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PURPOSE: To summarize recently published research reports and practice guidelines on emergency medicine (EM)-related pharmacotherapy. SUMMARY: Our author group was composed of 14 EM pharmacists, who used a systematic process to determine main sections and topics for the update as well as pertinent literature for inclusion. Main sections and topics were determined using a modified Delphi method, author and peer reviewer groups were formed, and articles were selected based on a comprehensive literature review and several criteria for each author-reviewer pair. These criteria included the document "Oxford Centre for Evidence-based Medicine - Levels of Evidence (March 2009)" but also clinical implications, interest to reader, and belief that a publication was a "key article" for the practicing EM pharmacist. A total of 105 articles published from January 2011 through July 2018 were objectively selected for inclusion in this review. This was not intended as a complete representation of all available pertinent literature. The reviewed publications address the management of a wide variety of disease states and topic areas that are commonly found in the emergency department: analgesia and sedation, anticoagulation, cardiovascular emergencies, emergency preparedness, endocrine emergencies, infectious diseases, neurology, pharmacy services and patient safety, respiratory care, shock, substance abuse, toxicology, and trauma. CONCLUSION: There are many important recent additions to the EM-related pharmacotherapy literature. As is evident with the surge of new studies, guidelines, and reviews in recent years, it is vital for the EM pharmacist to continue to stay current with advancing practice changes.
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Medicina de Emergencia/organización & administración , Farmacéuticos/organización & administración , Servicio de Farmacia en Hospital/organización & administración , Servicio de Urgencia en Hospital/organización & administración , Medicina Basada en la Evidencia , Humanos , Guías de Práctica Clínica como Asunto , Rol ProfesionalRESUMEN
Ketamine is utilized often in the emergency department (ED) for rapid sequence intubation, procedural sedation, and acute pain management. The treatment of migraine headache in the ED varies widely and is dependent on several factors including migraine cause, previous successful abortive methods, and provider preference. Several medications are currently employed to treat acute migraine including nonsteroidal anti-inflammatory drugs, triptans, antihistamines, prochlorperazine, and corticosteroids, among others. Interest in ketamine as an abortive agent to treat migraine has increased as evidenced by recent studies evaluating its use in the ED. This review examines the data regarding the use of ketamine to treat migraine headache. The concept of treating migraine headache with ketamine has been studied for more than 20 years. Early studies conducted primarily in the outpatient setting evaluated ketamine through multiple routes of administration and differing migraine causes with varying results. These early data seem to suggest that ketamine provides relief from headache severity but provides little information regarding the optimal dose and route of administration. Recent active comparator and placebo-controlled trials in the ED utilizing subdissociative doses of ketamine (0.2-0.3 mg/kg intravenously) show conflicting results. To confound the decision regarding its use further, ED providers encounter differing recommendations regarding its place in therapy. Current data suggest that ketamine may provide pain relief to patients with migraine headache. Although there may be a role for ketamine in certain cases after more robust evidence becomes available, currently it is premature to incorporate ketamine into routine use. Several questions remain to be answered including its overall efficacy, place in therapy, dosage, and risk of undesirable side effects.
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Analgésicos/administración & dosificación , Servicio de Urgencia en Hospital , Ketamina/administración & dosificación , Trastornos Migrañosos/tratamiento farmacológico , Humanos , Manejo del Dolor , Dimensión del DolorRESUMEN
Ayahuasca is a hallucinogenic tea that is most commonly comprised of the vine Banisteriopsis caapi alone or in combination with other plants such as Psychotria viridis. This concoction results in an orally active form of dimethyltryptamine (DMT), a hallucinogenic amine. Despite use in South America as a medicinal agent and component in religious ceremonies, interest in its recreational use and spiritual effects has led to increased use in the United States. We describe a unique case following ingestion of ayahuasca tea in a patient with history of schizophrenia resulting in personal injury and property damage. A review of ayahuasca toxicity and evaluation of serious adverse effects is also presented.
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PURPOSE: To characterize hypoglycemia management and identify characteristics associated with refractory (need for additional treatment following initial management) and recurrent (adequate initial treatment followed by blood glucose [BG] ≤50 mg/dL) hypoglycemia. METHODS: Retrospective review of adult emergency department (ED) patients who presented to a large academic medical center with hypoglycemia (BG ≤ 50 mg/dL) between January 2011 and July 2015. Data collection focused on BG measurements and treatment practices. Data are reported using descriptive statistics, Wilcoxon rank sum, and χ2 analysis as appropriate. RESULTS: Two hundred forty-four patients were included (mean age, 59 ± 18.7 years; weight, 85 ± 24.3 kg). Patients arriving via prehospital care (n = 124) were assessed faster in the ED (median, 25 minutes; interquartile range [IQR], 10-40 minutes) compared with ambulatory arrival (median, 43 minutes; IQR, 17-95 minutes; P = .0018). There were 174 patients with a BG ≤ 50 mg/dL in the ED. Of those, 108 (62.1%) were treated with intravascular bolus dextrose/intramuscular glucagon and 21 patients (12%) did not receive any treatment or food. The overall median time to treatment after identification of hypoglycemia was 12 minutes (IQR, 6-27.8 minutes); treatment was administered faster after bedside point-of-care testing assessment compared with when serum samples resulted (11 [IQR, 6-23.5] minutes vs 25 [IQR, 10.75-42.5] minutes, respectively; P = .015). The overall time to repeat BG was obtained 22 (IQR, 8-44) minutes after bolus treatment, but this interval increased with subsequent measurements. Refractory or recurrent hypoglycemia occurred in 30.3% of patients. Mean initial BG was lower in the subset of patients who developed refractory hypoglycemia compared with those who did not (35.1 ± 9.8 vs 37.6 ± 10.2 mg/dL, P = .079), although not statistically significant. Patients with recurrent hypoglycemia were also less likely to receive dextrose containing intravenous fluids compared with those without recurrent hypoglycemia (P = .028). Infection was the only associated characteristic with refractory or recurrent hypoglycemia (P = .021). CONCLUSIONS: Overall, 12% of patients did not receive treatment for hypoglycemia in the ED with a BG ≤ 50 mg/dL. Time to treatment after identification was faster when identified by care testing vs serum sample result. Time to repeat BG in the ED was relatively quick, but did increase over time. About one-third of patients had refractory or recurrent hypoglycemia and infection was associated with this occurrence. Lack of dextrose containing intravenous fluid was associated with the incidence of recurrent hypoglycemia.