In this episode, I will discuss pharmacist participation on rapid response teams.

According to the wikipedia definition (don’t tell my former professors I referenced that site!):

A rapid response team (RRT) is a team of health care providers that responds to hospitalized patients with early signs of clinical deterioration on non-intensive care units to prevent respiratory or cardiac arrest.

Who can activate a rapid response call?  Anyone at my hospital, but it is usually the bedside nurse who calls.

Who is on the team?

– Critical Care Nurse
– Respiratory Therapist
– Hospitalist
– Pharmacist

False alarms

You should accept that you will get some calls that turn out unnecessary.  That’s OK.  The team should never say anything negative if they determine the call was unnecessary – this could lead the same person to avoid calling in the future when they might really need help!

Notification

A beeper system is used at my hospital to notify the rapid response team.

Reaching the room/area

Take the stairs when possible.

Identify yourself to staff already in attendance.

Observe the patient and the care being administered.

Ask for an explanation of the situation.

Pharmacist’s role

Obtain needed medications.

Look for medication related causes of the patient’s deterioration.

Assist the team as needed, often by reading aloud recent labs and meds administered.

Anticipate and prepare in advance for the patient’s pharmacotherapy needs.

Problems encountered during rapid response calls are primarily due to problems with

OXYGEN DELIVERY*

*Sometimes the problem is with ATP generation (hypoglycemia)

Nerdy pharmacist equation:

Oxygen Delivery = stroke volume x heart rate x hemoglobin x %oxygen saturation

Bonus nerdy equation:

Blood Pressure = cardiac output x peripheral vascular resistance

Let’s take a moment to review some common causes of decreased oxygen delivery…

Conditions that lower % oxygen saturation

Functional airway obstruction

Caused by a decreased level of consciousness whereby muscles relax and allow the tongue to obstruct the pharynx.

Treatments include:

– Airway maneuvers
– Antidote therapy
– Intubation

Mechanical airway obstruction

This could be caused by aspiration of foreign body, angioedema, bleeding, or stridor.

Treatments include:

– Anaphylaxis treatment
– Racemic epinephrine nebs
– Intubation (likely will be difficult) or surgical airway

Remember the requirements for normal breathing

– An intact respiratory center in the brain
– Intact nervous pathways from brain to diaphragm and accessory muscles
– Adequate diaphragm and accessory muscle function
– Unobstructed flow

Respiratory rate is an important indicator of inadequate oxygen delivery

Lack of oxygen → anaerobic respiration → lactic acidosis → tachypnea

Other causes of lower % oxygen saturation

– Pulmonary Embolism
– Shunting

Causes of low hemoglobin

– Blood loss
– Coagulopathy
– Hemolysis (might be from meds!)
– Disseminated intravascular coagulation

Causes of low cardiac output

Cardiac output = stroke volume x heart rate

Decreased stroke volume which could be from
– Decreased contractility
– Myocardial infarction
– Acidosis
– Medications

Decreased preload which could be from
– Low intravascular volume (blood loss, sepsis)
– High intrathoracic pressure (after intubation)

Fall in systemic vascular resistance which could be from
– Sepsis, pancreatitis, decompensated liver disease
– Any medication that blocks the sympathetic nervous system (metoprolol, clonidine)

Other causes
– Bradycardia
– Direct action on arteriole smooth muscle
– Medications
– Hyperthermia

Look for the consequences of hypotension

Inadequate CO → inadequate O2 delivery→ organ failure→ lactate formation → shock

Altered mental status and oliguria are two easy ways to look for organ failure.

Speaking of altered mental status…

Altered mental status causes

– Decreased Oxygen delivery
– Decrease blood glucose
– Meds! Check pupils:

Big pupils = sympathetic overactivity, anticholinergic toxicity
Small pupils = opioid toxicity, cholinergic toxicity

Speaking of drug toxicity…

Be aware of common toxidromes

– Anticholinergic
– Cholinergic
– Opioids
– Sympathomimetics

Future episodes will include Pharmacotherapy essentials for dealing with the following:

1. Sepsis
2. Anaphylaxis
3. Hyperkalemia
4. Opioid reversal
5. Seizures
6. Stridor
7. Methemoglobinemia
8. Acute agitation
9. Urgent intubation

Here are some additional resources for self study

1. A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies
2. Hospital Pharmacy Academy
3. ACLS guidelines
4. Surviving Sepsis guidelines
5. Stroke guidelines
6. AMI guidelines
7. Institutional Hypoglycemia protocol
8. Institutional Code blue policy
9. Pharmacists as Members of the Rapid Response Team
10. Pharmacists to the (Early) Rescue

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If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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