Rapid sequence intubation and the role of the emergency medicine pharmacist: 2022 update.

PURPOSE: The dosing, potential adverse effects, and clinical outcomes of the most commonly utilized pharmacologic agents for rapid sequence intubation (RSI) are reviewed for the practicing emergency medicine pharmacist (EMP). SUMMARY: RSI is the process of establishing a safe, functional respiratory system in patients unable to effectively breathe on their own. Various medications are chosen to sedate and even paralyze the patient to facilitate an efficient endotracheal intubation. The mechanism of action and pharmacokinetic/pharmacodynamic profiles of these agents were described in a 2011 review. Since then, the role of the EMP as well as the published evidence regarding RSI agents, including dosing, adverse effects, and clinical outcomes, has grown. It is necessary for the practicing EMP to update previous practice patterns in order to continue to provide optimal patient care. CONCLUSION: While the agents used in RSI have changed little, knowledge regarding optimal dosing, appropriate patient selection, and possible adverse effects continues to be gained. The EMP is a key member of the bedside care team and uniquely positioned to communicate this evolving data.

"Not for human consumption": a review of emerging designer drugs.

Synthetic, or "designer" drugs, are created by manipulating the chemical structures of other psychoactive drugs so that the resulting product is structurally similar but not identical to illegal psychoactive drugs. Originally developed in the 1960s as a way to evade existing drug laws, the use of designer drugs has increased dramatically over the past few years. These drugs are deceptively packaged as "research chemicals," "incense," "bath salts," or "plant food," among other names, with labels that may contain warnings such as "not for human consumption" or "not for sale to minors." The clinical effects of most new designer drugs can be described as either hallucinogenic, stimulant, or opioid-like. They may also have a combination of these effects due to designer side-chain substitutions. The easy accessibility and rapid emergence of new designer drugs have created challenges for health care providers when treating patients presenting with acute toxicity from these substances, many of which can produce significant and/or life-threatening adverse effects. Moreover, the health care provider has no way to verify the contents and/or potency of the agent ingested because it can vary between packages and distributors. Therefore, a thorough knowledge of the available designer drugs, common signs and symptoms of toxicity associated with these agents, and potential effective treatment modalities are essential to appropriately manage these patients.

Rapid-sequence intubation and the role of the emergency department pharmacist.

PURPOSE: The pharmacology, pharmacokinetics, safety, and dosing of medications used during the pretreatment and paralysis with induction steps of rapid-sequence intubation (RSI) and the role of the pharmacist in RSI are reviewed. SUMMARY: RSI is a process involving the administration of a sedative induction agent and a paralytic agent to facilitate endotracheal intubation. This is a procedure in which the emergency department (ED) pharmacist can play an integral role, especially in the steps of pretreatment, paralysis with induction, and postintubation management. The pretreatment phase occurs three minutes before administration of induction and neuromuscular blockers. The purpose of pretreatment is to attenuate the pathophysiologic response to laryngoscopy and intubation. Three minutes after the pre-treatment agents have been administered, paralysis with induction will begin. The purpose of induction is to produce a state of general anesthesia, allowing for the administration of paralytics and facilitation of ideal intubating conditions. It is advisable for the ED pharmacist to be familiar with the steps and medications involved with RSI so that appropriate interventions may be made, facilitating both the successful intubation and the safety of the patient. The relative chaos that may occur during emergent RSI requires the ED pharmacist to have a clearly defined primary plan as well as contingency plans to deal with potential complications. Commonly used medications during intubation include lidocaine, fentanyl, etomidate, midazolam, thiopental, ketamine, succinylcholine, and rocuronium. CONCLUSION: The selection of an appropriate sedative and neuromuscular blocker during the pretreatment and paralysis with induction steps of RSI can be facilitated by an ED pharmacist.