LUNCH AND LEARN December 12, 2014 Featured Speaker: Renee Petzel Gimbar, PharmD Emergency Medicine/Medical Toxicology Clinical Pharmacist Clinical Assistant Professor University of Illinois at Chicago College of Pharmacy University of Illinois Medical Center at Chicago 1 CE Activity Information & Accreditation (Pharmacist and Tech CE) 1.0 contact hour Funding: This activity is self funded through PharMEDium. It is the policy of 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. Petzel Gimbar has no relevant commercial and/or financial relationships to disclose. 2 www.proce.com 1
Online Evaluation, Self-Assessment and CE Credit Submission of an online self assessmentand and evaluation isthe only way to obtain CE credit for this webinar Go to www.proce.com/pharmediumrx Print your CE Statement online Live CE Deadline: January 9, 2015 CPE Monitor CE information automatically uploaded to NABP/CPE Monitor within 1 to 2 weeks of the completion of the self assessment and evaluation Event Code Code will be provided at the end of today s activity Event Code not needed for On Demand 3 Ask a Question Submit your questions to your site manager. Questions will be answered at the end of the presentation. Your question...? 4 www.proce.com 2
Resources Visit www.proce.com/pharmediumrx to access: Handouts Activity information Upcoming live webinar dates Links to receive CE credit 5 STERILE PRODUCTS IN THE EMERGENCY DEPARTMENT 6 Renee Petzel Gimbar, PharmD Clinical Assistant Professor Clinical Pharmacist, EM/Med Tox Director, PGY2 Emergency Medicine University of Illinois College of Pharmacy www.proce.com 3
OBJECTIVES Define the role of the pharmacist in the emergency 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 setting Explain the impact of standardized medication labeling and administration for improving medication safety in the emergency department 7 YOU WORK WHERE? Emergency Medicine Pharmacy Bedside hands on pharmacy Pharmacy consultation Code Blue Code MI Code Stroke Critically ill patients Emergency medicine i pharmacy residency training i 8 www.proce.com 4
EMERGENCY SITUATIONS Cardiac arrest Acute ischemic stroke (AIS) Rapid sequence intubation (RSI) Moderate sedation Critical care medication titration 9 MEDICATION DELIVERY IN THE ED Patients don t come into the ED with intravenous access Intravenous Intramuscular Subcutaneous Intraosseous Intranasal Endotracheal 10 www.proce.com 5
INTRAOSSEOUS ACCESS 11 INTRANASAL ADMINISTRATION 12 www.proce.com 6
MEDICATION SAFETY IN THE ED The Joint Commission 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 13 MEDICATION SAFETY IN THE ED Institute for Safe Medication Practices Supporter of prefilled, labeled syringes Typical patient-specific doses No cross-contamination Drug name and dose/strength 14 www.proce.com 7
MEDICATION SAFETY IN THE ED 15 MEDICATION SAFETY IN THE ED 16 www.proce.com 8
MEDICATION SAFETY IN THE ED 17 RAPID-SEQUENCE INTUBATION Technique for facilitating endotracheal intubation by rapidly administering sedatives and neuromuscular blocking agents in patients with impending respiratory failure or altered mental status 18 www.proce.com 9
RAPID-SEQUENCE INTUBATION Timeline of Events Before Intubation T 5 minutes Patient history & physical Supply preparation Preoxygenate the patient, cardiac monitoring T 3 minutes T 1 minute Premedicate (optional) to blunt response to intubation Induction and paralysis Cricoid pressure Timeline of Events After Intubation T + 1 minute Confirm tube placement auscultation End tital CO 2 detector Secure ETT with tube holder 19 CXR Consider need for continued sedation/paralysis PREMEDICATIONS To blunt physiologic response to intubation, which includes preventing: Bradycardia Tachycardia Hypertention Elevated intracranial and intraocular pressure Cough and gag reflexes Hypoxia Atropine Fentanyl Lidocaine 20 www.proce.com 10
ATROPINE Anticholinergic agent that works to block reflex 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 21 FENTANYL Synthetic opioid used to blunt elevations in heart rate 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, seizure Avoid use in patients who are already hypotensive 22 www.proce.com 11
LIDOCAINE Antiarrhythmic agent that minimizes risk 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 23 SEDATIVE Agent that causes no awareness of procedure and has rapid onset and short duration of action with minimal effects on cerebral perfusion and cardiovascular hemodynamics Etomidate Midazolam Ketamine Propofol Methohexital 24 www.proce.com 12
MIDAZOLAM Short-acting benzodiazepine 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 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 awakening Advantages: bronchodiatory effect in asthmatic patients Disadvantages: delirium upon awakening, increased airway secretions, elevations in ICP, IOP, BP 26 www.proce.com 13
PROPOFOL General anesthetic 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 27 METHOHEXITAL Barbiturate 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, p lowers ICP Disadvantages: hypotension, bronchospasm secondary to histamine release 28 www.proce.com 14
PARALYTIC Neuromuscular blocker that facilitates the 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 Rocuronium Vecuronium 29 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 www.proce.com 15
ROCURONIUM Non-depolarizing neuromuscular blocking agent 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 in liver disease Advantages: relatively quick onset, minimal effect on blood pressure Disadvantages: long duration of action, consider need for continued sedation 31 VECURONIUM A long-acting non-depolarizing neuromuscular blocking agent 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 www.proce.com 16
MODERATE SEDATION Drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or with tactile stimulation During procedure maintains: Patent airway, spontaneous ventilation Cardiovascular function 33 MODERATE SEDATION -ADULTS Onset of Action Duration of Action Dose Midazolam 1-5 min (IV) 5-15 min (IM) 1-2.5mg IVP 30-120 min (IV) Repeat q2 min prn Max 0.1mg/kg Lorazepam 5-10 min (IV) 30-60 min (IM) 4-6 hr (IV) 6-12 hr (IM) 0.5-2mg IVP Repeat q10 min prn Max 0.2mg/kg Fentanyl 1-2 min (IV) 30-60 min (IV) 25-50 mcg IV Repeat q3-5 min prn Max 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 prn34 Max 20 mg 34 www.proce.com 17
MODERATE SEDATION PEDIATRICS Midazolam Onset Duration Dose (mg/kg) 0.05-1mg/kg (IV/IM) 1-5 min (IV) 60-120 min (IV/IM) Single max dose: 1-2mg 5-15 min (IM) 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) 35 CRITICAL CARE IN THE ED Hypertensive crisis Labetalol Tachyarrhythmias Diltiazem Amiodarone Esmolol Sepsis/hypotension Norepinephrine Vasopressin Epinephrine Phenylephrine 36 www.proce.com 18
HYPERTENSIVE EMERGENCY Blood pressure (BP) >180/110 with end organ dysfunction Decrease MAP by 20-25% within 1 hour Continued decrease over 24-48 hours to goal BP 37 LABETALOL Nonselective beta blocker 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? Caution in patients with CHF, cocaine toxicity, asthma, elderly patients 38 www.proce.com 19
TACHYARRHYTHMIAS Atrial fibrillation (Afib) Atrial flutter (Aflutter) Paroxysmal supraventricular tachycardia (PSVT) Ventricular tachycardia (Vtach) Ventricular fibrillation (Vfib) 39 DILTIAZEM Non-dihydropyridine calcium channel blocker 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 infusion 40 www.proce.com 20
AMIODARONE Antiarrhythmic medication possessing characteristics 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 41 ESMOLOL Selective beta blocker 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 42 www.proce.com 21
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 resusciation Major healthcare issue Significant mortality associated with sepsis 43 NOREPINEPHRINE Vasopressor with alpha and beta effects 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 44 www.proce.com 22
VASOPRESSIN Vasopressor effecting the V 1 receptors 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: 0.0303 or 0.0404 units/min Fixed dosing 45 EPINEPHRINE Vasopressor with alpha and beta effects Indication: hypotension Third line treatment of sepsis & septic shock Initial dosing: 0.1 mcg/kg/min Administration: central access preferred Disadvantages: tachycardia Bedside access 46 www.proce.com 23
PHENYLEPHRINE Alpha adrenergic agent 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 ischemia Central access heavily preferred 47 HOW TO ENSURE MEDICATION 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 48 www.proce.com 24
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 49 (Healthcare) Inc. Accessed November 21-Dec 1, 2014. Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet. 2000; 356: 411-17. 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-Propofol Combination (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. Overgaard CB, DaikV Dzavik V. Inotropes o and vasopressors. o 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. 50 www.proce.com 25
QUESTIONS? 51 www.proce.com 26