New Therapeutic Options

Ketamine

Advantage to the pre-filled syringe, you can administer 0.1 mg/kg or 10 mg and reassess for pain control and order a repeat dose if necessary.

Cap single doses at 20 mg IVP x 1.

In regards to the 4mg/kg dose for agitated delirium, this typically requires the concentrated product (500mg/5mL) to reduce volume when giving IM.

 

Emerging Treatment: Lidocaine for Renal Colic

Renal colic is often associated with acute severe pain and effective pain killers such as opioids, NSAIDs, and/or spasmolytic agents play important roles in the treatment of this pain. Recently, the use of low dose intravenous (IV) lidocaine has also been associated with pain relief in renal colic patients. Lidocaine is an anesthetic amide that reversibly blocks voltage-dependent sodium channels and thus may lead to inhibition of nerve impulse transmissions. At low doses lidocaine is a relatively safe medication with a short half-life and transient and rapidly reversible toxicity symptoms.  Dosing of lidocaine for renal colic at Mercy will be 1.5mg/kg (max 200mg) in 50ml NS IV Piggyback over 20 minutes.  This medication will be made in the pharmacy as it requires the preservative free lidocaine solution. 

Mild side effects patients may experience include lightheadedness, dizziness, nausea, and/or perioral numbness.

Ashley Cook PharmD

 

C1 ESTERASE INHIBITOR HUMAN (BERINERT®)

Berinert is indicated for use in acute hereditary angioedema attacks and has potential off label use for severe ACE-induced angioedema. The product will be restricted to ED and ICU physicians.

(Berinert) is indicated for the treatment of acute abdominal or facial attacks of hereditary angioedema (HAE) in adults and adolescents.

(Berinert) is approved for IV administration only. It should be administered by slow IV push injection, at a rate of approximately 4 mL/min (about 5-10min for average size patients), and not in combination with other medicinal products or solutions. The recommended dose is 20 units/kg. It should be administered at room temperature within 8 hours of reconstitution. The drug will be stored and prepared in the main pharmacy. Berinert will be delivered to the ED in a syringe ready for administration.

The most common adverse reactions observed in clinical trials with Berinert were a subsequent HAE attack, headache, nausea, diarrhea, abdominal pain, muscle spasms, pain, and vomiting. The most serious adverse reaction reported in patients treated with Berinert was an increase in the severity of pain associated with HAE.

C1 esterase inhibitors are contraindicated in patients who have a history of life-threatening immediate hypersensitivity reactions, including anaphylaxis to any C1 esterase inhibitor products. Warnings/precautions: Thrombotic events have occurred in patients receiving off-label, high-dose C1 esterase inhibitor therapy. Patients with known risk factors for thrombotic events should be closely monitored. Risk of infection transmission (since product is made from human plasma – no infections have been clearly linked to C1 esterase inhibitors)

Michael Thiefault PharmD

 

Topical Tranexamic Acid for Epistaxis

Consider nasal packing with 500mg in 5ml of normal saline of Tranexamic acid for epistaxis in patients that are utilizing anticoagulation.

Use of topical TXA has been shown to reduce time spent in the ED and has been found to be safe.

Toradol – New Analgesic Ceiling

“Ketorolac has similar analgesic efficacy at intravenous doses of 10, 15, and 30 mg, showing that intravenous ketorolac administered at the analgesic ceiling dose (10 mg) provided effective pain relief to ED patients with moderate to severe pain without increased adverse effects.”

Motov S, Yasavolian M, Likourezos A, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial.  Ann Emerg Med 2016. [Article in press link]