TILEmergencyPharmacist
@TILEDPharmD
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*TIL= Today I Learned* Residents & students of @ChillaPharmD posting the things they are learning on their emergency medicine pharmacy rotation. 💊👩⚕️👨⚕️💊
Bay Area, CA
Joined July 2019
👇.
Every rotation, I have my #pharmacyresidents & #pharmacystudents keep a list of 100 things they learned. Instead of hiding it in a local folder, they‘ll tweet the list as we go-to share knowledge & interact w you all!🙂.Follow us @TILEDPharmD.#twitterx #medtwitter #nursingtwitter.
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What does your institution use for post-TBI seizure prophylaxis? 🤔👇.
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Phenytoin is the recommended 🏆agent for PTS prophylaxis in the Brain Trauma Foundation guidelines for severe TBI. More recent practice is moving ➡️ levetiracetam, which has (so far) not been found superior to phenytoin for this indication. 📚 PMID: 2115976, 34286461, 23592358.
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Seizures were significantly ⬇️ in the phenytoin group ONLY during the early phase, but caused an INCREASE in seizures in the late phase of injury! 🤯 make sure those antiepileptics get 🛑 stopped 🛑.
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💊 seizure prophylaxis is provided during the first 7 days after injury. A 1990 📝 studied incidence of seizures in the early (≤ 7 days) and late (8+ days) phases of TBI in patients receiving phenytoin or placebo.
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Risk factors for early PTS include GCS ≤ 10, immediate seizures, post-traumatic amnesia, linear or depressed skull fracture, penetrating head injury, subdural/epidural/intracerebral hematoma, cortical contusion, age ≤ 65 years, or chronic alcohol use.
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TIL: let's talk about seizure prophylaxis in TBIs! 💥🧠🤕 Clinical post-traumatic seizures (PTS) are seen in ~12% of patients with severe TBI and up to 25% if subclilnical EEG-detected seizures are included. Early PTS are defined as a seizure within 7 days of initial injury.
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Haloperidol has also been used effectively for CHS! The HaVOC trial compared haloperidol 0.05mg/kg and 0.1mg/kg IV with ondansetron 8mg and found haloperidol to be superior 🏆 in ⬇️ abd pain and nausea, with less use of rescue meds and ⬇️⏳ to ED discharge.
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One of the 🔑 features of CHS is compulsive hot baths 🛀 and showers 🚿 with associated symptom relief. Topical capsaicin🌶️ applied to the abdomen has been used successfully in CHS! A 2021 study found ⬇️ rescue med use and ⬇️⏳to ED discharge after capsaicin use.
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CHS pathophysiology is unclear, but may be caused by dysregulated cannabinoid receptors in the CNS and GI tract. The only true cure for CHS is to stop cannabis consumption ✋🛑.
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TIL: intractable nausea and vomiting 🤢🤮 with recent cannabis use? Consider cannabinoid hyperemesis syndrome (CHS)! While cannabis can be used to treat N/V, it can cause a paradoxical vomiting 🚬🔄🤮 that does not respond to usual antiemetics.
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What dose do you start nitroglycerin at when treating SCAPE? Do you use a bolus? Would love to hear your thoughts! #TwitteRx #MedTwitter #FOAMed.
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When addressed quickly, SCAPE resolves quickly! ⏰ keep an 👀 on that nitro drip rate and titrate ⬇️ rapidly when blood pressure starts decreasing. And as always, treat the underlying cause 🥳. 📚 PMID: 32278569, 29776826, 34215472.
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Current nitroglycerin dosing practice is to start ~100-200mcg/min and titrate to SBP </= 140. There is evidence for giving nitroglycerin IV bolus before starting infusion! Check out this bolus/infusion algorithm published in the Journal of Emergency Medicine:
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Management of SCAPE includes noninvasive positive pressure ventilation (push that fluid out of those alveoli!) and nitroglycerin. At high doses, nitroglycerin causes arterial and venodilation ➡️ reduced preload and afterload ➡️ ‼️decreased pulmonary congestion‼️.
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Key symptoms of SCAPE are severe dyspnea😮💨with rapid onset, hypoxemia, hypertension, rales, and visible B lines on ultrasound. Early and aggressive treatment is 🔑 to preventing CV collapse and intubation!.
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Causes include medication nonadherence 💊 volume overload ‼️sympathomimetic use 💉 MI 🫀 exertion, and anxiety. Risk ⬆️ in patients with chronic LV failure.
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TIL: sympathetic crashing acute pulmonary edema (AKA SCAPE or flash pulmonary edema) is a severe presentation of decompensated CHF where a symptomatic surge⚡️causes rapid fluid shifts into the pulmonary vasculature 🌊🫁.
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Epi injection into the anterolateral thigh resulted in much higher concentrations than injecting into the deltoid, which is a major 🔑 in anaphylaxis management‼️ . That’s why they say: Blue to the sky 🔹☁️, orange to the thigh🦵🍊✨.
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TIL: ever wondered why EpiPens are given in the thigh🍗and not in the deltoid/glutes like other IM injections? Check out this awesome graph from a 2001 study (PMID 11692118) comparing epinephrine 0.3mg absorption after injecting into the thigh (T) and arm (A)! 📈
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