Medications for Lactating Mothers in the Emergency Department

By Liz Rozycki, PharmD, Specialty Practice Pharmacist, Emergency Medicine, OSU

There is no shortage of information regarding the benefits of breast milk for infants and mothers, likewise, there is no shortage of challenges that face a mother who is trying to breastfeed her baby through the recommended one to two years of age. Medication use during lactation, for acute or chronic conditions, poses a challenge to mothers and clinicians.  Is this medication safe for my baby? Is there an alternative? Do I have to “pump and dump”?  Especially for mothers who are presenting to the emergency department, if a medication is required, there is likely some reason they came in and treatment is warranted.

The easy, conservative and often unwarranted approach to medication use in lactating mothers is instructing them to pump and dump during medication use. Depending on the duration of medication therapy, this recommendation may result in a mother deferring her medical care in lieu of her child or may be the end of the breastfeeding journey. Although some mothers may have a stash of milk accumulated and may be able to pump and dump for a short period of time, this may not always be the case.  The goal of this blog post is to make sure all other options have been evaluated before you discharge a patient with the recommendation to “pump and dump”. 

Continue reading

Cardiogenic Shock and Peri-Intubation Arrest – It Happens

By Zach Adams MD, OSUEM PGY2 // Edited by Michael Barrie MD, OSU EM Assistant Professor

A 65 year-old patient presents with a history of ischemic cardiomyopathy and multiple medical co-morbidities. Initial triage vital signs show a BP of 83/40 with a pulse of 120 and oxygen saturation of 92%.  He appears in extremis.

On initial evaluation, the patient is mentating well but complaining of shortness of breath. Heart sounds are distant and lungs are otherwise clear.  You note mottled peripheral extremities, which appear cyanotic and are cold to touch.  He tells you that he was recently hospitalized, but does not know what and whether or not he is still being treated.

While obtaining initial lab studies and getting the patient hooked up to the monitor, you perform a RUSH exam and note extremely poor systolic function of the left ventricle and the IVC is distended without respiratory variation.  You suspect this is cardiogenic shock.  What is cardiogenic shock?  What are your next steps in management?

Continue reading

Tricyclic Toxicity – Key Points

By Dr. Zach Adams, OSU EM PGY1 // Edited by Dr. Michael Barrie, OSU EM Assistant Professor

Pertinent to the previous post – I was working a shift at East the other day with Dr. Southerland and, low and behold, a TCA overdose came rolling through the doors. The patient had taken an unknown quantity of amitriptyline an hour before arrival. The patient was solemn but easily aroused. Vital signs showed sinus tachycardia with declining systolic BPs in the low 100s. Activated charcoal 1 g/kg was administered via an NGT (as the patient refused to drink the activated charcoal). Poison control was called and even though the QRS duration was less than 100 ms, we gave 2 mg/kg of sodium bicarb for the following:

Continue reading

Anticholinergic toxicity and physostigmine – what’s the data?

Mad_as_a_Hatter-Title_Card

By Dr. Zach Adams, OSU EM PGY1 // Edited by Dr. Michael Barrie, OSU EM Assistant Professor

A 21 year-old male presents via EMS from a rock and roll festival to the ED with agitation, hyperthermia, and confusion. On exam the patient has large pupils, and skin is dry to the touch. Multiple staff members are trying to keep the patient restrained in the bed to start the medical workup, when the nurse ask you a “B-52” and leather restraints. After just listening to April’s EM:RAP Episode, you consider a diagnostic trial of physostigmine, but you also hear the voice of your local toxicologist in the back of your mind saying “giving physostigmine will cause seizures and death!” What should you do?

Continue reading

Etomidate for RSI in the Seizing Patient

BED07620

By Elizabeth Rozycki PharmD, BCPS, Specialty Practice Pharmacist, Emergency Medicine, Ohio State University) // Edited by Michael Barrie MD @MikeBarrieMD, OSUEM Assistant Professor // Zach Adams MD, OSUEM PGY1 Resident

A 61 year old female patient presents after a fall and possible seizure activity witnessed by family members.  The patient has no history of seizures.  On exam the patient has a tongue laceration and apparently lost control of their bladder during the event. The patient has a GCS of 8 and is waxing and waning so the decision is made to intubate for airway protection. Blood pressure is 168/98, hear rate 112 and patient has good oxygen saturation on a non-rebreather.  Your friendly and helpful pharmacist inquires about which medications you would like for induction and paralysis.   Etomidate? The patient seized… will etomidate lower their seizure threshold? 

The Bottom line: Maybe, but the evidence is not great. If possible, use an alternative RSI agent such as propofol or ketamine.

Continue reading

The forgotten lead- aVR

By Chris Paul MD, OSU EM Assistant Professor // Edited by Michael Barrie MD, OSU EM Assistant professor

54 yo F presented with chest pain and shortness of breath for two days
past medical history included prosthetic aortic valve, endocarditis, MI, DM, HTN, HLD, cough variant asthma and stroke

Vital signs -HR 130’s, bp – 110’s, spO2 – low 90s/high 80’s

initial EKG

IMG_2843 copy

What’s your interpretation? Plan for management?

Continue reading

ED Thoracotomy

By Dr. Daniel Zach Adams, OSUEM resident // edited by Michael Barrie OSUEM Assistant Professor

Out of all the various procedures we’re expected to be able to perform in the ED, a resuscitative thoracotomy (EDT) has to be the most intense but least common, depending on your demographic.  EM:RAP did a great job this past month on going through indications, contraindications, and some of the finer details (EM:RAP January Edition – Trauma Surgeons Gone Wild: When to Crack the Chest).  My summary:

  1. Use of bedside US can determine who may benefit from a thoracotomy – i.e. those without evidence of cardiac motion have a survival rate of ZERO (the skinny).
  2. EAST trauma and the Western Trauma Association guidelines differ:
    • EAST
      • Pulseless thoracic penetrating injury WITH signs of life – strong recommendation for EDT
      • Pulseless thoracic penetrating injury WITHOUT signs of life – conditional recommendation for EDT
      • Pulseless EXTRA-thoracic penetrating injury (not including isolated cranial injuries – obviously)  WITH signs of life – conditional recommendation for EDT
      • Pulseless EXTRA-thoracic penetrating injury WITHOUT signs of life – conditional recommendation for EDT
      • Pulseless BLUNT trauma WITH signs of life – conditional recommendation
      • Pulseless BLUNT trauma WITHOUT signs of life – DO  NOT PEFORM EDT
    • Western Trauma Association 
      • CPR is utilized as a time marker for performance – check out the algorithm
        • Blunt trauma, CPR >10 minutes – no go
        • Penetrating trauma, CPR >15 minutes – no go

In our center we rarely do EDT, likely because we see less penetrating thoracic injury than other settings. That said, there’s some good resources out there to stay sharp on this potentially life saving procedure.  Something worth watching by Dr. Raul Comibra on YouTube – link – if you’re bored and looking for some more insight.  Pretty long, but it goes through a lot to include some technique and covers the Western Trauma Association guidelines in some more detail.  As with anything, mental preparation and a solid understanding of the indications, contraindications and how to proceed is key.  The details of how to proceed after you get into the chest seems to be the more difficult task – glad we have great trauma colleagues!