EM RC Pulm Slides 2up

Complex Case: Pulmonary
Daniel H. Jarrell, PharmD, BCCCP, BCPS

Clinical Pharmacist – Emergency Medicine
Banner University Medical Center – Tucson
Clinical Assistant Professor, Department of Pharmacy Practice and Science
University of Arizona College of Pharmacy
Tucson, Arizona
Relevant Financial Relationship Disclosure

No one in control of the content of this activity has a
relevant financial relationship (RFR) with an ineligible
company.
As defined by the Standards of Integrity and Independence in Accredited Continuing Education definition of ineligible
company. All relevant financial relationships have been mitigated prior to the CPE activity.
Key Abbreviations
• ADR: adverse drug reaction • GABA: gamma‐aminobutyric acid
• ARDS: acute respiratory distress • GVHD: graft versus host disease
syndrome • HSV: herpes simplex virus
• BMT: bone marrow transplant • ICP: intracranial pressure
• BPS: behavioral pain scale
• IOP: intraocular pressure
• ICS: inhaled corticosteroid
• CPOT: critical care pain observation tool
• KOBI: ketamine only breathing
• DHR: drug hypersensitivity reaction intubation
• DSI: delayed sequence intubation • NMDA: N‐methyl‐D‐aspartate
• ETT: endotracheal tube • PaCO2: partial pressure of carbon dioxide
• FEV1: forced expiratory volume in arterial blood
• FiO2: fraction of inspired oxygen • PADIS: Pain, Agitation/Sedation,
Delirium, Immobility, and Sleep Disruption
Key Abbreviations (cont.)

• PCO2: partial pressure of carbon dioxide
• RASS: Richmond Agitation Sedation Scale
• RSI: rapid sequence intubation
• SaO2: arterial oxygen saturation
• SpO2: oxygen saturation
• SJS: Stevens‐Johnson syndrome
• TEN: toxic epidermal necrolysis
• UOP: urine output
• VBG: venous blood gas
• WHO: World Health Organization
Learning Objectives
• Identify initial management in medical emergencies using available
patient‐specific information (e.g., age‐related, risk factors, relevant acuity
indices).
• Summarize strategies for procurement, preparation, and administration of
time‐sensitive therapies.
• Adjust patient‐centered care plan based upon response, monitoring and
patient‐specific information.
• Identify adverse drug events and medication errors in emergency
medicine.
• Evaluate protocols for adherence to evidence‐based guidelines to assure
safe and cost‐effective medication use and optimal resource allocation.

Case: Pulmonary
• TF is a 44‐year‐old female presenting to the emergency department (ED) with
subjective fever and chills, productive cough, shortness of breath, and wheezing.
The wheezing has progressively worsened over the past 3 days but it became much
worse in the past 2 hours. She works full time at a daycare center and was recently
exposed to several sick children. She reports being intubated three times for
asthma exacerbations prior to this visit with the last intubation approximately 3
years ago.
Patient Case (cont.)

• Past medical history • Drug allergies
– Asthma – Amoxicillin (anaphylaxis)
– Anxiety – Cefdinir (anaphylaxis)
• Medication history • Social history
– Albuterol 90 mcg HFA MDI
— 2 puffs every 6 hours as needed for
– No smoking or recreational drug
wheezing and/or shortness of breath use
– Fluticasone propionate/salmeterol – Occasional alcohol
230 mcg/21 mcg HFA MDI
— 2 puffs twice daily
– Buspirone 10 mg
— 1 tablet twice daily
Question 1: Which of the following is a risk factor
for asthma‐related death in TF?
A. Age
B. Alcohol use
C. Anxiety
D. Previous intubations
Asthma Exacerbation
Asthma Definition
• Allergic disease
– Increased bronchial hyperresponsiveness
– Increased vascular permeability
– Bronchial smooth muscle spasm
– Release of inflammatory mediators
• Heterogenous
– Triggers, clinical manifestations, and responsiveness to treatment
vary
Lazarus SC. N Engl J Med. 2010;363:755‐64.
Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2021. Available from: www.ginaasthma.org.
Asthma Exacerbations
Progressive increase in symptoms
Common triggers
Shortness of breath
Patient’s clinical status
Cough Respiratory infections
Wheezing Allergen exposure Worsens and requires
Chest tightness Air pollution a change in treatment
Decrease in lung Seasonal changes
function Poor treatment
adherence

Adult Asthma Exacerbation Severity
Symptoms Mild/Moderate Severe
Altered mental status Absent Agitated/confused/drowsy
SaO2 90‐95% < 90%
Speech Speaks in sentences Speaks in few words
Heart rate (beats per minute) 100‐120 > 120
Respiratory rate (breaths per Increased from baseline > 30
minute)
Positioning Prefers sitting Sits hunched forward
Wheeze intensity Variable Chest quiet
Factors Associated with Increased Risk of Asthma‐

Related Death
Previous intubation or ICU admission ≥ 2 hospitalizations for asthma in past year

Current or recent oral corticosteroid use Low socioeconomic status
Poor adherence to inhaled
Food allergy
corticosteroid
Coexisting illness (e.g., pneumonia, diabetes,
History of psychiatric disease
arrhythmia)

• On exam, TF has coarse wheezing through all lung fields and is
speaking in short sentences. She appears to be in mild distress
and anxious. She ran out of her rescue inhaler yesterday after
using it approximately 4 times per day the past few days. Two
peripheral IVs are inserted, supplemental oxygen is initiated,
and a 1‐L crystalloid intravenous (IV) infusion is administered.

• Initial ED vital signs
– BP: 110/75 mm Hg
– HR: 122 beats per minute
– RR: 31 breaths per minute
– SpO2: 92% on room air
– Temperature: 38.5°C
Question 2: Which of the following is most
appropriate to administer to TF at this time?
A. IV aminophylline
B. Inhaled albuterol
C. Oral prednisone
D. IV magnesium sulfate
Asthma Exacerbation Management

• Primary therapies • Adjunctive therapies
– Supplemental oxygen – Magnesium sulfate
– Inhaled short‐acting beta2‐ – Epinephrine
adrenergic agonists – Methylxanthines
– Inhaled anticholinergics – Leukotriene receptor antagonists
– Systemic corticosteroids – Antibiotics

Supplemental Oxygen
• Target oxygen saturation depends on age, other comorbidities
– Children 6‐11 years
—94% to 98%
– Adults
—96%
• Controlled low‐flow oxygen is preferred over high
concentration oxygen therapy

Inhaled Beta2‐Adrenergic Agonists

• Albuterol 2.5 mg nebulized or 4‐8 90‐mcg puffs metered‐dose
inhaler (MDI) every 20 minutes
– Severe exacerbations may not comply with MDI
• MDI with spacer is equivalent in efficacy to pressurized nebulizer
• Intermittent nebulizer vs. continuous nebulization
– Conflicting results
– 2002 meta‐analysis: similar effects on lung function and hospitalization
rate
– 2003 Cochrane review: greater improvement in peak expiratory flow (PEF)
and forced expiratory volume in 1 second (FEV1) with reduced admission
rates Rodrigo GJ et al. Chest. 2002;122(1):160‐5.
Dhuper S et al. J Emerg Med. 2011;40(3):247‐55.
Cates CJ et al. Cochrane Database Syst Rev. 2006;(2):CD000052.
Camargo CA et al. Cochrane Database Syst Rev. 2003;2003(4):CD001115.
Anticholinergic Agents
• Ipratropium not recommended as monotherapy in ED
– Slow onset of action
• Used in combination with short‐acting beta2‐agonists
– Improved bronchodilator effect
– Reduced rates of hospital admission in patients with severe airflow
obstruction, especially in children; no benefit after hospitalization
Rodrigo GJ et al. Thorax. 2005;60:740‐6.

Gelb AF et al. Pulm Pharmacol Ther. 2008;21:630‐6.
Qureshi F et al. N Engl J Med. 1998;339(15):1030‐1035.
Rodrigo GJ et al. Am J Respir Crit Care Med. 2006;161:1862‐8.
Plotnick LH et al. Cochrane Database Syst Rev. 2000;4:CD000060.
Systemic Corticosteroids
• Recommended for patients with exacerbations presenting to
ED
– Improved lung function
– Reduced hospitalization
– Lower rate of relapse after discharge
• Oral and parenteral administration equally effective in
pediatric patients
– Only parenteral studied in adults
Barnett PL et al. Ann Emerg Med. 1997;29(2):212‐17.
Rowe BH et al. Cochrane Database Syst Rev. 2001;(1):CD002178.
Corticosteroid Dosing
Resource Dose Strategy
Prednisone 1 mg/kg/day orally (50
Global Initiative for Asthma
mg/dose MAX)
National Asthma Education Prevention
Prednisone 40-80 mg/day orally
Program (NAEPP) Guidelines
Adults: Hydrocortisone 500 mg/dose
Doses > 100 mg prednisone equivalent to lower doses orally or Methylprednisolone 125 mg/dose
IV or IM
Cochrane Review
Pediatrics: 1-2 mg/kg/day of
prednisolone/prednisone orally (40
mg/dose MAX)
Cloutier MM et al. J Allergy Clin Immunol. 2020;146(6):1217‐70.
Rowe BH et al. Cochrane Database Syst Rev. 2001;(1):CD002178.
Magnesium Sulfate
• Adults
– Possibly improved lung function
– Conflicting data regarding effect on hospital admissions
– 2 g IV over 20 minutes
• Pediatrics
– Significantly improved lung function
– Reduced rates of hospital admission
– 40‐50 mg/kg IV over 20‐60 minutes
• Systemic recommended over
inhaled/nebulized therapy
Silverman RA et al. Chest. 2002;122(2):489‐97.
Mohammed S et al. Emerg Med J. 2007;24(12):823‐830.
Kew KM et al. Cochrane Database of Syst Rev. 2014;1:CD010909.
Rowe BH et al. Cochrane Database of Syst Rev. 2000;1:CD001490.
Therapies Not Routinely Used or Not
Recommended for Acute Asthma Exacerbations
Agent Recommendation
Useful for long-term asthma control, not
Inhaled corticosteroids
rescue therapy
Indicated for concomitant anaphylaxis or
Epinephrine
angioedema
Risk of adverse events exceeds potential
Methylxanthines
benefit
Limited available evidence to support use
Leukotriene receptor antagonists
acutely
Consider for patients with probable
Antibiotics
bacterial infection
Acute Exacerbation of Chronic Obstructive

Pulmonary Disease (AECOPD)
COPD Definition
• Acquired and preventable disease primarily from tobacco
smoking
– Persistent airflow obstruction
– Progressive decline in lung function
Global Strategy for the Diagnosis, Management and Prevention of COPD. 2022 Report.
Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2021. http://goldcopd.org.
COPD Exacerbations
Cough increased in frequency and severity
Increased sputum volume or changed character
Dyspnea increased
Common Causes of COPD Exacerbation
Respiratory viral infections Bacterial infections Environmental factors

•Rhinovirus most common •Haemophilus influenzae •Pollution
•Influenza •Streptococcus pneumoniae •Ambient temperature
•Exacerbations more •Pseudomonas aeruginosa
severe, last longer, more (bronchiectasis)
hospitalizations
Differential Diagnosis
• Pneumonia
• Pleural effusion
• Pulmonary edema
• Pneumothorax
• Pulmonary embolism
• Cardiac dysrhythmias
Treatment of COPD Exacerbations Based on Severity
Mild – can be controlled with an increase in dosage of regular medications
• Short-acting bronchodilators
Moderate – requires treatment with systemic corticosteroids or antibiotics
• Short-acting bronchodilators
• Oral corticosteroids
• Oral antibiotics
Severe – requires hospitalization or evaluation in the ED
• ED visit or hospitalization
Severe COPD Exacerbation Subclassification

Acute respiratory Acute respiratory
No respiratory failure failure failure
Non‐life‐threatening Life‐threatening
Respiratory rate
20‐30 > 30 > 30
(breaths per minute)
Accessory muscle use No Yes Yes
Mental status No change No change Acute change
Oxygen therapy Venturi mask 24‐35% Venturi mask 24‐35%
> 40% FiO2**
requirement FiO2** FiO2**
PaCO2* > 60 mm Hg
Increase in PaCO2* or
Blood gas No increase in PaCO2* or pH ≤ 7.25
50‐60 mm Hg
**FiO2: fraction of inspired oxygen
*PaCO2: partial pressure of carbon dioxide
COPD Exacerbation Risk Factors
• Concomitant asthma and COPD
• Allergic phenotypes
• High degree of inflammation
• Past exacerbations
• Chronic bronchitis
Hurst JR et al. N Engl J Med. 2010;363:1128‐38.

COPD Exacerbation Management

• Primary therapies
– Respiratory support
— Supplemental oxygen
— Noninvasive positive pressure ventilation
— Mechanical ventilation
– Inhaled beta2‐adrenergic agonists +/‐ short‐acting anticholinergics
— No difference in efficacy between MDI and nebulizer therapy
– Systemic corticosteroids
– Antibiotics if indicated
Van Geffen WH et al. Cochrane Database Syst Rev. 2016;8:CD011826.

Respiratory Support for Patients with COPD
Exacerbations
• Target oxygen saturation 88‐92%
– Decreased mortality compared with high‐flow non‐titrated oxygen
• Noninvasive positive pressure ventilation
– Decreased morbidity/mortality in hospitalized patients with acute
respiratory failure
• Mechanical ventilation
– Noninvasive preferred if possible
Austin MA et al. BMJ. 2010;341:c5462.
Indications for Use of Ventilatory Support in

Patients with COPD Exacerbations
• Noninvasive positive pressure • Mechanical ventilation
ventilation – Inability to tolerate or failure of
noninvasive positive pressure
– PaCO2 ≥ 45 mm Hg and arterial pH ≤ ventilation
7.35 – Respiratory or cardiac arrest
– Severe dyspnea with respiratory – Decreased consciousness or agitation
muscle fatigue and/or increased work uncontrolled by sedation
of breathing – Massive aspiration/persistent
vomiting
– Persistent hypoxemia despite oxygen – Inability to remove pulmonary
therapy secretions
– Severe hemodynamic instability
unresponsive to fluids/vasopressors
– Severe arrhythmia
Systemic Corticosteroids in Patients with COPD
Exacerbations
• Benefits • Recommendations
– Improve lung function – 5‐7 days noninferior to 14 days of
– Improve oxygenation therapy
– Shorten recovery time — Longer duration associated with
increased risk of pneumonia and
– Shorten hospitalization
mortality
– Oral noninferior to intravenous
route
de Jong YP et al. Chest. 2007;132(6):1741‐7.

Leuppi JD et al. JAMA. 2013;309(21):2223‐31.
Sivapalan P et al. BMJ Open Respir Res. 2019;6:e000407.
Antibiotic Benefits in Patients with COPD

Exacerbations
• Shorten recovery time
• Reduce risk of early relapse
• Reduce risk of treatment failure
• Reduce length of hospital stay
Indications for Use of and Duration of Antibiotic Therapy
for Patients with COPD Exacerbations
• Patient requires noninvasive or invasive mechanical ventilation OR
• Presence of all 3 cardinal symptoms
– Increase in dyspnea
– Increase in sputum volume
– Increase in sputum purulence*
*if positive, only need 2/3 cardinal symptoms to initiate antibiotics
• Duration of 5‐7 days
• CRP and procalcitonin not recommended to make initiation
decisions Global Strategy for the Diagnosis, Management and Prevention of COPD. 2022 Report.
Antimicrobial Selection in Patients with COPD

Exacerbations
Low Risk for Pseudomonas High Risk for Pseudomonas*
Amoxicillin/clavulanate or
Ciprofloxacin
ampicillin/sulbactam
Doxycycline Levofloxacin
Macrolide
*Bronchiectasis, recent hospitalization and IV antibiotic use within the last 90 days
• TF’s wheezing and shortness of breath begin to improve with
the treatment given. Her chest X‐ray demonstrates bilateral
lower lobe infiltrates but is otherwise unremarkable
Patient Case (cont.) – Initial ED Labs

Venous blood gas BMP CBC
• pH 7.37 • Na 137 mmol/L • WBC 17.4 K/μL

• pO2 45 mm Hg • Cl 104 mmol/L • Hgb 9.8 g/dL
• pCO2 31 mm Hg • K 4.2 mmol/L • HCT 40%
• HCO3 17 mmol/L • CO2 19 mmol/L • Plt 424 K/μL
• Ca 8.4 mg/dL
• BUN 15 mg/dL
• SCr 0.8 mg/dL
• Glucose 115 mg/dL
• Current vital signs
– BP: 115/82 mm Hg
– HR: 110 beats per minute
– RR: 26 breaths per minute
– SpO2: 95% on 4 L/min oxygen via nasal cannula
– Temperature: 38.9°C
Question 3: Which of the following is the most

appropriate initial antibiotic dose to provide to TF at
this time?
A. Doxycycline 100 mg
B. Amoxicillin 1 g + azithromycin 500 mg
C. Levofloxacin 750 mg
D. Vancomycin 15‐20 mg/kg + cefepime 2 g
Pneumonia
Etiology
• Viral vs. bacterial
– No specific test to differentiate
– Correlate with clinical picture and constellation of findings
• Influenza
– Antivirals recommended regardless of duration of illness if inpatient
– Antivirals suggested regardless of duration of illness if outpatient
Metlay JP et al. Am J Respir Crit Care Med. 2019;200(7):e45‐67.

Community‐Acquired Pneumonia (CAP)
Differential Diagnosis
Abnormal X-ray Normal X-ray
Congestive heart failure with viral AECOPD
syndrome Influenza
Aspiration pneumonitis Acute bronchitis
Pulmonary embolism (PE) Pertussis
Acute exacerbation of pulmonary fibrosis Asthma with viral syndrome
Acute exacerbation of bronchiectasis
Acute eosinophilic pneumonia
Hypersensitivity pneumonitis
Pulmonary vasculitis
Wunderink RG et al. N Engl J Med. 2014;370:543‐51.
Mortality Predictors and Admission Decision Tools

• Pneumonia severity index (PSI)
– More complex, formal scoring, electronic decision support
• CURB‐65
– Easier to calculate
– Not as validated as PSI but may be more specific
• Patient factors may override clinical decision tool
• Recent guidelines prefer PSI over CURB‐65, but both
potentially useful
– Both unable to determine level of care
CURB‐65 Criteria
Confusion Present
BUN ≥ 20 mg/dL
Respiratory rate ≥ 30 breaths per minute
Blood pressure < 90 mm Hg systolic or ≤ 60 mm Hg diastolic
Age ≥ 65 years
Assign 1 point for each criterion. Score ≥ 3 points suggests need for hospital admission
Lim W et al. Thorax. 2003;58(5):377‐82.
Criteria for Severe CAP

• IDSA/ATS 2007 guideline
– 1 major criterion OR
– 3 minor criteria
• SMART‐COP
– Similar elements to IDSA/ATS 2007 guidelines
– Components not as universally available for real‐time decision
making
—Albumin, pH, PaO2
Mandell LA et al. Clin Infect Dis. 2007;44:S27‐72.

IDSA: Infectious Diseases Society of America; ATS: American Thoracic Society; PaO2: partial pressure of oxygen Charles PGP et al. Clin Infect Dis. 2008;47(3):375‐84.
IDSA/ATS 2007 Criteria for Severe CAP
Major Minor
• Septic shock with need for vasopressors • Respiratory rate ≥ 30 breaths/minute
• Respiratory failure requiring mechanical • PaO2/FiO2 ≤ 250
ventilation • Multilobar infiltrates
• Confusion/disorientation
• BUN ≥ 20 mg/dL
• WBC < 4 K/μL
• Platelets < 100 K/μL
• Core temperature < 36°C
• Hypotension requiring aggressive fluid
resuscitation
Phua J et al. Thorax. 2009;64:598‐603.
Mandell LA et al. Clin Infect Dis. 2007;44:S27‐72.
Risk Factors for Bacterial Infection in Patients with

CAP
• Comorbidities • MRSA/Pseudomonas
– Chronic heart, lung, liver, – Prior respiratory isolation
or renal disease – Recent hospitalization +
– Diabetes mellitus parenteral antibiotics past
– Alcoholism 90 days
– Malignancy
– Asplenia

Antibiotic Selection for CAP in Adults
• Outpatient – No comorbidities or risk factors for
MRSA/Pseudomonas
– Amoxicillin 1g oral three times daily
– Doxycycline 100mg oral twice daily
– Macrolide (azithromycin 500 mg oral day 1, then 250 mg oral
days 2‐5 OR clarithromycin 500 mg oral twice daily OR 1000
mg ER oral daily)
— If local pneumococcal resistance < 25%
Antibiotic Selection for CAP in Adults (cont.)

• Outpatient – With comorbidities
– Beta‐lactam + macrolide
— Amoxicillin/clavulanate oral (500 mg/125 mg three times daily OR 875
mg/125 mg twice daily)
— Cefpodoxime 200 mg oral twice daily
— Cefuroxime 500 mg oral twice daily
– Beta‐lactam + doxycycline 100 mg oral twice daily
– Respiratory fluoroquinolone
— Levofloxacin 750 mg oral daily
— Moxifloxacin 400 mg oral daily

• Inpatient non‐severe CAP – No risk factors for MRSA/Pseudomonas
— Ampicillin/sulbactam 1.5 g‐3 g IV every 6 h
— Cefotaxime 1‐2 g IV every 8 h
— Ceftriaxone 1‐2 g IV daily
— Ceftaroline 600mg IV every 12 h
– Respiratory fluoroquinolone
— Levofloxacin 750 mg oral or IV daily
— Moxifloxacin 400 mg oral or IV daily
– Alternative: beta lactam + doxycycline 100 mg oral or IV daily

• Inpatient severe CAP – no risk factors for MRSA/Pseudomonas
– Beta‐lactam + respiratory fluoroquinolone

• Inpatient – with risk factors for MRSA/Pseudomonas
– MRSA
— Vancomycin 15 mg/kg IV every 12 h adjusted based on levels
— Linezolid 600mg IV every 12 h
– Pseudomonas
— Piperacillin/tazobactam 4.5 g IV every 6 h
— Cefepime 2 g IV every 8 h
— Ceftazidime 2 g IV every 8 h
— Aztreonam 2 g IV every 8 h
— Meropenem 1 g IV every 8 h
— Imipenem 500 mg IV every 6 h
Antibiotic Selection for CAP in Adults

• Suspected aspiration pneumonia
– Routine antimicrobial coverage not recommended
— Exception: lung abscess/empyema

Corticosteroids for CAP
• Routine use not recommended for non‐severe CAP
• Routine use not suggested for severe CAP
• Routine use not suggested for severe influenza
• Recommended for CAP + refractory septic shock
– Surviving Sepsis Campaign

• Antibiotic therapy is initiated, and TF receives another 1 L of
crystalloid fluid by IV infusion. Approximately 5 minutes after
starting antibiotic therapy, she develops a rash and urticaria
along with acute worsening of shortness of breath and
wheezing. She has two episodes of vomiting and complains
that her tongue feels larger than normal.
Question 4: What is the most appropriate
intervention for TF at this time?
A. Diphenhydramine 50 mg intravenous push
B. Epinephrine intravenous infusion 2 mcg/min
C. Epinephrine 0.3 mg intramuscular in the thigh
D. Epinephrine 0.5 mg subcutaneous in the deltoid
Allergic Reactions
Adverse Drug Reaction (ADR)
• Harmful or unpleasant reaction
• Results from use of medicinal product
• Predicts hazard from future administration
• Warrants prevention or specific treatment, alteration of the
dosage regimen, or withdrawal of the product
Demoly P et al. Allergy. 2014;69:420‐37.
ADR Types
• Type A
– Overdoses and pharmacologic reactions
– Dose dependent and predictable
• Type B
– Drug hypersensitivity reaction (DHR)
– Clinically resembles allergy
—Dose independent, unpredictable, noxious
—Unintended response to a drug taken at usual dose

Drug Hypersensitivity Reaction (DHR)
• Preferred term for drug allergic reaction
– Allergic and non‐allergic forms
• Drug allergy
– Adverse reaction
– Caused by antibodies and/or activated T‐cells
– Directed against drug or metabolite
Non‐allergic examples
Mechanism Implicated Drugs
Nonspecific mast cell/basophil histamine
Opioids, vancomycin
release
Bradykinin accumulation Angiotensin converting‐enzyme inhibitors
Complement activation Protamine
Alteration in arachidonic acid metabolism NSAIDs
Pharmacologic effect causing adverse reaction Beta‐blockers with asthma
Allergic Reaction Classification
Reaction Mechanism Features
Urticaria, angioedema, anaphylaxis, bronchospasm,
Type I IgE; Immediate
rhinitis, conjunctivitis, nausea, vomiting, diarrhea
Type II IgG/IgM cytotoxic Hemolytic anemia, cytopenia, thrombocytopenia

IgG/IgM immune Vasculitis, lymphadenopathy, fever, arthropathy, rashes,
Type III
complexes serum sickness
Mirakian R et al. Clin Exp Allergy. 2008;39:43‐61.
Allergic Reaction Classification (cont.)

Reaction Mechanism Features
T‐helper cell activation of Contact dermatitis, bullous exanthema, tuberculin
Type IVa
monocytes/macrophages reaction
T‐helper cell eosinophilic
Type IVb Maculopapular and bullous rashes
inflammation
Contact dermatitis; maculopapular, pustular, and
Type IVc Cytotoxic T‐cells
bullous exanthema; hepatitis
T‐cell neutrophil
Type IVd Pustular exanthema
activation
Mirakian R et al. Clin Exp Allergy. 2008;39:43‐61.

Anaphylaxis
Background
• Definition
– Serious allergic reaction that is rapid in onset and may cause death
• Likely underrecognized and undertreated in the prehospital
setting and ED
• Risk factors associated with death
– Infancy, advanced age, asthma, chronic respiratory disease,
cardiovascular disease, mastocytosis, severe atopy
• Causes
– Certain food, insect stings, certain medications, idiopathic
Sampson HA et al. Food Allergy, Dermatologic Diseases, and Anaphylaxis. 2005;115(3):P584‐91.

Organ System Involvement in Anaphylaxis
Percentage of Patients
Organ System Signs and Symptoms
Experiencing
Skin and mucosa Urticaria, angioedema, pruritis, rash 80‐90
Stridor, shortness of breath,
Respiratory 70
bronchospasm, cyanosis
Tachycardia, bradycardia,
Cardiovascular hypotension, dysrhythmia, cardiac 45
arrest
Abdominal pain, nausea, vomiting,
Gastrointestinal 45
diarrhea
Altered mental status, dizziness,
Central nervous system 15
headache
Zilberstein J et al. J Emerg Med. 2014;47(2):182‐7.
Clinical Diagnosis of Anaphylaxis*

Exposure Systems involved
Unknown 1. Skin +/‐ mucosal AND
exposure 2. Respiratory, cardiovascular, or other end‐organ dysfunction
Two or more of the following
1. Skin/mucosa
Likely allergen
2. Respiratory
exposure
3. Cardiovascular or other end‐organ dysfunction
4. Gastrointestinal
1. Cardiovascular (hypotension)
Known allergen
‐Children: age‐specific or >30% decrease in baseline
exposure
‐Adults: systolic blood pressure < 90 mmHg or > 30% decrease in baseline
*Anaphylaxis diagnosis highly likely if any of the above 3 criteria met Simons FER et al. World Allergy Organ J. 2011;4:13‐37.
Anaphylaxis Management
• Supplemental oxygen + continuous capnography
• Intubation considerations
– Respiratory distress
– Altered mental status
– Upper airway obstruction
• Circulatory shock (distributive, hypovolemic, cardiogenic)
– Increase preload
—Crystalloid fluid bolus (5‐10 mL/kg) within first few minutes; up to 1‐2 L in adults and
30 mL/kg in children
—Supine positioning
—Leg elevation controversial
Epinephrine for Anaphylaxis

• WHO: essential medication for the treatment of anaphylaxis
• Administer as soon as anaphylaxis suspected
• Reverses vasodilation, angioedema, and bronchoconstriction
• Positive chronotrope/inotrope
• Inhibits mast cell mediator release
• Delay or lack of administration accounts for majority of deaths
in patients with anaphylaxis
– No absolute contraindication to use in the setting of anaphylaxis
WHO: World Health Organization Simons FER et al. World Allergy Organ J. 2011;4:13‐37.
Epinephrine Administration for Anaphylaxis
• 0.01 mg/kg of 1‐mg/mL solution (Max 0.3‐0.5 mg)
intramuscular (IM) every 5‐15 minutes as needed
– Middle anterolateral aspect of thigh
• Higher systemic concentrations with administration IM in leg
vs IM or SC in arm
• May inject through clothing

Simons FER et al. J Allergy Clin Immunol. 2001;108:871‐3.
Epinephrine Administration for Anaphylaxis (cont.)

• IV epinephrine
– Recommended for circulatory shock or unresponsive to two IM doses
– Continuous infusion preferred to intermittent boluses
—Lower incidence of adverse effects
– Initiate at 1 mcg/min, increase every 3‐5 minutes up to 10 mcg/min
—If infusion not available, may consider 0.1 mg of 0.1‐mg/mL solution every 5
minutes in adults
—Weight‐based dosing or pediatrics: initiate 0.1 mcg/kg/minute, increase every
3‐5 minutes up to 1 mcg/kg/min with a maximum of 10 mcg/min

Adjunctive Therapies for Anaphylaxis
• Antihistamines
– 2007 Cochrane review – no evidence of effectiveness
– H1 and H2 antihistamines may relieve cutaneous symptoms
—Cardiovascular, pulmonary, and gastrointestinal symptoms unaffected
– Diphenhydramine 1 mg/kg (25‐50 mg) +/‐ famotidine; all oral or IV
• Corticosteroids
– 2012 Cochrane review – no evidence of effectiveness
– Not shown to reduce biphasic symptoms
– Methylprednisolone 1‐2 mg/kg IV (125mg) or hydrocortisone 200mg IV
• Beta2‐agonists
– Consider for wheezing, shortness of breath, cough
– Not routinely given, limited data Zilberstein J et al. J Emerg Med. 2014;47(2):182‐7.
Cardona VC et al. World Allergy Organization J. 2020;13:100472.
Sheikh A et a. Cochrane Database Syst Rev. 2007;1:CD006160.
Choo KJL et al. Cochrane Database Syst Rev. 2012;4:CD007596.
Refractory Anaphylaxis
• Consider intubation if not already performed
• Consider alternative vasopressors if unresponsive to epinephrine
• Consider glucagon in the presence of beta‐adrenergic receptor
antagonist
– Bypasses beta‐adrenergic receptor
– Direct inotropic/chronotropic effects
– Administer 1‐5 mg IV over 5 minutes followed by infusion of 5‐15 mcg/min
—Pediatrics 20‐30 mcg/kg IV over 5 minutes (max 1mg)
– Emesis and aspiration risk
• TF’s rash, urticaria, wheezing, and shortness of breath begin to
improve after administration of epinephrine. Upon further
review of the events leading up to TF’s suspected allergic
reaction, it was discovered the RN had given her
ampicillin/sulbactam instead of her prescribed therapy. The RN
states that ampicillin/sulbactam was prescribed for the patient
in the next bed and accidentally switched the antibiotics in the
room. The RN is hesitant to report the medication error out of
fear of punitive action and is asking what should be done.
Question 5: What is the most appropriate action

after discovery of this medication error?
A. Let the RN decide whether to report the medication error since the RN
was directly involved
B. Advise the RN not to report the medication error since TF improved
with treatment
C. Advise the RN to report the medication error because additional
treatment was necessary
D. Explain to the RN that all medication errors should be reported
regardless of outcome
Question 6: Which of the following policy changes or
actions would be most helpful in preventing this type of
medication error in the future?
A. Remove all antibiotics from the automated dispensing cabinet override
list
B. Require a prospective review of all antibiotic orders by a pharmacist
prior to administration
C. Use barcode scanning technology at the bedside for all antibiotics and
other medications
D. Require a witness for administration of all antibiotics as is done for
other high‐risk medications

• TF’s rash and urticaria completely resolve shortly after
administration of epinephrine, however, she is now
complaining of heart palpitations and appears very anxious,
pale, diaphoretic, and in the tripod position. Upon lung
auscultation, wheezing is absent and it is difficult for the
provider to hear any air movement.
• Venous blood gas • Current vital signs
– pH 7.18 – BP 98/71 mmHg
– pO2 42 mmHg – HR 154 beats/min
– pCO2 53 mmHg – RR 50 breaths/min
– HCO3 19 mmol/L — very shallow
– SpO2 86%
— 15 L /min O2
Question 7: Based on TF’s current status, what is

the most likely reason she will need to be
intubated?
A. Inability to protect airway
B. Current or impending respiratory failure
C. To facilitate diagnostic imaging
D. To allow for continuous paralysis
Rapid Sequence Intubation (RSI)
Rapid Sequence Intubation

• “Virtually simultaneous administration of a potent sedative
agent and a neuromuscular blocking agent for the purpose of
endotracheal intubation”
Mark JA et al. Rosen's Emergency Medicine: Concepts and Clinical Practice, 8th ed 2014.
Reasons to Intubate
• To prevent aspiration in patients unable to protect their airway
– Altered mental status; decreased Glasgow Coma Scale (GCS) score
– Seizures/status epilepticus
• Current or impending respiratory failure
– Pneumonia, COPD/asthma exacerbation, anaphylaxis, Ludwig’s angina, burns
with airway involvement/edema
• Facilitation of medical procedures or other treatment
– Prevent/treat hyperthermia
— Hypothermia protocol post cardiac arrest, drug‐induced hyperthermia (sympathomimetics,
serotonin syndrome, neuroleptic malignant syndrome)
– Perform procedures or surgery
— Elective surgery, endoscopy, imaging
– Pain control

• The treatment team asks you to prepare etomidate and
rocuronium for rapid sequence intubation, however, TF
becomes increasingly agitated making it difficult to provide
supplemental oxygen and other therapies.
Question 8: What is the most appropriate response
to TF’s agitation to facilitate intubation?
A. Administer etomidate as soon as possible
B. Change induction agent to ketamine, administer as soon as
possible
C. Change induction agent to lorazepam, administer as soon as
possible
D. Change induction agent to propofol, administer as soon as
possible
7 P’s of Intubation
• Preparation (t‐10 minutes)
– Assemble all necessary equipment and drugs
• Preoxygenation (t‐5 minutes)
– Replace nitrogen in patient’s reserve with oxygen (nitrogen wash out)
• Pre‐intubation optimization (t‐3 minutes)
– Ancillary medications to mitigate adverse physiological consequences of
intubation
• Paralysis with induction (t=0)
• Protection and positioning (20‐30 seconds)
• Placement with proof (45 seconds)
• Post‐intubation management (60+ seconds)
– Long‐term sedation, analgesia, or paralysis
Mace SE. Emerg Med Clin North Am. 2008;26(4):1043‐68.
Physiologic Response to Intubation
• Sympathetic stimulation (“fight or flight” response)
– Increased catecholamine release
—↑HR; ↑MAP
—↑ICP
—↑IOP
• Parasympathetic stimulation (“vagal response”)
– < 1 year of age
—↓HR
MAP: mean arterial pressure; ICP: intracranial pressure; IOP: intraocular pressure
Pretreatment/Premedication
• Attenuate physiologic response to RSI
• Approximately 3 minute onset
• Supporting evidence extremely limited
• Lidocaine
– 1‐1.5 mg/kg IV
– May attenuate cough/gag reflex
– May attenuate increase in ICP
• Atropine
– 0.02 mg/kg IV
– May attenuate vagal stimulation‐induced bradycardia in pediatrics
• Fentanyl
– 3‐5 mcg/kg IV
– May a enuate ↑ BP/↑ HR; sympatholy c

Induction (Sedation)
• Induce unconsciousness
• Enhance effects of neuromuscular blocker (NMB)
• Enhance intubation conditions
Induction Agent Properties

Etomidate Ketamine Propofol Midazolam
Ultrashort‐acting Non‐
Drug
non‐barbiturate NMDA antagonist; benzodiazepine Benzodiazepine;
Class/Mechanism
hypnotic; inhibits glutamate general anesthetic; ↑ GABA ac vity
of Action
stimulates GABA ↑ GABA ac vity
0.3mg/kg (0.2‐ 1.5‐2mg/kg
IV Dose 1‐2mg/kg 0.2‐0.3mg/kg
0.6mg/kg) Obesity: TBW
Time to Onset 15‐30 seconds 30‐60 seconds 15‐30 seconds 2‐3 minutes
Duration 5‐7 minutes 10‐20 minutes 5‐7 minutes 30‐120 minutes
Hemodynamic
Neutral ↑HR/↑BP ↓BP ↓BP or Neutral
Effect Expected
Analgesia? No Yes No No
GABA: Gamma-aminobutyric acid; NMDA: N-methyl-D-aspartic acid; TBW: total body weight Reynolds SF et al. Chest. 2005;127(4):1397‐412.
Induction Agent Properties(cont.)
Etomidate Ketamine Propofol Midazolam
PRIS (Propofol‐
Myoclonus Nystagmus, related infusion
(33%); adrenal sialorrhea, ↑IOP; syndrome) when
Possible
Side Effects suppression; ↓ emergence used in high
hypotension
seizure phenomenon; doses for long
threshold? laryngospasm periods;
hypotension
Contraindications No absolute Schizophrenia? Soy/Egg allergy? No absolute
Unpredictable
Other Concerns ↑ ICP? ↑ Triglyceride dosing to achieve
desired effect
Reynolds SF et al. Chest. 2005;127(4):1397‐412.
Considerations for Induction Agent Selection

AVOID UTILIZE
Hypotension Propofol; Midazolam? Etomidate, ketamine
Ketamine (unless
Hypertensive Propofol, midazolam, etomidate
sympathomimetic cause)
Midazolam (longer duration of Propofol, etomidate, ketamine (avoid

Head Injury or ↑ ICP
action) with CSF outflow obstruction)
Septic Shock Etomidate?
Seizure Disorder Etomidate? Ketamine, propofol, midazolam
Asthma or Bronchospasm Ketamine, propofol

Paralytic Agents for RSI – Neuromuscular Blockers
• Depolarizing
– Succinylcholine
• Non‐depolarizing (everything else)
– Rocuronium
– Cisatracurium
– Vecuronium
Paralytic Agent Properties

Succinylcholine Rocuronium Cisatracurium Vecuronium
Non‐depolarizing Non‐depolarizing Non‐depolarizing
Mechanism Depolarizing NMB
NMB NMB NMB
1‐1.5mg/kg (up to 0.1‐0.2mg/kg 0.1mg/kg
1‐1.2mg/kg
IV Dose 2mg/kg pediatrics) Obesity: IBW Obesity: IBW
Obesity: IBW
Obesity: TBW
Time to Onset 15‐30 seconds 45‐90 seconds 45‐90 seconds 2‐5 minutes
Duration 5‐7 minutes 30‐60 minutes 30‐60 minutes 45‐90 minutes
Plasma
cholinesterase Hoffman
Metabolism Renal > Hepatic Hepatic > Renal
Pseudo‐ elimination
cholinesterase
Paralytic Agent Properties
• Contraindications, warnings, and side effects
– No absolute contraindications to use of rocuronium, cisatracurium,
vecuronium
—Duration longer than sedative induction agents
—Post‐intubation management implications
– Succinylcholine
—Transient hyperkalemia (↑ 0.5‐1 mmol/L most patients)
—↑ ICP? ↑ IOP?
—Malignant hyperthermia; burns; crush injuries; neuromuscular disorders;
pseudo‐cholinesterase deficiency
Alternative Intubation Strategies

• Delayed sequence intubation (DSI)
– Induction, or more likely sub‐induction, with delayed paralysis to optimize pre‐
intubation conditions
—“Procedural sedation” for preoxygenation
—May be useful for agitation or preoxygenation‐intolerant patient
– Ketamine usually preferred
—Maintains respiratory drive/airway reflexes
• Ketamine only breathing intubation (KOBI)
– Similar to DSI, but without use of paralytic
– May be useful for patients who are difficult to intubate or unable to tolerate
significant periods of apnea
—Obesity, limited neck mobility, other anatomical issues
—Diabetic ketoacidosis, salicylate toxicity, severe acidosis
Merelman AH et al. West J Emerg Med. 2019;20(3):466‐71.

Ketamine Dosing per Intubation Strategy
• RSI
– Optimize intubating conditions, achieve anesthesia
– 1 – 2 mg/kg
• DSI
– “Procedural sedation” to optimize preoxygenation
– 0.5 – 1 mg/kg
—Smaller doses may be successful
• KOBI
– Much more variable depending on reason for use
– Administer slowly, rapid infusion increases apnea risk
Merelman AH et al. West J Emerg Med. 2019;20(3):466‐71.

• TF is successfully intubated. She is placed on the ventilator with
lung protective mechanical ventilation strategies along with a rate
of 10 breaths/minute due to her likely severe asthma exacerbation.
She is initiated on a fentanyl infusion of 100 mcg/h and propofol
infusion of 20 mcg/kg/min shortly after intubation. Approximately
45 minutes after intubation, TF’s Richmond Agitation and Sedation
Scale (RASS) score changes from ‐5 to +3, she is experiencing
ventilator dyssynchrony, and cannot be calmed with verbal
reassurance
– BP 115/77 mmHg; HR 124 beats/min; RR 25 breaths/min (10 from
ventilator); SpO2 96% on 100% FiO2
Question 9: Which of the following is the most
appropriate response to manage TF at this time?
A. Administer rocuronium 80 mg IV bolus
B. Increase fentanyl infusion to 200 mcg/h
C. Administer midazolam 5 mg IV bolus
D. Increase propofol infusion to 30 mcg/kg/min
Post‐intubation Management
When Does Pain Occur?
• Events prior to intubation
• Caused by intubation process itself
• Procedures after intubation
• Endotracheal tube (ETT) pain
– Retrospective trial evaluating 150 ICU patients
– ETT pain at its worst = 8/10
– ETT pain at its least = 5/10
Wood S et al. J Emerg Med. 2011;40(4):419‐27.

Rotondi AJ et al. Crit Care Med. 2002;30(4):746‐52.
Devlin JW et al. Crit Care Med. 2018;46(9):e825‐73.
Negative Effects of Poor Pain Control

• Higher incidence of chronic pain, posttraumatic stress disorder
(PTSD) symptoms, and lower health‐related quality of life
• Increases catecholamine release, impairs tissue perfusion
• Deleterious effects on immune response

Schelling G et al. Crit Care Med. 1998;26(4):651‐9.
PADIS Recommendations
• Preemptive analgesia
– Opioid‐based regimens
– Rephrase as post‐intubation analgesia and sedation
— Analgosedation
— A1 sedation
— Analgesia‐first sedation
• Target light level of sedation
– Non‐benzodiazepines first line
PADIS: Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption Devlin JW et al. Crit Care Med. 2018;46(9):e825‐73.
ED vs ICU Management of the Recently Intubated Patient

• Procedures and/or diagnostic scans often performed
immediately after intubation in ED
• Higher staff‐to‐patient care ratios in ED
• Unpredictable nature and dynamic acuity in ED
• Variable and usually shorter length of stay in ED
• Often leads to deeper levels of sedation acutely in the ED
compared with ICU

Post‐intubation Literature in the ED
• 2008 trial by Bonomo et al
– Inadequate anxiolysis and analgesia very common, especially with long‐acting paralytics
• 2009 trial by Kendrick et al
– Average time to additional sedation 46 +/‐ 49 minutes
– All received long‐acting paralytics
• 2013 trial by Watt et al
– Succinylcholine patients received additional sedation quicker than rocuronium patients
—15 minutes vs. 27 minutes
• 2013 published cohort by Weingart et al
– Approximately 1 million intubations
– < 50% received sedatives during post‐intubation
period in ED
Watt JM et al. Emerg Med J. 2013;30(11):893‐5.
Bonomo JB et al. Am J Emerg Med. 2008;26:469‐72.
Weingart GS et al. Am J Emerg Med. 2013;31(1)222‐6.
Kendrick DB et al. Pediatr Emerg Care. 2009;25(6):393‐6.
Peri and Immediate Post‐intubation Sedation

• When using a long‐acting paralytic (rocuronium, cisatracurium, vecuronium), it is
essential to provide a sedative and amnestic through the duration of paralysis
Etomidate
Propofol
Ketamine Midazolam Additional sedation/analgesia should be provided
Succ. Rocuronium Vecuronium
MINUTES
Chong et al. Am J Emerg Med. 2014;32(5):452‐6.
Opioid Agent Properties
Fentanyl Hydromorphone Morphine
Approximate
100 mcg (0.1mg) 1.5 mg 10 mg
equi‐analgesic IV dose
Time to onset 1‐2 minutes 5‐15 minutes 5‐10 minutes
Elimination half‐life 0.5‐1 hour 2‐3 hours 3‐4 hours
50‐100 mcg every 0.2‐0.6 mg every 1‐2
IV dose (adults) 2‐4 mg every 1‐2 hours
30‐60 minutes hours
Initial infusion rate
50‐300 mcg/hr 0.5‐3 mg/hr 2‐30 mg/hr
(adults)
Accumulation of active
Less hypotension Less hypotension metabolite in renal disease
Other
than morphine than morphine Histamine release‐induced
hypotension
Pain Assessment in Mechanically‐Ventilated

Patients
• Pain Scales
– Behavioral Pain Scale (BPS)
– Critical Care Pain Observation Tool (CPOT)
• Vital signs should prompt further evaluation but are not
sensitive or specific
– Respiratory rate
– Tachycardia
– Hypertension
– Diaphoresis

Critical Care Pain Observation Tool (CPOT)
Indicator Description
0 – no muscular tension observed
Facial expression 1 – frowning, brow lowering, orbit tightening, and levator contraction
2 – all of the above plus eyelids tightly closed
0 – does not move at all
1 – slow, cautious movements, touching/rubbing pain site, seeking attention through
Body movements movements
2 – pulling tube, attempting to sit up/climb out of bed, moving limbs/thrashing, not
following commands, striking at staff
0 – no resistance to passive movements
Muscle tension 1 – resistance to passive movements
2 – strong resistance to passive movements, inability to complete
Compliance with 0 – alarms not activated, easy ventilation OR talking in normal tone or no sound
ventilator (intubated) OR 1 – alarms stop spontaneously OR sighing, moaning
vocalization (extubated) 2 – asynchrony, blocking ventilation, alarms frequently activated OR crying out, sobbing
Total score (range 0‐8) Patient likely in significant pain if ≥ 3

Gelinas et al. Am J Crit Care. 2006;15(4):420‐7.
Sedative Agent Properties

Time to Onset Elimination Half‐ Maintenance
Agent IV Bolus Dose
After IV Bolus Life Dosing
3‐12 hours (short
Propofol 30‐60 seconds 0.25‐1 mg/kg 5‐70 mcg/kg/min
term use)
0.02‐0.1
Midazolam 2‐5 minutes 3‐11 hours 0.01‐0.05mg/kg
mg/kg/hr
Ketamine 30‐60 seconds 2‐3 hours 0.5‐1 mg/kg 0.1‐2.5 mg/kg/hr
0.2‐0.7 mcg/kg/hr
1 mcg/kg over 10
Dexmedetomidine 5‐10 minutes 1.8‐3.1 hours Up to 1.5
minutes
mcg/kg/hr

Patanwala et al. J Intensive Care Med. 2017;32(6):387‐95.
Sedation Assessment in Mechanically‐Ventilated Patients
• Sedation scales
– Richmond Agitation Sedation Scale (RASS)
– Ramsay Sedation Scale (RSS)
– Sedation Agitation Scale (SAS)
• PADIS guidelines recommend light level of sedation
– Unless contraindicated or not feasible
Richmond Agitation Sedation Scale (RASS)

Score Term Description
+4 Combative Overtly combative, violent, immediate danger to staff
+3 Very agitated Pulls or removes tube(s) or catheter(s), aggressive
+2 Agitated Frequent non‐purposeful movements, fights ventilator
+1 Restless Anxious but movements not aggressive or vigorous
0 Alert and calm
Not fully alert, sustained awakening (eye‐opening/contact) to
‐1 Drowsy
voice > 10 seconds
‐2 Light sedation Briefly awakens with eye contact to voice < 10 seconds
‐3 Moderate sedation Movement or eye opening to voice but no eye contact
No response to voice, but has movement or eye opening to
‐4 Deep sedation
physical stimulation
‐5 Unarousable No response to voice or physical stimulation
Sessler CN et al. Am J Respir Crit Care Med. 2002;166(10):1338‐44.
Bolus vs Continuous Infusion of Sedative and
Analgesic Agents
• Boluses treat acute needs
– Pain, inadequate sedation, agitation
• Continuous infusions for chronic needs; maintenance
– Increasing infusion rates do not treat acute needs
– May lead to complications if aggressively titrated
– Increases in infusion rates should almost always be preceded by
bolus therapy to achieve goal
Boluses Prevent the Ongoing Cycle

(Re)-Initiation
Titration without
boluses
Aggressive
Acute agitation
Titration
Over-sedation or
Discontinuation
ADE
• An hour later, TF’s RASS score has improved and she is no longer having
ventilator dyssynchrony. She is now on continuous albuterol nebulization
through the ventilator circuit at 15 mg/hr, has received IV
methylprednisolone 125 mg, and two doses of IV magnesium sulfate 2 g.
TF is having some movement to physical stimulation but no response to
voice. The team would like to keep TF deeply sedated (RASS score ‐4) to
maintain ventilator compliance. The team is asking for recommendations
considering her post‐intubation management to facilitate deep sedation.
She is currently receiving fentanyl infusion of 200 mcg/hr and propofol
infusion of 40 mcg/kg/min
– BP 130/87 mmHg; HR 104 beats/min; RR 10 breaths/min (10 from ventilator);
SpO2 97% on 100% FiO2
Question 10: Which of the following strategies is

most appropriate for TF at this time?
A. Switch propofol infusion to dexmedetomidine infusion
B. Switch propofol infusion to midazolam infusion
C. Initiate cisatracurium infusion
D. Continue current strategy
Sedation Goals
• Moving target
• Aggressive management while patient control needed or
paralyzed (immediate post‐intubation phase)
• Sedation weaned as tolerated to target guideline‐driven
recommendations
– Harm associated with early deep levels of sedation (RASS score ‐3 to
‐5) as early as 4 hours post‐intubation
Shehabi Y et al. Intensive Care Med. 2013;39(5):910‐8.

Shehabi Y et al. Am J Respir Crit Care Med. 2012;186(8):724‐31.
Scenarios Leading to Pitfalls

• Patients who are hypotensive
• Patients unconscious/unresponsive prior to intubation
• Patients who receive naloxone
• Patients who receive rocuronium/cisatracurium/vecuronium
Question 11: As part of your bedside clinical
documentation, what impact did you likely have as the
bedside pharmacist for TF’s intubation management?
A. Significant reduction in time to post‐intubation sedation
B. Significant reduction in time to extubation
C. Significant reduction in hospital length of stay
D. Significant reduction in mortality
ED Pharmacist Impact on Post‐intubation

• 2013 trial by Amini et al
– Pharmacist presence vs no pharmacist presence
– Significant reduction in time to post‐intubation sedation
• 2016 trial by Robey‐Gavin et al
– Implementation of ED pharmacist services
– Significantly improved post‐intubation management and time to sedation and
analgesia
• 2018 trial by Kilber et al
– Previous average 27 minutes before additional sedation with etomidate and
rocuronium in 2013 publication was decreased to median time of 9 minutes
– Effect sustained with and without direct pharmacist presence at bedside
Amini A et al. Am J Health‐Syst Pharm. 2013;70(17):1513‐17.
Kilber E et al. Am J Emerg Med. 2018;36(7):1129‐33.
Robey‐Gavin E et al. J Emerg Med. 2016;50(2):308‐14.
Multi‐Pronged Effort in Post‐intubation
Management
• Direct bedside involvement
• Education of providers, nurses, and other staff
• Integration into protocol and clinical pathway development
Farmer BM et al. J Med Toxicol. 2018;14(1):114‐6.

Ortmann MJ et al. Am J Health Syst Pharm. 2021;78(3):261‐75.
Post‐intubation Key Takeaways

• Analgesia is the cornerstone of post‐intubation care (PADIS
guidelines)
• Patients should receive IV boluses before adjusting infusions of
sedatives and analgesics, especially to address acute needs
• Paralysis without adequate sedation/analgesia should be a “never
event”
• Goals for analgesia and sedation (e.g., RASS score should be
established)
– Adjust goal as needed
– Adjust analgesia and sedation to achieve goal
Key Takeaways
• Key Takeaway #1
– Inhaled beta2‐adrenergic agonists, inhaled ipratropium, and oral or IV
corticosteroids reduce complications and hospitalization rates in patients
with severe asthma exacerbation
• Key Takeaway #2
– Antibiotics for COPD exacerbations are indicated for patients undergoing
mechanical ventilation or that meet criteria based on the cardinal
symptoms and should only be continued for 5‐7 days
• Key Takeaway #3
– Antibiotic treatment for CAP is based on comorbidities, severity, and the
presence or absence of risk factors for Staphylococcus aureus or
Pseudomonas
Key Takeaways (cont.)

• Key Takeaway #4
– Anaphylaxis is a medical emergency requiring immediate treatment with
intramuscular epinephrine. Other routes or treatment modalities have
limited use.
• Key Takeaway #5
– Use of long‐acting paralytics for intubation put patients at risk for
inappropriate post‐intubation management. EM pharmacists can identify
and significantly reduce this potential risk.
• Key Takeaway #6
– Appropriate post‐intubation analgesia and sedation requires IV bolus
therapy to meet acute needs before increasing infusions rates.
Daniel H. Jarrell, PharmD, BCCCP, BCPS

Clinical Pharmacist – Emergency Medicine
Banner University Medical Center – Tucson
Clinical Assistant Professor, Department of Pharmacy Practice and Science
University of Arizona College of Pharmacy
Tucson, Arizona

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Complex Case: Pulmonary

Daniel H. Jarrell, PharmD, BCCCP, BCPS

Relevant Financial Relationship Disclosure

Key Abbreviations (cont.)

Complex Case: Pulmonary

Patient Case (cont.)

Lazarus SC. N Engl J Med. 2010;363:755‐64.

Factors Associated with Increased Risk of Asthma‐

Previous intubation or ICU admission ≥ 2 hospitalizations for asthma in past year

Lazarus SC. N Engl J Med. 2010;363:755‐64.

Patient Case (cont.)

Asthma Exacerbation Management

Lazarus SC. N Engl J Med. 2010;363:755‐64.

Lazarus SC. N Engl J Med. 2010;363:755‐64.

Inhaled Beta2‐Adrenergic Agonists

Rodrigo GJ et al. Thorax. 2005;60:740‐6.

Acute Exacerbation of Chronic Obstructive

Cough increased in frequency and severity

Increased sputum volume or changed character

Respiratory viral infections Bacterial infections Environmental factors

Severe COPD Exacerbation Subclassification

Hurst JR et al. N Engl J Med. 2010;363:1128‐38.

COPD Exacerbation Management

Van Geffen WH et al. Cochrane Database Syst Rev. 2016;8:CD011826.

Indications for Use of Ventilatory Support in

de Jong YP et al. Chest. 2007;132(6):1741‐7.

Antibiotic Benefits in Patients with COPD

Antimicrobial Selection in Patients with COPD

Patient Case (cont.) – Initial ED Labs

• pH 7.37 • Na 137 mmol/L • WBC 17.4 K/μL

Question 3: Which of the following is the most

Metlay JP et al. Am J Respir Crit Care Med. 2019;200(7):e45‐67.

Mortality Predictors and Admission Decision Tools

Lim W et al. Thorax. 2003;58(5):377‐82.

Criteria for Severe CAP

Mandell LA et al. Clin Infect Dis. 2007;44:S27‐72.

Risk Factors for Bacterial Infection in Patients with

Metlay JP et al. Am J Respir Crit Care Med. 2019;200(7):e45‐67.

Metlay JP et al. Am J Respir Crit Care Med. 2019;200(7):e45‐67.

Antibiotic Selection for CAP in Adults (cont.)

Metlay JP et al. Am J Respir Crit Care Med. 2019;200(7):e45‐67.

Metlay JP et al. Am J Respir Crit Care Med. 2019;200(7):e45‐67.

Antibiotic Selection for CAP in Adults (cont.)

Metlay JP et al. Am J Respir Crit Care Med. 2019;200(7):e45‐67.

Metlay JP et al. Am J Respir Crit Care Med. 2019;200(7):e45‐67.

Antibiotic Selection for CAP in Adults

Metlay JP et al. Am J Respir Crit Care Med. 2019;200(7):e45‐67.

Metlay JP et al. Am J Respir Crit Care Med. 2019;200(7):e45‐67.

Patient Case (cont.)

Demoly P et al. Allergy. 2014;69:420‐37.

Demoly P et al. Allergy. 2014;69:420‐37.

Demoly P et al. Allergy. 2014;69:420‐37.

Type II IgG/IgM cytotoxic Hemolytic anemia, cytopenia, thrombocytopenia

Mirakian R et al. Clin Exp Allergy. 2008;39:43‐61.

Allergic Reaction Classification (cont.)

Mirakian R et al. Clin Exp Allergy. 2008;39:43‐61.

Sampson HA et al. Food Allergy, Dermatologic Diseases, and Anaphylaxis. 2005;115(3):P584‐91.

Clinical Diagnosis of Anaphylaxis*

Epinephrine for Anaphylaxis

Zilberstein J et al. J Emerg Med. 2014;47(2):182‐7.

Epinephrine Administration for Anaphylaxis (cont.)

Zilberstein J et al. J Emerg Med. 2014;47(2):182‐7.

Question 5: What is the most appropriate action

Patient Case (cont.)