Background Receipt of opioids in the emergency department (ED) has been identified as a risk factor for long-term opioid use. Little is known about opioid use patterns in the setting of ureterolithiasis pain management in the ED. Objectives We sought to describe patient- and facility-level factors associated with the administration of intravenous (IV) opioids to patients treated with ketorolac for ureterolithiasis in the ED. Methods Patients with ureterolithiasis treated in the ED and discharged home were identified for inclusion and stratified into groups who received IV opioids plus IV ketorolac or IV ketorolac alone, using a national US ED dataset from 2021-2022. Chi square and Fisher’s exact tests were used to conduct univariable analysis, and a backwards elimination approach was used for multivariable analysis. Results A total of 127,395 individuals were identified in the dataset for inclusion, of which 59,916 received an IV opioid. Obesity (odds ratio [OR] 1.353), an income level in the 76th-100th percentile (OR 1.341), a history of cancer (OR 1.305), and depression (OR 1.304) occurred more frequently among patients treated with IV opioids. In comparison to facilities in the Northeastern US, facilities in the Western US (OR 1.898), Midwestern US (OR 1.643), and Southern US (OR 1.555) administered IV opioids to patients more often. Conclusions In this study, a multitude of variables were associated with IV opioid use for ureterolithiasis pain management in the ED. These findings suggest that both clinical and contextual variables may influence opioid utilization practices in ureterolithiasis management.

As emergency department (ED) crowding and patient boarding reach critical levels nationwide, the role of the emergency medicine pharmacist (EMP) must be both defined and safeguarded. While EMPs are increasingly valued for their contributions to acute care, their responsibilities often unintentionally expand during periods of operational strain, particularly when admitted patients remain in the ED for prolonged durations. EMPs should ideally be resourced to remain focused on time-sensitive, high-risk medication management where their expertise is most impactful and not be used as default providers for all pharmacotherapy needs during ED boarding. This perspective outlines our position on the ideal scope of EMP practice during times of congestion, advocating for clearly defined role boundaries, strategic collaboration with other pharmacy team members, and system-level support to prevent dilution of emergency care. EMPs must be empowered to prioritize critical ED workflows, support resuscitations, and lead initiatives in education, protocol development, and patient safety, without being overextended by responsibilities that can be absorbed by other team members.

The American College of Clinical Pharmacy (ACCP) advocates for board certification of clinical pharmacists in one of the recognized specialties as a fundamental qualification and requirement for providing and supervising trainees in the provision of direct patient care. However, data linking pharmacist board certification to patient outcomes are limited, and many methodological challenges exist to effectively evaluate the impact of board-certified pharmacists (BCPs). The purpose of this ACCP white paper is to critically analyze study design characteristics in order to inform future studies assessing the impact of BCPs on patient outcomes. Value depends on the stakeholder perspective, which informs the study design. This white paper considers the feasibility and applicability of various study methods that may be used to evaluate the impact of BCPs, including overall study design, study group assignment, outcome measures, reporting of clinical practice activities, identification of confounding variables, and statistical analyses, including methods to control for confounders. The 2025 ACCP Research Affairs Committee was surveyed to rate the feasibility and applicability of studying the impact of BCPs on outcomes by stakeholder perspective. Studies from the health care system or provider perspectives were rated as providing the best balance between feasibility and applicability, whereas various study design characteristics (e.g., prospective study designs, use of “length of” or disease-related surrogate markers as primary outcomes, adjusting for specific confounders) were rated highly and are desirable for future studies.

Beta-blocker (BB) overdose presentations to the emergency department represent a significant contributor to cardiovascular toxic exposures and associated morbidity and mortality. Overdose is characterized primarily by bradycardia, hypotension, atrioventricular blockade, and cardiogenic shock, alongside potential central nervous system depression. The severity of clinical manifestations is influenced by agent-specific pharmacologic properties, formulation (e.g., extended-release), and dose. Specific therapies discussed include atropine, glucagon, hyperinsulinemic euglycemia therapy, intravenous lipid emulsion, methylene blue, and extracorporeal treatments such as hemodialysis and extracorporeal membrane oxygenation. BB overdose requires prompt recognition in the emergency department and a tiered therapeutic approach tailored to the severity of presentation and specific agent involved. While foundational interventions remain vital, adjunctive therapies such as hyperinsulinemic euglycemia therapy and methylene blue offer mechanistically distinct options that may improve outcomes in refractory cases. Further studies are warranted to clarify optimal treatment sequencing, comparative efficacy, and long-term outcomes in BB toxicity.

BACKGROUND:Migraine is an often-disabling condition and a common presentation to the Emergency Department (ED). Rapid and effective treatment are essential to reduce symptom burden, prevent recurrence, and improve patient outcomes. This review provides a comprehensive, evidence-based overview of the pharmacologic management of acute migraine in the ED, including first-line therapies, rescue medications, adjunctive care strategies, and considerations for special populations. First-line agents for acute migraine include dopamine antagonists, nonsteroidal anti-inflammatory drugs, and triptans, with treatment tailored to severity, comorbidities, and previous response. Rescue therapies such as dexamethasone, valproic acid, magnesium sulfate, and, in rare cases, dihydroergotamine and caffeine, are indicated for refractory or recurrent symptoms. Supportive interventions such as intravenous fluids and antiemetics can enhance treatment response. Special populations, including pregnant individuals, pediatric, and geriatric patients, as well as those with cardiovascular disease, require individualized management. It is critical for ED personnel to provide not only optimal pharmacotherapy but also safe medication administration, astute monitoring for adverse effects, and the provision of discharge education to prevent migraine recurrence and ensure outpatient follow-up.

Procedural sedation and analgesia (PSAA) is integral to facilitating painful and anxiety-inducing medical procedures in the emergency department (ED). Optimal PSAA enhances procedural success and improves both patient and provider satisfaction. The selection of appropriate sedative and analgesic agents, routes, and dosages, which depend on various patient- and procedure-specific factors is a complex process. Alternative routes of administration, such as intranasal, intramuscular, and oral, are all options, each with their own inherent benefits and limitations. It is important for providers to take into account patient-specific considerations, including age, medical history, body weight composition, and pregnancy, which can significantly impact PSAA effectiveness and safety. Implementation strategies targeted to minimize medication errors and optimize workflow are also important considerations in PSAA. By adopting a comprehensive and evidence-based approach, health care providers can navigate the intricacies of PSAA and ensure the best possible care for patients in the ED.

Elevated intracranial pressure (ICP) is a critical condition associated with significant morbidity and mortality, requiring prompt and effective management. Mannitol and hypertonic saline (HTS) are the two most widely used hyperosmolar agents in clinical practice for ICP reduction, each with distinct pharmacologic properties, efficacy profiles, and safety considerations. This review aims to provide a comprehensive assessment of the mechanisms, clinical efficacy, safety, practical considerations, and guideline recommendations associated with the use of mannitol and HTS for the management of elevated ICP. Current available data does not clearly support one hyperosmolar agent over another and both agents are considered equivalent. Consensus recommendations vary, but the most recent recommendations seem to support the use of HTS over mannitol, mostly due to potential pharmacodynamic advantages that have been shown in smaller investigations. Further research is warranted to refine dosing strategies, clarify administration concerns, and address knowledge gaps in comparative efficacy and safety.

Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Acute hyperkalemia is characterized by high concentrations of potassium in the blood that can potentially lead to life-threatening arrhythmias that require emergent treatment. Therapy involves the utilization of a constellation of different agents, all targeting different goals of care. The first, and most important step in the treatment of severe hyperkalemia with electrocardiographic (ECG) changes, is to stabilize the myocardium with calcium in order to resolve or mitigate the development of arrythmias. Next, it is vital to target the underlying etiology of any ECG changes by redistributing potassium from the extracellular space with the use of intravenous regular insulin and inhaled beta-2 agonists. Finally, the focus should shift to the elimination of excess potassium from the body through the use of intravenous furosemide, oral potassium-binding agents, or renal replacement therapy. Multiple nuances and controversies exist with these therapies, and it is important to have a robust understanding of the underlying support and recommendations for each of these agents to ensure optimal efficacy and minimize the potential for adverse effects and medication errors.

Multiple agents exist for the reversal of oral Factor Xa inhibitor (FXa) associated bleeding, including Coagulation FXa Recombinant, Inactivated zhzo (andexanet alfa) and 4-factor prothrombin complex concentrate (4F-PCC). While classified as a 3F-PCC product, Profilnine contains up to 35 IU of Factor VII (per 100 IU of Factor IX) in addition to therapeutic levels of Factors II, IX, and X, and has demonstrated a similar impact on prothrombin time and blood product usage in non-warfarin related bleeding. This was a retrospective, multicenter study at four medical centers of adult patients who presented with major bleeding associated with oral FXa inhibitors and received either 4F-PCC (n = 64) or 3F-PCC (n = 61). The primary outcome was hemostatic effectiveness. Secondary outcomes included the incidence of thromboembolism, in-hospital mortality, and length of stay. The most common indication for reversal was intracranial bleeding. For the primary outcome, 84

Study objective: Four-factor prothrombin complex concentrate (4F-PCC) is standard of care for emergent vitamin K antagonist (VKA) reversal but optimal dosing is uncertain. This meta-analysis estimated the proportion of patients treated with fixed dose (FD) 4F-PCC who achieved adequate reversal and compared safety and efficacy of FD versus weight-based dose (WB) strategies. Methods: This review was conducted according to PRISMA guidelines. Medline and Scopus were searched and included studies evaluating FD regimens and comparing FD and WB for emergent VKA reversal. Data was pooled using random effects. Subgroup analyses examined heterogeneity. Risk of bias was assessed with NewcastleOttawa Scale and RoB2 score. Results: Twenty-three studies (n = 2055) were included with twelve (n = 1143) comparing FD versus WB. The proportion of patients achieving goal INR with FD varied depending on the INR target, being significantly higher for INR <2 (90.9%, 95% Confidence Interval (CI) 87.2, 94.06) compared to INR <1.6 (70.97%, 95%CI 65.33, 76.31). Compared to WB, FD was less likely to achieve a goal INR <1.6 (Risk Difference (RD) -13%, 95% CI -21, -4) but achieved similar reversal for a goal INR <2.0, (RD -1%, 95%CI -7, 4). There was no difference in hospital mortality (RD 4%, 95%CI -2, 9) or thrombosis (RD 0.0%, 95%CI -3, 3). Conclusion: FD VKA reversal was associated with significantly lower attainment of goal INR compared to WB with lower INR targets. This did not translate to differences in hospital mortality, but these results should be interpreted cautiously in light of the observational nature of the included studies. (c) 2023 Elsevier Inc. All rights reserved.

The 2023 ACCP Research Affairs Committee was charged with developing a commentary to address best practices in pharmacy resident research and quality improvement projects and to consider methods to overcome the challenges encountered in conducting these projects. Literature regarding best practices was evaluated, and approaches were recommended that might help (1) advance the value of the projects to stakeholders; (2) overcome limited preparation for research by residents and mentors, including writing skills and dissemination experience; (3) overcome challenges related to resources (e.g., time and mentors); and (4) avoid burnout among residents and mentors. Although there are many challenges to completing projects and disseminating the results, studies have provided useful recommendations to help circumvent the barriers.

PURPOSE:This article summarizes emerging nontraditional therapies administered via the nebulization route for use in the emergency department (ED). SUMMARY:Although traditional routes of medication administration (eg, intravenous) have been the mainstay of administration modalities for decades, these routes may not be appropriate for all patients. Nowhere is this more readily apparent than in the ED setting, where patients with a variety of presentations receive care. One unique route for medication administration that has increasingly gained popularity in the ED is that of aerosolized drug delivery. This route holds promise as direct delivery of medications to the site of action could yield a more rapid and effective therapeutic response while also minimizing systemic adverse effects by utilizing a fraction of the systemic dose. Medication administration via nebulization also provides an alternative that is conducive to rapid, less invasive access, which is advantageous in the emergent setting of the ED. This review is intended to analyze the existing literature regarding this route of administration, including the nuances that can impact drug efficacy, as well as the available literature regarding novel, noncommercial nebulized medication therapy given in the ED. CONCLUSION:Multiple medications have been investigated for administration via this route, and when implementing any of these therapies several practical considerations must be taken into account, from medication preparation to administration, to ensure optimal efficacy while minimizing adverse effects. The pharmacist is an essential bedside team member in these scenarios to assist with navigating unique and complex nuances of this therapy as they develop.

Procedural sedation and analgesia is an essential activity in the emergency department for managing pain and anxiety during a variety of medical procedures. Various pharmacotherapy options, including opioid analgesics, antiemetics, anticholinergics, sedatives, and ketamine have been utilized, all with their unique efficacy and safety profiles. This review highlights the challenges associated with using certain agents and discusses emerging trends such as the use of newer synthetic opioids and the expanding use of dexmedetomidine. Overall, the selection of the optimal agents for procedural sedation and analgesia should be guided based on the unique characteristics of each agent tailored to the needs of the specific procedure, along with consideration for individual patient characteristics.

Traumatic Brain Injury (TBI) remains a significant global health concern with significant impact on morbidity and mortality. This narrative review explores adjunctive pharmacologic agents to be employed by emergency medicine clinicians during Advanced Trauma Life Support (ATLS) in patients presenting with a TBI. Pharmacologic agents are commonly employed for the management of rapid sequence intubation and post-intubation analgosedation, hemodynamics, intracranial pressure, coagulopathy, seizure prophylaxis, and infection. This narrative review discusses current evidence and controversies to optimize adjunct pharmacotherapies during the acute management of TBI within the emergency department.

Procedural sedation and analgesia (PSAA) is integral to facilitating painful and anxiety-inducing medical procedures in the emergency department (ED). Optimal PSAA enhances procedural success and improves both patient and provider satisfaction. The selection of appropriate sedative and analgesic agents, routes, and dosages, which depend on various patient- and procedure-specific factors is a complex process. Alternative routes of administration, such as intranasal, intramuscular, and oral, are all options, each with their own inherent benefits and limitations. It is important for providers to take into account patient-specific considerations, including age, medical history, body weight composition, and pregnancy, which can significantly impact PSAA effectiveness and safety. Implementation strategies targeted to minimize medication errors and optimize workflow are also important considerations in PSAA. By adopting a comprehensive and evidence-based approach, health care providers can navigate the intricacies of PSAA and ensure the best possible care for patients in the ED.

Procedural sedation and analgesia is an essential activity in the emergency department for managing pain and anxiety during a variety of medical procedures. Various pharmacotherapy options, including opioid analgesics, antiemetics, anticholinergics, sedatives, and ketamine have been utilized, all with their unique efficacy and safety profiles. This review highlights the challenges associated with using certain agents and discusses emerging trends such as the use of newer synthetic opioids and the expanding use of dexmedetomidine. Overall, the selection of the optimal agents for procedural sedation and analgesia should be guided based on the unique characteristics of each agent tailored to the needs of the specific procedure, along with consideration for individual patient characteristics.

Background Emergency physicians play a critical role in mitigating the opioid epidemic in public health. Objectives To analyze the prescribing of emergency physicians for opioids among Medicare beneficiaries enrolled in the Part D program from 2013 to 2019. Methods We conducted a retrospective, cross-sectional, descriptive analysis of Medicare Part D prescriber data, focusing on opioid claims between 2013 and 2019. The primary outcome variables evaluated included proportion of opioid claims, trends of the most prescribed opioids, cost of opioid claims, and days' supply per claim. Results A total of 63,586 emergency physicians were identified over the study period. Opioid prescription by emergency physicians decreased from 14.45% to 11.55%, and the cost spent on opioid drugs declined by 50%. The use of drugs such as hydrocodone-acetaminophen and oxycodone-acetaminophen declined substantially, whereas tramadol and acetaminophen-codeine prescription increased. The opioid prescribing rate and days' supply also decreased. Conclusions The decline in traditional opioid agents such as hydrocodone-acetaminophen was partly offset by an increase in opioids like tramadol, which carry additional potential adverse events. Opioid prescribing rate, average days' supply, and cost of opioid drugs significantly decreased from 2015 to 2019, after a spike in 2015. All regions observed a decrease in emergency physicians, but opioid prescribing rates varied across regions. These trends highlight successful opioid stewardship practices in some areas and the need for further development in others. This information can aid in designing tailored guidelines and policies for emergency physicians to promote effective opioid stewardship practices.