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Trauma-related deaths represent a leading cause of mortality among persons younger than 45 years. A significant percentage of these are secondary to hemorrhage. In trauma, massive and rapid loss of blood creates an imbalance in hemostasis. Mainstays of resuscitation include surgical interventions, restoring intravascular volume, and pharmacologic interventions. Providers continue to search for improved pharmacologic options for achieving hemostasis. Tranexamic acid is an antifibrinolytic and inhibits fibrinolysis by blocking the lysine-binding sites on plasminogen. Tranexamic acid works to stabilize and inhibit the degradation of existing clots. Tranexamic acid has been prospectively proven to reduce mortality in trauma-related hemorrhage. Its use will likely expand into such areas as resuscitation and massive transfusion protocols and the prehospital setting. Therefore, it is critical for emergency medicine providers to be familiar with appropriate use of tranexamic acid in order to maximize efficacy and decrease the potential adverse events.

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BACKGROUND: Etomidate is a commonly used sedative during rapid sequence intubation (RSI). Septic patients are at an increased risk of independently developing adrenal suppression, which has been associated with increased mortality in some studies. Since etomidate affects cortisol production, its use in septic patients is controversial. However, data are still lacking to prove that etomidate should be avoided in this patient population. OBJECTIVES: The objective was to review patients diagnosed with sepsis who received etomidate during RSI. Our hypothesis is that patients who receive etomidate will experience clinically significant hypotension within the first 24 hours of intubation. METHODS: A retrospective cohort study was conducted on patients intubated in the emergency department (ED) and medical/surgical floors at our institution from 2004 to 2010. Once patients with a diagnosis of sepsis were identified, it was determined whether the patients received etomidate or a different sedative during intubation. The primary endpoint was clinically significant hypotension: systolic blood pressure <90 mm Hg or mean arterial pressure <60 mm Hg. RESULTS: One hundred fifty-seven patients, 110 etomidate and 47 non-etomidate, were included in the final analysis. Hypotension was seen in 79 (71.8%) patients who received etomidate and in 14 (29.8%) patients who received another sedative (P ≤ .001). There were no statistically significant differences in secondary objectives. CONCLUSION: Etomidate use for induction of anesthesia during RSI was associated with clinically significant hypotension when compared to other sedatives. The hypotension was transient and did not translate into statistically significant differences in the secondary clinical endpoints.

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Nerve agents are extremely toxic and are some of the most lethal substances on earth. This group of chemicals consists of sarin, cyclosarin, soman, tabun, VX, and VR. It is currently unknown how many countries possess these chemicals and in what quantities. These agents work through altering the transmission and breakdown of acetylcholine by binding to, and inactivating, acetylcholinesterase. This results in an uncontrolled and overwhelming stimulation of both muscarinic and nicotinic receptors. Receptor activation at these sites can lead to a wide variety of clinical symptoms, with death frequently resulting from pulmonary edema. Antidotal therapy in this setting largely consists of atropine, pralidoxime, and benzodiazepines, all of which must be administered emergently to limit the progression of symptoms and prevent the enzyme inactivation from becoming permanent. This article reviews the mechanism of action of the nerve agents and their effects on the human body, the currently available therapies to mitigate their impact, and important therapeutic considerations for health care practitioners in the emergency department.

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Medication errors are an all-too-common occurrence in emergency departments across the nation. This is largely secondary to a multitude of factors that create an almost ideal environment for medication errors to thrive. To limit and mitigate these errors, it is necessary to have a thorough knowledge of the medication-use process in the emergency department and develop strategies targeted at each individual step. Some of these strategies include medication-error analysis, computerized provider-order entry systems, automated dispensing cabinets, bar-coding systems, medication reconciliation, standardizing medication-use processes, education, and emergency-medicine clinical pharmacists. Special consideration also needs to be given to the development of strategies for the pediatric population, as they can be at an elevated risk of harm. Regardless of the strategies implemented, the prevention of medication errors begins and ends with the development of a culture that promotes the reporting of medication errors, and a systematic, nonpunitive approach to their elimination.

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BACKGROUND: Escherichia coli (E. coli) is a frequent uropathogen in urinary tract infections (UTI). Widespread resistance to sulfamethoxazole-trimethoprim (SMX-TMP) and increasing resistance to fluoroquinolones amongst these isolates has been recognized. There are limited data demonstrating risk factors for resistance to both SMX-TMP and fluoroquinolones. OBJECTIVE: This study was conducted to assess for the prevalence of community resistance amongst E. coli isolates to SMX-TMP and levofloxacin in ambulatory patients discharged from the emergency department (ED). METHODS: Adults presenting for evaluation and discharged from the ED with a diagnosis of an E. coli UTI were retrospectively reviewed. Utilizing demographic and clinical data the prevalence of E. coli resistance and risk factors associated with SMX-TMP- and fluoroquinolone-resistant infection were determined. RESULTS: Among the 222 patients, the mean rates of E. coli susceptibility to levofloxacin and SMX-TMP were 82.4% and 72.5%, respectively. Significant risk factors for resistance to SMX-TMP included prior antibiotic use (p=0.04) and prior diagnosis of UTI (p= 0.01). Significant risk factors for resistance to levofloxacin included: male gender, age, presence of hypertension, diabetes, chronic respiratory disease, nursing home resident, previous antibiotic use, previous diagnosis of UTI, existence of renal or genitourinary abnormalities, and prior surgical procedures (p <0.05 for all comparisons). The number of hospital days prior to initial ED evaluation (p<0.001) was determined to be a predictive factor in hospital and ED readmission. CONCLUSIONS: These results suggest that conventional approaches to monitoring for patterns of susceptibility may be inadequate. It is imperative that practitioners develop novel approaches to identifying patients with risk factors for resistance. Identification of risk factors from this evaluation should prompt providers to scrutinize the use of these agents in the setting of patients presenting with an uncomplicated UTI in the ED.

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Evidence that acute injury and critical illness can result in an elevation of blood glucose levels is not a new concept. However, the last decade has seen a rise in publications describing the potential harm of this unique form of hyperglycemia and the subsequent benefits of glucose control. More recently, the untoward effects of tightly controlling glucose concentrations in this setting have been more thoroughly elucidated. This has lead to a challenging clinical conundrum for practitioners both inside and outside of the intensive care unit. The latest guidelines attempt to shed light on this dilemma and provide guidance for practitioners. This article reviews the progression of the research, the multiple guidelines that have been published, and the clinical implications on the treatment of critical illness hyperglycemia, with particular focus on the emergency department.

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Background: Escherichia coli (E. coli) is a frequent uropathogen in urinary tract infections (UTI). Widespread resistance to sulfamethoxazoletrimethoprim (SMX-TMP) and increasing resistance to fluoroquinolones amongst these isolates has been recognized. There are limited data demonstrating risk factors for resistance to both SMX-TMP and fluoroquinolones. Objectives: This study was conducted to assess for the prevalence of community resistance amongst E. coli isolates to SMX-TMP and levofloxacin in ambulatory patients discharged from the emergency department (ED). Methods: Adults presenting for evaluation and discharged from the ED with a diagnosis of an E. coli UTI were retrospectively reviewed. Utilizing demographic and clinical data the prevalence of E. coli resistance and risk factors associated with SMX-TMP- and fluoroquinolone-resistant infection were determined. Results: Among the 222 patients, the mean rates of E. coli susceptibility to levofloxacin and SMX-TMP were 82.4% and 72.5%, respectively. Significant risk factors for resistance to SMX-TMP included prior antibiotic use (p=0.04) and prior diagnosis of UTI (p= 0.01). Significant risk factors for resistance to levofloxacin included: male gender, age, presence of hypertension, diabetes, chronic respiratory disease, nursing home resident, previous antibiotic use, previous diagnosis of UTI, existence of renal or genitourinary abnormalities, and prior surgical procedures (p <0.05 for all comparisons). The number of hospital days prior to initial ED evaluation (p<0.001) was determined to be a predictive factor in hospital and ED readmission. Conclusions: These results suggest that conventional approaches to monitoring for patterns of susceptibility may be inadequate. It is imperative that practitioners develop novel approaches to identifying patients with risk factors for resistance. Identification of risk factors from this evaluation should prompt providers to scrutinize the use of these agents in the setting of patients presenting with an uncomplicated UTI in the ED (AU)

Antecedentes: Escherichia coli (E. coli) es un uropatogeno frecuente en infecciones del tracto urinario (UTI). Se ha reconocido la resistencia generalizada al sulfametoxazol-Trimetoprim (SMX-TMP) y la resistencia creciente a fluoroquinolonas entre los aislados. Hay datos limitados que muestren los factores de riesgo para la resistencia tanto a SMX-TMP como a fluoroquinolonas. Objetivos: Este estudio fue realizado para evaluar la prevalencia de resistencia en la comunidad en aislamientos de E. coli a SMX-TMP y levofloxacino en pacientes ambulatorios dados de alta en un servicio de urgencias (ED). Métodos: Se revisó retrospectivamente a los adultos que se presentaron para evaluación y fueron dados de alta del ED con un diagnóstico de una UTI con E. coli. Utilizando datos demográficos y clínicos se calculó la prevalencia de resistencias a E. coli y los factores de riesgo asociados a infecciones resistentes a SMX-TMP y fluoroquinolonas. Resultados: Entre los 222 pacientes, las tasas medias de susceptibilidad a levofloxacino y SMXTMP fueron de 82,4% y 72,5%, respectivamente. Los factores de riesgo significativos para la resistencia a SMX-TMP incluían el uso previo del antibiótico (p=0,04) y el diagnóstico previo de UTI (p=0,01). Los factores de riesgo significativos para resistencia a levofloxacino incluían sexo masculino, edad, presencia de hipertensión, diabetes, enfermedad respiratoria crónica, vivir en residencia de ancianos, uso previo del antibiótico, diagnóstico previo de UTI, existencia de anomalías renales o genitourinarias , y cirugías previas (p<0,05 para todas las asociaciones). El número de días anteriores a la evaluación inicial en el ED (p<0,001) se identificó como un factor predictivo de readmisión hospitalaria y al ED. Conclusiones: Estos resultados sugieren que los abordajes convencionales para monitorizar los patrones de susceptibilidad pueden ser inadecuados. Es necesario que los facultativos desarrollen nuevos abordajes para identificar pacientes con factores de riesgo de resistencias. La identificación de los factores de riesgo para esta evaluación debería impulsar a los profesionales a examinar el uso de estos antibióticos en los pacientes que presentan una UTI no complicada en el ED (AU)

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The rabies virus is transmitted through exposure to infected saliva during either a bite or direct contact with mucosal tissues. Infection with this virus results in a progressive encephalitis, ultimately leading to coma, end-organ damage, and death. Because rabies-associated mortality is strikingly high, preventing viral transmission associated with an exposure is paramount. Fortunately, 2 available options exist for this purpose and include the rabies vaccine and the associated immunoglobulin. Patients presenting for consideration of rabies postexposure prophylaxis constitute a frequent complaint seen in the emergency department (ED) in most geographical areas. Management of these patients should be guided by an accurate and thorough discussion of the circumstances surrounding their exposure to attain maximum pharmacological benefit and avoid viral transmission. This article provides an overview of the practice recommendations surrounding rabies virus prophylaxis and their associated pharmacological characteristics in the ED.

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Rabies is a devastating encephalitis caused by RNA viruses that use mammals as reservoirs. In the United States, most naturally acquired human cases have come from bats. The use of appropriate preexposure and postexposure prophylaxis can be nearly 100% effective. If prophylaxis is not used, or is implemented incorrectly, the patient may develop clinical rabies, which is almost universally fatal. All health care practitioners should be familiar with the appropriate evaluation of patients presenting with a possible rabies exposure and ensure that expeditious and appropriate prophylaxis is provided to help prevent the development of this lethal disease.

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Rapid sequence intubation is a stepwise process developed to assist health care providers in placing emergent artificial airways for patients requiring assisted ventilation. This practice includes routine administration of sedative and neuromuscular blocking agent (NMBA) medications for patient comfort during endotracheal tube placement. Members of the multidisciplinary team should be well educated about the various medications used during this process to ensure safe medication practices in an emergent situation. Recent drug shortages have forced many health care professionals to use alternative medications with which they are less familiar. The intent of this review is to familiarize health care providers with the pharmacology and adverse effect profiles of alternative sedative and NMBA medications used in emergent airway placement in light of recent drug shortages.

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PURPOSE: Health care-associated pneumonia (HCAP) is a serious infection dependent on proper treatment that often presents in the emergency department (ED) and deviation from treatment guidelines appears to be high. This study was conducted to evaluate the impact of emergency medicine pharmacists (EPhs) on adherence of empiric antibiotic therapy to guideline recommendations. METHODS: A retrospective chart review of adult patients with HCAP who presented to an academic medical center ED from September 1, 2008 to June 30, 2010 was conducted. The control group included those patients with HCAP who presented to the ED outside of the EPhs' hours (23:00-13:00), and the treatment group consisted of those patients who presented during the EPhs' hours (13:00-23:00). RESULTS: The 81 patients presenting inside the EPhs' hours were significantly more likely to receive guideline adherent empiric antibiotics than the 70 patients presenting outside the EPhs' hours (49.38% vs 25.7%, P = .005). Also, patients in the treatment group received antibiotics in a shorter amount of time (11.37 vs 15.56 hours, P = .272) and at more appropriate doses (85.2% vs 77.1%, P = .29) although these outcomes were not statistically significant. CONCLUSION: The presence of the EPh significantly increased the likelihood of at-risk patients receiving empiric antimicrobial therapy consistent with guideline recommendations.

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PURPOSE: To describe the role that an emergency medicine (EM) clinical pharmacist has on the management of patients presenting to the emergency department (ED) with sepsis, severe sepsis, or septic shock. METHODS: The clinical consultations documented by the EM pharmacists at an academic, teaching hospital over a 2-year period were retrospectively reviewed. RESULTS: During the study period, a total of 585 consultations were provided by the EM pharmacists to 130 patients who presented to the ED with a diagnosis of sepsis, severe sepsis, or septic shock. Dosing recommendations were the most frequent consultations provided (n = 309, 53%), followed by the addition of appropriate empiric antibiotics (n = 131, 22%) and medication preparation (n = 108, 19%). Antibiotics (n = 307, 83%) and vasopressors (n = 31, 8%) were the medication classes regularly involved in EM pharmacist consultations. Vancomycin (n = 90, 28%) and norepinephrine (n = 15, 48%) were the most common agents involved in these consultations. CONCLUSION: A clinical EM pharmacist has multiple roles in the early management of patients presenting with sepsis, severe sepsis, or septic shock in the ED. Most commonly, they have a role in optimizing empiric antibiotic selection and dosing; thereby ensuring adequate antimicrobial coverage in this complex patient population.

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Acutely agitated and combative patients are commonly seen and evaluated by health care providers in the emergency department. Treatment options have evolved significantly in recent years with the advent of intramuscular atypical antipsychotics and an expanded repertoire of patient-friendly oral formulations. Selection of the ideal pharmacologic treatment of an acutely agitated patient strengthens the patient-prescriber relationship and promotes adherence to future therapy. In this article, advantages and disadvantages of various treatment modalities for undifferentiated, psychotic, and nonpsychotic agitation are reviewed, including alternatives to the commonly prescribed haloperidol and lorazepam combination. Atypical antipsychotics may be superior in certain patients, with the added benefit of easier conversion to maintenance therapy. Special consideration is given to the treatment of acutely agitated geriatric patients suffering from delirium and/or dementia. Management of these patients should be guided by etiology and patient characteristics to obtain maximum therapeutic benefit. Although emergency department providers may only see a given patient once, the health care team must have an evidence-based approach to the care that is provided in the emergency department, as it can significantly influence the patient's overall course of treatment in the outpatient setting.

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Acute stroke is a common presentation to emergency departments and is the third leading cause of death in the United States. Despite the frequency of this event, and its substantial morbidity and mortality, few therapies exist to limit the damage from this devastating diagnosis. One pharmacotherapy for ischemic stroke that has demonstrated efficacy in this setting is tissue plasminogen activator (Activase; tPA; alteplase). Current guidelines for this agent recommend its use within the first 3 hr of the onset of stroke symptoms in patients who meet specified criteria. However, more recent data have lead to recommending the extension of this time frame to 4.5 hr after onset of symptoms in specific patient populations. Although this therapy has demonstrated efficacy in improving outcomes, its use is often complicated by complex inclusion and exclusion criteria, risk of hemorrhage, requirement for intense patient monitoring, substantial cost, and the potential for devastating medication errors.

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STUDY OBJECTIVE: To evaluate the safety and cost-effectiveness of a clinical protocol adopted in June 2006 that included a comprehensive, objective assessment of snake bite envenomations and standardized the use of Crotalidae polyvalent immune Fab antivenom (FabAV). DESIGN: Retrospective medical record review. SETTING: Academic medical center that serves as the regional level I trauma center. PATIENTS: Seventy-five adults treated with FabAV for snake envenomations in the emergency department between June 1, 2003, and June 1, 2009; 30 patients received treatment according to the protocol (treatment group), and 45 patients received treatment that did not adhere to the protocol (control group). MEASUREMENTS AND MAIN RESULTS: Demographic and envenomation characteristics, as well as treatment details, were collected for all patients. In addition, information on quantity of FabAV vials required, length of hospital stay, and length of intensive care unit stay were compared between the treatment and control groups. In the treatment group, significantly fewer vials of FabAV were used (2.5 vs 4.727 vials, p=0.007). This decreased in usage correlated to a cost savings of approximately $2000/patient. Despite no significant difference in the severity of the envenomations between the two groups (p=0.379), the treatment group experienced a significantly shorter hospital length of stay (1.933 vs 2.791 days, p=0.030). No significant difference in the progression to fasciotomy or the development of allergic reactions was noted between the two groups. CONCLUSION: Use of a clinical protocol related to snake envenomations resulted in approximately two fewer vials of FabAV required for each patient. In addition, the treatment group experienced a shorter hospital length of stay without a corresponding increase in adverse events or envenomation progression. Data show that use of the protocol was cost-effective. The development of institution-specific multidisciplinary protocols regarding snake bite envenomations is recommended. Clinical pharmacists can play a vital role in the protocol development to ensure that optimal care is provided for this distinct patient population.

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Appropriate selection and utilization of vasopressor therapy are important in the treatment of vasodilatory shock, because inappropriate use can result in increased morbidity and mortality. Vasopressors are differentiated on the basis of their receptor activity, as well as their pharmacokinetic and pharmacodynamic properties. Understanding the pathophysiology of receptor responses in shock, dose-dependent receptor activity variations, and unique patient-specific factors that alter response, all assist the health care provider in selecting the appropriate agent for each patient. Treatment is further individualized on the basis of clinical response and medication titration, as well as laboratory value changes. The intent of this review is to discuss relevant management issues associated with vasopressor use in the emergency department.

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STUDY OBJECTIVE: The primary objective of this study is to determine the activities of pharmacists that lead to medication error interception in the emergency department (ED). METHODS: This was a prospective, multicenter cohort study conducted in 4 geographically diverse academic and community EDs in the United States. Each site had clinical pharmacy services. Pharmacists at each site recorded their medication error interceptions for 250 hours of cumulative time when present in the ED (1,000 hours total for all 4 sites). Items recorded included the activities of the pharmacist that led to medication error interception, type of orders, phase of medication use process, and type of error. Independent evaluators reviewed all medication errors. Descriptive analyses were performed for all variables. RESULTS: A total of 16,446 patients presented to the EDs during the study, resulting in 364 confirmed medication error interceptions by pharmacists. The pharmacists' activities that led to medication error interception were as follows: involvement in consultative activities (n=187; 51.4%), review of medication orders (n=127; 34.9%), and other (n=50; 13.7%). The types of orders resulting in medication error interceptions were written or computerized orders (n=198; 54.4%), verbal orders (n=119; 32.7%), and other (n=47; 12.9%). Most medication error interceptions occurred during the prescribing phase of the medication use process (n=300; 82.4%) and the most common type of error was wrong dose (n=161; 44.2%). CONCLUSION: Pharmacists' review of written or computerized medication orders accounts for only a third of medication error interceptions. Most medication error interceptions occur during consultative activities.

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Positive outcomes of antimicrobial stewardship programs in the inpatient setting are well documented, but the benefits for patients not admitted to the hospital remain less clear. This report describes a retrospective case-control study of patients discharged from the emergency department (ED) with subsequent positive cultures conducted to determine whether integrating antimicrobial stewardship responsibilities into practice of the emergency medicine clinical pharmacist (EPh) decreased times to positive culture follow-up, patient or primary care provider (PCP) notification, and appropriateness of antimicrobial therapy. Pre- and post-implementation groups of an EPh-managed antimicrobial stewardship program were compared. Positive cultures were identified in 177 patients, 104 and 73 in pre- and post-implementation groups, respectively. Median time to culture review in the pre-implementation group was 3 days (range 1-15) and 2 days (range 0-4) in the post-implementation group (P = .0001). There were 74 (71.2%) and 36 (49.3%) positive cultures that required notification in the pre- and post-implementation groups, respectively, and the median time to patient or PCP notification was 3 days (range 1-9) and 2 days (range 0-4) in the 2 groups (P = .01). No difference was seen in the appropriateness of therapy. In conclusion, EPh involvement reduced time to positive culture review and time to patient or PCP notification when indicated.

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Toxicology screens are used to detect the presence of prescription, nonprescription, or illicit substances. These tests are used in emergency situations to detect intentional or accidental overdose, to monitor drug dependency, and to screen for medical or legal purposes. An initial immunoassay reports qualitative results based on established cut-off concentrations. As a screening test, the initial immunoassay is less sensitive and therefore must be interpreted in the context of confounding variables such as the testing method, the substance being screened, and patient-specific characteristics. Either gas chromatography or high-performance liquid chromatography can be used to confirm positive results.

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Out-of-hospital cardiac arrest continues to be associated with high morbidity and mortality as the mortality rate has been documented to be as high as 90% in patients who experience the insult at home. For those who survive, more than 50% will have some form of brain damage. Despite the devastation of this event, therapeutic options for improving outcomes in this population are unfortunately limited. However, therapeutic hypothermia has been evaluated in 2 landmark randomized, controlled trials in patients who experienced an out-of-hospital cardiac arrest with the results showing an improvement in both neurologic outcomes and mortality. Providers must be familiar with the rationale behind the therapy, the physiological effects of the cooling and rewarming processes, and the pharmacologic management that aides in improved outcomes and minimizes complications.

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