Ryan Feldman PharmD DABAT
@EMPoisonPharmD
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Host @LabPoison . EM PharmD, PGY2 faculty, Prof📚 @ , Toxicologist(DABAT) @Center_poison ,🔬 views=mine
Milwaukee, WI
Joined September 2015
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You're working in the ED when a 30 y.o male presents 30 minutes after envenomation to the right index finger by his pet snake (left).
He has a picture of culprit (right) , and it is definitely NOT from America.
A 🧵on U.S. exotic envenomation management.
(shared with consent)
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In this case we said no. This snake was from Indonesia and data suggested worse Venom-F(ab) binding fro F(ab) raised against distant snake lineages.
THE POINT IS VERY NERDY PEOPLE ARE AVAILABLE AT 1-800-222-1222 TO THINK HARD ABOUT WHAT ANTIVENOM TO USE FOR THIS DANGER NOODLE
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After researching, Thai Green Pit Viper Antivenom seemed to be the best option.
Heck lets say you happen to be a snake expert and figured this out yourself in the ED.
How would you get a foreign antivenom?
ONCE AGAIN BIG SURPISE CALL A POISON CENTER 1-800-222-1222
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Note: Zoo's cant sell their investigational drug, they give it away without guaranteed repayment. Every effort should be made to reimburse them so they can replenish stock and stay safe from sneks.
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If you ARE high risk (near a zoo, pet or venom facility) work with establish relationships with PC/ZOO ahead of time. It will take a lot of the work out of this low frequency high complexity event.
I hope you never need this info, but if you do, I hope it is useful.
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Hey
@Walgreens
. I was on hold for >75 minutes trying to fix a medication issue for a mutual patient before call dropped. Im calling from an ED for emergent issues. Why are your pharmacies so understaffed that RPH/techs can’t even interact w/ healthcare workers to fix problems?
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In this case, we used the antivenom index and found 5 zoos with Thai Green Pit Viper antivenom (TGPAV)
A literal team of specialist at the poison center (and anyone with a free hand) began cold calling herpetologist in zoo's across the country to beg them for antivenom.
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This involved a Blue Indonesian pit viper (Trimereserus Insularis) but this could have been any exotic snake. There have been 50-110 exotic snake bites reported to Poison Centers annually since 2012.
P.S. limited free copies of report available here:
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Poison Centers have access to the Antivenom index ()
Institutions housing exotic venomous animals often maintain a supply of antivenom in case of envenomation. They can upload their inventory here.
The index shows the foreign antivenom supply in the U.S.
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This took off.🚀
Just in time for poison prevention week! PSA poison centers provide 24/7 FREE expert medical advice from snake bite to overdose at 1-800-222-1222
If you want more from the world of poison centers/toxicologists, check out (
@labpoison
)!
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The HOSPITAL does not have to get an investigational new drug application (IND). This was already done by the zoo when they imported it.
So tell em to relax.
The hospital just need to give the zoo a written report so they can upkeep there IND.
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Finally we got a hold of an out of state zoo willing to donate vials. But how do we get it?
Toxicologists can identify appropriate antivenom and Poison Centers can track it down, but rarely can they transport it. This is on the hospital, AND hospitals may have concerns...
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The patient was met at bedside by an ED MD who was med tox faculty, the med tox team, and antivenom arrived shortly after. He received treatment and had a great outcome.
Using foreign antivenom in the US is complex. Take aways
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Exotic venomous animals are found in several environments within the U.S. including zoos, homes of reptile enthusiasts, laboratories of venom milking industries, and in illegal venomous reptile trafficking rings. In this case, it was a pet of a reptile hobbyist.
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All bites can benefit from wound cleaning, demarcation of injury zones, and tetanus.
Beyond that, you need to know the sepcies/venom. Patients or zoo's will often known exactly what species it is, but don't try to figure out effects on your own.
CALL A POISON CENTER
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-Exotic envenomation can happen, literally anywhere. -CALL A POISON CENTER to figure out what antivenom you need and where it is.
-Hospital can get it, dont fear reuglation (you don't need your own IND, do get emergency IRB)
AND FINALLY
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So what toxicity can you expect from an exotic snake? Most know the U.S. Crotalids are tissue destructive. But exotic venoms ranges from neurotoxic to hemorrhagic/destructive.
Some may or may not have antivenom.
You might not know the type, so focus on basics.
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We went with
#2
.
Having hospital pharmacy staff who were at the poison center that day and were members of the medical toxicology division helped navigate the med use process and navigate hospital concerns.
The agreed to transport and couriered 20 vials from the zoo!
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We were initially consulted through the Poison Center. We received the call from an OSH that the patient was envenomated by his pet Blue Tree Pit Viper on his right hand and they wanted to know if they could give CroFab.
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So we had 2 options
1. Connect zoo with OSH and hope OSH wasn't so freaked out over regulation they would get the antivenom
2. Transfer patient across town to our hospital where med tox staff were part of hospital pharm department and tox bedside consult was available.
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A final concern they may have is cost. In this case, out of state helicopter transort and 20 vials of AV was less than that of 2 vials of CroFab. It may not always be that but if your alternative is giving a costly ineffective u.s. antivenom, seems like a no brainer
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The hospital DOES need to get emergent IRB approval, hopefully they have a system in place. But even then you can give antivenom without approval in life/limb threatening scenario.
You just need to get further doses approved and file notice to you rIBR.
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The 1st concern might be use of a non FDA Approved therapy. There is FDA guidance on use of foreign antivenom (), but its intimidating.
It involves things like getting a investigational new drug application and IRB approval. The hospital may be nervy. BUT
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Took a new job today, so far I love my boss.
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Seeing the medical community come out of the wood work to rally in defense of pharmacists has actually been somewhat faith restoring 😂
How do you tell a medical doctor?
Real doctors: *reluctant to state they are doctors in public/social forums*
Non-MD/DOs: *take every opportunity to say they are a doctor…* (chiropractors, naturopaths, pharmacists, apothecaries, charlatans…)
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If you've ever wondered what some of the inefficiencies in healthcare are, a pharmacy just called to ask if they could switch doxycycline monohydrate to hyclate. There is a 2% percent chance the prescriber even knew there were two dosage forms.
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When antibiotics are ordered in an asymptomatic patient who’s “UA is positive for UTI”
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“Consulted with pharmacy and was informed this dose is only for caterpillars”
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I'm grateful to work in the emergency department where I am constantly reminded I will die. Probably without much warning.
It fixes so many silly problems to see past the delusion that this life is permanent.
Imagine it ends NOW. What would you regret putting off? Just do it.
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🚨OK, YOU ALL PROMISED YOU WOULD READ IT🚨
Study finally published➡️
CAN METRONIDAZOLE CAUSE A DISULFIRAM REACTION?! ➡️No
Just read the introduction & discussion to go on a wild historical ride on how this myth even came to be
#TwitterX
#MedEd
#EMRx
Up until 3 am after a 10 hour shift to respond to 112 reviewer comments about a dumb article no one will ever read but I just care so deeply about publishing it because I think it will help dispel an unsubstantiated medical myth SO IT BETTER GET PUBLISHED AND YALL BETTER READ IT
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Asked ChatGPT to write me a poem about Emergency Medicine Pharmacists. I think it nailed it.
#TwitteRx
#EMRx
#Medtwitter
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With so much change and uncertainty here, now more than ever, it is important that we as a community remember that the mitochondria is the powerhouse of the cell.
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Sad I had to miss the Wisconsin ACEP emergency medicine research forum due to Rona but I have no doubt my students killed their presentation. They at the very least killed the title! ☺️
#EMRX
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I noticed I was very hungry the day I got my 1st dose of vaccine so I did a little math to calculate the increase in metabolic demand related to synthesizing spike protein.
A 🧵 1/x
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Just used a fav🏅ED pharm pearl. (Phearl?)
Pt w/ lac needs local anesthetic (LA) but amide/ester allergy?
The Benadryl block→Use DPH’s Na+ block for LA effect.
Blinded studies→DPH=lidocaine 1%.
1 ml DPH 50 mg/ml + 4 ml NS=1%
Worked like a charm!!
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This is truly wild. Pre mortem rigor mortis due to Salicylate induced ATP depletion from oxphos uncoupling.
Prior to this had only heard about with DNP
A 42-year-old man who ingested 488 grams of ASA developed rigid isotonic flexion in the upper and lower extremities in the perimortem period. The authors suspect impaired muscle relaxation due to severe ATP depletion.
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Hooray we can continue to not give TNK after 4.5 h
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Welcome EM PGY2s!
Your at a new institution, w/ new relationships to build. ☝️way to build rapport➡️ valuable interventions.
To start w/ a bang here are a few 🍞&🧈 recs (and evidence)you can drop at bedside to show you are a drug 🤓!
EMPharmDs feel free to add on!
#FOAMed
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Merry Christmas all. I gift you this bingo board. It was made by a friend who has an EM PharmD wife, ID PharmD sister in law, and hospital PharmD in laws. He uses it to stay entertained during holiday get together chit chat. It brings me GREAT joy. The spelling is key. 🎄🎅🤶🧑🎄
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So in an unexpected turn of events, I talked to a number of drug companies at
#ASHP22
and many were pretty interested in the concept. A few follow up meetings planned. Some said it may even be cheaper since there are less containers. That would be a cost effective win.
#Twitterx
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If you are going to attribute neurologic sequelae to cefepime and you don't call it enc-efepime-alopathy you are missing a huge opportunity
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Ok fine, SOMETIMES, the loading dose can cause AKI, there’s always the exception
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It would be great if state laws empowered our community colleagues to make these sorts of changes to "opt out" for pharmacist to change as opposed to them feeling they have to contact prescriber for each piece of minutia the prescriber wrote incorrectly.
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LOVE seeing pharmacist publish in
@NEJM
I’ve never met Jeff Brattberg but I’ve seen his lectures (required to qualify for pharmacy naloxone dispensing in WI). Seems he has played a pivotal role in⬆️ OUD treatment nationwide, way to be an example!
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Ok Halloween is over but I couldn't resist because EM pharmacists were made for this meme. Tell me I am wrong.
#EMRx
#Twitterx
#emergencymedicine
#FOAMed
#pharmacist
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Magnesium finally getting an official
#AHAJournals
AF guideline recommendation after riding the bench for years
#MedTwitter
Stop coming out with new guidelines yall I’m getting tired of reading
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When I see an order for rasburicase on my ED patient placed by an emergency medicine physician and see no note from oncology.
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Can’t believe I almost missed this dropping today.
Long awaited US/Canada Acetaminophen treatment guidelines. More to come on this soon.
Also shout out to tox orgs for being so PahrmD inclusive. Look at all those PharmDs on the author list👀
#MedEd
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how can you not love tox
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ANOTHER PREHOSPITAL POST ROSC NE vs EPI (TWO IN TWO MONTHS!?)
EPI again with more re-arrests than NE. More nails in the coffin.
Nice work
@MayoClinic
@CBthePHARMD
@EDWieru
and the many authors involved!
#MedTwitter
#TwitterX
#MedEd
#FOAMed
#FOAM
Thank you for confirming my fever dream I scribble down on paper 5 years ago.
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Published today. Another unregulated SUPPLEMENT that can have serious consequences, especially if home med drug interactions are not considered.
The patient hoped their story could be a warning. Many OTC supplements may have yohimbine!
#FOAM
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Great reminder that the potatoes you will eat today have 38 ug/kg of diazepam in it (Plants have benzodiazepine receptors).
Thus it is reasonably appropriate to flumaeznil yourself post baked potato to get through the slump.
It's Thanksgiving once again and time for new medical toxicology fellows to review GABA receptors, endozepines, idiopathic recurrent stupor, cholesterol anesthesia, and anticonvulsant potatoes.
@ToxAndHound
@ToxicSnowEM
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Drafting the policy right now that any time I am running around the ED with things that cost more than 5,000 dollars I get to carry it around in this slick suitcase
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No idea who left a toxidrome elf on the shelf in the ED pharmacy office but just another reason why I love working with the awesome EM team at
@MCWEmerMed
😂😂😂😂
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First 30 min of 7 d stretch, prevented ICU admission by optimizing drug therapy and prevented an ED readmit via care coordination. My overhead should now be covered.
EVERYTHING FROM HERE ON OUT IS JUST MONEY IN YOUR BANK C-SUITE
(Why all ED's should have a PharmD)
#TwitteRx
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Enjoyed writing this tox review w/
@leonardjbRx
in "PSAP 2023 Book 2- Critical Care and Emergency Medicine "
If your institution pays for some PSAPs and you need the CE its a good broad review of tox basics and a number of specific drug overdoses (see bullet 5)!
#EMRx
#TwitteRx
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Really fantastic Highyield round up of the articles/guidelines from 2023 that may change how you practice after 2023.
Available here:
Awesome group of people to work with as well!
🚨4th Annual
@EMPHARM_NET
pub🚨
EDucated: EM pharmacotherapy literature of 2023
@jlkoehl
@CBthePHARMD
@bfaine1
@MeganARech
@DEZ_EM_Pharm
@GilbertPharmD
@gavin_howington
@RxEmergency
@giles_slocum
@annezepeski
@EMPoisonPharmD
@ThePeoplesRuben
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If you were ever curious as to why it’s an”amp” of D50
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Our study of initial vasopressor dosing s/p ROSC out today in JEM ➡️
Assessed rearrest , arrythmia, and time @ BP Goal.
👉No difference w/ any dose, or if pressor started before or after MAP <65 mmHg
Way to go
@AbbySPharmD
!
#MedEd
#FOAMed
#FoamCC
Cardiac arrest patient with ROSC requiring vasopressors. You are stating your infusion of NE or Epi at:
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Back home after an energizing
#NACCT2023
!
Grateful for the extra wins this year, FAACT and a Research award 🏆
But what I really ❤️ about this is conf is the energy you get from meeting others just as passionate to work together and change how we treat poisoning. Invigorating!
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What NAC "bag" regimen do you use? 1, 2, 3?
Answer = NONE. You use multiple infusion rates and total doses. These could be delivered from a single "bag" with adjusted rates or multiple bags!
It's time to kill error prone "bag" terminology in NAC studies
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12/x
To summarize none of this is useful and this was dodgy estimated science at best, I am sorry if you read this far. Myself and my learners had fun theorizing how to calculate this 😂😂
Eat as much as you want on vaccs day anyways, because you know, spike proteins and such.🍰
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EM Pharamacy friends 👋
Rolling out TNK tomorrow.
Other than the sheer euphoria from ease of administration any thing people noticed workflow/safety/pitfall wise during the transition?!
#TwitteRx
#EMRx
#emergencymedicine
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Well it happened. On a flight and "med emergency" called (It ended up being very minor, all is ok).
Two medical professionals on ✈️, Me + ER RN. See each other and realize, WE WORK TOGETHER 😂
Live view of getting a resusc bay buddy while walking into a 10k foot "emergency"
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YOUR CHILD JUST SWALLOWED YOUR MEDICINE.
You should:
A. Text friend who is MD (who has no tox triage training and can’t follow up) for free medical advice
B. Call experts at the poison center. Who know what they are doing AND give free medical advice.
STOP CHOOSING A
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Tell me your an EM pharmacist without telling me your an EM pharmacist. Opened my calculator and saw this from whatever I was doing last week. I bet you can figure out the patients weight too…😁
#EMRX
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Come get all your burning questions answered!
A 56-year-old male applied 17 nonprescription lidocaine 4% patches to his thigh (with some patch overlap) because of thigh pain. The patient did not experience lidocaine toxicity.
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Me watching our EM PGY2 RSI there first patient w/ full institutional support (i.e., written policies supporting ability to to give meds as part of a pharmacist scope)
#TwitteRx
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Found out a manuscript was accepted and a few hours later I was awarded this! Next stop lotto ticket. Some days are better than others 😁🎉.
Thanks
@MOKeefePharmD
and
@AbbySPharmD
for nominating😁. Few things as rewarding as helping resis grow to be amazing pharmacists!
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A fun part of emergency medicine is SOMETIMES someone comes to the ED and DIES and you do some cool stuff and THEY COME BACK TO LIFE and SOMETIMES you did cool stuff SO WELL that they are awake after and THANK YOU for saving their life.
That is a good vibe for the day
#Vfib
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Up until 3 am after a 10 hour shift to respond to 112 reviewer comments about a dumb article no one will ever read but I just care so deeply about publishing it because I think it will help dispel an unsubstantiated medical myth SO IT BETTER GET PUBLISHED AND YALL BETTER READ IT
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I am sure this was a great presentation and I appreciate the excitement around this topic. I don't want to ruin everyone's shiny new toy BUT the clinical data for this therapy is so confounded it may as well be ABSENT so I think I need to add a grain of salt to this thread.
Flumazenil can decrease NAPQI formation and reduce oxidative stress caused by NAPQI in APAP toxicity; use in conjunction with NAC. May consider as an adjunct in massive ingestion or if hepatoxicity is already present.
@wein_rachel
#SCCM2023
#PharmICU
@SCCM_CPP
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Never thought I’d BE a case report, but here we are🤷
Outcomes from confirmed fent exposure are needed to fight misinformation, & sometimes in science accident=opportunity😅
Our article (w/
@BenWWeston
!) in🧵 below. Hope it does some good!
#FOAMed
#MedEd
#Twitterx
#MedTwitter
New case report, pub'd online just yesterday. An accidental exposure to large quantities of liquid fentanyl onto skin that was compromised (i.e. cuts/abrasions) HAD NO EFFECT ON THE PERSON INVOLVED. 🙂
In other news, no one is ODing from touching fentanyl
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This took off.🚀
Just in time for poison prevention week! PSA poison centers provide 24/7 FREE expert medical advice from snake bite to overdose at 1-800-222-1222
If you want more from the world of poison centers/toxicologists, check out (
@labpoison
)!
You're working in the ED when a 30 y.o male presents 30 minutes after envenomation to the right index finger by his pet snake (left).
He has a picture of culprit (right) , and it is definitely NOT from America.
A 🧵on U.S. exotic envenomation management.
(shared with consent)
205
1K
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Some drugs in the emergency department are really just totems that imbue you with the power to handle any scenario.
How it feels running to a patients room with a heart full of hope and pocket full of concentrated ketamine.
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Would say paramedics are some of the most curious, competent, get it done no matter the challenge people we work with as well. ED Pharms, seek out paras to learn about the challenges of medicine in a rig!
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Stewardship initiatives that would work, would not cause harm, but no one would let me do:
1. All providers get a daily vanco ration. If you run out, you have to borrow from other provider, they have to agree w/ you and give you one of theirs
2. Board w/ # quinolone Rx by name
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A useful pharm fact it seems most don't know.
I get a lot of questions about crushing potassium tabs or using powder. Most are XR so cant crush.
BUT if you have Klor Con "M" tabs, "M"=microcrystalline.
Dissolves in 4 oz water <2 minutes!
#MedEd
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Stop coming out with new guidelines yall I’m getting tired of reading
2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation
#AHAJournals
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NE vs EPI in ROSC. EPI use had more re arrest or inhosptial mortality 36/48 75% vs 37/40 (92.5%). No major difference in demographics/confounding found. Hypothesis generating. Lead author available for 1.5 hours for Q’s and poster for Download :
#FOAMed
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I have a state data base that shows any controlled Rx a pt is on (adderall, opioids, benzos, even pregabalin). Beyond confirming use, not super useful. Why does this not exist for anticoagulants?!? I would use this way more in my head injured elderly pop. Who do I talk to?!?
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ED PHARMS. Dont forget to be a post intubation hypotension steward!Optimize pre intubation resuscitation!
Check shock index (HR/SBP) to ID pts at high risk for hypoTN. If HR/SBP >0.8 consider peri intubation volume if possible or even pressor
#FOAMed
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Our Letter to the Editor (and response) in
@Neurology
regarding
@AANmember
@SCCM
@AmerAcadPeds
Brain death guidelines.
Determination of Brain death after overdose is complex and toxicologists should be involved. Five half lives not adequate.
#MedEd
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At other conferences you go to stuffy happy hours. At EM conferences you play happy hour dodge ball. Other conferences should be taking note.
Im outside. My beer was not $37. I have seen nature. Better than Mandalay Bay
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🚨 AHA Poisoning Cardiac Arrest (CA) 🚨
Covers ~12 different classes, nothing that novel
A few 🔑👉
-Poison CA≠Reg CA; ECMO, antidotes & Tox consult crucial
-Consider VA ECMO in CS or arrythmia
-No flumazenil CA
-No Succs in ACHi OD
-No ILE for BB
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Im outside. My beer was not $37. I have seen nature. Better than Mandalay Bay
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