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Kyle A Weant,1 Abby M Bailey,2 Stephanie N Baker2 1North Carolina Public Health Preparedness and Response, North Carolina Department of Health and Human Services, Raleigh, NC, 2University of Kentucky HealthCare, Department of Pharmacy Services, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA Abstract: 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. Keywords: emergency medicine, pharmacy, medication errors, pharmacists, pediatrics

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.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

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. [ABSTRACT FROM AUTHOR]

The use of high-dose methylprednisolone in acute spinal cord injuries remains controversial. This article is the second of a 2-part series presenting the conflicting viewpoints of today's practitioners. Part 1 of this series appeared in the April 2010 issue. [ABSTRACT FROM AUTHOR]

The use of high-dose methylprednisolone in acute spinal cord injuries remains controversial. This article is the first of a 2-part series presenting the conflicting viewpoints of today's practitioners. Please see next month's article presenting the opposing side of the argument. [ABSTRACT FROM AUTHOR]

Introduction: Relative adrenal insufficiency has been shown to occur in the settings of critical illness and septic shock, impairing the body's ability to respond to stress. Studies have demonstrated that the treatment of adrenal insufficiency (AI) results in shock reversal, hemodynamic stability, and a subsequent decrease in mortality. Endocrine changes and AI have been reported in patients with spinal cord injuries during their extended courses of rehabilitation.Discussion: We describe two cases of patients with cervical spine injuries who presented with acute adrenal insufficiency following their injuries. With the addition of low-dose corticosteroids, each patient had symptom resolution and demonstrated clinical improvement.Conclusion: Patients with spinal cord injuries are at risk for AI, both in the acute and chronic settings following injury prompting the need for an increased awareness of this condition. Although variability exists in the exact criteria for the diagnosis of AI, the combination of clinical symptoms, depressed serum cortisol concentrations, and responsiveness to exogenous steroid therapy should all contribute to the diagnosis of this condition. [ABSTRACT FROM AUTHOR]

Cerebral edema is a significant cause of elevated intracranial pressure and a consequence of secondary injury following traumatic brain injury. The use of hyperosmolar agents has been theorized to reduce intracranial pressure through osmotic effects on the water content of the injured brain. The most commonly used agents for this purpose are mannitol and hypertonic saline. While these agents have demonstrated efficacy, prospective, randomized clinical data are somewhat limited. This article reviews the available data concerning the safety, efficacy, and monitoring of osmotic agents when used to treat elevated intracranial pressure. [ABSTRACT FROM AUTHOR]

Elevations in intracranial pressure often occur after traumatic brain injury. A limited array of medications is available for the treatment of intracranial hypertension. Metabolic suppression agents may be used in this situation to suppress electrical activity in the brain, diminish the cerebral metabolic rate of oxygen consumption, and, as a consequence, decrease cerebral blood volume and intracranial pressure. Propofol and pentobarbital have unique characteristics that make each desirable, yet difficult to use in the setting of traumatic brain injury. The subject of this review is to discuss the role of these agents in treating refractory elevated intracranial pressure through metabolic suppression. [ABSTRACT FROM AUTHOR]

Postoperative hypertension is a serious complication following surgery that can result in significant complications if left untreated. [ABSTRACT FROM AUTHOR]

Procedural sedation and analgesia is an essential activity in the emergency department for managing pain and anxiety during a variety of medical procedures. Various pharmacotherapy options, including opioid analgesics, antiemetics, anticholinergics, sedatives, and ketamine have been utilized, all with their unique efficacy and safety profiles. This review highlights the challenges associated with using certain agents and discusses emerging trends such as the use of newer synthetic opioids and the expanding use of dexmedetomidine. Overall, the selection of the optimal agents for procedural sedation and analgesia should be guided based on the unique characteristics of each agent tailored to the needs of the specific procedure, along with consideration for individual patient characteristics., Competing Interests: The authors have no conflict of interests to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Objective: Four-factor prothrombin complex concentrate (4F-PCC) is standard of care for emergent vitamin K antagonist (VKA) reversal but optimal dosing is uncertain. This meta-analysis estimated the proportion of patients treated with fixed dose (FD) 4F-PCC who achieved adequate reversal and compared safety and efficacy of FD versus weight-based dose (WB) strategies., Methods: This review was conducted according to PRISMA guidelines. Medline and Scopus were searched and included studies evaluating FD regimens and comparing FD and WB for emergent VKA reversal. Data was pooled using random effects. Subgroup analyses examined heterogeneity. Risk of bias was assessed with Newcastle-Ottawa Scale and RoB2 score., Results: Twenty-three studies (n = 2055) were included with twelve (n = 1143) comparing FD versus WB. The proportion of patients achieving goal INR with FD varied depending on the INR target, being significantly higher for INR <2 (90.9%, 95% Confidence Interval (CI) 87.2, 94.06) compared to INR <1.6 (70.97%, 95%CI 65.33, 76.31). Compared to WB, FD was less likely to achieve a goal INR <1.6 (Risk Difference (RD) -13%, 95% CI -21, -4) but achieved similar reversal for a goal INR <2.0, (RD -1%, 95%CI -7, 4). There was no difference in hospital mortality (RD 4%, 95%CI -2, 9) or thrombosis (RD 0.0%, 95%CI -3, 3)., Conclusion: FD VKA reversal was associated with significantly lower attainment of goal INR compared to WB with lower INR targets. This did not translate to differences in hospital mortality, but these results should be interpreted cautiously in light of the observational nature of the included studies., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: This article summarizes emerging nontraditional therapies administered via the nebulization route for use in the emergency department (ED)., Summary: Although traditional routes of medication administration (eg, intravenous) have been the mainstay of administration modalities for decades, these routes may not be appropriate for all patients. Nowhere is this more readily apparent than in the ED setting, where patients with a variety of presentations receive care. One unique route for medication administration that has increasingly gained popularity in the ED is that of aerosolized drug delivery. This route holds promise as direct delivery of medications to the site of action could yield a more rapid and effective therapeutic response while also minimizing systemic adverse effects by utilizing a fraction of the systemic dose. Medication administration via nebulization also provides an alternative that is conducive to rapid, less invasive access, which is advantageous in the emergent setting of the ED. This review is intended to analyze the existing literature regarding this route of administration, including the nuances that can impact drug efficacy, as well as the available literature regarding novel, noncommercial nebulized medication therapy given in the ED., Conclusion: Multiple medications have been investigated for administration via this route, and when implementing any of these therapies several practical considerations must be taken into account, from medication preparation to administration, to ensure optimal efficacy while minimizing adverse effects. The pharmacist is an essential bedside team member in these scenarios to assist with navigating unique and complex nuances of this therapy as they develop., (© American Society of Health-System Pharmacists 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Acute hyperkalemia is characterized by high concentrations of potassium in the blood that can potentially lead to life-threatening arrhythmias that require emergent treatment. Therapy involves the utilization of a constellation of different agents, all targeting different goals of care. The first, and most important step in the treatment of severe hyperkalemia with electrocardiographic (ECG) changes, is to stabilize the myocardium with calcium in order to resolve or mitigate the development of arrythmias. Next, it is vital to target the underlying etiology of any ECG changes by redistributing potassium from the extracellular space with the use of intravenous regular insulin and inhaled beta-2 agonists. Finally, the focus should shift to the elimination of excess potassium from the body through the use of intravenous furosemide, oral potassium-binding agents, or renal replacement therapy. Multiple nuances and controversies exist with these therapies, and it is important to have a robust understanding of the underlying support and recommendations for each of these agents to ensure optimal efficacy and minimize the potential for adverse effects and medication errors., Competing Interests: Disclosure: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Methadone is a mu-opioid agonist with a delayed time to peak concentration that requires an extended period of monitoring following an overdose. Available data suggests that the combination of psychostimulants with methadone may augment antinociception and tolerance to opioids. Case Report: A 26-year-old male (83.9 kg) presented to the ED approximately 1 hour after unintentionally ingesting 200-250 mg of liquid methadone and an energy drink, along with 20 mg of dextroamphetamine/amphetamine prior to the event. Vital signs were: blood pressure (BP), 143/91 mmHg; heart rate (HR), 74; respirations (RR), 16; oxygen saturation 95% on room air. His urine drug screen was positive for amphetamines and methadone. Patient was monitored for 4 hours with no change in status and was discharged home. Approximately 26 hours later patient was found cyanotic and apneic. Patient was given 2 mg of naloxone and awoke with normal mental status. On presentation the patient's vital signs were: BP, 114/70 mmHg; HR, 114; RR 16; oxygen saturation 94% on 3 liters nasal cannula. During his ED stay, he required 2 doses of naloxone secondary to oxygen desaturation and was admitted to the hospital. His repeat urine drug screen was positive for amphetamines and methadone. The patient was discharged the following day. Discussion: This case illustrates an unintentional methadone overdose combined with the intentional ingestion of an energy drink and dextroamphetamine/amphetamine that possibly masked the toxicity for over 24 hrs. Monitoring parameters for methadone overdoses may need re-evaluation in the setting of the co-ingestion of a stimulant.

The emergency department (ED) is a frequent utilizer of alternative routes of medication administration (e.g., intranasal) for a variety of indications. Over the last several years, investigations into the use of medications via the nebulization route have greatly increased, with varying degrees of efficacy identified. This route has multiple theoretical advantages. Medications affecting bronchopulmonary function or secretions can be administered directly to the site of action, possibly utilizing a lower dose and hence minimizing side effects. It is also possible to have a faster onset of action compared with other routes, given the enhanced surface area for absorption. One group of medications that has been explored via this route of administration, and is frequently administered in EDs across the nation, is opioids, most notably fentanyl, hydromorphone, and morphine. However multiple questions exist regarding the implementation of these therapies via this route, including efficacy, dosing, and the functional aspects of medication administration that are more complex than that of more traditional routes. The intent of this review is to explore the supporting literature behind the use of nebulized opioids, most specifically fentanyl, hydromorphone, and morphine, in the ED for the treatment of acute pain presentations and provide the most up-to-date guidance for practitioners., Competing Interests: Disclosure: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Acute bacterial skin and skin-structure infections (ABSSSIs) are frequent clinical presentations to emergency departments (EDs) across the nation that can require substantial resources to treat due to several factors. These include an increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) as the causative organism, limited availability of oral antibiotics that treat ABSSSIs secondary to MRSA, absorption and pharmacodynamic concerns with oral therapy, and regimen adherence. In patients who are unable to tolerate oral therapy, or are unable to adhere to prescribed antibiotics, inpatient admission for intravenous (IV) antibiotics may be necessary. Although inpatient IV antibiotics used to treat MRSA, such as vancomycin, are relatively inexpensive, hospital admission itself incurs significant associated costs. The introduction of the long-acting lipoglycopeptides, dalbavancin and oritavancin, has many potential advantages for the treatment of ABSSSIs including one- or two-dose regimens, allowing patients to receive their dose in the ED or infusion center and avoid inpatient admission altogether. Existing data have borne out these results, demonstrating that these agents can significantly reduce the length of hospital stay and the overall treatment cost of ABSSSIs. However, as these agents have nontraditional therapeutic regimens compared with alternative IV and oral agents that require consistent dosing, it is imperative to have decision support tools in place to ensure that this therapy is utilized in appropriate patients with ABSSSIs and that its true benefits can be realized for both the patient and the health care system., Competing Interests: Disclosure: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Literature has found that individuals with opioid use disorders have increased fasting insulin levels and that antagonism of the μ-receptor with naloxone blunted this hypoglycemic effect. We describe a 35-year-old woman with no history of diabetes who presented after being found unconscious where she was given naloxone and became awake and combative. Her blood glucose (BG) on presentation was 175 mg/dl, which declined to 40 mg/dl, and dextrose was administered. Subsequently, it declined to 42 mg/dl and was again given dextrose. Later her BG fell to 67 mg/dl and she was given dextrose and started on a dextrose infusion. She was then administered IV naloxone and 1 hr later the infusion was discontinued and she had no further hypoglycemic events. Clinicians should consider altering monitoring parameters in the setting of acute overdoses to include repeated glucose assessment to ensure early identification of hypoglycemia and the potential influence of naloxone., Competing Interests: Disclosure: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Emergency medicine pharmacists (EMPs) have been demonstrated to have a positive impact on patient outcomes in a variety of clinical scenarios in the emergency department (ED), yet their distribution across the nation is suboptimal. An emergency medicine pharmacy intensity score tool (EMPIST) would not only facilitate the quantification of EMP staffing needs and ideal resource deployment times, but would also allow practitioners to triage patient care activities. The purpose of this investigation was to develop an EMPIST and evaluate its relationship to EMP activities., Methods: This was a multicenter, prospective, observational analysis of an EMPIST developed by practicing EMPs. EMPs prospectively documented their clinical activities during usual care for patients in their ED. Spearman's rank-order correlation was used to determine any correlation between the EMPIST and pharmacist activities., Results: In total, 970 EMP activities and 584 EMPIST items were documented in 352 patients by 7 EMPs across 7 different EDs. The most commonly documented EMP interventions performed were bedside monitoring (12.7%), initiation of nonantimicrobial therapy (12.6%), and antimicrobial therapy initiation and streamlining (10.6%). The total EMPIST was found to significantly correlate with EMP activities, and this correlation was consistent across both "diagnostic/presentation" and "medication" items (P < 0.001 for all comparisons)., Conclusion: The EMPIST significantly correlated with EMP activities, with consistent correlation across all subgroups. Its utilization has the potential to enhance bedside clinical practice and optimize the deployment of limited EMP services. Additional investigations are needed to examine the validity of this tool and identify any relationship it may have to patient outcomes., (© American Society of Health-System Pharmacists 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Centers for Disease Control and Prevention (CDC) recommendations for the treatment of marine-associated wound infections include empiric coverage for Vibrio species with a combination of a third-generation cephalosporin and doxycycline. These recommendations are based on limited data and it remains unclear if this regimen is also indicated for prophylaxis., Objective: The purpose of this analysis was to assess the antibiotic regimens used in the emergency department (ED) for prophylaxis of marine-associated injuries relative to the CDC recommendations and evaluate any clinical impact., Methods: A retrospective review evaluated adult patients discharged from the ED over a 4-year period with an antibiotic prescription following an injury with marine exposure., Results: 114 patients were included in the analysis. The majority of patients were < 40 years of age with no previous medical history and presented after sustaining a laceration secondary to oyster shells. 97.4% received prophylactic antibiotic therapy that did not match the CDC recommendations, with the majority receiving doxycycline monotherapy (82%). A 1.8% 30-day ED revisit rate was noted with 2 patients returning for therapy failure. No patients were admitted to the hospital within 30 days and no documented adverse effects related to antibiotic therapy were noted., Conclusion: Current prophylactic antibiotic prescribing practices diverge from the current CDC recommendations for the treatment of marine-associated infections, however, an effect secondary to these variations was not observed. Further investigations of prophylaxis against Vibrio infections in low-risk patients is warranted to limit collateral damage and improve antimicrobial stewardship in the ED.

Status epilepticus (SE) is a frequent medical emergency that requires expedited treatment to avoid the ensuing high incidence of morbidity and mortality associated with prolonged seizures. Protracted seizure duration itself has the potential to result in maladaptive neuronal responses that can not only further increase seizure duration and worsen clinical outcomes but also lead to reduced responsiveness to pharmacotherapy. Benzodiazepines are consistently recommended as first-line treatment due to their rapid onset and efficacy in terminating seizures, followed by the emergent administration of an antiepileptic drug (AED). Various benzodiazepine and AED options are recommended and can be utilized in this setting, all with their own unique advantages and challenges. With time at a premium, agents should be selected that can be rapidly administered and have an advantageous pharmacokinetic profile in order to limit seizure duration and optimize outcomes. The intent of this review is to provide an outline of the importance of time-to-treatment implementation in this setting, assess the landscape of options that may provide timing advantages, and examine potential strategies for deploying expeditious therapy., Competing Interests: Disclosure: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Urinary tract infections (UTIs) are one of the most common indications for antimicrobial use in the emergency department (ED). Appropriate empiric selection is crucial to ensure optimal care while limiting broad-spectrum antibiotic use. The primary objective of this study was to evaluate the relationship between patient-specific risk factors and drug resistant urinary pathogens in patients discharged from the ED and followed by Emergency Medicine Pharmacists (EMPs). Methods: This was a single-center, retrospective chart review of adult (≥18 years old) patients with positive urine cultures discharged from the ED. The association between risk factors and pathogen resistance to ≥1 classes of antibiotics was evaluated using multivariate logistic regression. Risk factors included the following: hospitalization within the previous 30 days, intravenous antibiotic use within 90 days, diabetes, clinical atherosclerotic cardiovascular disease, psychiatric disorder, dementia, current antibiotic use for any indication, previous lifetime history of UTIs, indwelling or intermittent catheterization, hemodialysis, previous lifetime history of a urologic procedure, urinary tract abnormality, immunosuppressive disease or medications, current residence in a nursing or rehabilitation facility, and history of a multidrug resistant organism (MDRO). Results: A total of 1018 patients were included. There was an increase in the odds of antibiotic resistance in patients with cystitis and ≥2 risk factors (Odds Ratio [OR] = 1.70, 95% CI = 1.24-2.32). In those with pyelonephritis, there was a non-significant increase in the odds of resistance for those with ≥2 risk factors (OR = 1.83, 95% CI = 0.98-3.42). Patients with pyelonephritis discharged on inappropriate antibiotics were more likely to return to the ED within 30 days ( P  = .03). Conclusions: For patients with cystitis discharged from the ED, those with ≥2 patient-specific risk factors had significantly increased odds of antibiotic resistance. Patients with pyelonephritis, but not cystitis, who were discharged on inappropriate antibiotics were more likely to return to the ED within 30 days. In conjunction with an EMP culture follow-up program, the identification of risk factors for antimicrobial resistance can be used to design more patient-specific empiric antibiotic selections., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Introduction: Tramadol is an opioid analgesic that binds to mu-opioid receptors and inhibits the uptake of norepinephrine and serotonin. Through its activation of these receptors, it has potential to increase the utilization of glucose and/or decrease hepatic gluconeogenesis., Case Report: A 55-year-old male presents to the Emergency Department (ED) via Emergency Medical Services (EMS) following a self-reported overdose of alprazolam, lorazepam, acetaminophen with codeine, and tramadol. During EMS transport, the patient was found to be hypoglycemic with a glucose of 30 mg/dL and was administered 25 grams of intravenous (IV) dextrose 50% in water. The patient had no past medical history of diabetes mellitus, hypoglycemia, or hyperglycemia and was normoglycemic on his prior presentations to our facility 3 months and 2 years prior. Subsequent analysis found that the patient was negative for acetaminophen, ethanol, salicylates, tricyclics, and lithium. His urinalysis was positive for opiates and benzodiazepines. Upon arrival to the ED, the patient's blood glucose was 131 mg/dL but subsequently dropped to 73 mg/dL, necessitating the initiation of continuous IV fluids containing dextrose. These fluids were discontinued 3.5 hrs later and the patient was discharged 16 days later., Discussion: This case illustrates that hypoglycemia can be a presenting symptom in patients with an acute overdose of tramadol with no previous history of glycemic dysregulation. Upon presentation it is important to closely monitor serum glucose concentrations to identify hypoglycemia early in order to initiate necessary hypoglycemia protocols.

Patients with hematological malignancies, both treated and untreated, or solid tumors undergoing treatment are at risk of life-threatening complications, which may present in the emergency department (ED). Such emergencies are diverse in etiology and often require prompt treatment. Traditional complications, such as febrile neutropenia, have had recent guideline updates, which incorporate new evidence and a new validated risk stratification tool. In addition, newer approaches to treatment, such as chimeric antigen receptor (CAR) T-cell therapy, are becoming more widely available and have unique associated toxicities. This review discusses the management of the following hematological and oncological emergencies likely to be encountered in the ED: febrile neutropenia, CAR T-cell toxicities, differentiation syndrome, tumor lysis syndrome, hypercalcemia of malignancy, and hyponatremia., Competing Interests: Disclosure: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Rabies post-exposure prophylaxis (rPEP) in the emergency department (ED) is associated with high costs, complicated administration protocols, and a time-sensitive vaccination series that often requires ED follow-up visits for subsequent vaccine administration. This study sought to characterize the number of redirected vaccine administrations in those patients referred to ID Clinic, guideline compliance, and opportunities for improvement. Methods: Retrospective chart review of adult and pediatric patients presenting to the ED from 2016 to 2019 and prescribed rabies immunoglobulin. Results: Of the 89 patients included, 66.3% were referred to ID Clinic. Those referred to clinic had significantly fewer average visits to the ED for repeat vaccination ( P  < .001). Of the 177 vaccinations prescribed for patients referred, 105 were administered in clinic. Overall, having insurance significantly increased the odds of completing the prescribed vaccination series (Odds Ratio (OR) = 4.34, 95% Confidence Interval (CI) = 1.34 to 15.52). Among those patients referred to clinic, having insurance significantly increased the odds of receiving any follow-up doses in clinic (OR = 6.00, 95% CI = 1.48 to 25.98), receiving all of their prescribed follow-up doses in clinic (OR = 10.00, 95% CI = 1.72 to 190.80), and completing the entirety of their vaccination series (OR = 5.89, 95% CI = 1.50 to 26.21). Conclusions: The use of an ID Clinic referral process for rPEP resulted in a significant reduction in the average number of visits to the ED for repeat vaccination, hence avoiding 105 ED visits. Insurance status was a significant factor in both the utilization of the ID Clinic referral system and overall completion of the vaccination series. Future research should explore workflows inclusive of both ED care and outpatient follow-up, care plans for the uninsured, and mechanisms to limit the number of patients that fail to complete the recommended vaccination series., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

Objectives: The pediatric emergency department (PED) is an especially high-risk setting for medication errors. Several factors contribute to this risk including the need to provide care to complex patients who are unknown to staff, the frequent use of verbal orders, and the necessity of weight-based dosing. This investigation sought to assess one potentially error-prone event, antibiotic prescriptions written for patients being discharged from the PED, and to characterize the occurrence of medication errors to identify opportunities for improvement., Methods: This was a retrospective study of pediatric patients seen at a large academic medical center PED. All prescriptions written for an antibiotic for patients 18 years or younger that were discharged from the PED from 2015 to 2018 were evaluated for errors in directions, indication, dose, quantity, and refills. Because antibiotic dosing can vary based on indications, only disease states with guideline-specific dosing recommendations were evaluated for dosing errors., Results: A total of 11,815 antibiotic prescriptions were analyzed for patients discharged from the PED, and 1986 (16.8%) errors were identified. Of all the prescriptions reviewed, 517 (4.4%) contained an incomplete prescription error. Discharge prescriptions written by off-service physicians were more likely to contain incomplete prescription errors (5.1%) when compared with emergency medicine physicians (3.9%; P = 0.022). A dosing error rate of 18.5% (1469 prescriptions) was identified for the 7930 disease state-specific prescriptions reviewed. Underdosing errors were significantly more common (51.6%) than overdosing errors (29.3%; P < 0.0001). Among the different agents, there was noted to be a significant difference in the antibiotics most commonly involved in dosing errors (P < 0.0001). Additionally, there was also a significant difference in the incidence of dosing errors between different disease states (P < 0.0001). No significant difference was found in the incidence of dosing errors across physician specialties (P = 0.872)., Conclusions: We identified 1986 (16.8%) total errors in this analysis of antibiotic prescriptions written on discharge from the PED. Among the disease states evaluated, dosing errors were identified in 18.5% of prescriptions with the most common error being underdosing. Literature evaluating pediatric prescription errors, and specifically antibiotic discharge prescriptions, is quite limited. Further investigation is necessary in this area, and strategies should be developed leveraging technology, enhancing education, and using pharmacy personnel to help reduce antibiotic prescribing errors for patients discharged from the PED., Competing Interests: Disclosure: These authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Hypotension in the Emergency Department (ED) and the prehospital setting has been associated with significant morbidity and mortality. Limited literature exists exploring the utilization of intravenous (IV) bolus-dose epinephrine (BDE) by Emergency Medical Services (EMS)., Methods: A retrospective review evaluated patients transported to an academic medical center who had received IV BDE by a single urban EMS system from 2016 to 2020. The primary outcome was to assess the influence IV BDE had on systolic blood pressure (SBP). Secondary objectives were to assess changes in heart rate (HR), the impact of dose variability on SBP, and the incidence of severe hypertension (SBP > 220 mmHg)., Results: A total of 55 patients who received 96 administrations of IV BDE were included in the analysis. The most common individual dose was 10 μg (76.0%) and 45.5% received multiple doses. The median weight-based dose of BDE was 0.14 μg/kg. A significant increase in SBP (median 14.0 mmHg) was noted among all patients following BDE administration compared with baseline (p < 0.001). No significant difference was found in HR following BDE compared with baseline (p = 0.375). Those that received a BDE dose >10 μg were noted to have a significantly greater rise in SBP than those that received 10 μg (30.0 mmHg vs. 11.0 mmHg; p = 0.022). Similarly, patients that received a dose ≥0.2 μg/kg had a significantly greater increase in SBP compared with those that received <0.2 μg/kg (30.0 mmHg vs. 10.0 mmHg; p = 0.048). There were no incidences of severe hypertension following therapy., Conclusion: The utilization of IV BDE in the prehospital setting for acute hypotension resulted in a significant rise in SBP. A dose-response relationship was noted both in terms of a flat-based dose and a weight-based dose, with higher doses yielding a greater change in SBP. Additional investigations are necessary to further explore the most appropriate dose of this agent in this setting and its influence, if any, on clinical outcomes., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Propofol is a frequently used agent for procedural sedation in the emergency department (ED). Some have suggested that propofol dosing in this setting should be adjusted in elderly patients; however, limited data exist supporting this recommendation. Additional factors that may contribute to altered propofol dose requirements in this setting have not been thoroughly explored. The objective of this analysis was to ascertain the effect age may have on the propofol dose required during procedural sedation in the ED. This retrospective study was conducted at a Level 1 academic medical center ED and included patients 18 years or older who received propofol for procedural sedation from 2015 to 2017. Those patients who were 18-64 years of age were compared with those 65 years or older. Between the two groups, total and weight-based propofol requirements for sedation, opioid doses, and adverse events were compared. This analysis included 101 procedural sedations. The median induction dose and opioid requirements before or during the procedure were not significantly different between the two groups. Compared with patients 18-64 years of age, those 65 years or older had significantly less total weight-based propofol requirements (p = 0.024) and required less total propofol for sedation (p = 0.007). In addition, patients 65 years or older required fewer repeat doses of propofol during the procedure than younger patients (p = 0.043). The incidence of adverse effects, including respiratory suppression, was not significantly different between the two groups. Patients 65 years or older may have lower weight-based propofol dosing requirements than younger patients. Utilizing a reduced total dose and repeat dosing strategy for propofol in this setting may be indicated. Further investigations are recommended to clarify factors that signal the need for more tailored dosing., Competing Interests: Disclosure: The authors report no conflicts of interests., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The Emergency Department (ED) is known for its high rates of medication errors secondary to many characteristics such as unfamiliar patients, lack of continuity of care, increasing patient volumes, reliance on verbal orders, and fewer safety mechanisms. The purpose of this study was to quantify and characterize the medication errors that occur in patients discharged from the ED., Methods: Prescriptions for patients discharged from the adult ED at an academic medical center from 2015 to 2018 were reviewed. Errors in discharge medication orders were documented as well as characteristics of these errors including medication class, errors in prescription directions, quantity prescribed, and refills given inappropriately., Results: A total of 115,933 prescriptions were reviewed and a total of 20,498 errors were identified within 19,126 prescriptions. Of the errors identified, 4048 (19.7%) involved prescription directions, 6537 (31.9%) were errors in quantity prescribed, and 9913 (48.4%) were prescriptions written with refills. The proportion of errors among different prescriber statuses was significantly different when comparing all prescribers (p < .001). Prescriptions written by Non-Emergency Medicine residents had significantly more errors in quantity and refills (p < .001, p < .001), and prescriptions written by Emergency Medicine residents had significantly more errors in directions (p < .001)., Conclusions: This review identified a 16.5% error rate among all prescriptions provided to patients upon ED discharge that varied among different subcategories of medications. This is consistent with the limited literature that is currently available on the topic. These results could assist institutions in developing targeted mitigation strategies to limit medication misadventures in patients discharged from the ED., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Hypoglycemia is a frequent cause of emergency medical services (EMS) activation; however, limited evidence exists to support optimal prehospital treatment., Objective: This study sought to compare the safety and efficacy of the administration of 10% dextrose (D10) intravenously (IV) versus 50% dextrose (D50) IV for the treatment of hypoglycemia in the prehospital setting., Methods: This was a retrospective cohort study of patients who received IV dextrose by EMS and were transported to an academic teaching hospital emergency department between 2014 and 2017., Results: Four hundred seventy-eight eligible patients were reviewed, with 161 patients receiving D10 and 150 patients receiving D50. There was no significant difference found regarding the need for dextrose retreatment prior to hospital arrival between the D10 and D50 groups (0.6% vs 2.0%; P = .565). The prehospital reassessment glucose in the D50 group was a significantly higher than the D10 group (151.9 vs 124.6 mg/dL, P = .001) and this difference was maintained on hospital arrival (129.5 vs 108.0 mg/dL, P = .011). No significant difference was found between groups with regard to hospital admission, length of stay, or in-hospital mortality., Conclusion: When comparing D10 with D50 for the treatment of hypoglycemia by EMS, there were no significant differences in the need for dextrose retreatment prior to hospital arrival. The use of D50 resulted in a significantly higher blood glucose concentrations both in the prehospital setting and upon hospital arrival. Further study is needed in larger patient populations to evaluate the use of D10, the need for dextrose readministration, and its impact on clinical outcomes.

Introduction: Acetaminophen is a commonly used analgesic and antipyretic, with the potential to cause significant injury when ingested in toxic amounts. Although the antidote n-acetylcysteine (NAC) is available, evidence supporting dose recommendations for patients weighing over 100 kg are lacking. We performed a retrospective, multi-center analysis to determine if a capped NAC dosing scheme is similar to a non-capped dosing scheme in patients weighing over 100 kg., Methods: Between January 2009 and January 2016, we identified patients presenting to 12 different centers who were evaluated for acetaminophen poisoning treatment. Patients must have weighed greater than 100 kg and were evaluated and identified as needing treatment for acetaminophen-related poisoning with NAC. The primary outcome was occurrence of hepatic injury, defined as an AST or ALT ≥ 100 IU/L. Secondary endpoints included number of drug-related adverse events, occurrence of hepatotoxicity, cumulative NAC dose, regimen cost, length of hospital and intensive care unit stays, and in-hospital mortality., Results: There were 83 patients identified as meeting the pre-specified inclusion and exclusion criteria. A capped NAC dosing scheme resulted in no difference in hepatic injury when compared to a non-capped regimen (49.4% vs 50%, p = 1.000). The capped dosage regimen was associated with a lower cumulative dose (285.2 mg/kg vs 304.6 mg/kg, p < 0.001) and cost. No other statistically significant differences were identified among the secondary endpoints., Conclusion: A capped NAC dosing scheme was not associated with higher rates of hepatic injury or hepatotoxicity in obese patients in the setting of acetaminophen poisoning when compared to a non-capped regimen. Further research is needed to verify these results.

Atrial fibrillation/flutter (AF) remains the most common rhythm disturbance in adult patients presenting to emergency departments (EDs). Although pharmacologic cardioversion has been established as safe and effective in recent-onset AF, its use in U.S. EDs is uncommon. The purpose of this study was to assess the safety and efficacy of intravenous (IV) procainamide for pharmacologic cardioversion in patients presenting to the ED with AF of <48-hr duration. Patients presenting to the ED with recent-onset AF (<48 hr) undergoing a cardioversion strategy with IV procainamide from 2017 to 2019 were reviewed. Clinical outcomes assessed included rates of cardioversion, hospital admission, stroke, and return ED visits for arrhythmia or serious adverse events. A total of 64 patients received procainamide therapy-60.9% achieved cardioversion and 35.9% were admitted to the hospital. The mean dose was 1062.4 mg (12.1 mg/kg). No patients returned to the ED secondary to stroke and 9.4% experienced complications attributed to procainamide, the most common being hypotension. Within 30 days of therapy, 20.3% of patients returned to the ED secondary to arrhythmia recurrence. Patients experiencing cardioversion with procainamide were less likely to be admitted to the hospital (25.6% vs. 52.0%; p = 0.04) or receive a rate control agent (17.9% vs. 64.0%; p = 0.001). There was no significant difference in the rate of 30-day return between those who experienced pharmacologic cardioversion and those who did not (p = 0.220). The implementation of a procainamide-based acute cardioversion strategy for patients presenting to the ED with recent-onset AF resulted in a 60% cardioversion rate, which was associated with a significantly higher rate of discharge from the ED. Transient hypotension was the most common adverse event. Further investigation into ED-based protocols for management of recent-onset AF is necessary to better understand their safety and efficacy., Competing Interests: Disclosure: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: There is currently no consensus regarding the necessity of emergency department (ED) glucose reduction to manage hyperglycemia in patients presenting without a hyperglycemic emergency. Known consequences of intravenous (IV) insulin administration include hypoglycemia, hypokalemia, and increased ED length of stay. The primary objective of this study was to assess the impact of IV regular insulin on glucose reduction and ED length of stay in patients presenting to the ED with non-emergent hyperglycemia. Secondary objectives included the characterization of potential adverse events., Methods: This was a retrospective, observational study of patients ≥18 years who received IV regular insulin and were discharged from the ED at a large academic Trauma Center. Univariate and multivariable regression analyses were utilized to determine if an association existed between IV insulin administration and blood glucose as well as ED length of stay., Results: A total of 405 patients were included in the analysis. An insulin dose >5 units was associated with a greater reduction in blood glucose (difference = 37.4 mg/dL; p < .001) but no difference in ED length of stay relative to ≤5 units. Furthermore, 7.9% of patients developed hypokalemia and 0.4% developed hypoglycemia., Conclusion: The use of >5 units of IV regular insulin for the management of isolated hyperglycemia in the ED was associated with a modest reduction in blood glucose and no difference in ED length of stay compared with those that received ≤5 units. However, use of IV insulin for this purpose resulted in a 7.9% occurrence of hypokalemia., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Although guidelines recommend specific benzodiazepine doses for the treatment of generalized convulsive status epilepticus (GCSE), underdosing appears to be common. The purpose of this investigation was to assess benzodiazepine dosing strategies for the initial management of GCSE in patients presenting to the Emergency Department (ED)., Methods: This was a retrospective review of adult patients who received benzodiazepines in the ED for treatment of GCSE. Characteristics of those achieving seizure cessation following initial benzodiazepine therapy were assessed., Results: 222 patients presented to the ED and received 403 doses of benzodiazepines, of which 1.5% conformed with recommendations. First-line therapy was successful in 86.8% of patients with an average dose of 1.6 mg (0.02 mg/kg). No difference in dosing was noted between those experiencing early cessation and those that did not (p = 0.132). Patients experiencing early cessation were significantly less likely to receive further doses, be intubated, or be admitted to the intensive care unit (ICU) or hospital (p < 0.05 for all comparisons). Those that received early antiepileptic drug therapy were significantly less likely to receive additional benzodiazepine doses, be intubated, or be admitted to the ICU or hospital (p < 0.05 for all comparisons)., Conclusions: According to guideline recommendations, there was consistent underdosing of benzodiazepines noted in both prehospital and ED settings. Early seizure cessation and the early receipt of an antiepileptic drug were found to be associated with multiple significant clinical outcomes. Future investigations should explore optimal dosing strategies for benzodiazepines as well as the impact of early antiepileptic drug administration., Competing Interests: Declaration of Competing Interest The authors have none to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Malignant hyperthermia (MH) is caused by a genetic disorder of the skeletal muscle that induces a hypermetabolic response when patients are exposed to a triggering agent such as volatile inhaled anesthetics or depolarizing neuromuscular blockers. Symptoms of MH include increased carbon dioxide production, hyperthermia, muscle rigidity, tachypnea, tachycardia, acidosis, hyperkalemia, and rhabdomyolysis. Common scenarios for triggering agents are those used are during surgery and rapid sequence intubation. Hypermetabolic symptoms have a rapid onset; hence, prompt recognition and treatment are vital to prevent morbidity and mortality. The first-line treatment agent for an MH response is dantrolene. Further treatment includes managing complications related to a hypermetabolic response such as hyperkalemia and arrhythmias. This review is focused on the recognition and treatment considerations of MH in the emergency department to optimize therapy and improve patient morbidity and mortality., Competing Interests: Disclosure: The authors report no conflicts of interests., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Similar to teaching certificate programs, which have been incorporated in many pharmacy residencies to improve teaching skills, resident research certificate programs could provide residents with more exposure to biostatistics and research design. However, few research certificate programs have been described. Objective: To assess the impact of a research certificate program on residents' attitude toward, confidence in, and knowledge of research. Methods: A resident research certificate program was created for the 2018-2019 residency class at our institution, which included 33 pharmacy residents (15 postgraduate year-1 [PGY1] and 18 PGY2 residents). The program consisted of 7 sessions aimed at providing residents with research training. To earn a certificate, participants were required to attend 6 or more sessions and achieve a score greater than or equal to 70% on a postassessment. An optional questionnaire assessing attitude, confidence, and knowledge was also administered at baseline and following the certificate program. Results: Of the 33 residents participating in the research certificate program, 21 (9 PGY1 and 12 PGY2) residents completed both the baseline and follow-up questionnaire and were included in the analysis. All items assessing attitude and 3 of 6 items assessing confidence improved significantly following the certificate program when compared to baseline ( P < .05 for all). Median knowledge scores were no different on the baseline versus follow-up questionnaire ( P = .54). Conclusions: After completing a research certificate program, resident knowledge scores did not differ from baseline, but attitudes toward research and confidence appeared to improve. Research certificate programs could be an avenue for providing pharmacy residents with increased exposure to and comfort with biostatistics and research design., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2019.)

Purpose: There is conflicting evidence to support the superiority of weight-based (WB) dosing of intravenous (IV) diltiazem over non-weight-based (NWB) dosing strategies in the management of atrial fibrillation (AFib) with rapid ventricular response (RVR)., Methods: A retrospective review evaluated patients presenting to the emergency department (ED) in AFib with RVR and receiving IV diltiazem from 2015 to 2018. Those receiving a NWB dose were compared with those receiving a WB dose based on actual body weight (ABW). Secondary analyses evaluated safety profiles of the regimens and compared response in groups defined by ABW or ideal body weight (IBW)., Results: A total of 371 patients were included in the analysis. No significant difference was observed in achieving a therapeutic response (66.5% vs. 73.1%, p = 0.18) or adverse events between the groups. Patients receiving a WB dose were significantly more likely to have a HR < 100 bpm than those receiving a NWB dose (40.9% vs. 53.5%, p = 0.01). When groups were defined by IBW, WB dosing was associated with a significantly higher incidence of achieving a therapeutic response (62.7% vs. 74.3%, p = 0.02)., Conclusion: In patients presenting with AF with RVR, there was no significant difference in achieving a therapeutic response between the two strategies. A WB dosing approach did result in a greater proportion of patients with a HR < 100 bpm. The utilization of IBW for WB dosing may result in an increased achievement of a therapeutic response., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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., (© American Society of Health-System Pharmacists 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Atrial fibrillation (AF) is the most common tachyarrhythmia managed in the emergency department (ED). Visits to the ED for a presentation of AF have been increasing in recent years, with an admission rate that exceeds 60% in the United States and contributes substantially to health care costs. Recent-onset AF-defined as symptom onset less than 48 hr-is a common ED presentation for which rate control or acute electrical or pharmacological cardioversion may be appropriate treatment modalities depending on patient-specific circumstances. The focus of this review is to discuss the current recommendations regarding the management of recent-onset nonvalvular AF in the ED, discuss medication administration considerations, and identify implementation strategies in the ED to optimize throughput and reduce hospital admissions.