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Procedural sedation and analgesia (PSAA) is integral to facilitating painful and anxiety-inducing medical procedures in the emergency department (ED). Optimal PSAA enhances procedural success and improves both patient and provider satisfaction. The selection of appropriate sedative and analgesic agents, routes, and dosages, which depend on various patient- and procedure-specific factors is a complex process. Alternative routes of administration, such as intranasal, intramuscular, and oral, are all options, each with their own inherent benefits and limitations. It is important for providers to take into account patient-specific considerations, including age, medical history, body weight composition, and pregnancy, which can significantly impact PSAA effectiveness and safety. Implementation strategies targeted to minimize medication errors and optimize workflow are also important considerations in PSAA. By adopting a comprehensive and evidence-based approach, health care providers can navigate the intricacies of PSAA and ensure the best possible care for patients in the ED., Competing Interests: Disclosure: The authors have no conflict of interests to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Procedural sedation and analgesia is an essential activity in the emergency department for managing pain and anxiety during a variety of medical procedures. Various pharmacotherapy options, including opioid analgesics, antiemetics, anticholinergics, sedatives, and ketamine have been utilized, all with their unique efficacy and safety profiles. This review highlights the challenges associated with using certain agents and discusses emerging trends such as the use of newer synthetic opioids and the expanding use of dexmedetomidine. Overall, the selection of the optimal agents for procedural sedation and analgesia should be guided based on the unique characteristics of each agent tailored to the needs of the specific procedure, along with consideration for individual patient characteristics., Competing Interests: The authors have no conflict of interests to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Patients who develop an intracerebral hemorrhage (ICH) following thrombolysis in acute ischemic stroke (AIS) have a mortality rate as high as 50%. Treatment options include blood products, such as cryoprecipitate, or antifibrinolytics, such as tranexamic acid (TXA) or ε-aminocaproic acid (EACA). Current guidelines recommend cryoprecipitate first-line despite limited data to support one agent over another. In addition, compared to antifibrinolytics, cryoprecipitate is higher in cost and requires thawing before use. This case series seeks to characterize the management of thrombolytic reversal at a single institution as well as provide additional evidence for antifibrinolytics in this setting. Patients were included for a retrospective review if they met the following criteria: presented between January 2011-January 2017, were >18 years of age, were admitted for AIS, received a thrombolytic, and received TXA EACA, or cryoprecipitate. Twelve patients met the inclusion criteria. Ten (83.3%) developed an ICH, one (8.3%) experienced gastrointestinal bleeding, and one (8.3%) had bleeding at the site of knee arthroscopy. Eleven patients received cryoprecipitate (median dose: 10 units), three received TXA (median dose: 1,000 mg), and one patient received EACA (13 g). TXA was administered faster than the first blood product at a mean time of 19 min and 137 min, respectively. Hemorrhagic expansion (N = 8, 66.67%) and inhospital mortality (N = 7, 58.3%) were high. While limited by its small sample size, this case series demonstrates significant variability in reversal strategies for thrombolysis-associated bleeding. It also provides additional evidence for the role of antifibrinolytics in this setting., Competing Interests: Disclosure: The authors have no financial disclosures or conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

The emergency department (ED) is a frequent utilizer of alternative routes of medication administration (e.g., intranasal) for a variety of indications. Over the last several years, investigations into the use of medications via the nebulization route have greatly increased, with varying degrees of efficacy identified. This route has multiple theoretical advantages. Medications affecting bronchopulmonary function or secretions can be administered directly to the site of action, possibly utilizing a lower dose and hence minimizing side effects. It is also possible to have a faster onset of action compared with other routes, given the enhanced surface area for absorption. One group of medications that has been explored via this route of administration, and is frequently administered in EDs across the nation, is opioids, most notably fentanyl, hydromorphone, and morphine. However multiple questions exist regarding the implementation of these therapies via this route, including efficacy, dosing, and the functional aspects of medication administration that are more complex than that of more traditional routes. The intent of this review is to explore the supporting literature behind the use of nebulized opioids, most specifically fentanyl, hydromorphone, and morphine, in the ED for the treatment of acute pain presentations and provide the most up-to-date guidance for practitioners., Competing Interests: Disclosure: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Stevens-Johnson syndrome and toxic epidermal necrolysis represent a spectrum of severe cutaneous adverse reactions that carry the potential for severe, long-term adverse effects, including death. Although medications are most commonly implicated in the development of these diseases, other factors, including infection and genetics, play a role. Management is generally supportive in nature and includes maintenance of the patient's airway, breathing, and circulation. Special disease considerations include the use of skin barrier management, unique infection prevention measures, and systemic immunomodulatory therapies.

Sepsis continues to be a devastating, costly, and challenging syndrome to manage in emergency departments (ED) across the nation, and its impact seems to be only increasing. Recently, consensus recommendations have made some profound changes in the way we approach, classify, and treat sepsis. The ED serves as an important initial screening and intervention point for sepsis, and ED care can have a profound impact on overall morbidity and mortality. The provision of early fluid resuscitation, antimicrobial therapy, and vasopressor therapy, if appropriate, is essential in early care. The intent of this review was to compare and contrast changes associated with the management of sepsis in the ED, with particular focus on guideline recommendations for pharmacotherapeutic management.

Nausea and vomiting are 2 of the most common complaints of patients presenting to the emergency department (ED). In addition, antiemetics are the most commonly prescribed medications in the ED behind analgesics. Treating these conditions can be complex, especially as one considers that nausea and/or vomiting could be the primary presenting illness or simply a symptom of a more complex etiology. Although there is a wide variety of pharmacotherapeutic options in the armamentarium to treat these conditions, very few consensus recommendations exist to help guide the use of antiemetic agents in the ED, leading to wide variability in medication use. Contributing to these variations in practice is the extended spectrum of etiologies and potential physiological factors that contribute to the development of nausea or vomiting. A thorough understanding of the pharmacology and administration of these agents can help practitioners devise tailored antiemetic regimens based upon the underlying etiology.

Approximately 1.6% of all emergency department (ED) visits in the United States are for vaginal bleeding in early pregnancy, translating to around 500,000 ED visits per year. A potentially life-threatening condition, ectopic pregnancy occurs in 1.5%-2% of pregnancies. Many patients will require either surgical or pharmacological intervention following a positive diagnosis. With regard to pharmacological options, methotrexate, largely known for its use in the oncology arena, has emerged as the most effective nonsurgical option and the pharmacological agent of choice. However, this therapy is not without its own unique adverse event profile and patients should be adequately educated on the monitoring parameters of this pharmacotherapy.

It is not uncommon for providers in the emergency department to take care of patients who are taking anticoagulant therapy in the outpatient setting. However, the bigger challenge is caring for these patients when they present with bleeding that could be secondary to 1 or more of these medications. In recent years, this class of medications has expanded from warfarin to include direct thrombin inhibitors and Factor Xa inhibitors. As this class of medications has evolved, so has the approach to the reversal of these agents. Thus, it is imperative that providers in the emergency department be familiar not only with the anticoagulants that patients may be taking in the outpatient setting but also with their reversal agents.

Hereditary angioedema attacks are rare, but emergency care providers must be aware of the clinical presentation and treatment of these patients because the emergency department remains the most common setting where these patients seek treatment. If providers are not aware of the past medical history of these patients, they are likely to receive standard therapies for respiratory distress and anaphylaxis including antihistamines, corticosteroids, and epinephrine. However, these medications may not work in these patients, given the pathophysiology of their underlying disease. Since 2009, several new therapies have been approved for the treatment of acute hereditary angioedema attacks. This article discusses pathophysiology, clinical presentation, and use of novel therapies for the management of angioedema.

Although several biological agents have been recognized as presenting a significant threat to public health if used in a bioterrorist attack, those that are of greatest importance are known as the Category A agents: Bacillus anthracis (anthrax); variola major (smallpox); Yersinia pestis (plague); Francisella tularensis (tularemia); ribonucleic acid viruses (hemorrhagic fevers); and Clostridium botulinum (botulism toxin). In the previous issue, Part I of this review focused on the clinical presentation and treatment of anthrax, plague, and tularemia. In this second part of this 2-part review of these agents, the focus is on the clinical presentation and treatment of smallpox, viral hemorrhagic fevers, and botulism toxin. The utilization of mass prophylaxis to limit the morbidity and mortality associated with all these agents is also discussed along with the role emergency care personnel play in its implementation.

Bioterrorism presents a real and omnipresent risk to public health throughout the world. More than 30 biological agents have been identified as possessing the potential to be deployed in a bioterrorist attack. Those that have been determined to be of the greatest concern and possess the greatest potential of use in this arena are known as the Category A agents: Bacillus anthracis (anthrax); Variola major (smallpox); Yersinia pestis (plague); Francisella tularensis (tularemia); viral hemorrhagic fevers; and Clostridium botulinum toxin (botulism toxin). Although the Centers for Disease Control and Prevention utilizes surveillance systems to identify illnesses, the weight of diagnosing, effectively treating, and notifying the appropriate public health officials lies squarely on the shoulders of emergency care personnel. Part I of this two-part review will focus on the clinical presentation and treatment of anthrax, plague, and tularemia. The subsequent Part II of this review will discuss smallpox, viral hemorrhagic fevers, botulism toxin, and the provision of mass prophylaxis.

Trauma-related deaths represent a leading cause of mortality among persons younger than 45 years. A significant percentage of these are secondary to hemorrhage. In trauma, massive and rapid loss of blood creates an imbalance in hemostasis. Mainstays of resuscitation include surgical interventions, restoring intravascular volume, and pharmacologic interventions. Providers continue to search for improved pharmacologic options for achieving hemostasis. Tranexamic acid is an antifibrinolytic and inhibits fibrinolysis by blocking the lysine-binding sites on plasminogen. Tranexamic acid works to stabilize and inhibit the degradation of existing clots. Tranexamic acid has been prospectively proven to reduce mortality in trauma-related hemorrhage. Its use will likely expand into such areas as resuscitation and massive transfusion protocols and the prehospital setting. Therefore, it is critical for emergency medicine providers to be familiar with appropriate use of tranexamic acid in order to maximize efficacy and decrease the potential adverse events.

Nerve agents are extremely toxic and are some of the most lethal substances on earth. This group of chemicals consists of sarin, cyclosarin, soman, tabun, VX, and VR. It is currently unknown how many countries possess these chemicals and in what quantities. These agents work through altering the transmission and breakdown of acetylcholine by binding to, and inactivating, acetylcholinesterase. This results in an uncontrolled and overwhelming stimulation of both muscarinic and nicotinic receptors. Receptor activation at these sites can lead to a wide variety of clinical symptoms, with death frequently resulting from pulmonary edema. Antidotal therapy in this setting largely consists of atropine, pralidoxime, and benzodiazepines, all of which must be administered emergently to limit the progression of symptoms and prevent the enzyme inactivation from becoming permanent. This article reviews the mechanism of action of the nerve agents and their effects on the human body, the currently available therapies to mitigate their impact, and important therapeutic considerations for health care practitioners in the emergency department.

Evidence that acute injury and critical illness can result in an elevation of blood glucose levels is not a new concept. However, the last decade has seen a rise in publications describing the potential harm of this unique form of hyperglycemia and the subsequent benefits of glucose control. More recently, the untoward effects of tightly controlling glucose concentrations in this setting have been more thoroughly elucidated. This has lead to a challenging clinical conundrum for practitioners both inside and outside of the intensive care unit. The latest guidelines attempt to shed light on this dilemma and provide guidance for practitioners. This article reviews the progression of the research, the multiple guidelines that have been published, and the clinical implications on the treatment of critical illness hyperglycemia, with particular focus on the emergency department.

The rabies virus is transmitted through exposure to infected saliva during either a bite or direct contact with mucosal tissues. Infection with this virus results in a progressive encephalitis, ultimately leading to coma, end-organ damage, and death. Because rabies-associated mortality is strikingly high, preventing viral transmission associated with an exposure is paramount. Fortunately, 2 available options exist for this purpose and include the rabies vaccine and the associated immunoglobulin. Patients presenting for consideration of rabies postexposure prophylaxis constitute a frequent complaint seen in the emergency department (ED) in most geographical areas. Management of these patients should be guided by an accurate and thorough discussion of the circumstances surrounding their exposure to attain maximum pharmacological benefit and avoid viral transmission. This article provides an overview of the practice recommendations surrounding rabies virus prophylaxis and their associated pharmacological characteristics in the ED.