Emergency Medication Administration Research Articles

Alternative routes to intravenous procedural sedation to cardiovert unstable wide complex tachycardia – case report and review of literature

Background: Cardioversion is the treatment of choice in an unstable patient with arrhythmia. It requires analgesia and sedation, which is usually given via intravenous route. However, when there is a failure to get vascular access, alternatives routes to intravenous (IV) sedation and analgesia are needed. Case Presentation: A 59 year old male patient was presented to the emergency department (ED) complaining of chest pain and palpitation. His electrocardiogram (ECG) showed new onset rapid narrow complex atrial fibrillation, which then converted to wide complex tachycardia. Initially, the patient remained hemodynamically stable, but his blood pressure dropped, when cardioversion was indicated. In this case, intranasal (IN) and intraosseous (IO) routes were used, both of which are uncommon to be used for sedation in an unstable patient. The sedatives bioavailability and dosage via non intravenous (non-IV) routes are not commonly used, hence, literature was reviewed to find out the appropriate sedative dosage via non-IV routes specifically in IN and IO route for moderate sedation in ED, to facilitate procedures like cardioversion. Conclusion: It was believed that IN and IO routes are good alternatives to intravenous routes when timely vascular access can't be secured and when emergency medication administration is required.

Alternative routes to intravenous procedural sedation to cardiovert unstable wide complex tachycardia – case report and review of literature

Background: Cardioversion is the treatment of choice in an unstable patient with arrhythmia. It requires analgesia and sedation, which is usually given via intravenous route. However, when there is a failure to get vascular access, alternatives routes to intravenous (IV) sedation and analgesia are needed. Case Presentation: A 59 year old male patient was presented to the emergency department (ED) complaining of chest pain and palpitation. His electrocardiogram (ECG) showed new onset rapid narrow complex atrial fibrillation, which then converted to wide complex tachycardia. Initially, the patient remained hemodynamically stable, but his blood pressure dropped, when cardioversion was indicated. In this case, intranasal (IN) and intraosseous (IO) routes were used, both of which are uncommon to be used for sedation in an unstable patient. The sedatives bioavailability and dosage via non intravenous (non-IV) routes are not commonly used, hence, literature was reviewed to find out the appropriate sedative dosage via non-IV routes specifically in IN and IO route for moderate sedation in ED, to facilitate procedures like cardioversion. Conclusion: It was believed that IN and IO routes are good alternatives to intravenous routes when timely vascular access can't be secured and when emergency medication administration is required.

Prescribing Practices for Agitation Medication in Obese Patients Admitted to the Emergency Department.

Weight is a factor that influences the dosages of many medications, although no clinical studies have evaluated this factor in the use of agitation medications in the obese population. The objectives of this study were to assess the need for weight considerations in dosing antipsychotics and benzodiazepines for patients with agitation and to assess prescribing patterns in agitated patients. This retrospective cohort study compared outcomes between obese and nonobese adult patients who received at least one parenteral administration of an antipsychotic or benzodiazepine for agitation in the emergency department. The primary outcomes were total antipsychotic and benzodiazepine doses within 24 hours (in chlorpromazine equivalents and lorazepam equivalents, respectively). Key secondary outcomes included antipsychotic and benzodiazepine doses used for first administration, incidence of repeat emergency medication administration within 24 hours, time to next administration, and number of repeat administrations within 24 hours. The study examined 115 patient encounters in each cohort of patients in the study. The baseline characteristics of the 2 study cohorts were similar. Both groups had similar mean 24-hour antipsychotic usage [272.7 chlorpromazine equivalents (nonobese cohort), 313.5 chlorpromazine equivalents (obese cohort); P=0.157] and mean 24-hour benzodiazepine usage [0.9 lorazepam equivalents (both cohorts); P=0.750]. Differences between the study cohorts on all of the secondary outcomes were also not statistically significant (P>0.05). This study did not find the use of higher dosages of agitation medication in the obese compared with the nonobese population. Future prospective trials, with possible emphasis on individual medications, specific etiologies of agitation, or morbid obesity, are required to confirm this finding or to elucidate potential differences in optimal medication dosages for the obese population.

Knowledge about, and attitudes towards epilepsy among school staff: A UK-based survey

ObjectiveTo survey attitudes towards, and knowledge about, epilepsy among school staff in a defined geographical region in the United Kingdom. MethodsSchool staff (n = 160) from 18 schools (56% of eligible schools) where children with epilepsy were currently attending were surveyed. Surveys were developed in collaboration with educational professionals. Questions focussed on attitudes towards, and knowledge about, epilepsy. Factors associated with attitudes and knowledge were analyzed using multivariable logistic regression. ResultsThe majority of staff expressed positive attitudes towards the inclusion of children with epilepsy in school, although for most questions there was a significant minority who expressed less positive views. Only 30% of staff agreed that they would feel confident managing a child having a seizure whilst 42% of all staff would be concerned if they had to administer emergency medication. Regarding knowledge, half (50%) of respondents correctly indicated that a child who has a seizure should not always leave the classroom, whilst 54% knew that an ambulance should not always be called every time a child has a seizure. Regarding seizure semiology, almost all respondents (96%) answered ‘yes’ when asked if seizures could involve convulsions/limb jerking or whole-body convulsions. The vast majority (94%) also identified that seizures could involve ‘staring blankly into space’. From a list of eight medical/neurodevelopmental conditions, epilepsy was the condition staff ranked of most concern. Factors independently associated with more positive attitudes and better knowledge included working in a special school as opposed to a mainstream school, having previously witnessed a seizure, and having been in receipt of training on epilepsy (all p < 0.05). Most respondents expressed a desire for more training on seizure management and on the learning and behavioral aspects of epilepsy. ConclusionWhilst attitudes toward children with epilepsy are largely positive, epilepsy was the condition staff were most concerned about. Additionally, attitudes towards seizure management and administration of emergency medication in school are less positive, and knowledge of correct actions in the event of seizures in the classroom is deficient in nearly half of respondents. More positive attitudes and better knowledge were associated with previous experience of witnessing seizures, working in special schools, and having received epilepsy training. School staff in UK schools are likely to benefit from access to training on epilepsy in order to improve attitudes and increase knowledge and confidence towards supporting a child with epilepsy in their classroom.

Rapid infusion of infliximab biosimilars and the incidence and severity of infusion-related reactions in patients with inflammatory bowel disease.

Infliximab is an anti-tumour necrosis factor agent used in the treatment of inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis. While the use of infliximab is well established in the treatment of IBD, there are now four recently FDA-approved infliximab biosimilars that are increasingly used due to their cost-benefit for patients, institutions and payors. In addition, shortening the length of infliximab infusions from 120 min (standard infusion) to 60 min or less (rapid infusion) has been shown to safely provide further cost-benefit while also improving patient convenience. The safety of rapid infusions has been well-established for the infliximab reference product, however, there are limited data available regarding the safety of rapid infusions for infliximab biosimilars. The purpose of this study was to compare the incidence and severity of infusion reactions among patients with IBD receiving rapid infusion of infliximab reference product compared with infliximab biosimilar. This was a retrospective analysis of electronic health record data of patients with a diagnosis of IBD receiving an infliximab reference product or infliximab biosimilar infusion between December 2020 and December 2021. Patient-level variables included demographics, immunomodulator use, IBD-related hospitalization and infliximab trough concentration and antibody levels. Infusion-related variables of interest included total number of infusions, drug, dose, dosing interval, infusion time and use of pre-medications. Infusion-related reactions were defined as safety concerns documented by the administering nurse (anaphylaxis, shortness of breath, hypotension, swelling, rash, pruritus, hives, flushing, chest pain, muscle pain, joint pain, fevers, chills, headache or hypertension) or administration of emergency medications. Fisher's exact test was used to compare reaction rates. A total of 188 patients met inclusion criteria for analysis, and a total of 1124 infusions were administered during the study period. There were no statistically significant differences among any of the pre-specified outcomes. There were no differences in the incidence of infusion reactions among rapid infusion (60 min) infliximab and infliximab biosimilars (p=0.863). Additionally, there were no differences in the incidence of infusion reactions among standard infusion (120 min) infliximab and infliximab biosimilars (p=0.993). Finally, there were no differences among the rate of infusion reactions between rapid infusion of infliximab biosimilars and standard infusion of infliximab biosimilars (p=0.536). Eight patients experienced safety issues, with three patients requiring emergency medications (1.6% of 188 patients). Rapid infusions of infliximab biosimilars were not associated with an increase in the incidence of infusion reactions compared with: rapid infusion of infliximab reference product, standard infusion of infliximab biosimilars, or standard infusion of infliximab reference product. This should reassure clinicians that rapid infusions of infliximab biosimilars are safe in clinical practice.

A Multidisciplinary Quality Improvement Initiative to Facilitate Penicillin Allergy Delabeling Among Hospitalized Pediatric Patients.

Penicillin allergy is reported in up to 10% of the general population; however, >90% of patients reporting an allergy are tolerant. Patients labeled as penicillin allergic have longer hospital stays, increased exposure to suboptimal antibiotics, and an increased risk of methicillin-resistant Staphylococcus aureus and Clostridioides difficile. The primary aim with our quality improvement initiative was to increase penicillin allergy delabeling to at least 10% among all hospitalized pediatric patients reporting a penicillin allergy with efforts directed toward patients determined to be low risk for true allergic reaction. Our quality improvement project included several interventions: the development of a multidisciplinary clinical care pathway to identify eligible patients, workflow optimization to support delabeling, an educational intervention, and participation in our institution's quality improvement incentive program. Our interventions were targeted to facilitate appropriate delabeling by the primary hospital medicine team. Statistical process control charts were used to assess the impact of this intervention pre- and postpathway implementation. After implementation of the clinical pathway, the percentage of patients admitted to hospital medicine delabeled of their penicillin allergy by discharge increased to 11.7%. More than one-half of those delabeled (51.2%) received a penicillin-based antimicrobial at time of discharge. There have been no adverse events or allergic reactions requiring emergency medication administration since pathway implementation. Our quality improvement initiative successfully increased the rate of penicillin allergy delabeling among low-risk hospitalized pediatric patients, allowing for increased use of optimal antibiotics.

The integral role of the clinical pharmacist in drug-assisted intubation at a newly established children\u2019s major trauma center

This commentary outlines how the clinical pharmacist can support the safe administration of emergency medications in trauma anesthesia for seriously injured children. Promoting the professional development of the clinical pharmacist provided an opportunity to strengthen a key step in our trauma care pathway. We describe the implementation of this process in a new hospital, which was to become the designated children’s trauma center for an entire country. Although the literature documents the use of pharmacists in emergency intubation, ours was a unique set of circumstances, where empowering the pharmacist in frontline clinical care provided additional quality assurance for rapid sequence induction and intubation in trauma. Medical simulation was a core part of socializing the advanced clinical practice role of pharmacy within the trauma team. It was our experience that the pharmacist helps to promote confidence and decision making among other members of the trauma team.

Emergency Medication Access and Administration in Schools: A Focus on Epinephrine, Albuterol Inhalers, and Glucagon.

Access to emergency medications is a growing concern, particularly regarding the availability, safety, and use of these medications in schools. The purpose of this article is to report results not previously published from a national survey, specifically regarding the emergency use of epinephrine, albuterol inhalers, and glucagon. A nonexperimental, cross-sectional design was utilized for this descriptive study. An online survey was distributed to school nurses in 2015, and data from 6,298 school nurse respondents are presented in the analysis. Findings related to stock and student-specific emergency medication use and storage, epinephrine usage data, and delegation of emergency medication administration to unlicensed assistive personnel are presented in this article. Further development of policies and procedures regarding emergency medication administration in schools is needed. School nurses are a valuable resource for obtaining knowledge in this area and keeping students safe at school.

Patient safety incidents and medication errors during a clinical trial: experience from a pre-hospital randomized controlled trial of emergency medication administration

To assess and evaluate patient safety incidents and in particular, medication errors, during a large multi-center pre-hospital trial of emergency therapy (PARAMEDIC2), in order to inform and improve future pre-hospital medicines trials. The PARAMEDIC2 trial was undertaken across five NHS Ambulance Services in England and Wales with randomisation between December 2014 and October 2017. Patients with an out -of-hospital cardiac arrest unresponsive to initial resuscitation were randomly assigned to 1mg intravenous adrenaline or matching placebo. Records were reviewed to identify trial medication errors involving documentation and/or clinical protocol errors occurring in trial participants. Causes of medication errors, including root cause analysis where available, were reviewed to identify patterns and themes contributing to these errors. Eight thousand sixteen patients were enrolled, of whom 4902 received trial medication. A total of 331 patient safety incidents was reported, involving 295 patients, representing an overall rate of 3.6% of these, 166 (50.2%) were documentation errors while 165 (49.8%) were clinical protocol/medication errors. An overall rate of 0-4.5% was reported across all five ambulance services, with a mean of 2.0%. These errors had no impact on patient care or the trial and were all resolved CONCLUSION: The overall medication error rate of 1.8% primarily consisted of administration of open-label adrenaline and confusion with trial medication packs. A similar number of patients had documentation errors. This study is the first to provide data on patient safety incidents relating to medication errors encountered during a pre-hospital trial of emergency medication administration and will provide supporting data for planning future trials in this area.

BSACI guideline for the diagnosis and management of peanut and tree nut allergy.

Peanut nut and tree nut allergy are characterised by IgE mediated reactions to nut proteins. Nut allergy is a global disease. Limited epidemiological data suggest varying prevalence in different geographical areas. Primary nut allergy affects over 2% of children and 0.5% of adults in the UK. Infants with severe eczema and/or egg allergy have a higher risk of peanut allergy. Primary nut allergy presents most commonly in the first five years of life, often after the first known ingestion with typical rapid onset IgE-mediated symptoms. The clinical diagnosis of primary nut allergy can be made by the combination of a typical clinical presentation and evidence of nut specifc IgE shown by a positive skin prick test (SPT) or specific IgE (sIgE) test. Pollen food syndrome is a distinct disorder, usually mild, with oral/pharyngeal symptoms, in the context of hay fever or pollen sensitisation, which can be triggered by nuts. It can usually be distinguish clinically from primary nut allergy. The magnitude of a SPT or sIgE relates to the probability of clinical allergy, but does not relate to clinical severity. SPT of ≥8mm or sIgE≥15KU/L to peanut is highly predictive of clinical allergy. Cut off values are not available for tree nuts. Test results must be interpreted in the context of the clinical history. Diagnostic food challenges are usually not necessary but may be used to confirm or refute a conflicting history and test result. As nut allergy is likely to be a long-lived disease, nut avoidance advice is the cornerstone of management. Patients should be provided with a comprehensive management plan including avoidance advice, patient specific emergency medication and an emergency treatment plan and training in administration of emergency medication. Regular re-training is required.

Sublingual (SLIT) versus oral immunotherapy (OIT) for food allergy.

Food allergy is a common condition for which the only currently approved treatments are avoidance of the allergenic food and the administration of emergency medications upon accidental exposure. Over the past 10 years, significant advances have been made in the field of food immunotherapy, with efforts focusing on allergen exposure via the oral mucosa. Oral immunotherapy (OIT) and sublingual immunotherapy (SLIT) are the two modalities that have been most extensively studied, and this article will review recent advances in our knowledge of the efficacy and safety of these treatments.

A review of the quality of care following prolonged seizures in 1–18 year olds with epilepsies

PurposeTo review the quality of care of children and young people with epilepsies who, following a prolonged seizure, received high-dependency or intensive care. To identify and learn from clinical, organisational, management or personal issues that contributed to these admissions, in order to inform practice and improve clinical services for children across the UK. MethodNotifications were collected from consultant paediatricians in England, Wales, Scotland and Northern Ireland over a 10-month period. For all eligible cases a clinical questionnaire was sent to the notifying clinician. A sample of these cases were selected for a detailed case note review. Case notes were reviewed by paediatrician–nurse pairs using a purpose-built assessment tool derived from national guidelines. ResultsData were collected from 135 clinical questionnaires, and 36 sets of case notes were reviewed. Findings were compared to national standards of care and emerging themes identified. There was evidence of good epilepsy management in many cases. In some cases there was evidence of a lack of clear emergency care plans, of delays in administration of emergency medication, and of deviation from established national guidelines. ConclusionThe findings of this review suggest there have been improvements in the care of children and young people with epilepsies presenting with prolonged seizures compared to previous studies. Nevertheless, further improvements are needed, particularly in communication with families and prompt administration of emergency medication.

G319 A review of the quality of care following prolonged seizures in children with epilepsies

ObjectiveTo review the quality of care of children and young people with epilepsies who received high-dependency or intensive care following a prolonged seizure. To identify and learn from any clinical,...

Use of Clozapine in a State Child and Adolescent Psychiatric Hospital

We assessed the predictors of clozapine initiation among youth 18 years and younger within a state psychiatric hospital. Administrative data (n = 358) were evaluated of inpatients from a long-term state child and adolescent psychiatric hospital. We investigated 25 background and clinical patient characteristics to determine which factors predicted clozapine initiation following the first 21 days of hospital admission. A Cox proportional model was used to evaluate factors that independently predicted the hazard rate of clozapine initiation. Emergency medication administration during the first 3 weeks of admission, which was more common among the clozapine (84.9 %) than control (61.7 %) patients (p < 0.001), was associated with a significantly increased probability of clozapine initiation (Hazard Ratio = 1.9, 95 % Confidence Interval = 1.2-3.1). Use of a mood stabilizer during the first 3 weeks of the inpatient was non-significantly related to an increased probability of clozapine initiation (Hazard Ratio = 1.7, 95 % Confidence Interval = 1.0-2.9). In this setting, emergency medication use predicts clozapine initiation suggesting that it may be used to treat patients with aggressive behavior.

Prehospital Medical Care and the National Ski Patrol: How Does Outdoor Emergency Care Compare to Traditional EMS Training?

The purpose of this study was to identify the differences between the educational curricula, skill sets, and funds of knowledge required for certification as an Outdoor Emergency Care Technician (OEC-T), Emergency Medical Technician (EMT), and Emergency Medical Responder (EMR). We directly and in detail compared topics and skills presented in the OEC-T curriculum with those presented in the EMT and EMR education and training curricula. The information and skills taught in the OEC-T curriculum are in general more extensive than those taught in EMR training but are not equivalent to EMT. The OEC-T program has more depth in environmental medical issues, such as altitude illness, hyperthermia and hypothermia. Completion of the EMR program is 112 hours shorter and constitutes 30% of the duration of the EMT program. Completion of the OEC-T program (for certification only and not including additional "on-hill" patroller training) is 80 hours shorter and is half the duration of the EMT program. The OEC-T curriculum includes a skill set and fund of knowledge that exceeds those of the EMR program, but does not include all the knowledge needed for an EMT program. The OEC-T program prepares out-of-hospital providers to care for patients in the wilderness, with special emphasis on snowsports pathology. The EMT program places a greater emphasis on medical disease and emergency medication administration. These differences should be considered when determining staffing requirements for agencies caring for patients with snowsports pathology.

Best Practices: Safety Guidelines for Injury-Free Management of Psychiatric Inpatients in Precrisis and Crisis Situations

Twin Valley Behavioral Healthcare developed safety guidelines for injury-free inpatient management, which were implemented in 2004. The guidelines focus on best practices in the areas of verbal and physical interactions between patients and staff, administration of emergency medication, communication of critical information during precrisis and crisis periods, measurement of safety outcomes, and application of safety rules via policies and use of the agency logo, "Working Smart=Working Safe." Between 2004 and 2008 staff injuries decreased 90%--from 91 to nine injuries. Restraints and seclusions fell by 36%, patient complaints by 37%, and the need for codes for staff to assist in a psychiatric emergency by 25%.

Best Practices: Safety Guidelines for Injury-Free Management of Psychiatric Inpatients in Precrisis and Crisis Situations

Twin Valley Behavioral Healthcare developed safety guidelines for injury-free inpatient management, which were implemented in 2004. The guidelines focus on best practices in the areas of verbal and physical interactions between patients and staff, administration of emergency medication, communication of critical information during precrisis and crisis periods, measurement of safety outcomes, and application of safety rules via policies and use of the agency logo, "Working Smart=Working Safe." Between 2004 and 2008 staff injuries decreased 90%--from 91 to nine injuries. Restraints and seclusions fell by 36%, patient complaints by 37%, and the need for codes for staff to assist in a psychiatric emergency by 25%.

Endotracheal administration of emergency medications.

When vascular access is delayed or unreliable in emergency situations, an endotracheal tube provides a rapid and reliable route for administration of medication. Epinephrine, lidocaine, and atropine have shown clinical efficacy when given by the endotracheal route. There is evidence that other medications including naloxone and diazepam may also be suitable for endotracheal use, but clear-cut recommendations await further studies of pharmacokinetics and toxicity.

Intracardiac Injections During Cardiopulmonary Resuscitation

Fifty-three patients were observed prospectively for the development of complications resulting from 147 intracardiac injections (ICIs) received during cardiopulmonary resuscitation (CPR). Although pericardial effusion was noted in six of 17 echocardiograms and a hemopericardium found in eight of 28 autopsies, cardiac tamponade was not observed. A pneumothorax developed in one patient. None of the autopsies disclosed coronary artery or ventricular lacerations. Percutaneous puncture of the heart during CPR seldom results in serious complications. When other sites are not readily available, ICIs are safe and valid for the administration of emergency medication.