Transcript Emerg Meds_07ho - University of Washington

“And I realized that they could never hurt me
more than they had just hurt me that night, and
that out of chaos like this had to come
confidence and skill. Something had happened
. . . ., and I didn’t know what, but I knew that
from taking the risks and learning and
remembering Fats, I had pinned down my
terror and exploded it to bits. From that night
on, I might be everything else, but I’d never
again be panicked in the House of God.”
Dr. Samuel Shem
THE HOUSE OF GOD (p. 140)
EMERGENCY
PHARMACOLOGY
Clinical Applications
Terry Mengert, MD
Frank Vincenzi, PhD
University of Washington
School of Medicine
CREDITS
The black and
white photographs in this
presentation
are from this
source
(published in
1989).
“Time is but the stream
I go a-fishing in.”
Henry David Thoreau
(1817-1862)
Why are
we here?
Emerg Pharm: OBJECTIVES
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•
•
•
HAVE FUN ?
Make DRUGS Alive!
Approach to Emergencies
Manage Patients
•
•
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•
Acute MI
Anaphylaxis
COPD Exacerbation
Septic Shock
Ventricular Fibrillation
• Learn by DOING
DRUGS
are TOOLS
Quick ADRENERGIC Receptor
Review
• Alpha 1: contraction or constriction
• Alpha 2: pre-synaptic stimulation INHIBITS
norepinephrine release
• Beta 1: mostly heart – chronotropic &
•
•
inotropic
Beta 2: relaxation of smooth muscle
(bronchial walls, blood vessels, GI tract,
bladder wall, & pregnant uterus)
Beta 3: adipose tissue
Adrenergic
Agonist
Classification;
From
Stringer JL: BASIC
CONCEPTS IN
PHARMACOLOGY
3rd edition
TRADITIONAL
Medical Approach
• History
• Physical Examination
• Differential Diagnosis
• Working Diagnosis
• Additional Studies
• Therapy
TIME MATTERS
• Pulseless VTach / VFib
• Acute Myocardial Infarction
• Acute Cerebrovascular
Accident
• Bacterial Meningitis
Initial CRITICAL / EMERGENCY
Care
• Primary Survey & Resuscitation
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•
•
•
•
Airway with C-Spine Control
Breathing & Ventilation
Circulation & Hemorrhage Control
Deficits & “DON’T” Regimen
Expose & Environmental Control
• Secondary Survey
• Definitive Care
CONCEPT
“The Safety Net”
O2 – IV’s – Monitor
2
3 “Pillars” of EMERGENCY
CARE at the Bedside
• SAFETY
NET
– Oxygen
– IV Access
– Monitors
• VITAL
SIGNS
– Pulse
– BP
– RR
–T
– Mental
–
Status
Others
•
PRIMARY
SURVEY
-- A
-- B
-- C
-- D
-- E
The DON’T Regimen
for Altered Mentation
• D = Dextrose
• O = Oxygen
• N = Naloxone
• T = Thiamine
Our FIRST
Patient !
CLINICAL CASE
This 58-year-old man presents to the ED
with 2 hr of chest pressure. He has
vomited twice and is diaphoretic.
Risks: age, cigarette use
Meds: ibuprofen, multivitamins
All: penicillin (anaphylaxis)
VS: P 80 (irregular), BP 150/100, RR 22,
T 37 C.
Begin Caring for HIM Now!
ACS: Initial Care
• Three Pillars
– O2 – IV’s – Monitors
– Vital Signs (“added” ones)
– Primary Survey: A, B, C, D, & E
• Working & Differential Diagnosis
• ACS: Emergency Drug Care: M O N A B + H
(“To Cath or not to cath, that is the question.”)
ACUTE CORONARY SYNDROME
Questions
• Name 4 life-threatening causes of
acute Chest Pain.
• What are the 3 Acute Coronary
Syndromes?
• What does the ECG show?
Acute Coronary Syndrome:
Questions (continued)
• CORNERSTONE INITIAL THERAPY
• Morphine
• Oxygen
• Nitroglycerin
• Aspirin (what if they are aspirin
allergic?)
• Beta Blocker
• Heparin
Acute Coronary Syndrome:
Questions (continued)
• Our patient’s initial blood pressure was
150/100 (“praise the Lord”). But what
would you do if his initial blood
pressure was 85/50, and
– Lungs are clear
– Patient is dyspneic and in pulmonary
edema (prominent pulmonary crackles)
Color Atlas & Text of Clinical Medicine, 3rd
Edition, Mosby, 2003, p. 223.
CHF Concepts: Positive
Inotropes in CHF
• Dobutamine
• Dopamine (dose dependent)
– dopaminergic receptors
– beta receptors
– alpha receptors
• Additional Teaching Point:
Why NOT Norepinephrine?
Acute Coronary Syndrome:
Questions (continued)
• Our patient survives! What
medications should he
eventually leave the hospital
taking?
Acute Coronary Syndrome:
Hospital Care
• A: aspirin, other anti-platelet drugs
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•
•
•
(clopidogrel, glycoprotein IIb/IIIa inhibitors),
anticoagulation (heparin), ACE inhibitors
B: beta blockers, blood pressure control
C: cholesterol measurement & control,
cigarette smoking cessation
D: diet, diabetes management
E: education, exercise
CLINICAL CASE
This 32-year-old RN arrives emergently
from the hospital cafeteria. She is allergic
to peanuts and inadvertently ate one on
her salad.
She presents with lip edema, diffuse
pruritis, generalized urticaria, and moderate
dyspnea with wheezing.
Meds: oral contraceptives
All: penicillin (anaphylaxis)
VS: P 130, BP 120/70, RR 34, T 37.5 C.
ANAPHYLAXIS: Initial Care
• Three Pillars
– O2 – IV’s – Monitors
– Vital Signs
– Primary Survey: A, B, C, D, & E
• Working & Differential Diagnosis
• Anaphylaxis: CORE DRUGS
ANAPHYLAXIS: Questions
• Clinical findings?
• Why do people die?
• Why is epinephrine the “drug of
choice?”
Anaphylaxis: PHARMACOLOGY
• Oxygen
• IV Crystalloid
• Epinephrine
• Albuterol
• Diphenhydramine
• Prednisone
• Others
– H2 Blockers
– Racemic Epinephrine
– Glucagon
REVIEW:
Acute MI – Visualization Exercise
• Rest, relax, take some deep breaths
• Clear your minds . . .
• Picture the following: “It is 2.5 years
from now and it is your first night on
call . . .”
CLINICAL CASE
This 75-year-old man is well known to the
UWMC. He has a long history of severe COPD.
This afternoon he presents to the ED in an acute
COPD exacerbation in the setting of a respiratory
tract infection.
Meds: multiple
All: NKDA
VS: P 120 (regular), BP 170/105, RR 32,
T 38.3 C.
Patient is awake, alert, diaphoretic, using
accessory muscles, dyspneic, wheezing, with
bibasilar coarse crackles.
COPD: Initial Care
• Three Pillars
– O2 – IV’s – Monitors
– Vital Signs (“additional” ones)
– Primary Survey: A, B, C, D, & E
• Working & Differential Diagnosis
• COPD Exacerbation: CORE DRUGS
COPD: Questions
• Definition
• Leading Cause
• Emergency Drugs
– Oxygen (use judiciously)
– Beta agonist (albuterol, ? terbutaline)
– Ipratropium bromide (Atrovent)
– Corticosteroids
– Others: antibiotics, diuretics
Pause -- COMPASS READING:
Where are we any way?
• Drugs are TOOLS
• Approach in Emergency Medicine
• Cases Thus Far
– Acute Myocardial Infarction
– Anaphylaxis
– COPD Exacerbation
– Acute Congestive Heart Failure
CLINICAL CASE
Seattle Paramedics bring to the ED a 35-year-old
woman who is comatose and was intubated in the
field. The lady has a history of injection drug use,
and, according to family, has been ill for 5 days
with a fever and cough. The family found the
patient unconscious this morning.
Meds: uncertain
All: Aspirin (stomach upset)
VS: P 130 (regular), BP 70/40, RR 22 (being bag
ventilated), T 39.5 °C.
OUTLINE YOUR CARE OF THIS PATIENT
Intubated & HYPOTENSIVE:
Initial Care
• Three Pillars
– O2 – IV’s – Monitors
– Vital Signs (“additional” ones)
– Primary Survey: A (confirm correct ET tube
placement), B, C, D, & E
• Working & Differential Diagnosis
• HYPOTENSIVE PATIENT: Core Care
Our Patient’s Care
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ET Tube Confirmation
The DON’T regimen
IV fluids: NS wide open
Admission Labs + Cultures
Vasopressor for BP support:
norepinephrine vs dopamine
• Antibiotics
• Considerations for adrenal gland
support
Concept: Goal-Directed
Therapy in Septic Shock
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Basic A – B – C’s + Emergency Diagnosis
Volume Resuscitation + Antibiotics
Vasopressor Therapy
Central Mixed Venous Oxygen Saturation
Monitoring (Transfuse to Hct > 30 if CVO2
< 70%; if still < 70%, add dobutamine
• Adjunctive Therapies: glucocorticoids,
drotrecogin alfa, intensive insulin therapy
CLINICAL CASE
Remember our 58-year-old man with the
acute anterior MI from the first hour?
The Cardiac Cath lab calls, and we are
preparing to transport him for emergent
catheterization and coronary artery stent
placement. He is pain free, but he
suddenly loses not only consciousness, but
also his pulse!
LET’S RESUSCITATE HIM !
“The undiscover’d country,
from whose bourn
No traveller returns -- . . .”
Hamlet
Acute Cardiac Arrest: Questions
• What do you do when you encounter an
•
•
unresponsive patient?
What are the 3 Arrest Algorithms?
CORNERSTONE INITIAL THERAPY
• C--A--C
• CPR until defibrillator arrives
• SHOCK (If VFib / pulseless VTach) – then
immediate return of CPR (5 cycles)
• IV placement -- Epinephrine-Shock
• Advanced Interventions (Intubate-ConfirmSecure)
• Amiodarone-Shock
CARDIAC ARREST—Again !
• VOLUNTEERS NEEDED (5 people)
– Chest compressions
– Breathing/Ventilation (two people)
– Defibrillator Manager
– Medication Delivery (“Drug pusher”)
– Code Captain (“The Class”)
CLINICAL CASE
You are on your ICM II hospital visit. You go
in to see a 52-year-old male who was
admitted the night before to a cardiac
monitored bed with recurrent chest pain.
The patient’s cardiac enzymes are all
normal.
You walk in to introduce yourself to the
patient. They take one look at you, their
eyes roll up, and they become
unresponsive ! (Definition: Bad Karma)
Pulseless VTACH & VFIB
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Primary Survey until Defibrillator arrives
200 J (bi-phasic; 360 J if monophasic)
Resume CPR for 5 cycles + place IV
Reassess: still in VFIB?
Epinephrine (1 mg IV push) then SHOCK
Intubate + Tube Confirmation + Secure
Anti-Arrhythmics & SHOCK
• Amiodarone: 300 mg IV push
• Lidocaine: 1.5 mg/kg IV push, may repeat
• Magnesium: 2 grams slow push
Emerg Pharm: OBJECTIVES
•
•
•
•
HAVE FUN ?
Make DRUGS Alive!
Approach to Emergencies
Manage Patients
•
•
•
•
•
Acute MI
Anaphylaxis
COPD Exacerbation
Septic Shock
Ventricular Fibrillation
• Learn by DOING