 1500 – 3500 m (4921- 11, 483 ft.)
Very high altitude = 3500 – 5500 m (11, 483 – 18, 045 ft.)
Extreme altitude = > 5500 m (> 18, 045 ft.)
Auerbach P. Wilderness Medicine 4th Ed
Oxygenation changes
High altitude = decrease PO2 in alveolus. Decreasing exercise performance with an increase in ventilation (decreased PCO2 arterial)
Auerbach P. Wilderness Medicine 4th Ed
High Altitude Pulmonary Edema
Occurs worldwide with highest incidence in winter months• Ski tourism
Pulmonary vasoconstriction and pulmonary hypertension• Nitric oxide• Prostacyclins• Sildenafil• Inhaled β agonist• Dietary L-arginine• Gingko biloba
Treatment is supplemental O2 and decreasing altitude• With possible portable hyperbaric chamber
HAPE prophylaxis
Those that have had previous bouts of HAPE are susceptible, with unpredictable recurrence
Most studies is acetazolamide followed by dexamethasone• Acetazolamide can help by creating bicarbonate diuresis and• Acetazolamide can help by creating bicarbonate diuresis and
simulating respirations• Also aids with countering insomnia at lower doses
Current controversies over the actual prophylaxis dose• Acetazolamide typically dosed as 500 mg/d
• Recent meta-analysis claims NNT(3) with 750 mg/d is better
• Side effects big issue with dose; paresthias and polyuria
Luks AM. Wilderness & Environmental Medicine. 2010;21:146‐55.Dumont L. et al. Travel Medicine and Infectious Disease. 2005;3:183‐8.
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 21 of 32
HAPE prophylaxis
Paresthias with acetazolamide ~ 42.9% vs. 5.6% of control• Called jhum jhum in Nepali
Polyuria with acetazolamide ~ 33.3% vs. 10% of control
D th i f l f th ith t i di ti Dexamethasone is useful for those with contraindications to acetazolamide
Concerns with using dexamethasone as prophylaxis since it just masks signs/symptoms
Luks AM. Wilderness & Environmental Medicine. 2010;21:146‐55.Dumont L. et al. Travel Medicine and Infectious Disease. 2005;3:183‐8.
HAPE prophylaxis
• Potentially dangerous since you may ascend too quickly since not feeling ill effects
• Recommendations to include are > 4000 m; since both we equally effective at higher doses• Dexamethasone 8 – 16 mg/d vs. acetazolamide 750 mg/d when
ascending > 500 m/dascending > 500 m/d
Dexamethasone is recommended in situations of contraindication with acetazolamide
Small trials also evaluated nifedipine 60 mg and spironolactone 75 mg and 100 mg
Luks AM. Wilderness & Environmental Medicine. 2010;21:146‐55.Dumont L. et al. Travel Medicine and Infectious Disease. 2005;3:183‐8.
Other HAPE prophylaxis
Tadalafil was studied versus placebo in those that were susceptible to HAPE• Small numbers and limited clinical experience compare with
nifedipine
SildenafilSildenafil
Salmeterol also a single placebo controlled study found that it decreased HAPE by 50% in susceptible climbers• Not recommended as monotherapy
Luks AM. Wilderness & Environmental Medicine. 2010;21:146‐55.
HAPE treatment
Oxygen, but if oxygen not available then there are a few pharmaceutical choices• Nifepidine has been key agent based on a single non-
randomized unblinded study• Not to be used as sole agent unless decent is dangerous and no
supplemental )2
• Phospodiesterase-5 inhibitors
• Fewer sides effects then seen with nifedipine• Less hypotension and tachycardia
• Becoming the preferred choice
Luks AM. Wilderness & Environmental Medicine. 2010;21:146‐55.
High Altitude Cerebral Edema
Potentially fatal situation that arise quickly Brain swelling, clinically it is an encephalopathy Signs/symptoms include
• Confusion/changes in consciousness• AtaxiaAtaxia• Papilledema• Urinary retention/incontinence• Difficulty speaking• Lassitude progresses to not being able to care for themselves• Blindness• Seizures• Coma
Hacket PH, et al High Altitude Medicine and Biology. 2004;5(2):136‐46.Luks AM, et al. Wilderness & Environmental Medicine. 2010;21:146‐55.
HACE prophylaxis
Also includes acetazolamide and dexamethasone• Dexamethasone is probably utilized more frequently in those
that are having to ascend too quickly• Search and rescue workers, military personnel
• Duration should not be longer than 10 days• Prevent adrenal suppression
Hacket PH, et al High Altitude Medicine and Biology. 2004;5(2):136‐46.Luks AM, et al. Wilderness & Environmental Medicine. 2010;21:146‐55.
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 22 of 32
Treatment
Descend immediately any delay can be fatal• Concerns if this occurs while sleeping
• Keep descending until the last point the climber was “normal” or at least 500 m
• Stagger may linger for a few daysgg y g y
Treatment with dexamethasone
Oxygen therapy and Gamow or portable hyperbaric chamber
Hacket PH, et al High Altitude Medicine and Biology. 2004;5(2):136‐46.Luks AM, et al. Wilderness & Environmental Medicine. 2010;21:146‐55.
Thank you
Physostigmine: It’s BackPhysostigmine: It s Back
Nicole M. Acquisto, Pharm.D., BCPSEmergency Medicine Clinical Pharmacy Specialist,
Department of PharmacyAssistant Professor, Department of Emergency MedicineUniversity of Rochester Medical Center, Rochester, NY
nicole_acquisto@urmc.rochester.edu
Nicole M. Acquisto, Pharm.D., BCPSEmergency Medicine Clinical Pharmacy Specialist,
Department of PharmacyAssistant Professor, Department of Emergency MedicineUniversity of Rochester Medical Center, Rochester, NY
nicole_acquisto@urmc.rochester.edu
Disclosure
Nicole M. Acquisto reports no relevant financial relationships.
Anticholinergic Toxicity
Peripheral Dry skin Flushing Xerostomia
Central Confusion Disorientation Psychomotor agitation
Cessation of perspiration Hyperthermia Mydriasis Tachycardia Urinary retention Decreased bowel sounds
y g Delirium Visual or auditory
hallucinations Ataxia
Mechanism of Action
Choline
Acetyl‐CoA
+Nerve Terminal
Post‐synaptic membrane
ACh
Acetate
Choline
Acetylcholinesterase
AChReceptor
Physostigmine
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 23 of 32
A Little History…
Controversy is rooted in the publication of case reports documenting the development of seizures and asystole that occurred when it was administered in TCA overdose
Seizures tend to occur when physostigmine is administered t idl i th tti f l t i t ttoo rapidly or in the setting of a pro-convulsant co-ingestant
Bradycardia and asystole occur due to the potentiation of vagal effects on cardiac tissue
Asystole occurs more commonly in patients with underlying cardiac arrhythmias or conduction disorders
Pentel P, Peterson CD. Ann Emerg Med. 1980;9:588‐90.Frascogna N. Curr Opin Pediatr. 2007;19:201‐5.
The Come Back… Studies to support its use in anticholinergic toxicity related to:
• Pure anticholinergics, antihistamines, atypical antipsychotics, cyclic antidepressants
Physostigmine vs. benzodiazepines (n = 52 total)• Reversing agitation 96% vs. 24%
• Reversing delirium 87% vs. 0%g
• Shorter recovery time 12 vs. 24 hours
• No difference in the incidence of ADE and length of stay
8 years of physostigmine experience• Rate of ADE < 5 % - diaphoresis, nausea and vomiting
• Rate of seizures < 1 %
• No cardiac arrhythmias
Retrospective study (n = 39)• Brief seizure in one patient
Beaver KM, et al. Am J Emerg Med. 1998;16:505‐7.Padilla RB, et al. Am J Emerg Med. 2002;20:569‐70.WeizbergM, et al. Clin Toxicol. 2006;44:319‐25.Cole JB, et al. Am J Emerg Med. 2001.Suchard JR. J Emerg Med. 2003;25:185‐91.Burns MJ, et al. Ann Emerg Med. 2000;374‐81.Rasimas JJ, et al. Clin Toxicol. 2010;48:648.Schneir AB, et al. Ann Emerg Med. 2003;42:14‐9.
Physostigmine Indication
• To avoid a higher level of care, intubation, catheterization, chemical or physical restraints from an anticholinergic drug overdose
Adult dose• 0.5 – 2 mg IV undiluted push over 10 minutes, may repeat every
15 – 30 minutes as needed Pediatric dosePediatric dose
• 0.01 – 03 mg/kg/dose Onset
• 5 minutes Duration
• 30 minutes – 2 hours Monitor for cholinergic effects
• Atropine readily available
Contraindications
Cardiac conduction abnormalities • QRS prolongation (> 120 msec) or AV block
(Type II or III)
Bradycardia < 60 bpm
Gastrointestinal/urinary obstruction
ConclusionPhysostigminePhysostigmine
Can be safely used in patients with anticholinergic toxicity for the resolution of significant symptoms
Thank You!
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 24 of 32
TPA for the PE in PEATPA for the PE in PEA
Alison M. Jennett-Reznek, PharmD, BCPSClinical Pharmacist – Emergency Medicine
December 5, 2012
Alison M. Jennett-Reznek, PharmD, BCPSClinical Pharmacist – Emergency Medicine
December 5, 2012
Disclosure
Alison Jennett Reznek reports no relevant financial relationships.
Pulseless Electrical Activity
Electrical activity on the monitor
Pulses are absent
Pneumonic to remember causes:• 6 H’s and 6T’s
H’s T’s
HypovolemiaHypoxia
Hydrogen ionsHyper or Hypokalemia
HypoglycemiaHypothermia
Tablets or toxinsCardiac Tamponad
Tension pneumothoraxThrombosis (cardiac/pulmonary)
TachycardiaTrauma (hypovolemia)
Signs to suspect PE
Prior to onset of cardiac arrest:• Sudden onset of severe dyspnea
• Tachypnea
• Chest pain
• TachycardiaTachycardia
• Cough
• Hemoptysis
• Cyanosis
• Low oxygen saturation
Patient specific considerations• Risk factors for PE (i.e. cancer, recent travel, history of DVT)
Indication for use of TPA
Suspicion of PE is high• Potential for harm
Cardiac arrest within 15 minutes • Earlier use may result in more favorable outcome
• Use later in resuscitation efforts may be futile or even harmful• Use later in resuscitation efforts may be futile or even harmful
No contraindications• Hemorrhage or suspected bleeding
Dosing Recommendations
rt-PA • Most studied and utilized
• Bolus dosing recommended in cardiac arrest setting
• Shortened infusion time has been studied
• 50 mg50 mg
• 100 mg
Tenecteplase • Bolus dosing
• 30-50 mg (weight-based)
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 25 of 32
Time is Perfusion
Reconstitution• High-risk medications
• Follow package recommendations to avoid errors
• Do not shake
Individual variations Individual variations• rt-PA
• Transfer device creates large hole in protective stopper making removal difficult
• Tenecteplase• Device contains safety needle for protection
Additional Therapy
Dependent on ROSC
Considerations include:• Heparin bolus +/- infusion
• Repeat bolus of rt-PA
• Follow up infusion of rt PA• Follow-up infusion of rt-PA
Use of Intranasal Medications in the E D t tEmergency Department
Renee Petzel Gimbar, PharmDClinical Assistant Professor
Clinical Pharmacist, EM/Med ToxUniversity of Illinois at Chicago College of Pharmacy
University of Illinois Hospital and Health Sciences System
Renee Petzel Gimbar, PharmDClinical Assistant Professor
Clinical Pharmacist, EM/Med ToxUniversity of Illinois at Chicago College of Pharmacy
University of Illinois Hospital and Health Sciences System
Disclosure
Renee Petzel Gimbar reports no relevant financial relationships.
Intranasal (IN) Route New(er) route of medication delivery
Rapid administration and onset of effects• Faster ED door to med administration
Bypass GI tract, absorption into systemic circulation and CNS• Drug levels similar to IV
Use both pre-hospital (EMS) and in Emergency Department (ED)
MAD Medication Delivery
Mucosal Atomizer Device (MAD)• Delivery of medication via fine mist absorbed via the nasal
mucosa
Have necessary supplies to obtain IV/IO access prior to th d i i t ti f IN di ti ifthe administration of any IN medications if necessary.• If an appropriate therapeutic response is not achieved after 2 IN
doses, consider an alternate route of administration like IV/IO access.
The maximum volume administered in each nostril is 1 mL (or 2 mL total). • In smaller children, volume may be smaller. Use the highest
medication concentration available to limit the volume.
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 26 of 32
Seizures/Status Epilepticus
Studies comparing IN midazolam and rectal diazepam in both pre-hospital and ED setting in pediatric patients
IN midazolam found to be as effective, if not more effective in this setting
Pain
Use of IN fentanyl for acute pain in multiple practice settings including ED
Treatment of pain related to fractures, burns
Implementation of fentanyl for children in a mixed adult and pediatric ED reduces time
to analgesic administration4
Single-center study• Review of pediatric patients given either IV morphine or IN
fentanyl prior to and after initiation of IN fentanyl protocol
Excluded if hemodynamic instability altered level of Excluded if hemodynamic instability, altered level of consciousness, altered RR, known opioid rxn, epistaxis or bilateral occluded nasal passages
Medication administration at the discretion of physician
• Fentanyl dosed at 1.5mcg/kg for patients aged 1-15 years
Decreased time to administration in fentanyl group by at least half (00:59 min to 00:32 min)
Use of intranasal fentanyl for the relief of pediatric orthopedic trauma pain5
Prospective, non-blinded, interventional study
Clinically suspected fracture in ED triage
81 patients (age 3-18, mean age 8 years old)
Weighed in triage fentanyl 2 mcg/kg INWeighed in triage, fentanyl 2 mcg/kg IN • Max dose 100mcg
Measured pain scores at 10, 20 & 30 min • Rescue pain meds considered if no relief after 20 min
Use of intranasal fentanyl for the relief of pediatric orthopedic trauma pain5
72% of patients• Onset of analgesia w/in 10 min
• 70-78% of these patients with sustained decrease in pain relief over study period
9% of patients required rescue analgesia after 20 min• Half of these patients were aged 9-18
• No differences in types of fractures
No vomiting, hypoxia, hypotension
No nasal complaints after administration
ED IN Fentanyl Use
IN fentanyl: • Pain management
• Pediatric patients (age 12 months – 18 years old)• 1 – 2 mcg/kg up to a maximum dose of 100mcg (50mcg/mL), may cg/ g up to a a u dose o 00 cg (50 cg/ ), ay
repeat after 5 minutes if no effect, maximum 2 IN doses
• Adult patients• Initial IN midazolam can be dosed at 0.2mg/kg up to a maximum
single dose of 10mg (5mg/mL), may repeat after 5 minutes if no effect, maximum 2 IN doses
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 27 of 32
Moderate Sedation
Midazolam• Adults & pediatric patients (1 – 18 years old) for the treatment of
anxiolysis during moderate sedation
• Initial IN midazolam can be dosed at 0.3mg/kg up to a maximum single dose of 10mg (5mg/mL), may repeat after 5 minutes if no effect, maximum 2 IN doses
Fentanyl• Adults and pediatric patients (age 1-18 years) as part of
moderate sedation
• 1 – 2 mcg/kg up to a maximum dose of 100mcg (50mcg/mL), may repeat after 5 minutes if no effect, maximum 2 IN doses
Opioid Toxicity6
Previous use of naloxone by multiple routes for reversal of opioids
Use by paramedics in field
Retrospective review of 344 EMS patients who received doses of 0 4 2 mg naloxone IN vs control group whodoses of 0.4-2 mg naloxone IN vs control group who received IV
Use of IN naloxone as effective as IV naloxone in the field• Patients receiving IN naloxone received higher dose
ED IN Naloxone Use
If unable to obtain IV access:• IN naloxone
• Adult patients
• 0.4 - 2mg/dose every 1-2 minutes up to 10 mg
• Pediatric patients
• Less than 20kg : 0.1mg/kg up to 2 mg, may repeat every 1-2 minutes up to 10 mg
• Greater than 20kg: 0.4 - 2mg/dose every 1-2 minutes up to 10 mg
SHOULD OBTAIN IV ACCESS ASAP
Other medications
Limited data for use of ketamine and ketorolac
As more literature published may be able to expand the medications delivered by this route
References
1. Effects of intranasal midazolam and rectal diazepam on acute convulsions in children: prospective randomized study. J Child Neurol. 2002;17:123-6.
2. Intranasal midazolam vs rectal diazepam in acute childhood seizures. Pediatr Neurol. 2006;34:355-9.
3. Prehospital intranasal midazolam for the treatment of pediatric seizures. PediatrEmerg Care. 2007;23(3):148-53.
4 Holdgate A Cao A Lo KM The implementation of intranasal fentanyl for children in a4. Holdgate A, Cao A, Lo KM. The implementation of intranasal fentanyl for children in a mixed adult and pediatric emergency department reduces time to analgesic administration. Acad Emerg Med. 2010;17:214-7.
5. Saunders M, Adelgais K, Nelson D. Use of intranasal fentanyl for the relief of pediatric orthopedic trauma pain. Acad Emerg Med. 2010;17:1155-61.
6. Merlin MA, Saybolt M, Kapitanyan R, Alter SM, et al.Intranasal naloxone delivery is an alternative to intravenous naloxone for opioid overdoses. Am J Emerg Med. 2010; 28:296-303.
7. UICHHSS Emergency Department Guideline for the use of Intranasal Medication
Nebulized Naloxone:A Kinder Gentler Awakening?A Kinder, Gentler Awakening?
Heather M. Schumann, PharmDAssociate Professor
California Northstate University College of Pharmacy
Heather M. Schumann, PharmDAssociate Professor
California Northstate University College of Pharmacy
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 28 of 32
Disclosure
Heather Schumann reports no relevant financial relationships.
The Situation
A 42 y/o male presents to the ED lethargic after overdosing on heroin.
BP 112/70 HR 84 RR 12 Temp AF O2 sat 70% 4L NC
PE: pinpoint pupils, shallow respirations, sclerosed veins
The MD orders naloxone, and nursing is attempting to start an IV
Would nebulized naloxone be appropriate for this patient?
Why the Need for Needleless Naloxone?
Rates of opioid abuse and overdoses are increasing
Prevention of occupational blood exposure in a high-risk patient population
Venous access not always readily obtainable
N Engl J Med. 2010;363:1981‐3.Prehospital Emergency Care 2012;16:289‐292.
Naloxone Opioid receptor antagonist indicated for reversal of
opioid induced respiratory depression
Various routes of administration• IV, IO, IM, SC, ET, IL, IN, nebulized
Onset of effect variable• Dependent on dose and route of administration
Duration of action variable• Dependent on dose of agonist and route of administration
Goldfrank’s toxicologic emergencies. New York, NY: McGraw Hill;2006:614‐7.Naloxone [package insert]. International Medication Systems, Limited, So. El Monte, CA; August 2001. http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=614. Accessed September 24, 2012.
Nebulized Naloxone
Nebulized naloxone 2mg/3mL normal saline
Successfully reversed respiratory and CNS depression in a patient with methadone toxicity• O2 saturation 100% and normal mental status within 5 minutes
Repeat nebulized dose required ~ 1 hour later
Mild withdrawal symptoms noticed
Due to recurrence of symptoms continuous naloxone infusion initiated, resulting in severe opioid withdrawal requiring intubation
The Journal of Emergency Medicine. 2003;24:185‐187.
Nebulized Naloxone in the Prehospital Setting
105 patients received nebulized naloxone in the field for treatment of suspected opioid overdose, altered mental status or respiratory depression
22% had complete response
59% h d ti l 59% had partial response
19% had no response
Average dose 1.7-1.8mg for partial and complete responders
Patients with a complete response received naloxone earlier in their care
Prehospital Emergency Care 2012;16:289‐292.
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 29 of 32
Proposed Benefits of Nebulized Naloxone
Needless administration
Equipment already available in ED
Allows for dose titration• Patient can remove face mask if withdrawal beginning
• Nebulized dose can be repeated if symptoms recur
Severe withdrawal symptoms seem to be avoided
Questions Remaining
Is nebulized naloxone equivalent to intravenous naloxone? To intranasal therapy?
Which patients are most likely to benefit from nebulized naloxone?
Wh t th t i di ti t th ? What are the contraindications to therapy?
What is the minimal respiratory rate required for successful reversal with nebulized naloxone?
What is the optimal dose of nebulized naloxone?
At what point should rescue intravenous naloxone therapy be administered?
Prehospital Emergency Care 2012;16:289‐292.
Back to the Situation
A 42 y/o male presents to the ED lethargic after overdosing on heroin.
BP 112/70 HR 84 RR 12 Temp AF O2 sat 70% 4L NC
PE: pinpoint pupils, shallow respirations, sclerosed veins
The MD orders naloxone, and nursing is attempting to start an IV
Would nebulized naloxone be appropriate for this patient?
Pulling Bedside Tricks, Part II“Off Label” Medication UseOff Label Medication Use
Assisting with Patient Care in the Emergency Room
Joanne C. Witsil, PharmD, RN, BCPSClinical Pharmacist ‐ Emergency Medicine/Toxicology
Cook County Hospital (Stroger) Chicago, IL
Joanne C. Witsil, PharmD, RN, BCPSClinical Pharmacist ‐ Emergency Medicine/Toxicology
Cook County Hospital (Stroger) Chicago, IL
Disclosure
Joanne C. Witsil reports no relevant financial relationships.
Content Warning You are about to participate in an educational
session that may contain content of an adult nature. These slides are designed for ADULTS only and may include ideas that some viewers may find inappropriate since the information deviates from FDA approved use
If you are under the age of 18, if such material offends you or if it is illegal to view such material in your community, please EXIT NOW
If you stay, please ALWAYS put patient SAFETY FIRST • Consider all drug and patient factors prior to
using the following agents
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 30 of 32
Objective
Describe alternative uses for medications routinely used in the emergency department
Oh my, what is going on in your drawers!
Looking down the empty drawer in pyxis, drug shortages!• Treating Nausea and Vomiting
• No traditional agents such as; metoclopramide, prochlorperazine, ondansetron!
• Consider Haloperidol (Haldol®)• Dosing: 1- 5 mg IM/slow IVP
• Most respond to the 5 mg dose • Consider for postoperative
nausea/vomiting (PONV), cyclic vomiting syndrome, motion sickness/vertigo, migraine
Am Fam Physician. 2007;76:76-84.
Oh my, what is going on in your drawers!
Help me, I am in pain and all we have is normal saline flushes!
• Pain Control• Running out of traditional agents; no morphine,
hydromorphone fentanylhydromorphone, fentanyl
• Consider Low-dose Ketamine (LDK)
• Dosing: 0.25 – 0.5 mg/kg slow IVP over 1 minute
• Consider for acute causes of pain presented in the ED especially trauma cases to supplement opioids
Am J Emerg Med. 2010;28:820-27.Ann Emerg Med. 2012;59:497-503.
Rub this on to make it feel better!
Do not put my baby to sleep!• Avoiding procedural sedation in cutaneous
abscess drainage in children• Consider applying Lidocaine 4% topical cream
prior to incision and drainage (I&D) • Procedure
• Apply the topical anesthetic cream on the abscess area
• Cover with occlusive dressing for 30-40 minutes
• Results: 24% with topical anesthetic verses 41% without topical anesthetic needed procedural sedation
Cassidy-Smith T, et al. Amer J Emerg Med. 2010- in press. PMID:21129885
Rub this on to make it feel better!
Slippery when wet with blood!• Opening traumatic swollen eyelids for
examination• Consider applying benzoin swab stick along upper
and lower eyelids to increase traction when retracting eyelids
• Procedure• Clean and dry upper and lower eyelids to
remove all excess blood from lids• Apply thin layer of benzoin fluid to the
eyelids, taking care not to contact eye or eyelashes
• Allow benzoin to dry• Use fingers or Q-tips to gently retract the
lids http://academiclifeinem.blogspot.com/2011/03/trick-of-trade-benzoin-for-opening.html
What is going on down there!
Taken in CCH ED 08/09/12
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 31 of 32
What is going on down there!
Maggots (Myiasis)! Get them out of there!
• Taking care of a maggot infested wound• Depending on the type of infestation the following
techniques are considered;
• Surgical removal with local anesthesia
• Skin lesion is locally anesthetized
• Site excised surgically
• Primary wound closure once done
McIntosh, M, et al. Forensic Science International. 2011 Jul 210(1):12-5.http://emedicine.medscape.com/article/1491170-treatment.
What is going on down there!
• Occlusion/Suffocation
• Products include petroleum jelly, liquid paraffin, beeswax or heavy oil, lard or bacon strips over the central punctum
• Wait for larva to emerge and then pluck with ttweezers
• Wound cleansing until further intervention
• Diluted solutions such as Dakin’s, isopropyl alcohol, betadine, hydrogen peroxide
• Dakin’s>isopropyl alcohol>betadine> hydrogen peroxide (order of % kill)
• No statistically significant differenceshttp://emedicine.medscape.com/srticle/1491170-treatmentMcIntosh, M, et al. Forensic Science International. 2011 Jul 2010(1):12-5.
Thank you!Thank you!
Think, Pair, Share!
From the Pearls you just heard, discuss with someone near you…
What is something you can apply in your setting?
What are challenges you would encounter?
Emergency Medicine Pearls 2012 2012 Midyear Clinical Meeting
© 2012 American Society of Health-System Pharmacists Page 32 of 32
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