Medication Use in the Trauma Bay

1. Medication Use in the Trauma Bay Nicole Acquisto, Pharm.D., BCPS Emergency Medicine Clinical Pharmacy Specialist, Department of Pharmacy Senior Instructor, Department of Emergency Medicine

2. Overview • RSI (Pre-induction, Sedation, Paralysis) • Procedural Sedation • Post-intubation sedation • Analgesia • Code Tray Medications • Cardiac Medications • Vasopressors • Antibiotics • Stroke • Miscellaneous

3. Rapid Sequence Intubation Pretreatment Time zero minus 3 minutes Sedation Time zero Paralytic Time zero Intubation Time zero plus 45 seconds

4. Pharmacologic Agents used for RSI

5. Airway Cart Med-Box • Etomidate – 40mg/20mL • Succinylcholine – 200mg/10mL • Rocuronium– 50mg/5mL • Lidocaine – 100mg/10mL • Epinephrine 1:10,000 – 1mg/10mL • Atropine – 1mg/10mL

6. Pharmacologic Agents used for RSI

7. Atropine Anti-cholinergic agent Used to prevent bradycardia associated with intubation (succinylcholine)

8. Lidocaine • Class Ib anti-arrhythmic • Head injury • May blunt increase in ICP due to intubation • May decrease pressor response

9. Pharmacologic Agents used for RSI

10. Etomidate • Carboxylatedimidazole derivative, non-barbiturate sedative hypnotic • No analgesic activity • Advantages • Minimal cardiovascular effects • Cerebral protective effects  reduces cerebral blood flow and cerebral oxygen uptake  decreasing ICP

11. Etomidate • Adverse effects • Myoclonus (up to 30%) • Adrenocortical suppression

12. Ketamine • Dissociative anesthetic • Sedative and analgesic properties • Little or no respiratory or cardiovascular depression • Available in 200 mg/20 mL vials (in the Pyxis)

13. Ketamine

14. Ketamine • Adverse effects • Emergence phenomenon (12%) • Hallucination and emotional distress • May last a few hours • Can prevent with benzodiazepines • Increase in salivation and bronchial secretions • Glycopyrrolate or atropine • Sympathomimetic effects • Can produce cardiac ischemia by increasing CO and BP • Nausea/Vomiting • Cerebral vasodilator – increase ICP

15. Midazolam • Benzodiazepine, Sedative hypnotic agent • Anticonvulsant effects • No analgesic activity • Large doses needed and variable effectiveness for RSI

16. Propofol Propofol(Procedural or Continuous) • Sedative hypnotic agent • Advantage • Very rapid onset of effect • Rapid offset • Antiemetic and anticonvulsant properties • Decreases ICP • Adverse Effects/Disadvantages • Hypotension (pulmonary vasodilator) • Can decrease cerebral blood flow and perfusion • Bradycardia and  CO • Contraindicated in egg/soy allergy • Short-acting sedative hypnotic • NO analgesia • May have anticonvulsant properties (at high doses) • Pharmacokinetics • Onset: 10-50 seconds • Duration: 3-10 minutes (quick onset/offset) • Dose • 0.5-1 mg/kg IV x1, then 0.5 mg/kg q2-3minutes to desired effect • 0.5-1 mg/kg load, then 10-20 mcg/kg/min  titrate (usual: 20-80 mcg/kg/min) • Pregnancy Category B • Adverse Effects • Hypotension (3-26%), respiratory depression • Pain at the injection site • Hypersensitivity reactions (avoid in patients with egg/soy allergies)

17. PropofolDon’t stop ‘til you get enough…

18. Pharmacologic Agents used for RSI

20. Neuromuscular Junction • Major Components • Motor nerve terminal • Neurotransmitter • Acetylcholine • Postsynaptic muscle endplate

21. Paralytics (After sedation) Depolarizing NMDA • Succinylcholine • Dose: 1-1.5 mg/kg IV (usual: 100-150 mg), 2-4 mg/kg IM • Onset: 30-60 sec, Duration: 5-10 min • Contraindicated: hyperkalemia, myopathy, crush injury > 3 days, burns >24 hrs, hx of malignant hyperthermia Non-Depolarizing NMDA • Rocuronium • Dose: 0.6-1 mg/kg • Onset: 60-90 sec, Duration: 30-60 min • Can be given following intubation if patient going to CT (Re-administer sedation!!!)

22. Sedation Following Intubation • Midazolam • Load: 0.05-0.1 mg/kg (usual: 1-4 mg) • Initial: 0.02-0.1 mg/kg/hr (usual: 1-6 mg/hr) • Available: 100 mg/100 mL NS – in Pyxis • Lorazepam – Use in liver failure (Does not undergo 1st pass metabolism) • Load: 0.02-0.05 mg/kg (usual: 1-4 mg) • Initial: 0.01-0.1 mg/kg/hr (usual: 1-5 mg/hr) • Available: 60 mg/60 mL D5W – from Pharmacy • Propofol – Use in head injury, short-term intubation • Load: 0.25-1 mg/kg (usual: 10-50 mg) • Initial: 10-20 mcg/kg/min (usual: 20-80 mcg/kg/min) • Titrate: 5 mcg/kg/min every 10 minutes • Available: 10 mg/mL (20mL, 100mL) – in Pyxis

23. Analgesia • Fentanyl • Load: 0.5-2 mcg/kg (25-100 mcg) • Duration: 20 - 60 min • Initial: 0.5-1.5 mcg/kg/hr (Usual: 25-200 mcg/hr) • Morphine - Accumulation of active metabolite (morphine-6-glucuronide) in renal failure/elderly • Dose: 0.05-0.1 mg/kg (4-8 mg) • Hydromorphone • Dose: 0.01 mg/kg (0.5-1 mg) Dose Equivalents: 10 mg IV morphine = 1.5 mg IV hydromorphone

25. Pulseless Arrest

26. Bradycardia

27. Tachycardia

28. Hyperkalemia

29. Vasopressors

31. Antibiotics - Trauma • Skin/Soft Tissue • Cefazolin 1-2 gm IV x1 (wt 80 kg) • Diliute with 10-20 mL NS, give IVP • Vancomycin 15 mg/kg (1-1.5 gm) IV x1 over 60 min (if PCN allergic) • Type III Open Fracture • Add Gentamicin 2-3 mg/kg IV x1 • Dilute in 100 mL NS, infuse over 60 min • OR Ciprofloxacin 400 mg IV x1 (age > 65) • Penicillin 4 million units IV x1 (open dirty wounds) • Abdominal Trauma • Ertapenem 1gm IV x1 • Dilute in 50 mL NS, infuse over 30 min • Cipro 400mg IV/Metronidazole 500mg IV x1 • Piperacillin/Tazobactam 3.375 gm IV x1

32. Antibiotics - Sepsis • Gram positive coverage • Vancomycin 20 mg/kg IV (Usual: 1-2 gm) • Gram negative coverage • Piperacillin/Tazobactam 4.5 gm IV • OR Cefepime 2 gm IV • OR Aztreonam 2 gm IV • OR Imipenem/Cilastatin 500-1000 mg IV • Plus (double cover for pseudomonas) • Tobramycin 3 mg/kg • Amikacin 15 mg/kg

33. Alteplase (rt-PA) for Ischemic Stroke • Total Dose • 0.9 mg/kg • Maximum dose = 90 mg • Bolus • 10% of the total dose over 1 minute • Infusion • 90% of the total dose over 60 minutes • Reconstituted by the Neurology/Stroke Attending or Emergency Pharmacist ONLY • Concentration = 100 mg/100mL

34. Alteplase (rt-PA)Programming the Alaris Smart Pump • Select the ICU/ED or Adult Stepdown profile • Select Alteplase (CVA/MI/PE) – concentration 100mg/100mL • Select the total volume to be administered • Volume = Dose since the concentration is 100mg/100mL • Ex: If total dose = 90 mg, select 90 mL • Select the dose to give over 1 hour (90% of the total dose) • Ex: If total dose is 90 mg x 0.9 (90%) = 81 mg • Select 81 mg/hr • Select to give a bolus over 1 minute (10% of total dose) • Ex: If the total dose is 90 mg x 0.1 (10%) = 9 mg • Select 9 mg and a duration of 1 minute

36. Cardiac - Miscellaneous • Aspirin 324 mg po • Nitroglycerin 0.4 mg SL • Hold for SBP < 90 • Clopidogrel 600 mg po x1 • Primary PCI • Clopidogrel 300 mg po x1 • Heparin 100 units/mL • 60 units/kg x 1 (Max 4,000 units) • 12 units/kg/hr (Max 1,000 units) • Use the weight-based profile in the Alaris pump

37. Respiratory - Miscellaneous • Opioid Overdose • Naloxone • Dose: 0.1-0.4mg IV over 1-2min • Unstable patient dose: 2mg IV over 1-2min • Short half-life compared to some narcotics, may need to repeat • Acute Asthma/COPD • Albuterol/Ipratropium nebs • Methylprednisolone 125 mg IV • Magnesium 2 gm IV over 20 minutes • Epinephrine 1:1000, 0.3 mg IM • Anaphylaxis • Diphenhydramine 50 mg IV • Methylprednisolone 125 mg IV • Famotidine 20 mg IV • Epinephrine 1:1000, 0.3 mg IM

38. When in Doubt…. • EPh Phone: x 5-6646 • Nicole • Pager: 16-4959 • Cell: 716-310-0504 • Main Pharmacy: x 5-5212