Being Prepared to Stand Out: Recommendations for Pre-Rotation Reading by EM Pharmacy Preceptors

Maybe you are an incoming PGY-2 EM pharmacy resident, or one of the increasingly many PGY-1’s who knows (or is considering) that EM is what they want to do. Pre-rotation preparation can do wonders to set residents up to meet the clinical challenges of the emergency department and stand out during rotation. A strong first rotation can help with early commitment as a PGY-1 or setting a precedent for the year as PGY-2.

Even for those who want to be as prepared as possible, knowing where to start can be a challenge. To aid residents in preparing, this document contains key literature and guidelines compiled by a diverse group of EM pharmacist preceptors from multiple practice sites across the United States. Remember, students are taught by others; experts teach themselves. Taking time to begin reviewing literature by yourself is a great first step to becoming an expert!

  1. What is in these tables?
    • “Landmark” trials that influence practice and guidelines relevant to EM practice
      • Each with key takeaways provided by EM Preceptors
    •  Not all inclusive, this is to give you a head start, not overwhelm!
  •  How to use it
    1. Don’t get overwhelmed- any content you cover before rotation is great, you are already ahead!
    2. Guidelines- (Start here, move on to articles as you feel comfortable)
      • Read bullet point recommendations from guidelines you are not familiar with
      • Make copies of treatment algorithms (ie: ACLS, status epilepticus) to have at your finger tips during rotation
    3.  Articles-
      • Skim or read abstracts of articles you don’t recognize
      • Go into more depth as you feel comfortable, write down questions to ask preceptors

A downloadable PDF version of the tables can be found here https://bit.ly/3lf7UVf

GuidelinesPubmed ID (paste in pubmed search bar), or link
AHA Stroke31662037
Focus on the TPA and BP management parts
American Epilepsy Society Status Epilepticus26900382

There is a flow chart on page 11 for treatment of status epilepticus, printing this is highly recommended

Surviving sepsis 201628101605
This is bread and butter for EM.
Focus on :
Table A. initial resuscitation
Table D. Antimicrobials
Table F. Fluid Therapy
Table G. Vasoactive medications
AHA Atrial fibrillation management30686041

Brief summary

  • Managing Arrythmia
    • Unstable= Direct Current Cardioversion (shock)
    • Stable = choose rate or rhythm control
    • Rate control = Rhythm control (AFFIRM trial), in ED usually rate control
      • Rate control outpatient HR goal <110 if asymptomatic and no heart failure, otherwise <85
      • Usual Rate control= beta blocker or non dihydropyridine calcium channel blocker
      • Digoxin or amiodarone if in decompensated heartfailure
      • Amiodarone if refractory to everything
  •   Managing thromboembolic risk
    • Anticoagulation for CHADS2VASC>2 or people with AF>48 h who are getting cardioversion
    • DOAC 1st line unless conditions below
    • Warfarin for valvular AF, obesity, or renal failure (though apixaban is a consideration in renal failure)
  1. Neuro critical care society  Reversal of Antithrombotic in intracranial hemorrhage guidelines
  2. American college of cardiology expert Consensus Decision Pathway on
  1. 26714677
  2. 32680646

Know your resources and internal protocols/formulary considerations regarding anticoagulant reversal, including what constitutes true “emergent reversal” indications

Chest Thrombosis guidelines
  1. 26867832
IDSA Guidelines:

  • Urinary Tract Infection (UTI)/Asymptomatic Bacteriuria (ASB)
  • Pneumonia (PNA)
  • Skin and Soft Tissue (SSTI)
  • Meningitis
https://www.idsociety.org/practice-guideline/practice-guidelines/#/date_na_dt/DESC/0/+/

Focus on initial treatment strategies, risk stratification to guide empiric therapy etc. Also collect your institutional antibiograms and guidance documents from your institution

CDC Sexually Transmitted Infectionhttps://www.cdc.gov/std/tg2015/default.htm
AHA Advanced Cardiovascular Life Supporthttps://www.ahajournals.org/doi/10.1161/CIR.0000000000000261

Summary: https://eccguidelines.heart.org/wp-content/uploads/2015/10/2015-AHA-Guidelines-Highlights-English.pdf

If you don’t have them memorized, keep your ACLS Tachydysrhythmia, Bradycardia, Post ROSC algorithm, and Pulseless Arrest algorithm cards on you

Downloadable PDFs available: https://www.acls.net/aclsalg.htm

American Diabetes Association Diabetic Ketoacidosis/Hyperglycemic Hyperosmolar Syndrome19564476

  • Focus on pathophysiology first.
  • Utilize the figures and tables as your quick treatment references.

Know your institutional order sets/protocols

Know if Applies to Your Site/Practice
Trauma EAST Guidelines – Damage control resuscitation in severe traumatic hemorrhage28225743

Focus on fluid resuscitation and pharmacologic considerations, know your institutional MTP if you are at a trauma center, see also references in second chart

Traumatic Brain Injury Guidelines27654000

  • Focus on the summary table
    • Hyperosmolar therapy
    • Seizure prophylaxis (at the end)
    • Analgesics, sedatives, anesthesia
Pediatric emergenciesPediatric EM is its own specialty, however many sites will see a mix of adults and children topics to consider for review if your site sees children may be

  1. Pediatric Advanced Life Support/Neonatal Resuscitation (PALS/NRS)
  2. Neonatal sepsis
  3. Febrile seizures
  4. Acute otitis media
Oncologic emergenciesIf you are an emergency department primarily in a cancer work, consider reviewing common oncologic emergencies

  • 29078931
  • Review covering
    • Hypercalcemia of malignancy
    • Superior vena cava syndrome
    • Spinal cord compression
    • Neutropenic fever
    • Pericardial effusions

Neurology- Key Articles

ArticlePubMed ID or LinkHow it Impacts Care
Stroke- NINDS/ECASS IIININDS: 7477192

ECASS III: 18815396

 

Trials that led to TPA approval for stroke.

The exclusion criteria are the same criteria we use to determine who cannot get tPA.

*Of note: recent reanalyses of these data have brought into question the actual efficacy of this intervention- see subsequent studies for details and nice discussions here: https://rebelem.com/thrombolysis-in-acute-ischemic-stroke-now-we-have-no-positive-rcts/

INTERACT223713578Set SBP Goal of < 140 for ICH patients.
ATACH-2272762342016 study demonstrating increased risk of AKI with aggressive BP lowering
Status epilepticus-

RAMPART Trial

21967361Where the AES 2016 guideline recommended doses for benzodiazepines in status came from.

Showed that if you have IV access give lorazepam; if you don’t, give midazolam (faster onset than trying to get IV and give lorazepam as it’s more lipophilic)

Status Epilepticus- ESETT Trial31774955Validation of dosing for 2nd line AED’s seen in the AES 2016 guidelines for levetiracetam, fosphenytoin, and valproic. Also shows no difference in efficacy.
Andexanet Alfa26559317May be valuable to know this exists
Fixed dose PCC vs weight based32536491

29564837

Using a fixed dose of PCC may be comparably efficacious for many patients, which would attenuate financial toxicity, but depends on outcome of interest- literature is early and rapidly evolving here

Blog post on use in warfarin reversal here:

http://www.emdocs.net/fixed-dose-pcc-dosing-for-vitamin-k-antagonist-associated-hemorrhage-is-it-safe-and-effective/

Cardiovascular/Pulmonary

ArticlePubMed ID or LinkHow it Impacts Care
Shock treatment- SOAP III trial20200382

 

Dopamine had higher mortality in cardiogenic shock than norepinephrine and had more arrhythmia overall.

Basis for recommendation of Norepinephrine as first line in cardiogenic shock guidelines. Also large basis for Norepinephrine first line in sepsis

NE vs EPI in cardiogenic SHOCK after PCI29976291EPI had worse outcomes than Norepi in cardiogenic shock
Push-Dose Pressors28601272Know your institutional protocols/if your site supports push-dose pressors and how to prepare

Also nice post here:-http://www.emdocs.net/push-dose-vasopressors-an-update-for-2019/

Pulmonary embolus- PEAPETT27422214Largest case series for the use of TPA during cardiac arrest from a PE (pay attention to the dosing, this is dosing you can utilize if you are in this scenario)
Other tPA in PE Studies-

1.MOPETT (2012)
2. PEITHO (2014),
3. TOPCOAT (2014),
4. Review (AJHP 2018)

  1. 23102885
  2. 24716681
  3. 24484241
  4. 29895520
Fibrinolytic dosing and implications for anticoagulation vary by PE severity – great posts below and know your institutional order sets/protocols

https://litfl.com/thrombolysis-for-submassive-pulmonary-embolus/

Hypertensive Heart failure-

High dose nitro trials

17509731

27825693

In hypertensive heart failure with pulmonary edema, high doses of nitroglycerin prevented intubation and appeared relatively safe in these populations
Arrhythmia- atrial fibrillation

AFFIRM trial

12466506

 

Rate = Rhythm for AF management. Rate had fewer adverse effects and hospitalization
Arrhythmia- V tach

PROCAMIO

27354046Procainamide had less hypotension and more cardioversion compared to amiodarone for stable monomorphic VT

Rapid Sequence Intubation

ArticlePubMed ID or LinkHow it Impacts Care
RSI Process and Medication Selection24259635

 

General overview of RSI and rationale for each medication option.

A short STATpearls on RSI here as well: 29083689

Etomidate vs. ketamine in RSI for trauma patients27993308Retrospective cohort suggesting comparable mortality and other outcomes between RSI induction agents in the adult trauma population
Etomidate for RSI induction in sepsis – meta-analyses22971586

25255427

Conflicting meta-analyses regarding the clinical significance of etomidate-induced adrenal insufficiency- a topic to be able to speak intelligently about since debate continues
Cochrane Review: succinylcholine vs. rocuronium for RSI26512948Succinylcholine superior at creating excellent intubating conditions when all doses compared, but no significant difference when rocuronium dosed at 1.2 mg/kg
Succinylcholine in TBI26799349Where the AES 2016 guidelines for levetiracetam, fosphenytoin, and valproic acid doses came from in status. Also shows they are all equal in efficacy the same.
Sugammadex32483081


31898175

27646527

21198485

 

Novel direct reversal agent for rocuronium (and vecuronium) – increasingly being explored/requested after paralytic use in the ED/ICU so here are some articles discussing its potential role in these situations

Sepsis

ArticlePubMed ID or LinkHow it Impacts Care
EGDT11794169

 

Pivotal trial by Rivers, et al. that changed sepsis management. (2001) Protocolized sepsis care impacts survival
PRISM23820242Meta-analysis of ProCESS, ARISE, ProMISe trials reassessing the benefit of EGDT (2017)
VASST18305265

25255427

Vasopressin use may reduce norepinephrine requirements in septic shock
CENSER30704260Investigation for early norepinephrine use in patients with septic shock
VITAMINS31950979Vitamin C+hydrocortisone+thiamine does not lead to a more rapid resolution of septic shock compared with hydrocortisone alone
Immediate vs early abx meta analysis32593430

 

The SEP-1 bundle is looking worse and worse
Initial Resuscitation Review

Fluid resuscitation / fluid stewardship reviews

32135409

29789983

31256705

Debate continues regarding the optimal fluid and vasopressor strategies – here is some good advice/discussion on this front!

Toxicology

ArticlePubMed ID or LinkHow it Impacts Care
General management/initial approach to poisoned patient22998986

17606094

18655942

 

Good foundational reviews on important toxicology concepts (for ex: ECG, toxidromes)
Tricyclic Antidepressants4022081

7618783

Boehnert and Lovejoy – using QRS interval over serum TCA levels to predict seizures/ventricular dysrhythmias

“Liebelt sign” paper – aVR vs QRS

High dose insulin euglycemia for BB/CCB

NAC in APAP and other hepatotoxicity

Alkalinization for Salicylate

Get your local Poison Control Center treatment guidelines and any institutional protocols/order sets

Pain, Agitation, Psych

ArticlePubMed ID or LinkHow it Impacts Care
Ketorolac27993418

 

Demonstrates a ceiling dose for ketorolac- 10 or 15 mg just as good as 30 mg but less adverse effects
Ketamine for pain27993308Ketamine is as good as opioids or can be used as an adjunct to opioids in the emergency department for acute pain. Check institutional protocls for dosing, 0.3 mg/kg was the initial dose evaluated against morphine
Acute agitation1.22461918

2. 22284066

 

  1. Psychopharmacology of Agitation: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup,
  2. Urgent and emergent psychiatric disorders (review article)
Conscious sedation

Review

21712213Need to know your drugs and how to dose/prepare them for the purpose of conscious (AKA “procedural”) sedation in the ED

Trauma

ArticlePubMed ID or LinkHow it Impacts Care
Systematic review of antibiotics for open fracture27490013

 

Focus on which antibiotics to use for which types of fracture
CRASH-2 trial and subsequent analysis re: timing of TXA20554319

21439633

Established initial role of TXA in hemorrhaging civilian trauma patients but with significant limitations; debate underway re: if TXA administration should be empiric or guided by viscoelastic assays now
TEG review32418869Focus on how TEG can be used to inform pharmacotherapy

 

  1. Focus on how TEG can be used to inform pharmacotherapy

Perioperative/Obstetric emergencies

Reach out to @SaraJPharmD to connect for comprehensive resources if interested!
ArticlePubMed ID or LinkHow it Impacts Care
Malignant Hyperthermia (MH)https://www.mhaus.org/healthcare-professionals/managing-a-crisis/Know which formulation(s) of dantrolene your institution carries and if any emergency boxes/protocols exist.

Call the MHAUS hotline if an MH emergency is occurring (like poison control hotline for tox cases): 1-800-644-9737

Local Anesthetic Systemic Toxicity (LAST)https://www.asra.com/advisory-guidelines/article/3/checklist-for-treatment-of-local-anesthetic-systemic-toxicityQuick guide on use intralipid for cardiovascular collapse in LAST. (Remember, you still use benzodiazepines for LAST induces seizures)
Ectopic pregnancy29232273

 

ACOG practice bulletins are authoritative resources for all things OBGYN
Postpartum Hemorrhage28937571Also Obstetric Hemorrhage toolkit here: https://www.acog.org/community/districts-and-sections/district-ii/programs-and-resources/safe-motherhood-initiative/obstetric-hemorrhage
Eclampsia/Preeclampsia, HELLP Syndrome30681541Hypertension is a big deal in the pregnant patient! Know thresholds for concern and unique drug therapies, institutional order sets etc.

Remember, review guidelines, skim articles, take away high points. Go more in-depth as you are comfortable and apply what you learn on rotation. You are ahead of the curve already!

Other Resources

  • Other resources from ASHP
    • ASHP EM REPS- https://bit.ly/3fVIJTB
      •  Recorded lectures from EM Pharmacists covering many core topics.
    • ASHP Emergency Care Resource Center: https://bit.ly/3h0FED5
      • Repository of key articles and guidelines on the Emergency Care Resource Center:
    • EM Pharmacist review of relevant articles 2011-2018
      • https://academic.oup.com/ajhp/article-abstract/77/16/1284/5881865?redirectedFrom=fulltext

Contributors to “Recommendations for Pre-Rotation Reading by EM Pharmacy Preceptors”
Ryan Feldman, PharmD, BCPS, DABAT- @EMPoisonPharmD
Emergency Medicine Clinical Pharmacist/Clinical Toxicologist
Froedtert & The Medical College of Wisconsin/Wisconsin Poison Center- Milwaukee, WI

Sara J. Hyland, PharmD, BCPS – @SaraJPharmD
Emergency Medicine/Perioperative Clinical Pharmacist
Grant Medical Center (OhioHealth)- Columbus, OH

Ashley N. Martinelli, PharmD, BCCCP- @RxMartinelli
Emergency Medicine Clinical Pharmacist, Emergency Medicine PGY-2 RPD
University of Maryland Medical Center- Baltimore, MD

Jessica Rivera Pescatore- PharmD, BCPS, DABAT- @Jess_rivera11
Emergency Medicine Clinical Pharmacist/Clinical Toxicologist
University of Alabama at Birmingham- Birmingham, AL

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Recommendations for Pre-Rotation Reading by EM Pharmacy Preceptors

Recommendations for Pre-Rotation Reading by EM Pharmacy Preceptors Recommendations for Pre-Rotation Reading by EM Pharmacy Preceptors

Recommendations for Pre-Rotation Reading by EM Pharmacy Preceptors