1. Nora Gharib and Nick Khanna

2.  Introduction  Statistics  Emergency Room Medications  Common Cases in ER  Patient Cases  The role of a Pharmacist in the ER  Conclusion

3.  A hospital department focusing on the acute care of patients that present without a prior appointment  This department must be prepared to provide initial treatment for a wide array of illnesses and injuries (some of which may be life- threatening and require immediate attention)  Open to the public 24 hours a day (although staff levels usually vary)

4.  Usually placed in its own section of the first floor of the hospital, with its own separate dedicated entrance  Prioritization of cases based on clinical need – achieved through the application of triage.

5.  First stage the patient encounters  Consists of a brief assessment, set of vital signs, and the assignment of a chief complaint  Usually completed by an emergency nurse  After initial assessment, patients can be passed to another area of the department or hospital,  A patients’ wait time is based on their clinical need.

6.  Exceptions: minor ailments may be treated at the initial triage stage  Patients with apparently serious/severe conditions can bypass triage and move to a more appropriate department immediately

7.  This is the area where the most seriously ill or injured patients will be treated  Important to contain the tools, staff and medication necessary for handling immediately life threatening illnesses and injuries  Typical staffing includes at least one physician and one nurse  May also include hospital pharmacists

8.  This department is appropriate for patients that are seriously ill, but not in immediate danger  Examples include chest pain, difficulty breathing, abdominal pain and neurological complaints  Advanced diagnostic testing completed here (lab tests, scans, MRI’s etc.)  Appropriate staff necessary

9.  This area is reserved for patients that do not have immediately life threatening conditions  Examples include fractures, dislocations and lacerations requiring suturing

10.  Results from the 2003 Canadian Community Health Survey  1/8 Canadians 15 or older reported that their most recent contact with a health professional occurred in a hospital ER  Rates of ER use highest among teens and young adults  In Ontario, administrative records for the year 2000 showed that trauma represented the largest proportion of all ER visits  Men were slightly more likely than women to have used ER services: 14% versus 12%.  ER use is inversely associated with household income.

11.  ER use was similar in the provinces and territories.(exceptions were higher use in New Brunswick, Nova Scotia and Yukon)  Residents of rural areas were more likely than urban dwellers to have used an ER  People who reported having a "regular doctor" were just as likely to report ER use as those that did not have a "regular" physician.  Those who had consulted a doctor more than five times in the past year were more likely to use an ER than people who went to the doctor less frequently.  Suggests that ER users are heavy users of other medical services, (need for ongoing care related to the health problem or injury?)

12.  Of the 2.4 million people whose most recent hospital visit had been in an ER, 73% reported receiving excellent or good care.  16% felt their care was fair  11%, felt their care was poor  Dissatisfaction with service may be related to over- crowding, waiting times or lack of understanding for the way hospitals prioritize treatment;  Statistically significant lower rates of dissatisfaction were reported by residents of Quebec and Yukon.  In Ontario, 24% of residents reported dissatisfaction with ER services (higher than the national rate!)

13.  Lidocaine  Epinephrine  Furosemide  Diazepam  Haloperidol  Succinylcholine  Atropine  Heparin  For an exhaustive list, see Feldman 2001

14.  Lidocaine: ◦ Can be used as a local anesthetic when injected subcutaneously (used for a nerve block). ◦ Used as an antidysrhythmic drug when injected IV (used to treat cardiac dysrhythmias). ◦ Anesthetic preparations come in 2 forms: with and without epinephrine.  Epinephrine ◦ Used in emergencies to stimulate the heart or dilate the bronchial tree. ◦ Use is limited by cardiac side effects. ◦ Can be mixed with lidocaine to prolong lidocaine’s effect and to control bleeding.

15.  Furosemide ◦ Acts as a diuretic, therefore allowing the patient to produce a greater volume of urine. ◦ Given to reduce the fluid overload in patients with CHF or hypertension. ◦ Can be given IV or PO.  Diazepam ◦ Benzodiazepine used as a powerful sedative and as an anti- convulsant for patients with seizures. ◦ Can be used for alcohol withdrawal, cocaine toxicity, and status epilepticus. ◦ Caution: Ability to produce respiratory depression.

16.  Haloperidol (Haldol) ◦ Antipsychotic, powerful sedative properties. ◦ Used for patients who are acting in a psychotic manner. ◦ Caution: Do not use to treat alcohol withdrawal or cocaine toxicity! Watch dosing, in large quantities can cause patient to become unconscious.  Succinylcholine ◦ Paralytic, leads to total muscular paralysis. ◦ Most often used for “rapid-sequence-intubation” to make tracheal intubation easier and to allow the patient to be mechanically ventilated. ◦ No analgesic properties, paralyzed patients still have the ability to see, hear and feel everything – therfore it is never used without sedation!

17.  Atropine ◦ Used to induce the heart to beat faster (i.e. chronotropy), as an antidote for certain organophosphate poisonings, or sometimes used as a drug for severe asthma.  Heparin ◦ Anticoagulant used to prevent blood from clotting. ◦ Used in patients suspected of having a myocardial infarction

18. 1. Stomach and abdominal pain, cramps, and spasms 2. Chest pain and related symptoms 3. Fever 4. Cough 5. Headache, pain in head 6. Back symptoms 7. Shortness of breath 8. Pain, site not referable to a specific body system 9. Vomiting 10. Symptoms referable to throat

19. A 53 old male arrives to the arrives to the emergency department (ER) with a myocardial infarction (heart attack). The following steps to treat this patient are taken: 1. Triaged to the resuscitation area 2. There he seen by an ER physician and receive oxygen and monitored and have an early ECG 3. Nurse will provide him with Aspirin (if not contraindicated or not already administered by the ambulance team); morphine or diamorphine will be given for pain; sublingual (under the tongue) or buccal (between cheek and upper gum) nitroglycerin (unless contraindicated by the presence of other drugs) 4. Following the ECG which reveals an ST segment elevation or new left bundle branch block suggests complete blockage of one of the main coronary arteries 5. Patients require immediate reperfusion (re-opening) of the occluded vessel 6. Two ways to accomplish this: thrombolysis (clot-busting medication) or percutaneous transluminal coronary angioplasty (PTCA). Both of these are effective in reducing significantly the mortality of myocardial infarction PTCA as it is somewhat more effective than thrombolysis if it can be administered early and being more accepted by most hospitals. Patient may need to be transferred to a nearby facility with facilities for angioplasty

20.  A 25 year old female comes into the ER department with acute exacerbations asthma. The following steps to treat this patient are taken: 1. She is assessed by triage nurse and treated with oxygen therapy, bronchodilators, steroids or theophylline 2. An urgent chest X-ray and arterial blood gases are ordered 3. ER Physician performs an overall assessment of patient from this information and makes a referral home or to the intensive care unit (ICU) if necessary

21.  As part of the interdisciplinary ED care team, pharmacists can provide care to critically ill patients by: ◦ gathering or reviewing medication histories and reconciling patients’ medications ◦ continuously assessing for and managing adverse drug reactions ◦ monitoring patient therapeutic responses (including laboratory values) ◦ monitoring for patient allergies and drug interactions ◦ providing drug information consultation to emergency physicians, emergency nurses, and other clinicians ◦ providing consultation on patient-specific medication dosage and dosage adjustments

22. ◦ providing patient and caregiver education, including discharge counseling and follow-up  Future Pharmacist ◦ offering vaccination screening, referral, and administration

23.  Statistics  Emergency Room Medications  Common Cases in ER  Patient Cases  The role of a Pharmacist in the ER

24.  Please feel free to post any questions on the discussion board (See LEARN)  Complete the Online Quiz ◦ Due March 25 th, 2013  Prepare for case presentations for next week’s class

25.  Carriere, Gisele. Use of hospital emergency rooms. Health Reports 16(1), 2004: 35-9.  Feldman, Henry. Common drugs used in the Emergency Room. 2001. Edited by Lewis Nelson, MD  Nawar, E.W., Niska, R.W., Xy, J. National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary. CDC Advance Data (386), 2007.  Elenbaas RM, Waeckerle JF, McNabney WK. The clinical pharmacist in emergency medicine. Am J Hosp Pharm. 1977; 34:843-6.