Vancouver Island Health Authority Residency Program
ER Rotation Outline
Preceptor Name: Richard Wanbon, Pharm.D.
Email address: Richard.wanbon@viha.ca
Name of rotation site: Royal Jubilee Hospital, Victoria
Learning goal for this rotation: To be exposed to the day-to-day working environment of the Emergency Department and to
become familiar with the use of medications in this setting. By the end of this rotation, the pharmacy resident should develop
patient assessment skills and be familiar with the treatment of pathological presentations and procedures common in the
Emergency Department setting.
Learning objectives for this practicum:
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6.
7.
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9.
To complete a minimum of two supervised best possible medication histories.
To complete a minimum of two supervised physical assessments and to integrate findings from these assessments into
a pharmaceutical care workup.
To complete a minimum of ten patient care work-ups per week (following the first week) depending on the activity
level of the department (e.g. a trauma / code or other learning opportunity may impact this expectation).
To demonstrate the ability to prioritize patient care workload such that the assigned ward tasks are completed within
each workday.
To provide a minimum of two supervised medication counseling sessions.
To be prepared for therapeutic discussions, and where possible, complete two patient work-ups for each of the
following topics (readings provided by preceptor):
a. Basic ECG interpretations
b. Advanced Cardiac Life Support (ACLS) treatment
c. Acute Coronary Syndromes (ACS)
d. Acute ischemic stroke
e. Shock (including sepsis & anaphylaxis)
f. Procedural sedation & rapid sequence intubation
g. Toxicology
h. Recreational drug use
To prepare and lead a therapeutic discussion for the preceptor. Preparations will include the provision of readings and
objectives one week prior to the discussion date. The resident may choose one of the following topics: acute CHF,
acute exacerbation of asthma / COPD, status epilepticus.
To prepare a formal response for one formal drug information question requiring the assessment of primary literature.
To provide an informal inservice to nursing staff (time permitting).
Learning activities: The Emergency Department is a dynamic, unpredictable environment that will allow the pharmacy
resident to be exposed to a variety of activities throughout this rotation. There will be opportunities to observe various
procedures that take place for patients admitted to the ER. The preceptor will try to arrange for an Ambulance ride-along
during the rotation.
The resident will be assigned patients to assess and develop a pharmaceutical plan for. The resident will discuss these with the
rotation preceptor daily.
Reading assignments will be provided to the resident in preparation for therapeutic discussions. The resident will also be
assigned a therapeutic discussion topic to lead for the preceptor.
Additional demonstrations and activities will be provided to the resident throughout the rotation.
Prepared by: Richard Wanbon, Pharm.D.
Date: October 2008
Therapeutic Topics
ACLS Session 1
Pre-reading: BMJ Feb 2002 articles “Basic ECG terminology” and “Leads, rate, rhythm and cardiac axis”
Discussion: we will go through a stepwise process to interpret an ECG
Additional activities: the preceptor will discuss the equipment found in the resuscitation room including the use of an AED
(defibrillator); the preceptor will also discuss and demonstrate appropriate basic life support measures including CPR
Objectives:
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2.
3.
To understand what an ECG reads and why multiple leads are used
To understand the meaning of the different components of an ECG including:
a. P-wave
b. PR-interval
c. Q-wave
d. QRS interval
e. ST-segment
f. T-wave
g. QTc-interval
To identify basic ECG rhythms for the following:
a. Normal ECG
b. Bradycardia
c. Sinus tachycardia
d. Atrial flutter
e. Atrial fibrillation
f. Junctional rhythms
g. Ventricular tachycardia
h. Ventricular fibrillation
i. Torsades de Pointes
j. Ventricular escape rhythms
k. Heart blocks
l. Ischemic changes
m. Branch blocks
n. ECG artifacts
o. Hyperkalemia
p. Wolf-Parkinson syndrome
ACLS Session 2
Pre-reading: ACLS 2005 (7-2, 7-3, 7-4); Curr Opin Crit Care 2002 editorial
Assignment: Browse the following website: www.lipidrescue.org
Objectives:
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2.
3.
To understand the initial steps in evaluating a patient with an unstable cardiopulmonary status
To understand the following ACLS conditions and their treatment algorithms:
a. Ventricular fibrillation / Pulseless ventricular tachycardia
b. Pulseless Electrical activity / asystole
c. Bradycardia
d. Tachycardia
e. Atrial fibrillation / flutter
To understand the medications commonly used in ACLS patients, including:
a. Mechanism of action and place in therapy
b. Dose
c. Method of administration
d. Monitoring parameters
e. Contraindications
Prepared by: Richard Wanbon, Pharm.D.
Date: October 2008
Acute Coronary Syndromes
Pre-reading: ACC / AHA STEMI guidelines (2009 update); NSTEMI case review (JAMA 2010)
Assignment: Describe the evidence describing the use of beta-blockers in the acute treatment of ACS
Objectives:
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To identify signs and symptoms of an acute coronary event.
To understand the pathways of care for ACS patients.
To identify drug therapy used in the treatment of ACS.
To describe dosing considerations, contraindications and adverse effects of treatment in the ER.
Acute Ischemic Stroke
Pre-reading: CMAJ 2008 (Cdn Stroke Guidelines update….focus on acute management section); N Engl J Med
2008;359:1317-29
Assignment: Are there any recent trials adding to the clinical controversy of BP management in the acute treatment of stroke?
Objectives:
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To identify signs and symptoms of stroke.
To list drug therapy options for the treatment of stroke.
To identify indications and contraindications for thrombolysis in the acute treatment of stroke.
Describe BP treatment goals and clinical questions surrounding the management of BP during an acute stroke.
Shock, Sepsis & Anaphylaxis
Pre-reading: CMAJ 2003: Diagnosis & management of anaphylaxis; CJEM 2008: Cdn Sepsis Guidelines
Inotropes & Vasopressor chart
Assignment: Describe the evidence supporting the use of corticosteroids in anaphylactic reactions
Objectives:
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To define anaphylaxis and identify the pathophysiology and common causes of anaphylaxis.
To identify the signs and symptoms of anaphylaxis and to distinguish anaphylactic shock from other forms of
shock including septic, hypovolemic, cardiogenic, neurogenic and obstructive shock.
To discuss the out-of-hospital treatment of anaphylaxis.
To discuss the ER treatment of anaphylaxis including both pediatric and adult dosing.
To differentiate between the effects of various inotropes and pressors.
To define SIRS and describe the pathophysiology of sepsis.
To describe treatment goals and the priorities of ED management of a septic patient.
Procedural Sedation & Rapid Sequence Intubation
Pre-reading: Procedural sedation (adults) chart, 7 P’s (RSI checklist), Interior Health RSI worksheet
Assignment: Describe the clinical controversy of the use of etomidate in procedural sedation
Objectives:
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To differentiate the pharmacotherapeutic principles between procedural sedation and RSI.
To describe key preparations / monitoring parameters necessary prior to procedural sedation or RSI.
To describe the differences between sedative agents used in the ED, including the contraindications for and specific
patient population considerations.
To describe the differences between paralytic agents used in the ED, including the contraindications for and specific
patient population considerations.
To describe monitoring parameters and treatment plans for maintaining an intubated patient.
Prepared by: Richard Wanbon, Pharm.D.
Date: October 2008
Overdoses & Toxicology
Pre-reading: General principles of toxicology from DPIC reference (to be provided while on rotation)
Assignment: none
Objectives:
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To list common overdoses seen in the ER
To describe methods for identifying the possible overdose agent
To discuss general treatment principles for treating an overdose
To identify sources of information for treatment plans
To discuss several drug-specific antidotes
Recreational Drug Use
Pre-reading assignment: none
Objectives:
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To become familiar with common recreational drugs.
To identify sources of information for recreational drugs.
To identify some prescription and over-the-counter agents that are abused.
To discuss the role of the pharmacist with this patient population.
Optional Topics (to be prepared and presented by the resident)
Acute exacerbation of CHF
Acute exacerbation of asthma / COPD
Status epilepticus
Prepared by: Richard Wanbon, Pharm.D.
Date: October 2008