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Koehl J, Brown CS, Faine B, Rech MA, Zimmerman DE, Flack T, Gilbert BW, Howington GT, Laub J, Porter B, Slocum GW, Zepeski A, Feldman R, Santiago RD, Sarangarm P. EDucated: The emergency medicine pharmacotherapy literature of 2023. Am J Emerg Med 2024; 82:166-173. [PMID: 38909552 DOI: 10.1016/j.ajem.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 05/01/2024] [Accepted: 06/06/2024] [Indexed: 06/25/2024] Open
Abstract
The purpose of this article is to summarize pharmacotherapy related emergency medicine (EM) literature indexed in 2023. Articles were selected utilizing a modified Delphi approach. The table of contents from pre-determined journals were reviewed and independently evaluated via the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system by paired authors. Pharmacotherapy-related publications deemed to be GRADE 1A and 1B were reviewed by the collective group for inclusion in the review. In all, this article summarizes and provides commentary on the potential clinical impact of 13 articles, 6 guidelines, and 5 meta-analyses covering topics including guideline releases and updates on rapid sequence intubation in the critically ill, managing cardiac arrest or life-threatening toxicity due to poisoning, and management of major bleeding following trauma. Also discussed are ongoing controversies surrounding fluid resuscitation, time and treatment modalities for ischemic stroke, steroid use in community-acquired pneumonia, targeted blood product administration, and much more.
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Affiliation(s)
- Jennifer Koehl
- Department of Pharmacy, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Caitlin S Brown
- Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Brett Faine
- Department of Emergency Medicine and Pharmacy Practice, University of Iowa, Iowa City, IA 52242, USA
| | - Megan A Rech
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, IL 60141, United States of America
| | - David E Zimmerman
- Duquesne University School of Pharmacy, University of Pittsburgh Medical Center-Mercy Hospital, Pittsburgh, PA 15282, USA
| | - Tara Flack
- Department of Pharmacy, IU Health Methodist Hospital, Indianapolis, IN 46202, USA
| | - Brian W Gilbert
- Department of Pharmacy, Wesley Medical Center, Wichita, KS 67205, USA
| | - Gavin T Howington
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY 40508, USA; Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY 40506, USA
| | - Jessica Laub
- Department of Pharmacy, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC 2940, USA
| | - Blake Porter
- Department of Pharmacy, University of Vermont Medical Center, Burlington, VT 05401, USA
| | - Giles W Slocum
- Department of Emergency Medicine and Department of Pharmacy, Rush University Medical Center, Chicago, IL 60612, USA
| | - Anne Zepeski
- Department of Emergency Medicine and Pharmacy Practice, University of Iowa, Iowa City, IA 52242, USA
| | - Ryan Feldman
- The Medical College of Wisconsin School of Pharmacy & Department of Emergency Medicine Division of Medical Toxicology, Froedtert Hospital Department of Pharmacy, Wisconsin Poison Center, Milwaukee, WI 53226, USA
| | - Ruben D Santiago
- Department of Pharmacy, Jackson Memorial Hospital, Miami, FL 33136, USA
| | - Preeyaporn Sarangarm
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM 87106, USA
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DePriest J, Nixon J. The Use of a Checklist to Optimize Electrolyte Replacement in the ICU. Am J Med Qual 2024; 39:118-122. [PMID: 38713599 DOI: 10.1097/jmq.0000000000000177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2024]
Abstract
Electrolyte replacement protocols are routinely used in intensive care units (ICU) to guide magnesium replacement. Guided by serum levels, these protocols include no patient-specific factors despite a literature showing ICU patients routinely have significant deficits despite normal serum levels. The authors developed a checklist to help identify patients requiring more aggressive magnesium replacement than the electrolyte replacement protocol would provide. The checklist included risk factors for having significant magnesium deficits and for developing arrhythmias. The checklist was retrospectively applied to 364 medical ICU patients. Diabetic patients prescribed outpatient diuretics were defined as the highest-risk population. A total of 88% of patients in this subgroup had normal magnesium levels. Despite averaging 3.4 risk factors per patient, only 3 of 32 patients received magnesium. Applying the checklist would have suggested additional repletion for at least 85% of patients. A checklist can help identify ICU patients who may require more aggressive magnesium supplementation than protocols will provide.
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Affiliation(s)
- Jack DePriest
- Department of Internal Medicine, Division of Pulmonary, Sleep and Critical Care Medicine, Prisma Health Midland-University of South Carolina School of Medicine, Columbia, SC
| | - Joanna Nixon
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 286] [Impact Index Per Article: 286.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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Kłosiewicz T, Cholerzyńska H, Zasada WA, Shadi A, Olszewski J, Konieczka P, Podlewski R, Puślecki M. Impact of Various Atrial Fibrillation Treatment Strategies on Length of Stay in the Emergency Department and Early Complications-3 Years of a Single-Center Experience. J Clin Med 2023; 13:190. [PMID: 38202197 PMCID: PMC10779744 DOI: 10.3390/jcm13010190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 11/29/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia presenting in emergency departments (EDs), vastly increasing mainly due to society's lifestyles leading to numerous comorbidities. Its management depends on many factors and is still not unified. Aims: The aim of this study was to compare different AF management strategies in the ED and to evaluate their influence on the length of stay (LOS) in the ED and their safety. We analyzed medical records over 3 years of data collection, including age, primary AF diagnosis, an attempt to restore sinus rhythm, complications, and length of stay. Patients were divided into three groups according to the treatment method received: only pharmacological cardioversion (MED), only electrical cardioversion (EC), and patients who received medications followed by electrical cardioversion (COMB). We included 599 individuals in the analysis with a median age of 71. The restoration of sinus rhythm and LOS were as follows: MED: 64.95%, 173 min; COMB: 87.91%, 295 min; SH: 92.40%, 180 min. The difference between the MED and EC strategies, as well as MED and COMB, was statistically significant (p < 0.001 in both). The total number of complications was 16, with a rate of 32.67%. The majority of them followed a drug administration, and the most common complication was bradycardia. Electrical cardioversion is a safe and effective treatment strategy in stable patients with AF in the ED. It is associated with a shortened LOS. Medication administration preceded the majority of complications.
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Affiliation(s)
- Tomasz Kłosiewicz
- Department of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland; (H.C.); (W.A.Z.); (P.K.); (R.P.); (M.P.)
| | - Hanna Cholerzyńska
- Department of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland; (H.C.); (W.A.Z.); (P.K.); (R.P.); (M.P.)
| | - Wiktoria Antonina Zasada
- Department of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland; (H.C.); (W.A.Z.); (P.K.); (R.P.); (M.P.)
| | - Amira Shadi
- College of Emergency Physicians in Poland, 5 Truflowa Street, 62-070 Dopiewiec, Poland; (A.S.); (J.O.)
| | - Jakub Olszewski
- College of Emergency Physicians in Poland, 5 Truflowa Street, 62-070 Dopiewiec, Poland; (A.S.); (J.O.)
| | - Patryk Konieczka
- Department of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland; (H.C.); (W.A.Z.); (P.K.); (R.P.); (M.P.)
| | - Roland Podlewski
- Department of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland; (H.C.); (W.A.Z.); (P.K.); (R.P.); (M.P.)
| | - Mateusz Puślecki
- Department of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland; (H.C.); (W.A.Z.); (P.K.); (R.P.); (M.P.)
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Ray L, Geier C, DeWitt KM. Pathophysiology and treatment of adults with arrhythmias in the emergency department, part 1: Atrial arrhythmias. Am J Health Syst Pharm 2023; 80:1039-1055. [PMID: 37227130 DOI: 10.1093/ajhp/zxad108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Indexed: 05/26/2023] Open
Abstract
PURPOSE This article, the first in a 2-part review, aims to reinforce current literature on the pathophysiology of cardiac arrhythmias and various evidence-based treatment approaches and clinical considerations in the acute care setting. Part 1 of this series focuses on atrial arrhythmias. SUMMARY Arrhythmias are prevalent throughout the world and a common presenting condition in the emergency department (ED) setting. Atrial fibrillation (AF) is the most common arrhythmia worldwide and expected to increase in prevalence. Treatment approaches have evolved over time with advances in catheter-directed ablation. Based on historic trials, heart rate control has been the long-standing accepted outpatient treatment modality for AF, but the use of antiarrhythmics is often still indicated for AF in the acute setting, and ED pharmacists should be prepared and poised to help in AF management. Other atrial arrhythmias include atrial flutter (AFL), atrioventricular nodal reentry tachycardia (AVNRT), and atrioventricular reentrant tachycardia (AVRT), which warrant distinction due to their unique pathophysiology and because each requires a different approach to utilization of antiarrhythmics. Atrial arrhythmias are typically associated with greater hemodynamic stability than ventricular arrhythmias but still require nuanced management according to patient subset and risk factors. Since antiarrhythmics can also be proarrhythmic, they may destabilize the patient due to adverse effects, many of which are the focus of black-box label warnings that can be overreaching and limit treatment options. Electrical cardioversion for atrial arrhythmias is generally successful and, depending on the setting and/or hemodynamics, often indicated. CONCLUSION Atrial arrhythmias arise from a variety of mechanisms, and appropriate treatment depends on various factors. A firm understanding of physiological and pharmacological concepts serves as a foundation for exploring evidence supporting agents, indications, and adverse effects in order to provide appropriate care for patients.
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Affiliation(s)
- Lance Ray
- Denver Health and Hospital Authority, Denver, CO
- Department of Emergency Medicine, University of Colorado, Aurora, CO, USA
| | - Curtis Geier
- San Francisco General Hospital, San Francisco, CA, USA
| | - Kyle M DeWitt
- University of Vermont Medical Center, Burlington, VT, USA
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Tchouapi PC, Anderson KE, Hein PN. Intravenous magnesium as an adjunct to standard of care for treatment of atrial fibrillation with rapid ventricular response. Acad Emerg Med 2023; 30:779-781. [PMID: 37021611 DOI: 10.1111/acem.14734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 04/07/2023]
Affiliation(s)
- Pierre-Carole Tchouapi
- Department of Emergency Medicine, SUNY Downstate Medical Center, New York, Brooklyn, USA
| | - Kevin E Anderson
- Department of Emergency Medicine, SUNY Downstate Medical Center, New York, Brooklyn, USA
| | - Paul Narayan Hein
- Department of Emergency Medicine, SUNY Downstate Medical Center, New York, Brooklyn, USA
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Enayati A, Gin JH, Sajeev JK, Cooke JC, Carey P, MacPherson M, Roberts L, Buntine P, Teh AW, Nogic J. Efficacy of intravenous magnesium for the management of non-post operative atrial fibrillation with rapid ventricular response: A systematic review and meta-analysis. J Cardiovasc Electrophysiol 2023; 34:1286-1295. [PMID: 37186322 DOI: 10.1111/jce.15911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/05/2023] [Accepted: 04/09/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Intravenous magnesium (IV Mg), a commonly utilized therapeutic agent in the management of atrial fibrillation (AF) with rapid ventricular response, is thought to exert its influence via its effect on cellular automaticity and prolongation of atrial and atrioventricular nodal refractoriness thus reducing ventricular rate. We sought to undertake a systematic review and meta-analysis of the effectiveness of IV Mg versus placebo in addition to standard pharmacotherapy in the rate and rhythm control of AF in the nonpostoperative patient cohort given that randomized control trials (RCTs) have shown conflicting results. METHODS Randomized controlled trials comparing IV Mg versus placebo in addition to standard of care were identified via electronic database searches. Nine RCTs were returned with a total of 1048 patients. Primary efficacy endpoints were study-defined rate control and rhythm control/reversion to sinus rhythm. The secondary endpoint was patient experienced side effects. RESULTS Our analysis found IV Mg in addition to standard care was successful in achieving rate control (odd ratio [OR] 1.87, 95% confidence interval [CI] 1.13-3.11, p = .02) and rhythm control (OR 1.45, 95% CI 1.04-2.03, p = .03). Although not well reported among studies, there was no significant difference between groups regarding the likelihood of experiencing side effects. CONCLUSIONS IV Mg, in addition to standard-of-care pharmacotherapy, increases the rates of successful rate and rhythm control in nonpostoperative patients with AF with rapid ventricular response and is well tolerated.
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Affiliation(s)
- Anees Enayati
- Department of Cardiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Julian H Gin
- Department of Cardiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Jithin K Sajeev
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jennifer C Cooke
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Patrick Carey
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Michael MacPherson
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Louise Roberts
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Paul Buntine
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
- Emergency Medicine Program, Eastern Health, Melbourne, Victoria, Australia
| | - Andrew W Teh
- Department of Cardiology, Austin Hospital, Melbourne, Victoria, Australia
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
- Austin Health Clinical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Jason Nogic
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
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Utility of magnesium sulfate in the treatment of rapid atrial fibrillation in the emergency department: a systematic review and meta-analysis. Eur J Emerg Med 2022; 29:253-261. [PMID: 35503562 DOI: 10.1097/mej.0000000000000941] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Atrial fibrillation with rapid ventricular response (Afib/RVR) is a frequent reason for emergency department (ED) visits and can be treated with a variety of pharmacological agents. Magnesium sulfate has been used to prevent and treat postoperative Afib/RVR. We performed a systematic review and meta-analysis to assess the effectiveness of magnesium for treatment of Afib/RVR in the ED. PubMed and Scopus databases were searched up to June 2021 to identify any relevant randomized trials or observational studies. We used Cochrane's Risk-of-Bias tools to assess study qualities and random-effects meta-analysis for the difference of heart rate (HR) before and after treatment. Our search identified 395 studies; after reviewing 11 full texts, we included five randomized trials in our analysis. There were 815 patients with Afib/RVR; 487 patients (60%) received magnesium treatment, whereas 328 (40%) patients received control treatment. Magnesium treatment was associated with significant reduction in HR [standardized mean difference (SMD), 0.34; 95% CI, 0.21-0.47; P < 0.001; I2 = 4%), but not associated with higher rates of sinus conversion (OR, 1.46; 95% CI, 0.726-2.94; P = 0.29), nor higher rates of hypotension and bradycardia (OR, 2.2; 95% CI, 0.62-8.09; P = 0.22). Meta-regressions demonstrated that higher maintenance dose (corr. coeff, 0.17; P = 0.01) was positively correlated with HR reductions, respectively. We observed that magnesium infusion can be an effective rate control treatment for patients who presented to the ED with Afib/RVR. Further studies with more standardized forms of control and magnesium dosages are necessary to assess the benefit/risk ratio of magnesium treatment, besides to confirm our observations.
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Dardas S, Khan A. Atrial flutter with flecainide-induced 1:1 conduction at a rate <200 b.p.m. at rest: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab396. [PMID: 34703982 PMCID: PMC8536867 DOI: 10.1093/ehjcr/ytab396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/15/2021] [Accepted: 09/28/2021] [Indexed: 11/23/2022]
Abstract
Background Class IC antiarrhythmic drug flecainide is commonly used in the management of atrial arrhythmias and in particular atrial fibrillation (AF). Although previously reported as a potential complication, atrial flutter (AFL) with 1:1 atrioventricular (AV) conduction is rare, with only few cases reported so far, most of which related to physical activity. In all previous reported cases, 1:1 conduction resulted in ventricular rates of >200 b.p.m. Case summary We report the case of a 60-year-old woman, who presented to our local emergency department with palpitations related to acute onset AF. The patient developed symptomatic 1:1 AFL with a rate of 192 b.p.m., shortly after administration of intravenous flecainide, which spontaneously converted back to AF and subsequently to sinus rhythm, with further administration of amiodarone and beta-blocker. Discussion The case raises awareness of this rare but potentially life-threatening complication to those using flecainide for pharmacological cardioversion of AF. QRS complex widening can be seen in the context of very rapid ventricular rates, posing additional diagnostic challenge, especially with rates of <200 b.p.m. Prescribing an AV nodal blocking agent, such as a beta-blocker, together with flecainide reduces significantly the risk of 1:1 conduction and should always be considered.
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Affiliation(s)
- Sotirios Dardas
- Department of Cardiology, King's Mill Hospital, Sherwood Forest Hospitals NHS Foundation Trust, Mansfield Rd, Sutton-in-Ashfield, Nottinghamshire NG17 4JL, UK
| | - Asif Khan
- Department of Cardiology, King's Mill Hospital, Sherwood Forest Hospitals NHS Foundation Trust, Mansfield Rd, Sutton-in-Ashfield, Nottinghamshire NG17 4JL, UK
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