Inpatient Emergencies 101
Healthcare providers in a hospital setting are typically responsible for a number of tasks during the course of a shift. Many of these can be routine and planned. For example, nurses will administer medications to patients at scheduled times, prescribers and their teams will make rounds at a specific time of day, and pharmacy technicians will make deliveries at certain intervals, such as once every hour. However, there are a number of emergency situations that can come up in the hospital that require the immediate attention of individuals contributing to the care of the patient. As a pharmacy technician, your role will most often be to make needed medications available in the most efficient manner possible. This Technician Tutorial will provide an overview of common inpatient emergencies, along with information about how you can be an effective member of the team providing care for these patients.
You are working your shift on a Saturday evening. You receive labels for an alteplase bolus and infusion (excerpts shown above), which you recognize as a stroke treatment, for a patient on a general medicine floor. Since you typically send alteplase boluses and infusions to the emergency department, you double-check with the pharmacist that this label is correct. She confirms that it is, and tells you it’s needed STAT for an inpatient who has had a stroke. You select a vial of alteplase 100 mg from the shelf, and get ready to prepare the patient’s alteplase.
What are the most common inpatient emergencies I should be aware of?
Cardiac arrest. Cardiac arrest, also referred to as “code blue,” “code 99,” etc, is likely to be the most recognized emergency in the hospital setting. Patients who arrest are experiencing dangerous heart arrhythmias due to malfunctions of the heart’s electrical system. There are a number of reasons that people arrest. One example is a heart attack. Others include illegal drug use and chest trauma. When the heart stops pumping blood effectively, vital organs such as the brain don’t receive enough blood flow or oxygen. This can lead to organ damage and death within minutes.
Cardiopulmonary resuscitation (CPR) and defibrillation (i.e., electrical shock) can save lives during cardiac arrest. In addition, algorithms (i.e., step-by-step guides) for the treatment of cardiac arrest have been developed by the American Heart Association (AHA). They’re referred to as Advanced Cardiovascular Life Support (ACLS) and Pediatric Advanced Life Support (PALS). The algorithms are updated every few years, and will influence the medications that are included in adult and pediatric crash cart trays. Meds that are currently included in the algorithms include epinephrine, atropine, and sodium bicarbonate. Often patients who arrest will need to have a breathing tube placed, so medications for sedating and paralyzing the patient may be included in crash cart trays as well.
Although patients who have heart attacks may go into cardiac arrest, that’s not always the case. In fact, the AHA differentiates the two by pointing out that cardiac arrest is an electrical problem with the heart, as previously mentioned, and that a heart attack is a circulation problem. More specifically, the heart muscle itself is not receiving adequate blood flow.
Many patients who have heart attacks will be conscious and able to breathe on their own. Heart attack patients will need to be treated right away with meds such as aspirin, morphine, and nitroglycerin to improve circulation and reduce pain. They may need to go to the cardiac cath lab for an intervention such as angioplasty or stent placement to open up blocked blood vessels and restore blood flow. If this is the case, they will need to be treated quickly with meds that reduce the risk of blood clots during the procedure such as aspirin, bivalirudin (Angiomax), clopidogrel, eptifibatide (Integrilin), heparin, etc. Some patients may also be able to be treated with these types of meds without an intervention. In general, the treatment will depend on the type and severity of the heart attack.
Trauma. Trauma is likely to be the most broadly defined emergency situation you’ll see in the hospital. We probably think of vehicle accidents first when we think of trauma. However, serious falls such as from a roof or ladder, crush injuries such as from a falling tree, amputations such as from heavy equipment, blast injuries such as from explosives, etc, also fall under the classification of trauma.
Depending on the size of your hospital, you may see very serious traumas or these cases may be routed to another bigger hospital. Hospitals that can treat the most serious traumas are designated as Level I trauma centers. Hospitals may call alerts for traumas, similar to alerts for cardiac arrests, when a trauma patient is known to be en route. This helps ensure staff and resources are available upon the patient’s arrival. In some hospitals, a pharmacist will be included in the team of individuals who respond to trauma alerts.
Stroke. Strokes are either caused by a bleed from a blood vessel in the brain, or a clot in a blood vessel in the brain. The end result of either situation is that blood flow to the brain is compromised. The phrase “time is of the essence” is very true for the treatment of strokes. In fact, you’ve probably heard the acronym “FAST” to help people quickly identify stroke symptoms in order to expedite medical care. (F=face droop, A=does one Arm drift downward if the person lifts both arms, S=is the person’s Speech slurred, T=Time, call 911 immediately.)
If a stroke is caused by bleeding, medications that lower blood pressure (e.g., labetalol, nicardipine) will be important to help prevent worsening of the bleed. Treatments for seizures (e.g., lorazepam, phenytoin) may also be needed. In addition, clotting factor medications such as Kcentra may be required, such as for patients whose bleed is associated with taking blood thinners (e.g., warfarin). On the other hand, if a stroke is caused by a clot, intravenous alteplase (Activase) must be administered within 4.5 hours of symptom onset to break up the clot. However, the chance of a good recovery literally drops as the minutes pass, so alteplase is ideally administered as soon as possible. In fact, some patients will only have a three-hour window where alteplase is considered useful. Certain patients will be candidates for alteplase administered intra-arterially, and this can be done up to six hours after symptom onset. Patients with strokes caused by clots may also require blood pressure lowering.
Stroke patients will most often come to the emergency department. However, as with cardiac arrest, strokes can also occur in inpatients, and interestingly, it is known that recognition and treatment of strokes in inpatients are often delayed in comparison with outpatients. Your hospital might have a stroke team designated to improve response time for stroke patients.
Sepsis. Sepsis, also referred to as septic shock in the most severe cases, is a whole body response to infection. Patients who are at a high risk of sepsis include people who are very young or very old, with chronic illnesses (e.g., diabetes), or serious illnesses (e.g., burns, cancer). Typically a patient’s blood pressure will drop to a dangerously low level, which will cause reduced blood flow to organs such as the kidneys. Since blood carries oxygen, this means the organs won’t get the oxygen they require to function, and they could sustain permanent damage.
The goals of treatment for sepsis are to stabilize blood pressure and treat the patient’s infection. Blood pressure is treated with IV fluids, typically normal saline or Lactated Ringer’s and less often, albumin. If IV fluids aren’t enough to bring up the patient’s blood pressure, medications that constrict the blood vessels and support the function of the heart may be needed. Norepinephrine (Levophed) is the vasopressor, or “pressor” for short, most often used for sepsis patients. Other pressors you may see used include dopamine, epinephrine, phenylephrine, and vasopressin.
“Broad spectrum” antibiotics will usually be started in order to cover all likely bacteria that could be causing the infection. You’ll often see a regimen such as vancomycin or linezolid (Zyvox), piperacillin plus tazobactam (Zosyn), and possibly fluconazole (Diflucan), an antifungal drug. This covers the main types of bacteria (e.g., gram-positive, gram-negative, and anaerobic), as well as fungi. Patients may have a better chance of recovery when antibiotics are started within one hour of recognition of sepsis symptoms, and Joint Commission looks for them to be started within three hours. For this reason, some hospitals are implementing sepsis alerts.
Once the alteplase is ready for the final check, you alert the pharmacist immediately. She thanks you, checks the bolus and drip, and tells you she is heading to the ICU to deliver them herself, since the patient is being transferred. You ask if you should be on the lookout for any other meds for this patient, and the pharmacist tells you she thinks everything they’ll need will be in the automated dispensing machines in the ICU.
What other conditions usually require expedited drug treatment?
As mentioned, the most common emergency scenarios are the ones listed above. However, there are many other situations that can be considered emergencies in a hospital setting, where drug treatment is very important. These include serious burns, severe allergic reactions (i.e., anaphylaxis), diabetic ketoacidosis (i.e., DKA), dangerously high blood levels of potassium (i.e., hyperkalemia), accidental leaks of certain IV meds from an IV line (i.e., extravasation or infiltration), and poisonings or overdoses. Take the lead from your pharmacist about how to prioritize in these situations so that patients get needed meds in a timely fashion.
What are some basic rules to keep in mind for any emergency?
Most importantly, keep calm. You’d be surprised at the number of people who “lose their heads” in emergency situations. Anyone can fall victim to the stress, even some physicians and nurses will come unglued. Staying calm not only helps you be more effective for the patient, but it’s also a good example for others.
In addition to keeping calm, you must stay focused. For example, if a med is requested, make sure there is follow through from prep to delivery, ideally with the med delivered to the patient’s bedside. This way, no snags can occur such as an unchecked IV prep waiting in line to be checked with a batch or a checked IV prep being placed in a bin for routine delivery or lying in a pneumatic tube while the team treating the patient is anxiously awaiting its arrival.
Communicate clearly and concisely. For example, if you are engaged in a task and an emergency comes up, check with the pharmacist if you are unclear of your role or your priorities. Ask for any details that you need to perform your duties. As mentioned, it’s not unusual for folks to succumb to stress and act in a rash manner. For example, if you receive a phone call and the person on the other end yells that they need “heparin,” calmly ask for the details you need to provide the correct medication. A second phone call or providing the wrong medication will waste valuable time that could have a significant impact on a patient’s survival or recovery.
Don’t take shortcuts that could compromise med safety in the name of speed. The damage caused by an error or mistake could easily outweigh the extra seconds or minutes needed to follow policies and procedures that are in place to improve med safety.
In fact, avoiding shortcuts may actually be extra important for emergencies because many of the meds used in these situations are high-alert. As a reminder, high-alert meds are those most likely to cause serious patient harm if an error occurs. Here are some examples. The clot buster alteplase (Activase), used for strokes, is high-alert because its main risk is serious bleeding; vasopressors used in sepsis are high-alert because they have intense effects on the cardiovascular system; and neuromuscular blockers such as rocuronium (Zemuron) used to paralyze patients for breathing tube placement are high-alert because accidental administration can be fatal. Be sure to follow any applicable policies on high-alert meds such as placing appropriate auxiliary labels, getting double checks, etc, even during emergencies.
Be available, and contact back-up if needed to maintain routine patient care duties. In many hospitals, pharmacists will physically attend responses to emergencies to prepare needed medications. If you have a break scheduled and a pharmacist is tending to an emergency, find out if you should reschedule your break or if another technician will be available to help out during the time that you are on break. Also find out in advance what you are expected to do if a pharmacist is called away to an emergency, since other patients will still need routine pharmacy services. For example, you may need to call a pharmacist from a different area to help cover, or you may need to contact admin for extra help.
A few minutes later, you leave the IV room to take your dinner break. You scan the area for one of the other pharmacists who is working to confirm that it’s okay for you to take your break now. You notice that your colleague covering the main pharmacy has stepped around the corner to retrieve some needed printer supplies. The phone rings, and you answer it. It’s a unit secretary in the ICU, and she hurriedly tells you she needs labetalol immediately for their stroke patient. You suspect she means the transferred patient, Mr. Dough, but you’re not sure. You also don’t know if she means a labetalol drip or labetalol prefilled syringes. You haven’t received a label for a labetalol drip in the IV room, so you doubt that’s the case.
To quickly get to the point, you ask her to confirm the patient’s name. It is, in fact, Mr. Dough. You access his profile on the computer nearby, and see that he has an active order for IV push labetalol, which is stocked in the ICU. You ask her to confirm that the nurse checked in the automated dispensing cabinet, and the unit secretary says yes, the nurse did check, and there are no syringes there. It needs to be restocked. You relay this info to your colleague, and he tells you “he is on it.” You wait in the main pharmacy until he comes back from delivering the labetalol syringes before taking your break.
What can I do to prepare for emergencies in general?
As they say, “an ounce of prevention is worth a pound of cure.” This adage certainly rings true when it comes to preparing for emergency situations in the hospital. Consider the meds that we have discussed in this Technician Tutorial, and make sure you know important info such as where these are stocked, how to prep them, any special considerations for dispensing, etc.
Don’t put off routine tasks if a workday seems slow. Since emergencies are by definition unexpected, the time you assume you will have may unexpectedly be filled with prepping meds for a head injury patient in the emergency department, for example, or mixing antibiotics and vasopressor infusions for a patient transferred to the ICU with sepsis.
Make sure that floor stock meds, such as those in automated dispensing machines, are maintained at par levels to help ensure needed medications are available quickly during emergencies. Some examples of these include epinephrine, heparin, insulin, dextrose 50%, and midazolam. Also, if you identify emergency meds that could be stocked in automated dispensing machines but currently are not, check with your pharmacist or admin about adding them.
In addition, make sure that any preassembled kits are available and in-date to ensure that needed meds are immediately accessible for administration to patients by prescribers and nurses. For example, most hospitals will have med trays for crash or code carts. Additional preassembled kits may include “tackle boxes” of emergency meds such as for patient transport, intubation kits, extravasation kits, etc. Don’t delay refilling these kits when they are used and returned to pharmacy. In addition, check every med when refilling a kit, even if it appears that only one or two were used. Otherwise, you might overlook a med that was inadvertently placed in the kit during the emergency or a med that was actually used, such as a pierced vial or an empty syringe. Make sure meds are placed in a standardized configuration in the kits to prevent delays due to having to search through the kit for a specific med. Avoid placing meds in these kits that expire soon, such as within two to three months, to prevent unnecessary restocking if a med expires before the kit is used. Finally, follow your pharmacy’s policy on placing an expiration date on the kit and on securing the meds in the kit, such as placing a special lock on a code cart when replacing a used med tray with a new one.
There’s software available that can help reduce the time associated with restocking kits. If you have a high volume of turnover with kits, ask your pharmacist or admin about the possibility that the software would be useful in your practice setting.
When you return from your dinner break, you pass your colleague and he mentions that “things are getting crazy.” He says he’s glad he took the time early on in the shift when the workload was lighter to tie up some loose ends such as restocking supplies in the main pharmacy, refilling used crash cart trays, etc. Otherwise, they’d have a chaotic mess on their hands now. At that exact moment, a crash cart is brought to the pharmacy for a tray replacement. Thankfully there are plenty of them on-hand, since your colleague was really thinking ahead.
What are some “rules of thumb” to keep in mind for specific emergencies?
Here are some quick bullet points summarizing key points about different emergencies.
- Epinephrine 1 mg/10 mL (1:10,000) syringes are one of the most commonly used meds during cardiac arrest. However, epinephrine is also commonly involved in drug shortages and dangerous errors. Avoid stocking multidose vials of epinephrine in place of the syringes or sending multidose vials of epinephrine to patient care units, since this could lead to fatal overdoses.
- Some patients will require different or more meds than are included in a crash cart med tray. Be available and ready to prepare and deliver these meds if needed.
- Stock meds in crash cart trays in a standardized format, so time isn’t wasted by physicians, nurses, or pharmacists searching for needed meds during a cardiac arrest.
- Antibiotics should be administered quickly, ideally within one hour of symptom recognition.
- Vasopressor infusions such as norepinephrine, epinephrine, dopamine, phenylephrine, and vasopressin may be needed for patients with sepsis.
- For patients with strokes due to clots, an alteplase IV bolus and drip should be started within 4.5 hours of symptom onset. However, the sooner these are administered, the better the patient’s chance of recovery. Some patients won’t be “candidates” for alteplase, however, such as if they have recently had an episode of serious bleeding.
- Patients with strokes due to bleeding will commonly need meds to lower blood pressure, treat seizures, and promote clotting of the blood.
- Don’t assume that stroke treatment will always start in the ED. Inpatients may also have strokes during their hospital stay.
- Needed meds for trauma patients will be variable, since the causes of trauma are also variable.
- Some commonly used meds for specific traumas and situations include the following:
- Methylprednisolone infusion for patients with head injuries.
- Etomidate plus rocuronium or succinylcholine for patients who need to be intubated.
- Antibiotics, if the patient has a “dirty wound.” These patients may also need tetanus shots. (Note that burn patients may also need a tetanus shot, since burn wounds often harbor bacteria that cause tetanus.)
If you want more specific information about emergencies and medications in your practice setting, consider starting a conversation with your pharmacist or admin. You might also consider asking about any opportunities to research this topic and provide the information to your colleagues, such as through a seminar or lunchtime talk.
Project Leader in preparation of this PL Technician Tutorial (311181): Stacy A. Hester, R.Ph., BCPS, Assistant Editor
Cite this document as follows: PL Technician Tutorial, Inpatient Emergencies 101. Pharmacist’s Letter/Pharmacy Technician’s Letter. November 2015 (Last modified August 2017).