When a patient is rushed through the doors of the emergency department (ED), every second counts, from identifying injuries to making the proper diagnosis and implementing the right treatment. As valuable members of a multidisciplinary ED team, pharmacists can improve medication safety and increase the quality of patient care.Imaging in the EDCourtney B. McKinney, PharmD, a postgraduate year (PGY)2 Critical Care/ Emergency Medicine Pharmacy Resident at the University of Arizona Medical Center in Tucson, explained that imaging in the ED is typically used by physicians to identify critical injuries in patients and aid in diagnosis. “We as pharmacists can use imaging to help guide drug therapy and help us triage patients who are likely to benefit from pharmacist intervention,” said McKinney.Three imaging studies are frequently used in the ED: noncontrast head computed tomography (CT) scan, focused assessment sonography in trauma (FAST), and x-rays or plain films. Pharmacists should be familiar with all three, McKinney noted; for example, noncontrast head CT scan is a routine part of stroke assessment used to differentiate between hemorrhagic and ischemic stroke. “It is critical to get the results of this imaging test [so we can] determine who is going to get tPA [tissue plasminogen activator],” McKinney told attendees. White areas on the CT scan represent blood, so “if there is white on your head CT scan, no tPA for your patient,” she added.A FAST scan is used to examine cardiac and abdominal injuries. Large amounts of black on the scan represent pooled blood in the abdominal cavity or around the heart. When this comes up on the scan, pharmacists should be prepared to provide sedation, analgesia, and preoperative antimicrobial therapy, McKinney noted.X-rays of the abdomen can be used to assess accidental or intentional ingestions. Pharmacists can use these films to determine whether “GI decontamination is something you want to pursue, whether you’re going to give an antidote, and how long you are going to observe the patient,” said McKinney.‘Bath salts’Abuse of mephedrone, methylenedioxypyrovalerone (MDPV), and methylone, a trio of designer synthetic stimulants commonly called “bath salts” is a trending problem (see page 19 of the February OTC supplement to Pharmacy Today).In 2010, poison centers in 43 states received 292 calls about these products. From January to February 2011, poison centers received 469 calls, according to Jeremy P. Hampton, PharmD, BCPS, a Clinical Specialist in Emergency Medicine at Truman Medical Centers in Kansas City, MO.ED pharmacists should recognize the symptoms of bath salts, noted Hampton, which include dry mucous membranes, flighty thoughts, aggression, and agitation. “Your mainstay treatment is going to be benzodiazepines … and [they] may take a higher dose than you’re normally used to using,” said Hampton. “[Patients] are going to be dry, so [use] fluid management. Hyperpyrexia is going to be a problem … so aggressively bring their temperature down.” The patient should be monitored for possible seizures. Intubation may also be necessary.Off-label use in the EDJoanne C. Witsil, PharmD, RN, BCPS, Clinical Pharmacist in Emergency Medicine/Toxicology at Cook County Hospital in Chicago, described several alternative uses for medications routinely used in the ED to assist with patient care. Witsil noted that the information presented in her talk deviates from FDA-approved use. “Always consider patient safety first and consider all your drug-to-patient factors prior to using any agent off label,” Witsil told attendees.The first off-label use Witsil described was to ease nasogastric tube (NGT) insertion, which can be painful for the patient and a difficult procedure for the health professional. Witsil suggested lubricating the first 3 inches of the NGT with lidocaine urological Jelly 2% (Urojelly) instead of plain water-soluble gel. For patients with irritable bowel syndrome or abdominal cramps, Witsil told attendees to consider mixing 1 mg of atropine and 25 mg to 50 mg of diphenhydramine into a 1-L bag of saline and infuse it over 1 hour as tolerated. She also suggested using 1 mL to 2 mL of mineral oil to suffocate an insect trapped in the ear canal. Once the insect is dead, apply a tissue adhesive to the wooden end of a cotton swap. Carefully touch the tip of the swab to the foreign object and wait for it to bond. The insect and the swab can then pulled out together as one unit. When a patient is rushed through the doors of the emergency department (ED), every second counts, from identifying injuries to making the proper diagnosis and implementing the right treatment. As valuable members of a multidisciplinary ED team, pharmacists can improve medication safety and increase the quality of patient care. Imaging in the EDCourtney B. McKinney, PharmD, a postgraduate year (PGY)2 Critical Care/ Emergency Medicine Pharmacy Resident at the University of Arizona Medical Center in Tucson, explained that imaging in the ED is typically used by physicians to identify critical injuries in patients and aid in diagnosis. “We as pharmacists can use imaging to help guide drug therapy and help us triage patients who are likely to benefit from pharmacist intervention,” said McKinney.Three imaging studies are frequently used in the ED: noncontrast head computed tomography (CT) scan, focused assessment sonography in trauma (FAST), and x-rays or plain films. Pharmacists should be familiar with all three, McKinney noted; for example, noncontrast head CT scan is a routine part of stroke assessment used to differentiate between hemorrhagic and ischemic stroke. “It is critical to get the results of this imaging test [so we can] determine who is going to get tPA [tissue plasminogen activator],” McKinney told attendees. White areas on the CT scan represent blood, so “if there is white on your head CT scan, no tPA for your patient,” she added.A FAST scan is used to examine cardiac and abdominal injuries. Large amounts of black on the scan represent pooled blood in the abdominal cavity or around the heart. When this comes up on the scan, pharmacists should be prepared to provide sedation, analgesia, and preoperative antimicrobial therapy, McKinney noted.X-rays of the abdomen can be used to assess accidental or intentional ingestions. Pharmacists can use these films to determine whether “GI decontamination is something you want to pursue, whether you’re going to give an antidote, and how long you are going to observe the patient,” said McKinney. Courtney B. McKinney, PharmD, a postgraduate year (PGY)2 Critical Care/ Emergency Medicine Pharmacy Resident at the University of Arizona Medical Center in Tucson, explained that imaging in the ED is typically used by physicians to identify critical injuries in patients and aid in diagnosis. “We as pharmacists can use imaging to help guide drug therapy and help us triage patients who are likely to benefit from pharmacist intervention,” said McKinney. Three imaging studies are frequently used in the ED: noncontrast head computed tomography (CT) scan, focused assessment sonography in trauma (FAST), and x-rays or plain films. Pharmacists should be familiar with all three, McKinney noted; for example, noncontrast head CT scan is a routine part of stroke assessment used to differentiate between hemorrhagic and ischemic stroke. “It is critical to get the results of this imaging test [so we can] determine who is going to get tPA [tissue plasminogen activator],” McKinney told attendees. White areas on the CT scan represent blood, so “if there is white on your head CT scan, no tPA for your patient,” she added. A FAST scan is used to examine cardiac and abdominal injuries. Large amounts of black on the scan represent pooled blood in the abdominal cavity or around the heart. When this comes up on the scan, pharmacists should be prepared to provide sedation, analgesia, and preoperative antimicrobial therapy, McKinney noted. X-rays of the abdomen can be used to assess accidental or intentional ingestions. Pharmacists can use these films to determine whether “GI decontamination is something you want to pursue, whether you’re going to give an antidote, and how long you are going to observe the patient,” said McKinney. ‘Bath salts’Abuse of mephedrone, methylenedioxypyrovalerone (MDPV), and methylone, a trio of designer synthetic stimulants commonly called “bath salts” is a trending problem (see page 19 of the February OTC supplement to Pharmacy Today).In 2010, poison centers in 43 states received 292 calls about these products. From January to February 2011, poison centers received 469 calls, according to Jeremy P. Hampton, PharmD, BCPS, a Clinical Specialist in Emergency Medicine at Truman Medical Centers in Kansas City, MO.ED pharmacists should recognize the symptoms of bath salts, noted Hampton, which include dry mucous membranes, flighty thoughts, aggression, and agitation. “Your mainstay treatment is going to be benzodiazepines … and [they] may take a higher dose than you’re normally used to using,” said Hampton. “[Patients] are going to be dry, so [use] fluid management. Hyperpyrexia is going to be a problem … so aggressively bring their temperature down.” The patient should be monitored for possible seizures. Intubation may also be necessary. Abuse of mephedrone, methylenedioxypyrovalerone (MDPV), and methylone, a trio of designer synthetic stimulants commonly called “bath salts” is a trending problem (see page 19 of the February OTC supplement to Pharmacy Today). In 2010, poison centers in 43 states received 292 calls about these products. From January to February 2011, poison centers received 469 calls, according to Jeremy P. Hampton, PharmD, BCPS, a Clinical Specialist in Emergency Medicine at Truman Medical Centers in Kansas City, MO. ED pharmacists should recognize the symptoms of bath salts, noted Hampton, which include dry mucous membranes, flighty thoughts, aggression, and agitation. “Your mainstay treatment is going to be benzodiazepines … and [they] may take a higher dose than you’re normally used to using,” said Hampton. “[Patients] are going to be dry, so [use] fluid management. Hyperpyrexia is going to be a problem … so aggressively bring their temperature down.” The patient should be monitored for possible seizures. Intubation may also be necessary. Off-label use in the EDJoanne C. Witsil, PharmD, RN, BCPS, Clinical Pharmacist in Emergency Medicine/Toxicology at Cook County Hospital in Chicago, described several alternative uses for medications routinely used in the ED to assist with patient care. Witsil noted that the information presented in her talk deviates from FDA-approved use. “Always consider patient safety first and consider all your drug-to-patient factors prior to using any agent off label,” Witsil told attendees.The first off-label use Witsil described was to ease nasogastric tube (NGT) insertion, which can be painful for the patient and a difficult procedure for the health professional. Witsil suggested lubricating the first 3 inches of the NGT with lidocaine urological Jelly 2% (Urojelly) instead of plain water-soluble gel. For patients with irritable bowel syndrome or abdominal cramps, Witsil told attendees to consider mixing 1 mg of atropine and 25 mg to 50 mg of diphenhydramine into a 1-L bag of saline and infuse it over 1 hour as tolerated. She also suggested using 1 mL to 2 mL of mineral oil to suffocate an insect trapped in the ear canal. Once the insect is dead, apply a tissue adhesive to the wooden end of a cotton swap. Carefully touch the tip of the swab to the foreign object and wait for it to bond. The insect and the swab can then pulled out together as one unit. Joanne C. Witsil, PharmD, RN, BCPS, Clinical Pharmacist in Emergency Medicine/Toxicology at Cook County Hospital in Chicago, described several alternative uses for medications routinely used in the ED to assist with patient care. Witsil noted that the information presented in her talk deviates from FDA-approved use. “Always consider patient safety first and consider all your drug-to-patient factors prior to using any agent off label,” Witsil told attendees. The first off-label use Witsil described was to ease nasogastric tube (NGT) insertion, which can be painful for the patient and a difficult procedure for the health professional. Witsil suggested lubricating the first 3 inches of the NGT with lidocaine urological Jelly 2% (Urojelly) instead of plain water-soluble gel. For patients with irritable bowel syndrome or abdominal cramps, Witsil told attendees to consider mixing 1 mg of atropine and 25 mg to 50 mg of diphenhydramine into a 1-L bag of saline and infuse it over 1 hour as tolerated. She also suggested using 1 mL to 2 mL of mineral oil to suffocate an insect trapped in the ear canal. Once the insect is dead, apply a tissue adhesive to the wooden end of a cotton swap. Carefully touch the tip of the swab to the foreign object and wait for it to bond. The insect and the swab can then pulled out together as one unit.
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