Cardiac arrest with residual blindness after overdose of Tessalon® (benzonatate) perles.

BACKGROUND: The extent to which benzonatate (Tessalon®), a structurally similar agent to other local anesthetics including tetracaine and procaine, poses a risk to the public is not fully appreciated as it is still one of the most widely prescribed antitussives available. OBJECTIVES: To report a case of cardiac arrest with residual blindness after Tessalon® overdose, review its clinical manifestations, toxicology and management considerations, and describe the need for rational prescribing. CASE REPORT: A 17-year-old woman with no previous medical history presented to the Emergency Department (ED) status post cardiac arrest. One to two hours prior, the patient had ingested at least 10 200-mg Tessalon® capsules as part of a suicide attempt. The patient was sedated, intubated, and given magnesium as prophylaxis against recurrent dysrhythmias. Emergent gastric lavage was performed and well tolerated. A 24-h hypothermia protocol with 6-h cooling period was initiated. Toxicological studies, chest radiograph, and a computed tomography scan of the head were all unremarkable. The patient was admitted to the Pediatric Intensive Care Unit for further work-up and supportive care. The patient was extubated and able to follow some commands 1 week post-admission. The patient developed blindness and experienced generalized confabulations, which did not resolve. CONCLUSION: Ingestion of Tessalon®, a seemingly innocuous and widely prescribed antitussive, may pose a risk to patients due to its potential for the rapid development of life-threatening adverse events and limited treatment options in the overdose setting. Rational prescribing and patient education is needed.

Tarka® (trandolapril/verapamil hydrochloride extended-release) overdose.

BACKGROUND: Patients with fixed-dose combination product overdoses involving verapamil and trandolapril may present differently than sole calcium channel blocker (CCB) or angiotensin-converting enzyme inhibitor (ACE-I) overdose alone, and may have implications for the toxicological management. The ACE-I component may confound the traditional response to antidotal and supportive therapy recommended for CCB overdoses. In such cases, it may be prudent to manage the trandolapril component concurrently while administering traditional CCB antidotes. OBJECTIVES: To report a probable case and review the toxicological management of a fixed-dose antihypertensive combination product toxicity involving verapamil and trandolapril (Tarka®). CASE REPORT: A 60-year-old man experienced dizziness and fell after ingesting five tablets of Tarka®. Eight hours later, he was found to be hypotensive and bradycardic. Therapy for CCB toxicity was initiated, including fluids, modified hyperglycemia-euglycemia insulin therapy, calcium chloride, activated charcoal, and glucagon. The patient's blood pressure and heart rate stabilized only after the administration and titration of dopamine and episodes of profuse vomiting in response to glucagon. The patient was transferred to the Cardiac Intensive Care Unit for further monitoring. He was considered stable to the point of all therapies being discontinued only 12 h post-ingestion. The patient was discharged 40 h after ingestion with no further sequelae. CONCLUSIONS: Lack of familiarity with the components of fixed-dose combination products poses a problem during overdose situations and may confound the presentation and delay resuscitation and acute stabilization.

Frequency of and reasons for pharmacy residents breaching the National Matching Services applicant agreement.

PURPOSE: The frequency of and reasons for pharmacy residents breaching the National Matching Services (NMS) applicant agreement were evaluated. METHODS: An electronic survey was sent via e-mail to residency program directors of ASHP-accredited postgraduate year 1 pharmacy residencies in the United States. The survey instrument was developed based on an initial pilot survey used to test the clarity and reliability of the questions. The primary objective of the survey was to determine the frequency with which pharmacy residents breach the NMS applicant agreement and fail to report to their assigned site. Characteristics of ASHP- accredited residency programs with residents who breached the NMS agreement and any punitive action taken on these individuals were also analyzed. RESULTS: Of the 636 surveys sent to residency program directors, 302 complete surveys were returned, yielding a response rate of 47.5%. Twenty-six respondents (8.6%) indicated that within the past five years, they had matched candidates who failed to report to their assigned site. Of these respondents, 13 (50%) reported the candidate to ASHP; 11 (44%) took no action. Respondents indicated that they would be comfortable reporting all candidates who breach the NMS agreement to ASHP and placing the candidates' information on a list accessible electronically only to residency program directors. CONCLUSION: Less than 10% of residency program directors reported having residency candidates who breached the NMS applicant agreement. The majority of these respondents indicated that these residents were not their first choices. The most common reason for candidate withdrawal was family obligation.

Pharmacist improves timely administration of medications to boarded patients in the emergency department.

PURPOSE: Our purpose was to assess the variations in timely administration of medications based on differences in nursing staff (ED nurses who are responsible for emergency and boarded patients vs inpatient nurses who are responsible for only boarded patients) and to determine whether a pharmacist's interventions can improve the timely administration of medications to boarded patients in the emergency department. METHODS: This was a prospective observational study. Patients were included in the study if they were aged 18 years or older, were physically located in the emergency department but had already been admitted to the medical center, and had medication orders. The pharmacist documented the medication orders and the allotted time for administration. Once the upper limit of the allotted time frame for administration had passed, the pharmacist determined whether the medications were given and interventions were then carried out for those medications that were not administered. Successful interventions were documented when the medication was given within 1 hour from the time of intervention. RESULTS: Seventy-nine patients were included in the study, resulting in 266 medication administration opportunities (emergency department, 146; inpatient, 120). Inpatient nurses administered medications in a timely manner at a significantly greater rate than ED nurses (83.3% vs 63.7%, P < .0001). The greatest difference was observed during the evening hours (95.2% vs 53.8% of medications administered for inpatient vs ED nurses, P = .002). The most common reason for medications not being administered by ED nurses was insufficient time (51.4%), and for inpatient nurses, it was that the medication order was not verified (77.8%). The pharmacist's interventions were successful with both the ED and inpatient nurses (95.5% and 94.1%, respectively). CONCLUSION: This study illustrates that assigning nurses with varying workloads as a means to manage overcrowding is likely to result in boarded patients in the emergency department not receiving their medications. ED pharmacists' interventions may fill the gap, ensuring compliance with the administration of medication orders prescribed for boarded patients and ensuring more timely administration. A multidisciplinary team approach is needed to manage current overcrowding issues.

A survey of drug information references emergency medicine clinicians utilize for prescribing in pregnant patients.

BACKGROUND: Clinicians practicing in Emergency Departments (EDs) using outdated pocket guides and other non-pregnancy-specific references when prescribing in pregnancy may place the pregnancy or fetus at risk. OBJECTIVE: To identify the references that emergency medicine (EM) clinicians use for prescribing in pregnant patients, the prescribing trends when clinicians are given the pregnancy category information, and clinician awareness of access to drug information references. METHODS: This cross-sectional survey was administered to EM clinicians. In part I, clinicians listed the top 3 drug information references that they routinely use in clinical practice. In part II, clinicians ranked their willingness to prescribe a Category A, B, C, D, or X drug using a 5-point Likert scale. In part III, clinicians selected from a list of electronic and print resources those that they consider available to them in the ED to find pregnancy-related drug prescribing information. Statistical analyses included frequency distribution and bivariate analysis. RESULTS: Fifty-five clinicians with an average of 5.71 +/- 7.95 years (+/- SD) in the profession completed the survey. The most commonly used references included Micromedex, Tarascon Pocket Pharmacopoeia, and Epocrates (29%, 18%, and 14%, respectively). Ten (18%) respondents stated that they would be willing to prescribe Category C drugs. Among the 5 pregnancy-specific drug information references that are available in our ED, only 20% of EM clinicians stated that these references were available to them. CONCLUSIONS: EM clinicians rely on general references to make prescribing decisions for pregnant patients and are willing to prescribe medications that have data to support safe use in pregnancy. A minority of EM clinicians acknowledged the availability of pregnancy-specific references in the ED. Increased awareness of references that incorporate human data into their pharmacotherapy recommendations is warranted to assist EM clinicians in achieving their goal of prescribing safely in the pregnant patient.

Effect of clinical pharmacists on care in the emergency department: a systematic review.

PURPOSE: A systematic literature review was conducted to ascertain the scope of involvement of clinical pharmacists in the emergency department (ED); summarize economic, humanistic, and clinical outcomes data; describe current limitations of these data; and identify areas for future research. METHODS: A search of MEDLINE, The Cochrane Library, International Pharmaceutical Abstracts, and CINAHL Plus databases was conducted. Articles were included in this review if the title and abstract indicated that the article's content addressed the scope of involvement of pharmacists in the ED or pharmacist interventions in the ED and their associated outcomes, such as humanistic outcomes, cost avoidance, or improved quality. Qualitative analyses were conducted to characterize pharmacists' activities and effects in the ED. RESULTS: Of the 533 returned citations, only 17 met the inclusion criteria. Each provided a description of clinical pharmacy services at 12 different institutions. Descriptions of these institutions and job responsibilities of the ED pharmacists are described. Six studies reported information about pharmacist interventions, including the number and types of interventions, time spent per intervention, and acceptance rate of interventions. Four studies reported cost-related outcomes data. CONCLUSION: A review of the literature revealed that pharmacists have been involved in the ED for decades. Services provided by pharmacists in the ED included traditional clinical pharmacy services, responding to medical emergencies, providing consultations on medication issues, identifying and reducing medication errors, and conducting medication histories at hospital admission. Some services were shown to be cost saving or cost avoiding.

A before and after study of medical students' and house staff members' knowledge of ACOVE quality of pharmacologic care standards on an acute care for elders unit.

BACKGROUND: The Assessing Care of Vulnerable Elders (ACOVE) comprehensive set of quality assessment tools for ill older persons is a standard designed to measure overall care delivered to vulnerable elders (ie, those aged > or =65 years) at the level of a health care system or plan. OBJECTIVE: The goal of this research was to quantify the pretest and posttest results of medical students and house staff participating in a pharmacotherapist-led educational intervention that focused on the ACOVE quality of pharmacologic care standards. METHODS: This was a before and after study assessing the knowledge ofACOVE standards following exposure to an educational intervention led by a pharmacotherapist. It was conducted at the 29-bed Acute Care for Elders (ACE) unit of Maimonides Medical Center, a 705-bed, independent teaching hospital located in Brooklyn, New York. Participants included all medical students and house staff completing a rotation on the ACE unit from August 2004 through May 2005 who completed both the pre-and posttests. A pharmacotherapist provided a 1-hour active learning session reviewing the evidence supporting the quality indicators and reviewed case-based questions with the medical students and house staff. Educational interventions also occurred daily through pharmacotherapeutic consultations and during work rounds. Medical students and house staff were administered the same 15-question, patient-specific, case-based, multiple-choice pre-and posttest to assess knowledge of the standards before and after receiving the intervention. RESULTS: A total of 54 medical students and house staff (median age, 28.58 years; 40 men, 14 women) completed the study. Significantly higher median scores were achieved on the multiple-choice test after the intervention than before (median scores, 14/15 [93.3%] vs 12/15 [80.0%], respectively; P = 0.001). CONCLUSION: A pharmacotherapist-led educational intervention improved the scores of medical students and house staff on a test evaluating knowledge of evidence-based recommendations for pharmacotherapy in the elderly.

Variation in medication information for elderly patients during initial interventions by emergency department physicians.

PURPOSE: Discrepancies between medication information received from elderly patients in the emergency department (ED) at the time of initial diagnosis or therapeutic intervention and information collected by pharmacists from outside caregivers (pharmacies and physicians) were studied. The time from patient arrival at the ED to initial intervention was also studied. METHODS: Written and oral medication histories of ED patients 65 years and older who were seen at an urban academic hospital between June 2003 and May 2004 were collected and represented information available at the time of initial diagnosis and treatment. A clinical pharmacist contacted all relevant physicians and pharmacies identified in the ED and compiled for each patient a medication profile. The times of ED arrival and initial intervention were recorded. RESULTS: For the 98 patients included, the mean discordance in drug names between the two resultant types of drug list exceeded 30%. The classes of medications that varied most frequently included antihypertensives, supplements, analgesics, nitrates, and antiplatelets and anticoagulants. The median time from patient entry to initial diagnostic intervention was 37 minutes, with a range from 1 to 599 minutes. The median time from patient entry to initial therapeutic intervention was 81.5 minutes, with a range from 8 to 598 minutes. CONCLUSION: A pilot study demonstrated that approximately one third of elderly patients' medication information available to the ED physician at the time of the initial diagnostic and therapeutic intervention differed from that obtainable from outside caregivers.

Room-temperature storage of medications labeled for refrigeration.

PURPOSE: Data regarding the recommended maximum duration that refrigerated medications available in hospital pharmacies may be stored safely at room temperature were collected and compiled in a tabular format. METHODS: During May and June of 2006, the prescribing information for medications labeled for refrigeration as obtained from the supplier were reviewed for data addressing room-temperature storage. Telephone surveys of the products' manufacturers were conducted when this information was not available in the prescribing information. Medications were included in the review if they were labeled to be stored at 2-8 degrees C and purchased by the pharmacy department for uses indicated on the hospital formulary. Frozen antibiotics thawed in the refrigerator and extemporaneously compounded medications were excluded. Information was compiled and arranged in tabular format. The U.S. Pharmacopeia's definition of room temperature (20-25 degrees C [68-77 degrees F]) was used for this review. RESULTS: Of the 189 medications listed in AHFS Drug Information 2006 for storage in a refrigerator, 89 were present in the pharmacy department's refrigerator. Since six manufacturers were unable to provide information for 10 medications, only 79 medications were included in the review. This table may help to avoid unnecessary drug loss and expenditures due to improper storage temperatures. CONCLUSION: Information regarding the room-temperature storage of 79 medications labeled for refrigerated storage was compiled.