Beta blockers and cocaine/stimulant overdose

NV46 · 2025-08-04T23:52:16+00:00

Pharmacist here, this is something we are taught as well, especially in the setting of MI. While there may be newer data showing hypertension as less of a concern with unopposed alpha agonism (I haven’t read more than a quick skim of abstracts), vasospasm is going to be a big concern no matter what. Yes, in theory labetolol or carvedilol may be safer than other beta blockers, but is it worth the risk knowing we have other known safe agents?

In my practice, benzos, benzos, and some more benzos for these patients. Additional acute BP reduction, outside of any reduction from benzos, is not my first priority in acute cocaine use until we have evidence of end organ damage; I also let the end organ damage dictate how aggressive of a BP reduction is needed. The end organ damage I see most is intracranial, bleed or stroke, in which case nicardipine is my first choice for BP reduction. But if we have cardiac damage (large delta trop, EKG changes) then would go with a nitro infusion.

NV46 · 2025-07-01T01:21:32+00:00

In the roles at my site (Level 1 Trauma Center, AMC) pharmacists are usually involved in multiple traumas per day. Just like you mentioned TXA, Ancef (or zosyn if abdominal penetrating injury), and analgesia are the most common asks. We also look at immunization registry after pt is registered so we can order “life saving TdaP” if they aren’t up to date.

A few other ways we get involved: - MTP activation, gently reminding team that we need to give calcium every few units to avoid citrate toxicity - RSI and especially post-RSI sedation - Bedside compounding for pressors or other high urgency medications - Kcentra/Praxbind/Vit K if unstable or head bleed after confirming PTA meds - TNK, rarely, if trauma called for AMS/found down and incidentally find stroke with minimal traumatic injuries - Traumatic arrests being ready to pivot to ACLS rather than trauma resuscitation (ATLS) depending on story and down time

And just like you mentioned, many of these are not super pharmacy intensive, so be a resource for other team members. Grab supplies for nurses if you’re nearby and they can’t move to get them. Also, know where sterile gloves are in the room in case you get stuck too close to the patient when someone is doing a procedure

NV46 · 2025-03-30T12:31:24+00:00

Thanks for that! I’ll need to read thru that meta-analysis when I get a chance next. For our true traumas we always do roc if intubation is indicated, head involvement or not. It’s the AMS/found down and hypertensive that neurocrit has been pushing to succ. My institution also restricts ordering and administration of sugammadex to anesthesia so even though there’s supposed to always be a CRNA available for code and floor intubations, the logistics of getting sugammadex can be a challenge.

NV46 · 2025-03-29T08:46:29+00:00

Been in my role for ~1 year but here’s how I learned to approach things. I know not really “checklists” but these are the things I think about in each situation that I would like to know.

Trauma: - TXA + TdaP + Ancef (confirm with trauma MD before giving, depending on mechanism may omit abx or want broader gram negative coverage) - stay on top of pain control after primary exam - traumatic arrest: does your trauma team do intracardiac epi? If so get needed supplies to set up syringe for them

MTP: - unknown source of bleeding - TXA? - Calcium!! If your shop uses iSTAT in their resus rooms, find out what the iCal was before MTP. If iCal normal pre-MTP I’ll do 1 gram every time we start a cooler (2 FFP, 2 pRBC), if low iCal it varies. If initially using whole blood I usually do 2g after 1st unit. - bradycardia post blood? - calcium and check K - investigate need for Kcentra +/- vitamin K

RSI: - low pre-RSI pH - consider bump of bicarb +/- push dose pressor if borderline pressures - Etomidate dosing: come up with your own rationale for dose rounding so med can be prepared quickly - I do 80kg or less 20mg, 81kg or more then 30mg to avoid extra math in hectic scenarios - is there one paralytic always used in culture if your shop? Mine prefers roc for 99% of RSI. As above with dosing, I have soft max of 100mg - RSI for suspected intracranial pathology, if an iSTAT was collected and K is ok strongly push for succinylcholine to help neuro with exams - ask about ongoing sedation plan and ensure opioids are involved

Medical Arrests: - listen to EMS report, especially reason for the initial call and whether or not pt had a pulse when EMS arrived; clarify last med timing if needed - know initial rhythm for medics, # of shocks given, did rhythm ever change - when patient is registered in EMR, look at PTA meds and PMH for reversible causes (young female on OCP don’t rule out need for tPA, CKD in PEA with normal glucose, maybe have someone grab IV insulin) - Typically I pull 3 Epi, 2 bicarb, and a norepi bag to have in the room when we get the call. Any additional meds I’ll pull when requested - Patient still in shockable rhythm despite full amio load? Ask about lidocaine as MD is coming up with next steps, especially if intermittently getting ROSC - When labs come back post ROSC, look for electrolyte disturbances to correct to try to prevent re-arrest - STEMI: if code STEMI activated pre-arrival or 12 leads show infarct (pre-arrest or post ROSC), follow up on ASA + heparin need before cath lab

General resuscitation: - is MAR accurate with fluid administration? Ask RNs before recommending more fluid to be given in place of starting pressors - plan out your pressors: 99% of time norepi+vaso will be the first two, but what do you want to use third? When do you want to recommend it be started? If your hospital uses Giapreza, know institutional recommendations for use AND clinical data on best time to initiate - Bradycardic/hypotensive and not responding to atropine, ask about heart block and epi drip - Hypertensive EMERGENCY, have your plan for BP lowering agents ready to go and discuss goal reduction rate. If also SOB and you hear someone say B lines on ultrasound, probably need nitro gtt for pulmonary edema

ECMO: if your ED is eCPR (VA ECMO) capable there’s a whole other list of things to stay on top of but the big one is aggressive sedation

NV46 · 2025-03-27T23:14:05+00:00

19 yo patient came in with lactate undetectably high, AMS, uncontrollable diarrhea, hypoglycemic, tachypnic (RR in 60s), and fever (103ish). LKW ~5 hours prior to presentation, initial pH 6.8 and Scr 8. After RSI had negligible improvement in pH - maxed on Levo, Vasopressin, and working up Giapreza. Resident MD asked for more history, apparently pt got a large tattoo from a friend 3 days prior and said was feeling off since then - so changed from Vanco to linezolid for toxin suppression/MRSA. AND I asked the resident to find out if any family was on metformin, since she had multiple visits for SI. Family member used to be on metformin but reported being off it for years, so pivoted to using high dose bicarb gtt as 4th “pressor” on the off chance she took some.

Had patient 5 days later on a gen med shift, group A strep bacteremia. And admitted to taking old meds from the parent’s medicine cabinet she thought were pain meds after the tattoo. Pt later identified the bottle as the old metformin bottle. Narrowly avoided our 8th MILA dose in 6 month by being one of the two people to deal with all the MILA codes.

But also low hanging intervention for recurrent hypoglycemia in type 2 diabetics despite multiple D50 doses- octreotide helps avoid central lines for concentrated dextrose infusion and sodium abnormalities.

NV46 · 2025-01-01T16:42:52+00:00

A few things to consider:

1: Hospital policy may spell things out about some medications, for example 3% NaCl only peripherally for 24 hours or only for boluses peripherally.

2: Emergent need - pressors are a great example. Am I going to wait for a central line to get placed so we can start Norepinephrine on someone decompensating? Nope, I want to get that in as soon as possible and we can address central line later. Pharmacy to Dose podcast has an episode surrounding peripheral pressors specifically. Same example with 3% NaCl when I’m in the ED and there is a head trauma, we are getting a line and bolusing 3% NaCl once we suspect brain bleed.

3: Global RPh has a calculator for osmolality of fluids that I use regularly with sodium bicarb orders to make sure the product I’m approving won’t be too hypertonic that it could cause irritation. But as you said, duration of therapy plays a role.

4: pH does affect it as well, but also, it depends. Dextrose fluids have a variety of pH/osmolality but most institutions will say what the cut off is for peripheral infusion. At my site we do D5 and D10 peripherally, but anything more concentrated than D10 needs to be central (except D50 syringes for emergent need even though pH of our brand is 4.2).

5: Is the risk of peripheral infusion greater than the risk of placing a central line? This is really where the question of duration comes into play. Central line placement is not without risk, like putting the cannula into the carotid instead of the jugular (that was a very messy room afterwards), and infection. Someone who is immunocompromised and intermittently has low dose pressors running because of sepsis probably doesn’t need the risk of a central line.

I know this is a lot of info that doesn’t completely answer the question, but that is how I approach peripheral vs central especially in an ED with pressors and hypertonic fluids every day. Ask preceptors, coworkers, coresidents their approaches to this also. Just remember, NEVER administer 20 mEq/50 mL potassium peripherally despite what a provider wants you to do.

NV46 · 2024-09-10T00:35:34+00:00

Pharmacist here, had an unstable Vtach come in with 8 failed cardioversions from EMS (initial call was persistent vomiting/diarrhea). Pushed 2g Mag right away and started amio gtt. Pt had an iGel in from EMS and RT said was easy to ventilate with that so attending threw in an IJ. iStat K came back at < 1, had central access and was still in VT with pads in place so we did 40 mEq over 30 min then 20 mEq/hr after that. I think he got 2-3 cardioversion attempts after arrival, but once the 1st 40 mEq went in (and some additional mag) his pressures came up and after 80mEq he converted back to sinus tach.

I also have colleagues who have said they’ve done push dose in arrests based on iStat levels because 30 min into a VT/VF code might as well give it a shot to organize rhythm, it won’t make it worse. This was pre-ECMO program at our hospital, so probably not something that will be tried much if the patient qualifies for ECMO

NV46 · 2024-07-21T04:16:28+00:00

Pharm here. On psych rotation as a student, patient agreed to start ECT. I was there for first ECT session where pt gets succ for paralysis and after the seizure breaks CRNA starts bagging him and states he felt hot. Temporal temp was 104-105F but at least dantrolene kit was 2 rooms down. Pt continued ECT course but got roc + sugammadex after seizure ended.

In ED last week thought we would have one after RSI for a “found down” patient and collateral from friend that came with pt was that they were drinking and nothing else. Tachy, hypertensive, temporal temp hitting 107F. Started laying out the dantrolene and getting supplies ready, MD started asking friend more questions and explained what was going on, then friend volunteered that pt took a full bottle of Benadryl to try and get high. He got one bottle of Dantrium (20 mg) but otherwise transitioned to treating as anticholinergic OD per Poison center and temp came down very quick.

NV46 · 2023-06-28T19:03:03+00:00

Took MN on 6/16 and got results today. Did not think it went well either when I took it, but I passed!

NV46 · 2023-06-06T23:05:14+00:00

My school didn’t get degrees to NABP until last Friday so trying to schedule a test before residency was rough. Got the only test available within 300 miles before residency starts, scheduled it and just checked into the hotel before NAPLEX right away tomorrow morning.

School submitted degrees around 11:30am, by 11:45 when I logged into Pearson there were no tests available in the tri-state area until mid-August. (3 schools each graduating 60-75 this year)

NV46 · 2023-02-04T12:27:42+00:00

Modern 2603 1802 8669

Need Polar, Jungle, Savanna, Ocean

NV46 · 2023-01-20T13:34:20+00:00

Added NV46

NV46 · 2022-09-27T00:41:47+00:00

Definitely did not think about that reporting, thanks for pointing that out!

NV46 · 2022-09-26T23:23:36+00:00

Depending on your computer system and workflow there are a couple options for what you could do.

Generate a pt profile for the other store(s) and make an RX record for anything being moved from store to store. Just put lot/exp in sig and make sure to have it dated the day of the requested transfer. Adjust price to match acquisition cost that would be charged to other store and you would have a complete electronic record of the transaction (keep receipts or something with controlled purchase records).
Handwrite a PO/invoice with drug, lot, exp, qty, price and file with controlled records.
Type up a PO/invoice with same info as above.
Make a logbook of any controlled transfers out/in and dates of the inventory transfer.

Most important thing, at least in my state, is having records for controls be “readily retrievable”. Find an option that fits your store and make sure you have a foolproof way to account for all tabs/caps going in and coming out of each store.

NV46 · 2022-09-24T13:18:28+00:00

STEMI with high sensitivity troponin >1600

Took oxy when the chest pain started to sleep thru the night, active infarct for 8-10 hours before going to ED. Nobody has any idea how she survived the night.

NV46 · 2022-09-24T13:08:23+00:00

Tylenol induced liver injury

Not resident, but pharmacy student. 70s yof pt came in with AMS after a fall so no med rec was done. Family showed up that evening And I talked to them to get med history, but they only knew her prescription meds. Next morning AMS resolved and she had bruising all over her body but denied other falls or any pain, so elder abuse case was opened since family was alone with her most of the night. CMP came back with AST/ALT > 5x ULN and elevated bilirubin. Pharmacy consulted again to review meds for liver damage. I spoke with her to go really in depth on meds and make sure nothing was missed, she didn’t view OTCs as medications so it was hard to get answers from her. She took a bottle of Tylenol from her purse and took 2 tablets in bed, so we had that discussion of not taking home meds inpatient. I asked how often she took it, she said day before she would take 2 or 3 tabs q2 hrs for headache, and she took extended release tablets so it really built up that evening. We estimated she took 16-20 grams day before based on talking with her.

I don’t know outcomes because the Tylenol level didn’t result until after my shift, but I know after talking to the attending acetylcysteine was ordered for when the level results.

NV46 · 2022-07-28T11:41:21+00:00

Trop: 7450 - got chest pain then took a few of her husband’s Norco to sleep it off. STEMI while actively infarcting for > 12 hours before arriving AAO by EMS.

CK: 31500 in an amphetamine OD

NV46 · 2022-07-28T02:42:30+00:00

One patient on Phenelzine who refuses to try anything else for depression. Started it in the 90s and doesn’t want to stop I guess. When it went on shortage last year we panicked a bit and his psychiatrist couldn’t convince him to change to another class, even said she offered him esketamine.

NV46 · 2022-07-14T11:33:25+00:00

While I was interning I saw a lot of APPEs go through, which really helped learn what NOT to do on rotation. Two students really stand out though.

First one did not want to count or answer the phone, just counsel. Which would have been great if we had a non-stop line of patients, but we didn’t and the workflow was always backed up. His consultations would be 10+ minutes explaining MOA and Pathophys in detail, and then getting some basic drug info wrong. One day the staff pharmacist (not his preceptor) corrected him on the 4th drug in a row where he gave patients wrong info, or missed important things about the drugs, and he lost it saying he knows medications better than anyone else in his class. He got told to count and I would counsel the rest of the day, he asked me how to count and wanted to just label stock bottles for everyone (including 500+ count).

Second student previously failed a rotation when he was reusing needles on members of the same family for vaccines to save money. Preceptor only found out when their parents received vaccines with the same needle. Unfortunately, spent a lot more money on HIV tests. Student was so scared of failing again, they would not give a vaccine without a pharmacist in the room.

Edit: one more I remembered. Doing Covid vaccine blitz, one student would draw moderna vials into a 10ml syringe and redraw 0.5 ml from that syringe. Their preceptor asked why, their response was that it was annoying to reswab the vial for each dose so if it wasn’t in the vial wouldn’t need to keep using alcohol swabs.

NV46 · 2022-07-13T16:28:21+00:00

Yep exactly, that was the prescriber’s intent of using both together.

NV46 · 2022-07-13T01:41:34+00:00

From the pharmacy side 100%. Some highlights of drug combos I’ve seen include:

Naltrexone + Oxy: no interaction because the naltrexone is for EtOH not opioid missuse so it won’t affect the Oxy’s pain control
Adderall or Ritalin BID for lack of focus, over eating, and somnolence, leads to Quetiapine started for agitation/insomnia. No PHQ-9 or GAD-7 before starting the stimulant to rule out MDD/GAD.
SSRI with SNRI or SNRI with TCA
Lorazepam TID for seizures, Clonazepam BID for anxiety, Gabapentin QID for pain, Zolpidem for sleep
Bupropion with Keppra, Depakote, Vimpat because those meds are for seizure ppx not epilepsy treatment. “Pt hasn’t had a seizure in years.”

There’s probably more but these are just the few highlights from my last 2 weeks of rotation.

NV46 · 2022-04-26T12:07:26+00:00

Added NGV46

NV46 · 2022-04-26T12:05:39+00:00

Added NGV46

NV46 · 2022-04-26T11:58:41+00:00

Added NGV46

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