CE Activity Information & Accreditation · Sterile Products in the Emergency Department PharMEDium Lunch and Learn Series ProCE, Inc. 5 EMERGENCY SITUATIONS Cardiac arrest Acute ischemic

Sterile Products in the Emergency DepartmentPharMEDium Lunch and Learn Series

ProCE, Inc.www.ProCE.com 1

Sterile Products in the Emergency DepartmentDecember 12, 2014

LUNCH AND LEARN

Featured Speaker: Renee Petzel Gimbar, PharmD

Emergency Medicine/Medical Toxicology Clinical PharmacistClinical Assistant ProfessorUniversity of Illinois at Chicago College of PharmacyUniversity of Illinois Medical Center at Chicago

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CE Activity Information & Accreditation

ProCE, Inc. (Pharmacist and Tech CE)

1.0 contact hour

Funding: This activity is self‐funded through

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g y gPharMEDium.

It is the policy of ProCE, Inc. to ensure balance, independence, objectivity and scientific rigor in all of its continuing education activities. Faculty must disclose to participants the existence of any significant financial interest or any other relationship with the manufacturer of any commercial product(s) discussed in an educational presentation. Dr. PetzelGimbar has no relevant commercial and/or financial relationships to disclose.



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STERILE PRODUCTS IN THEEMERGENCY DEPARTMENT

Renee Petzel Gimbar, PharmDClinical Assistant ProfessorClinical Pharmacist, EM/Med ToxDirector, PGY2 Emergency MedicineUniversity of Illinois College of Pharmacy

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OBJECTIVES

Define the role of the pharmacist in the emergency departmentemergency department

Describe 2 routes of medication delivery in emergency situations

List the indication(s) and mechanism of action of 4 medications used in the emergency department

Discuss the potential for medication errors in the ED tti ED setting

Explain the impact of standardized medication labeling and administration for improving medication safety in the emergency department

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YOU WORK WHERE? Emergency Medicine Pharmacy Bedside hands on pharmacy Bedside hands on pharmacy

Pharmacy consultation Code Blue Code MI Code Stroke Critically ill patients

E di i h id t i i Emergency medicine pharmacy residency training

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EMERGENCY SITUATIONS

Cardiac arrest

Acute ischemic stroke (AIS)

Rapid sequence intubation (RSI)

Moderate sedation Moderate sedation

Critical care medication titration

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MEDICATION DELIVERY IN THE ED Patients don’t come into the ED with

intravenous access intravenous access

Intravenous Intramuscular Subcutaneous Intraosseous Intranasal Endotracheal

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INTRAOSSEOUS ACCESS

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INTRANASAL ADMINISTRATION

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MEDICATION SAFETY IN THE ED The Joint Commission

National Patient Safety Goals National Patient Safety Goals

NPSG.03.04.01 Label all medications, medication containers, and other

solutions on and off the sterile field in perioperative and other procedural settings

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MEDICATION SAFETY IN THE ED Institute for Safe Medication Practices

Supporter of prefilled labeled syringes Supporter of prefilled, labeled syringes

Typical patient-specific doses

No cross-contamination

Drug name and dose/strength

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MEDICATION SAFETY IN THE ED

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RAPID-SEQUENCE INTUBATION

Technique for facilitating endotrachealintubation by rapidly administering sedatives intubation by rapidly administering sedatives and neuromuscular blocking agents in patients with impending respiratory failure or altered mental status

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RAPID-SEQUENCE INTUBATIONTimeline of Events Before IntubationT – 5 minutes Patient history & physical

S l iSupply preparationPreoxygenate the patient, cardiac monitoring

T – 3 minutes Premedicate (optional) – to blunt response to intubation

T – 1 minute Induction and paralysisCricoid pressure

Timeline of Events After IntubationT + 1 minute Confirm tube placement – auscultation

End tital CO2 detectorSecure ETT with tube holder CXRConsider need for continued sedation/paralysis

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PREMEDICATIONS

To blunt physiologic response to intubation, which includes preventing: which includes preventing: Bradycardia Tachycardia Hypertention Elevated intracranial and intraocular pressure Cough and gag reflexes Hypoxia Hypoxia

Atropine Fentanyl Lidocaine

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ATROPINE

Anticholinergic agent that works to block reflex bradycardia and dry secretionsreflex bradycardia and dry secretions Indications: Children <1 year of age Dose: 0.02 mg/kg

Min dose: 0.1 mg Max dose: 0.5 mg

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FENTANYL

Synthetic opioid used to blunt elevations in heart rate and blood pressure in response to intubationrate and blood pressure in response to intubation Also provides analgesia and sedation Indications: Use is optimal in patients with CNS

injury with suspected increased ICP Dose: 0.5 – 3 mcg/kg Onset of action: 2-5 minutes Monitor for hypotension, respiratory depression, yp , p y p ,

seizure Avoid use in patients who are already hypotensive

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LIDOCAINE

Antiarrhythmic agent that minimizes risk of arrhythmias resulting from intubation as of arrhythmias resulting from intubation as well as blunting rise in BP, ICP, and IOP Indications: Patients with CNS injury and

suspected increased ICP Dose: 1.5 mg/kg IVP Onset of action: ~ 60-90 seconds Monitor for development of arrhythmias

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SEDATIVE

Agent that causes no awareness of procedure and has rapid onset and short duration of action with has rapid onset and short duration of action with minimal effects on cerebral perfusion and cardiovascular hemodynamics Etomidate Midazolam Ketamine PropofolPropofol Methohexital

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MIDAZOLAM

Short-acting benzodiazepine Indications:Indications:

First line: Status epilepticus Second line: otherwise healthy patients, CNS injury with

low BP Onset of action: 60-120 seconds Duration of action: 20-30 minutes Dose: 0.05 – 0.2 mg/kg (children); normal adult dose:

0.2-0.3 mg/kg Monitor: blood pressure, respiratory rate Advantages: amnestic properties, anxiolytic,

anticonvulsant Disadvantages: hypotension and respiratory

depression 25

KETAMINE General anesthetic

Indications: Asthmatics, septic shock, p Contraindications: ↑ ICP & IOP, head trauma,

HTN, CHF, angina, psychotic disorders, glaucoma Onset of action: 1-2 minutes Duration of action: 5-15 minutes Dose: 1-2 mg/kg Monitor: BP, respiratory secretions, status upon

k iawakening Advantages: bronchodiatory effect in asthmatic

patients Disadvantages: delirium upon awakening,

increased airway secretions, elevations in ICP, IOP, BP

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PROPOFOL

General anesthetic D ti f ff t 3 10 i t Duration of effect: 3-10 minutes

Indications: CNS injury, stroke victims, patients requiring frequent neurological examinations

Bolus dose: 1-2 mcg/kg Administration rate: 5 – 75 mcg/kg/min Advantages: short duration of action Disadvantages: hypotension

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METHOHEXITAL

BarbiturateO t f ti 15 30 d Onset of action: 15-30 seconds

Duration of action: 10-20 minutes Dose: 1-1.5 mg/kg Monitor: blood pressure, heart rate,

respiratory rate Advantages: anticonvulsant properties, lowers g p p ,

ICP Disadvantages: hypotension, bronchospasm

secondary to histamine release28



PARALYTIC

Neuromuscular blocker that facilitates the process of intubation via skeletal muscle process of intubation via skeletal muscle paralysis and minimizes the risk of aspiration

Optimal agent should have rapid onset and short duration of activity with minimal side effects Succinylcholine

R i Rocuronium Vecuronium

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SUCCINYLCHOLINE Depolarizing neuromuscular blocking agent

Indications: First line: otherwise healthy patients, asthmatics Second line: CNS injury, status epilepticus

Contraindications: history of malignant hyperthermia, burns >24 hours, hyperkalemia, renal failure, crush injuries >24 hours, glaucoma, penetrating eye injuries

Onset of action: 30 – 60 seconds Duration of action: 4 – 8 minutes Dose: 1-2 mg/kg; dose reduction required in liver

dysfunction Advantages: rapid onset and short duration of

action Disadvantages: elevates ICP, IOP, hyperkalemia 30



ROCURONIUM

Non-depolarizing neuromuscular blocking agent Indications: Indications:

First line: CNS injury Second line: otherwise healthy patients, asthmatics

Onset of action: 60 – 120 seconds Duration of action: 30 – 60 minutes Dose: 0.6 – 1.2 mg/kg; dose reduction required

i li diin liver disease Advantages: relatively quick onset, minimal

effect on blood pressure Disadvantages: long duration of action,

consider need for continued sedation31

VECURONIUM

A long-acting non-depolarizing neuromuscular blocking agentg g Onset of action: 2-3 minutes Duration of effect: 45-60 minutes Indications:

Patients requiring prolonged paralysis

Prolonged effect seen in hepatic and renal disease

Must reconstitute powder form in vial! Bolus dose 0.1 mg/kg Adverse effects: prolonged paralysis,

tachycardia, hypotension 32



MODERATE SEDATION

Drug-induced depression of consciousness during which patients respond purposefully to verbal which patients respond purposefully to verbal commands, either alone or with tactile stimulation

During procedure maintains: Patent airway, spontaneous ventilation

C di l f ti Cardiovascular function

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MODERATE SEDATION - ADULTS

Onset of ActionDuration of

Action Dose

Mid l 1-5 min (IV) i (IV)1-2.5mg IVPR i Midazolam 1 5 min (IV)

5-15 min (IM) 30-120 min (IV) Repeat q2 min prnMax 0.1mg/kg

Lorazepam 5-10 min (IV)30-60 min (IM)

4-6 hr (IV)6-12 hr (IM)

0.5-2mg IVPRepeat q10 min prnMax 0.2mg/kg

25-50 mcg IVFentanyl 1-2 min (IV) 30-60 min (IV)

gRepeat q3-5 min prnMax 500mcg/4 hr

Morphine 5-10 min (IV)15-30 min (IM)

2-4 hr (IV)3-7 hr (IM)

1-2 mg IV Repeat q2-3 min prnMax 20 mg

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MODERATE SEDATION – PEDIATRICSOnset Duration Dose (mg/kg)

Midazolam 1-5 min (IV)5-15 min (IM) 60-120 min (IV/IM)

0.05-1mg/kg (IV/IM)Single max dose: 1-2mgTotal max dose: 5mg( ) Total max dose: 5mg

Lorazepam 5-10 min (IV)30-60 min (IM) 8-12 hr (IV/IM) 0.03-0.05mg/kg (IV/IM)

Total max dose: 5mg

Fentanyl 1-2 min (IV) 30-60 min (IV) 1-2 mcg/kg (IV)Total max dose: 5mcg/kg

Morphine 5-10 min (IV)15-30 min (IM)

2-4 hr (IV)3-7 hr (IM)

0.05-0.1mg/kg (IV/IM)Total max dose: 10mg or 0.3mg/kg

Ketamine 1 min (IV)5-10 (IM)

5-10 min (IV)15-30 min (IM)

0.5-1mg/kg (IV)3-7mg/kg (IM)

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CRITICAL CARE IN THE ED Hypertensive crisis

Labetalol

Tachyarrhythmias Diltiazem Amiodarone Esmolol

Sepsis/hypotension Sepsis/hypotension Norepinephrine Vasopressin Epinephrine Phenylephrine 36



HYPERTENSIVE EMERGENCY

Blood pressure (BP) >180/110 with end organ dysfunctiondysfunction

Decrease MAP by 20-25% within 1 hour

Continued decrease over 24-48 hours to goal BP

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LABETALOL

Nonselective beta blocker Also alpha effects Also alpha effects

Indication: hypertension, hypertensive crisis Dose: 20 mg IVP

Additional doses: 40-80 mg IVP q10 minutes

Onset of action: 2-5 minutes Peak effect: 5-15 minutes Max cumulative dose ? Max cumulative dose ? Caution in patients with CHF, cocaine toxicity,

asthma, elderly patients

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TACHYARRHYTHMIAS

Atrial fibrillation (Afib) Atrial flutter (Aflutter)

Paroxysmal supra-ventricular tachycardia (PSVT)

Ventricular tachycardia (Vtach)

Ventricular fibrillation (Vfib)

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DILTIAZEM

Non-dihydropyridine calcium channel blocker Indication: Afib Aflutter PSVT Indication: Afib, Aflutter, PSVT Dosing: 5-15 mg/hr after bolus adminstration Onset: 3 minutes Duration of effect: 0.5-10 hours Can convert to oral regimen after

patient controlled on continuous pinfusion

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AMIODARONE

Antiarrhythmic medication possessing characteristics of all 4 classescharacteristics of all 4 classes Indication: Afib, Vfib, Vtach Onset and duration after IV administration Dosing:

Bolus: pulseless 300 mg IVP, with a pulse 150 mg over 10 min Continuous infusion: 1mg/min x 6 hr, then 0.5 mg/min x 18 hrs

Potential issues with IV bag Adverse effects: hypotension, bradycardia, pulmonary

toxicity, skin changes

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ESMOLOL

Selective beta blocker Beta-1 Beta-1 Indication: SVT, aortic dissection, thyroid storm Dose:

Bolus: 500 mcg/kg over 30-60 seconds Continuous infusion: 50 mcg/kg/min titrated q4-10 min

Onset of action: 10-20 minutes Duration of effects: 10-30 minutes Short half-life

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SEPSIS

Systemic, deleterious host response to infection

Severe sepsis Acute organ dysfunction secondary to documented or

suspected infection

Septic shock Severe sepsis plus hypotension not reversed with fluid

i tiresusciation

Major healthcare issue

Significant mortality associated with sepsis 43

NOREPINEPHRINE

Vasopressor with alpha and beta effects First-line treatment of sepsis & septic shock First-line treatment of sepsis & septic shock Indication: hypotension Initial dosing: 10 mcg/min or 0.01 mcg/kg/min Administration: central access preferred Disadvantages: tachycardia Bedside access

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VASOPRESSIN

Vasopressor effecting the V1 receptors Adjunct treatment of sepsis & septic shock Adjunct treatment of sepsis & septic shock

Reduction in some anti-inflammatory markers

Indication: hypotension refractory to fluid recitation and initial norepinephrine infusion in sepsis

Dosing: 0 03 or 0 04 units/min Dosing: 0.03 or 0.04 units/min

Fixed dosing

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EPINEPHRINE

Vasopressor with alpha and beta effects Indication: hypotension Indication: hypotension Third line treatment of sepsis & septic shock Initial dosing: 0.1 mcg/kg/min Administration: central access preferred Disadvantages: tachycardia Bedside access

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PHENYLEPHRINE

Alpha adrenergic agent Indication: salvage agent for refractory hypotension Indication: salvage agent for refractory hypotension

in sepsis, tachycardic hypotensive patients Onset of action: immediate Duration of effect: 15-20 minutes Initial dosing: 100 mcg/min or 0.5 mcg/kg/min Advantages: does not effect heart rate Disadvantages: digit ischemiaDisadvantages: digit ischemia Central access heavily preferred

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HOW TO ENSUREMEDICATION SAFETY IN THE ED

Use of prepared syringes of medications

Limited use of medications drawn up at the bedside

Availability of continuous infusion medications

Good communication between members of the healthcare team

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REFERENCES Arrow EZ IO, Intraosseous Vascular Access website. http://www.arrowezio.com/. Accessed

November 15, 2014.

LMA MAD Intranasal Device website. http://www.lmana.com/pwpcontrol.php?pwpID=6359/. Accessed November 15, 2014.

Hospital National Patient Safety Goals 2014. The Joint Commission Website. http://www.jointcommission.org/hap_2014_npsgs/. Accessed November 15, 2014.

Acute Care ISMP Medication Safety Alert. Institute for Safe Medication Practices Website. https://www.ismp.org/newsletters/acutecare/articles/20061116_2.asp. Accessed November 15, 2014.

Hampton J. Rapid-sequence intubation and the role of the emergency department pharmacist. AJHP. 2011; 68:1320-30.

Stollings JL, Diedrich DA, Oye LJ, Brown Dr. Rapid-Sequence Intubation: A Review of the Process and Considerations When Choosing Medications. Ann Pharmcother. 2014; 48: 62-76.

Walls RM. Lidocaine and rapid sequence intubation. Ann Emerg Med. 1996; 27: 528-9

Jabre P, Combes X, Lapostolle F, Dhaouadi M, et al. Etomidate vs ketamine for rapid sequence intubation in the acutely ill patients: a multicentre randomised controlled trial. Lancet. 2009; 374: 293-300.

Drug monographs for atropine, lidocaine, fentanyl, midazolam, ketamine, propofol, methohexital, succinylcholine, rocuronium, vecuronium, lorazepam, morphine, labetalol, diltiazem, amiodarone, esmolol, norepinephrine, vasopressin, epinephrine, phenylephrine . In: DRUGDEX System [internet database]. Greenwood Village, CO: Thomson Reuters (Healthcare) Inc. Accessed November 21-Dec 1, 2014. Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet. 2000; 356: 411-17.

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REFERENCES Acute Dissection of the Descending Aorta: A Case Report and Review of the Literature.

Cariol Ter. 2013; 2: 199-213.

Devereaux D, Tewelde SZ. Hyperthyroidism and Thyrotoxicosis. Emerg Med Clin N Am. 2014; 32: 277-92.

Andolfatto G, Abu-Laban RB, Zed PJ, Staniforth SM, et al. Ketamine-PropofolCombination (Ketofol) vs Propofol Alone for Emergnecy Department Procedural Sedation and Analgesia: A Randomized Double-Blind Trial. Ann Emerg Med. 2012; 59: 504-12.

Green SM, Krauss B. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation in Children. Ann Emerg Med. 2004; 44: 460-71.

Moderate Sedation. University of Illinois Hospital and Health Sciences System Management Policy and Procedure. TX 3.02; 2012: 1-14.

Dellinger RP, Levy MM, Rhodes A, Annan D, et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012Crit Care Med. 2013; 41: 580-637.

O e gaa d CB D a ik V I ot o e a d a o e o Ci c latio 2008; 118: 1047 56 Overgaard CB, Dzavik V. Inotropes and vasopressors. Circulation. 2008; 118: 1047-56.

De Backer D, Biston P, Devriendt J, Madi C, et al. Comparison of Dopamine and Norepinephrine in the Treatment of Septic Shock. NEJM. 2010; 362: 779-89.

Russel JA, Walley KR, Singer J, Gordon AC, et al. Vasopression vs Norepinephrine Infusion in Patients with Septic Shock. NEJM. 2008; 358: 877-87.

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QUESTIONS?

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CE Activity Information & Accreditation · Sterile Products in the Emergency Department PharMEDium Lunch and Learn Series ProCE, Inc. 5 EMERGENCY SITUATIONS Cardiac arrest Acute ischemic