A few weeks ago, I interviewed Bryan Hayes, the Pharm ER Tox Guy, on the subject of avoiding medication errors during resuscitation. That was Part I; today we move on to Part II.

Bryan is a pharmacist with a fellowship in toxicology. He tweets as PharmERToxGuy and blogs at Academic Life in EM.

Insulin Drip Preparation

Flush 20- 50 cc of Insulin/NS drip through all IV tubing, before infusion begins (to saturate the insulin binding sites in the tubing) [UMD's protocol + Yale's]... Goldberg PA, et al. Diabetes Technol Ther 2006;8(5):598-601.

This article states you must prime 20 ml from a 100 ml bag containing Regular Insulin 1 unit/mL (Crit Care Med 2012;40(12):3266)

Nalaxone Dosing

 big doses are out, smaller doses are in.

I use 0.4 mg diluted in 10 ml of saline to yield 0.04 mg/ml. Give 1-2 ml at a time. If you think this is an opioid, but that amount didn't work, keep going--some overdoses require a ton of nalaxone

Hydromorphone

Hydromorphone dosing - why are our residents scared to give more than 4 mg of morphine, but have no problem giving 1 mg of hydromorphone (equal to 7 mg of morphine)?

Hydralazine

Hydralazine and its erratic blood pressure lowering in hypertensive emergency

Infusion Deadspace can delay drug initiation

Deadspace when initiating infusions on low ml/hr drips: this may result in an hour between initiation and drug reaching bloodstream. Should we infuse into flowing line? Draw up and inject until it hits vein?

(Anaesthesia 2013;68:640)

This article (Emerg Med J 2007;24:558–559) discusses the perils of ignoring deadspace for infusions

Syringe Labeling

Importance of labeling syringes properly

Should be Generic Drug Name and then concentration based contents (e.g. Succinylcholine 20 mg/ml)

(Br. J. Anaesth 2013;110:1056.)

Top Ten Drug Error Commandments (Abridged for ED Relevan ce)

* Never inject a drug from a non-labelled syringe

* Never inject a drug that you are not familiar with

* Keep all empty vials until you conclude resuscitation

* Whoever injects the drug is responsible for the drug

(Anaesthesia 2013;68:640)

and I would add a 5th

* Show the vial with the syringe you just mixed to whomever will be injecting

EMS Educast has a great podcast on human factors in medication errors