Transcript Emergency Department (ER) Overview

Nora Gharib and Nick Khanna
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Introduction
Statistics
Emergency Room Medications
Common Cases in ER
Patient Cases
The role of a Pharmacist in the ER
Conclusion
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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 lifethreatening and require immediate attention)
Open to the public 24 hours a day (although
staff levels usually vary)
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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.
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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.
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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
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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
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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
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This area is reserved for patients that do not
have immediately life threatening conditions
Examples include fractures, dislocations and
lacerations requiring suturing
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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.
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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?)
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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 overcrowding, 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!)
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Lidocaine
Epinephrine
Furosemide
Diazepam
Haloperidol
Succinylcholine
Atropine
Heparin
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For an exhaustive list, see Feldman 2001
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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.
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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.
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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.
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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.
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Haloperidol (Haldol)
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Succinylcholine
◦ 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.
◦ 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!
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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.
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Heparin
◦ Anticoagulant used to prevent blood from clotting.
◦ Used in patients suspected of having a myocardial
infarction
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Stomach and abdominal pain, cramps, and
spasms
Chest pain and related symptoms
Fever
Cough
Headache, pain in head
Back symptoms
Shortness of breath
Pain, site not referable to a specific body system
Vomiting
Symptoms referable to throat
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:
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Triaged to the resuscitation area
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There he seen by an ER physician and receive oxygen and monitored and have
an early ECG
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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
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Patients require immediate reperfusion (re-opening) of the occluded vessel
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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
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A 25 year old female comes into the ER
department with acute exacerbations
asthma. The following steps to treat this
patient are taken:
She is assessed by triage nurse and treated with
oxygen therapy, bronchodilators, steroids or
theophylline
An urgent chest X-ray and arterial blood gases are
ordered
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
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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
◦ providing patient and caregiver education, including
discharge counseling and follow-up
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Future Pharmacist
◦ offering vaccination screening, referral, and
administration
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Statistics
Emergency Room Medications
Common Cases in ER
Patient Cases
The role of a Pharmacist in the ER
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Please feel free to post any questions on the
discussion board (See LEARN)
Complete the Online Quiz
◦ Due March 25th, 2013
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Prepare for case presentations for next
week’s class
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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.