Pharmacology

Sepsis Alert๐Ÿ’‰๐Ÿฆ Vanco

โ€ข @theedtraumacist Vancomycin is a tricyclic glycopeptide antibiotic used to cover gramโž•bacteria such as methicillin resistant Staphylococcus aureus. ๐Ÿ’‰

Vancomycin works by inhibiting bacterial cell wall synthesis by binding to D-alanyl-D-alanine cell wall precursors, inhibiting polymerization and preventing linkage to the glycopeptide polymer located within the bacteriaโ€™s cell wall.

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When dosing vancomycin a couple of factors should be considered including the patientโ€™s weight, renal function, and presenting disease state. It is normally

dosed at 15-20 mg/kg, and even higher for more severe infections (25-30 mg/kg in patients with sepsis, infective endocarditis, meningitis, etc. with a max dose depending on your hospital protocol).

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In a study by Fuller and colleagues that reviewed vancomycin management in the ED, they reviewed 4441 doses of vancomycin given to patients with a weight measurement available. Vancomycin was dosed correctly in only 22.1% of patients ๐Ÿ˜ง with 71 % of patients being dosed below the recommended dose of 15-20 mg/kg ๐Ÿ˜ฑ. Vancomycin dosing is not one size fits all and patient specific characteristics should be considered when dosing this medication. ๐Ÿ’‰

#theedtraumacist #trauma #traumaninjas #miamitrauma #traumiami #emergencymedicine #emergencydepartment #pharmacy #pharmacylife #pharmlife #pharmvida #pharmsohard #pharmacystudent #pharmacyresident #pharmer

AEIOUTIPS Mnemonic DDx for Altered Mental Status

Have you ever taken care of a pt who had an altered mental status (AMS)? Patients with an altered mental status (or ALOC)are among the toughest to assess since there is no classic, “one size fits all” presentation.

The clinical presentation is often obscure, which makes recognizing changes in mental status a challenging endeavor. There are certain underlying pathophysiological conditions that can cause AMS. This is one of the largest differential diagnoses you may encounter in the ED, EMS or hospital setting. 

1-START WITH THE ABCS, IV, O2, โœ”๏ธskins & 12 lead ๐Ÿ–ค๐Ÿ’™๐Ÿ–ค

2-ASSESS the pt & extrapolate info from the family (i.e. med list) ๐Ÿ’Š

3-GET labs: ISTATs, & venous blood gas (VBG) ๐Ÿ’‰

4-Use AEIOUTIPS mnemonic to help w/DDx

5-Listen to emergency trauma mamaโ€™s new podcast to review a super interesting case study ๐Ÿ˜ฒ๐Ÿ’ช๐Ÿป๐Ÿ’ฏ๐Ÿค—

Phenylephrine

@rishimd Phenylephrine is a selective alpha-1 receptor agonist used in various settings for its vasoconstrictive properties. Whether this is as a decongestant (constricting vessels in the nasal/sinus mucosa) or a mydriatic to perform a fundoscopic exam, this medicationโ€™s selectivity gives me an idea of the expected response as well as potential side effects. โ˜บ๏ธ
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I most commonly use phenylephrine in the ICU and OR to treat acute hypotension caused by vasodilation from hypnotics, halogenated volatile anesthetics, or acute blood loss in tandem with ongoing resuscitation. Iโ€™m comfortable using a peripheral IV to bolus 40-120 mcg over a short period of time, but in the rare event of tissue infiltration, phenylephrineโ€™s alpha agonist effects can be antagonized with medications like phentolamine administered subcutaneously. If the need for long term afterload enhancement arises, I almost always switch to a norepinephrine or vasopressin drip. ๐Ÿ’Š
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Acute increases in systemic vascular resistance (SVR) will activate baroreceptors (ie, the carotid sinuses) which, in turn, increase vagal tone to the heart. Since phenylephrine does not have any beta-agonist properties, the unopposed increase in vagal tone is the mechanism by which the patientโ€™s heart rate decreases in response to an acutely elevated SVR. ๐Ÿ’‰๐Ÿ‘จ๐Ÿฝโ€โš•๏ธ
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Tag a friend who uses phenylephrine, let me know if/when youโ€™ve used it, and drop me a comment with questions! ๐Ÿ‘‡
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Benzodiazepines & Flumazenil

Remember that the reversal agent for benzodiazepines (Xanax, Ativan, Valium)=Romazicon (flumazenil) ๐Ÿ‘‡๐Ÿฝ๐Ÿ‘‡๐Ÿฝ๐Ÿ‘‡๐Ÿฝ Narcan-CAN reverse NARCOTICS (morphine, heroin etc.). ๐Ÿ‘‡๐Ÿฝ๐Ÿ‘‡๐Ÿฝ๐Ÿ‘‡๐Ÿฝ
Always have the reversal agents on hand for every drug that you are using, especially when performing a moderate sedation or any other type of procedure. 
In addition, have an Ambu bag, & an 
NP/OPA handy. Airway adjuncts are appropriate in the event the patient suffers from unanticipated respiratory issues, which are the most known side effect of the majority of these drugs. ๐Ÿ‘‡๐Ÿฝ๐Ÿ‘‡๐Ÿฝ๐Ÿ‘‡๐Ÿฝ
Use your nasal cannula w/ETCO2 monitoring so you can ensure your patients oxygenation & ventilation status. 
Maintain 35-45 and watch the waveform. ๐Ÿ‘‡๐Ÿฝ๐Ÿ‘‡๐Ÿฝ๐Ÿ‘‡๐Ÿฝ
Senior RN tip: I usually bring the crash cart in the room and then I feel more prepared for any potential complications.

Labeling Your Syringes

Regram from IG@rishimd

Every day as an anesthesiologist, I reconstitute, draw up, and administer antibiotics, hypnotics, narcotics, paralytics, inotropes/pressors, blood products, fluids, vasodilators, and a myriad of other medications. Each year, the FDA receives over 100,000 reports associated with a suspected medication error causing hospitalization, life-threatening emergency, morbidity, and even death! ๐Ÿ˜ท๐Ÿ’‰
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In light of the recent headlines regarding the fatal administration of vecuronium instead of midazolam (Versed), I wanted to see how you all promote safe medication administration practices. Here are two things I do with virtually every medication:
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First, I pre-label my syringes both sideways and circumferentially. Next, whenever I draw medications out of a vial, I have the inverted medication label facing me and the syringe label. This way, I can ensure Iโ€™m filling the right syringe with the right medication at the expected concentration. ๐Ÿ’‰๐Ÿ‘
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Whether itโ€™s cross-checking certain medications with a licensed provider, separating medications which look and sound similar, using electronically generated labels from medication QR codes, or even simple โ€œoff-the-protocolโ€ tips, drop me a comment with what you do regarding medication safety and a tag a friend who might be interested in seeing suggestions! We need to do better! ๐Ÿ™๐Ÿฝ๐Ÿ‘‡