Charles H. Brown, MSPharm, RPh, CACP, ACLS, PAL

Delaying CPR can drastically reduce a patient;s chances of surviving a medical emergency.  Knowing the American Heart Association's new guidelines ensures a quick and effective response.

One of your regular patients walks up to the pharmacy window to drop off 2 new prescriptions to be filled. While waiting, he suddenly complains of being dizzy, loses consciousness, falls to the floor, and is unresponsive. The pharmacy technician rushes to the patient to help and notices that the individual does not have a pulse, and does not appear to be breathing. Because you are the only pharmacist on duty, what can you immediately do to help your patient and perhaps even save his life? Do you wait 10 to 15 minutes for the paramedics to arrive?

Whether you are a pharmacist, pharmacy technician, or layperson, the idea of performing cardiopulmonary resuscitation (CPR) or administering an automated external defibrillator (AED) on a friend or stranger can be a frightening proposition, especially if it is your first time. After all, one might contract an incurable disease when exposed to a person’s bodily fluid(s), and this alone may make some individuals reluctant to perform CPR. However, this scenario depicts a potential medical emergency, possibly sudden cardiac arrest (SCA), and the individual requires prompt CPR/AED and medical attention for the best outcome.

Some may decide to wait for the paramedics to arrive—they are trained professionals. But any delay can be costly. At the time a cardiac arrest occurs the blood is fully oxygenated, but without adequate cardiopulmonary function the blood oxygen level will be depleted in a matter of a few minutes. When blood flow or breathing stops, seconds count. Permanent brain damage or death can occur quickly. A delay of 4 to 5 minutes in administering CPR/AED decreases a person’s chance of survival by as much as 40%. A delay of 10 minutes or longer results in death 95% of the time.

The provision of bystander CPR significantly improves outcome, but it is generally performed in less than 30% of cases. Each minute defibrillation with an AED is delayed reduces the chance of survival about 10%.1 With ventricular fibrillation, the heart is beating so rapidly it does not have time to fill with blood between beats, and cardiac output decreases to near zero.

SCA is the leading cause of death in adults and accounts for 325,000 annual adult deaths in the United States. SCA can happen to anyone without any warning signs or symptoms; it may also occur as a result of electrocution or near drowning. The person collapses, stops breathing normally, and is unresponsive. Survival rates from SCA outside of the hospital vary across the country from 3% to 15%. Prompt, effective administration of CPR/ AED can mean the difference between life and death.

The 2005 American Heart Association (AHA) CPR guidelines emphasized the traditional “ABC” procedures—open Airway, check for Breathing, and begin chest Compressions. In 2008, the heart group said untrained bystanders, or those unable or unwilling to do rescue breaths, could do hands-only CPR until paramedics arrive or a defibrillator is used to restore a normal heartbeat. For individuals unable or unwilling to administer mouth-to-mouth resuscitation, administering hands-only CPR was very appealing and it encouraged them to become more involved.

Not only was hands-only CPR generally more appealing, a 7-year study comparing the effects of chest compressions— only versus standard CPR found that survival rates were not significantly different whether or not mouth-to-mouth breaths were given.2,3 By performing resuscitation with only chest compressions—done immediately, forcibly, and rhythmatically, without any interruptions&mdash;you establish a more forward blood flow and better circulation for that period of time. It is a simpler CPR technique and it is easier to teach. The old CPR approach also took more time and delayed getting chest compressions started, which keeps the blood circulating. When the rescuers begin with chest compressions (hard and fast) first, they are acting like an artificial heart that carries blood and oxygen to keep vital organs alive until paramedics arrive.

The new 2010 AHA Guidelines for CPR and Emergency Cardiovascular Care switch the steps for CPR from ABC to CAB—chest Compressions, open Airway, and Breath (mouth-to-mouth). These new guidelines changed the old ones that called for rescuers to give 2 breaths first, then alternate with 30 chest compressions. According to the AHA, successful resuscitation following cardiac arrest requires an integrated set of coordinated actions, a so-called “Chain of Survival.”3 The chain links are as follows:

• Immediate recognition of cardiac arrest and activation of the emergency response system.

Prompt emergency activation and initiation of CPR requires rapid recognition of cardiac arrest. The victim’s breathing is absent or is not normal. Pulse detection by the rescuer alone is often unreliable. Consequently, rescuers should start CPR immediately. The old CPR directive of “look, listen, and feel for breathing” to aid recognition is no longer recommended.

• Early CPR with an emphasis on chest compressions—30 compressions, then 2 breaths.

Prompt, effective chest compressions are fundamental aspects of cardiac arrest resuscitation. CPR improves the victim’s chances of survival by providing the heart and brain circulation, and should be performed for all victims in cardiac arrest. Rescuers should focus on providing highquality CPR, which includes providing chest compressions at least 100 per minute to move oxygenated blood to vital organs, and providing chest compressions of adequate depth. For adults, a compression depth of at least 2 in (5 cm) is required. For infants, a compression depth of 1½ in (4 cm) is required, and for children a compression depth of about 2 in (5 cm) is required. Rescuers should allow complete chest recoil after each compression, minimize interruptions in compressions, and avoid excessive ventilation.

Opening the airway with a head tilt—chin lift or jaw thrust to allow unobstructed passing of air, followed by rescue breaths, can improve oxygenation and ventilation. Ventilations should be provided if the victim has a high likelihood of an asphyxial cause of the arrest (eg, infant, child, or drowning victim). Open the airway and check for breathing or blockage, watch for rise of chest, and listen for air movement.

If an advanced airway is in place, health care providers should deliver ventilations at a regular rate of 1 breath every 6 to 8 seconds (8 to 10 breaths/min), and compressions can be delivered without interruption.

Early defibrillation remains the cornerstone therapy for ventricular fibrillation and pulseless ventricular tachycardia. The 4-step automated process is as follows: 1) Apply pads, if possible without interrupting chest compressions; 2) turn the AED on; 3) the AED will analyze the victim’s heart rhythm; and 4) direct the rescuer either to provide a shock (ie, attempt defibrillation) or to continue CPR.

If you find yourself in a similar situation as the pharmacist and pharmacy technician in our Case Study, and you are fearful that your knowledge or abilities are not 100% complete, it is far better to do something than to do nothing at all.

The Table provides a step-by-step approach to performing CPR on an adult. Those individuals untrained in CPR or unable/unwilling to perform CPR can simply do chest compressions until help arrives. Remember, the difference between your doing something and doing nothing could save someone’s life. PT

Mr. Brown is a clinical pharmacist at Clarian Arnett Hospital and professor emeritus of clinical pharmacy at the Purdue University School of Pharmacy in West Lafayette, Indiana.

Articles

Delaying CPR can drastically reduce a patient;s chances of surviving a medical emergency.  Knowing the American Heart Association's new guidelines ensures a quick and effective response. 

Call 911, Administer CPR/AED!

Common knee injuries are responsible for 20 million physicians' office visits annually. Pharmacists are in a key position to help patients with knee injuries understand their condition and manage their pain.

Each year there are approximately 20 million visits to physicians’ offices because of knee injuries. It is also the most common reason reported for visiting an orthopedic surgeon. No other joint in the human body is as large, or as important, for smooth, powerful, and elegant movement, as the knee. With every running stride or landing from a jump, the knee absorbs and diffuses forces equivalent to 8 to 10 times an individual’s body weight. It coils when one pivots, allowing the foot to point in one direction and the trunk in another. It is a weight-bearing joint that straightens, bends, twists, and rotates. All of these movements increase one’s risk of acute or chronic knee injuries, a source for pain for millions.

The knee performs multiple tasks perfectly because just below the skin lies a lattice network of ligaments and tendons that weaves together multiple muscles and bones. The knee actually consists of 3 bones: the lower end of the thighbone (femur), the end of the shinbone (tibia), and the knee cap (patella). Articular cartilage is a type of slick, hard, bonelike, flexible, white connective tissue that covers the surface ends of the tibia and femur to reduce friction and allow bones to move easily against each other. Meniscus, another important structure in the knee, is a soft, tough,rubbery, crescent-shaped wedge, similarto a shock absorber, between the femur and tibia bones. Meniscus helps distribute the weight of the body across the knee joint, lubricates and protects the articular cartilage from wear and tear, stabilizes the knee when one slides and turns, and limits extreme knee flexion and extension. There are 2 types of meniscus: The lateral meniscus slides forward and backward, and the medial meniscus helps the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) stabilize the knee, absorbing up to 50% of the load applied to the inside of the knee.

Just behind the kneecap are 4 essential ligaments that connect the femur and tibia: 1) the MCL runs along the inside of the knee joint and provides stability to the medial (inner) part of the knee; 2) the lateral collateral ligament (LCL) runs along the outside of the knee joint and provides stability to the lateral (outer) part of the knee; 3) the ACL is in the center of the knee and limits rotation and forward leg movements; and 4) the posterior cruciate ligament (PCL) is in the center of the knee and limits backward leg movements.

Large upper leg muscles, the quadriceps, provide the leg with mobility and strength and enable straightening of the legs. The patella tendon protects the bones and soft tissue in the knee joint and slides when the knee moves, giving leverage to the leg muscles. The quadricepstendon hooks quadricep muscles to the patella and joins the patella tendon to form one continuous tendon surface that covers the patella. The hamstring muscles help the knees bend.

Some knee injuries (eg, muscle strain, tendonitis, bursitis) may result from overuse or overload and may develop gradually over days or weeks. Pain due to inflammation is often mild and intermittent in the beginning and intensifies over time. Knee pain is commonly caused by trying to do “too much too soon,” especially highimpact activities (eg, aerobics, brisk walking, running or jumping on hard surfaces or uneven ground, and excessive running up and down stairs), when one has not exercised for a long period of time. When muscles and tendons are stressed even slightly beyond their capabilities, micro- scopic tears can occur. These tears must be given a chance to heal before being subjected to vigorous activity to avoid overuse injury and pain.

Articular cartilage injuries may occur as a result of other physical injuries. The term “torn cartilage” in the knee usually refers to a torn meniscus, or meniscus cartilage injury. Meniscal tears are among the most common knee injuries. These tears may occur from a squatting, quick twisting, cutting, pivoting, or decelerating of the knee, or from forceful physical contact. When menisci are aged or weakened, an awkward twist when getting up from a chair may be enough to cause a tear. Older individuals are more likely to have degenerative meniscal tears. Athletes who play contact sports are also at risk for meniscal tears.

An individual may feel a “pop” when he or she tears a meniscus. Most individuals can still walk on the injured knee and continue activities. Over the next 2 to 3 days, the knee will gradually become swollen, red, stiff, and painful. One may experience catching of the knee, the sensation of the knee “giving way,” and the inability to move the knee though its full range of motion. Without treatment, a piece of the meniscus may detach and drift into thejoint, causing the knee to slip, pop, or lock. Individuals should seek treatment as soon as possible, especially if they hear a popping noise and feel the knee give out at the time of injury, have severe knee pain or swelling at the injury site, or cannot move the knee or begin limping.

Ligament tear injuries are common injuries among active individuals/athletes. Of the 4 major ligaments found in the knee, the ACL and the MCL are most often injured in sports or by physical stress. PCL injuries occur less often. In general, torn ligaments are caused by twisting the knee or falling. Individuals at high risk include those participating in sports, including sports that involve running, jumping, and sudden stopping. Sports during which participants make sharp, abrupt changes in direction—such as soccer, basketball, volleyball, tennis, and baseball, as well as contact sports such as football, wrestling, and hockey&mdash;put individuals at risk for injury and pain.

ACL injuries can occur as a result of rapidly changing direction, abruptly slowing down when running, and forcefully landing from a jump, which may cause tears in the ACL. Men and women athletes who participate in skiing or basketball, or those who wear shoe cleats, such as football players, are very susceptible to ACL injuries. When the ACL is torn, a loud signature pop is heard, followed by intense pain and immediate swelling of the knee joint.

Injuries to the MCL are usually caused by a severe, direct blow to the outside of the knee. These types of injuries often occur in contact sports, such as football, soccer, and skiing. PCL injuries may occur when an athlete receives a hard blow to the front of the knee or makes a simple misstep on the playing field.

Runner’s knee (patellofemoral pain or anterior knee pain) is a common cause ofknee pain in younger people. It accounts for approximately 25% of all knee injuries. Runners, cyclists, dancers, and basketball, soccer, and tennis players are at higher risk for runner’s knee. The affectedindividual usually experiences diffusepain behind the kneecap. Symptoms often worsen after climbing stairs, jumping, running, or a period of sitting.

Although not technically a sports injury, continual use of the knees over time may lead to some degree of degenerativearthritis, or osteoarthritis (OA). Knee OA is a common cause of knee pain. The risk of OA increases with age and knee usage. This 

condition occurs when the articular cartilage at the end of femur and fibia bones wears away and the bone-end surfaces roughen. Bone or cartilage fragments can also break off inside the joint capsule and float in joint fluids. Either problem can limit movement and cause mild to severe pain.

Treatment regimens for knee injuries must be individualized to the type and severity of the injury and often involve a combination of different treatment methods. To repair ACL injuries in an active athlete, ACL surgery and a lengthy rehabilitation period of 6 to 9 months are often required. Many other knee injuries can be successfully treated with medication and rehabilitation.

Typical Treatment Regimens for Knee Injuries:

The rest, ice, compression, elevation (RICE) method is effective for the treatment of acute knee injuries. This method should be implemented within the first 72 hours of the occurrence of sore muscles, joint aches, or swelling.

Stay off the injured joint or muscle. When this is not possible, use a cane, walker, or crutches. Ice. Ice the affected area every 2 to 3 hours, for no longer than 20 minutes per application.

Use an elastic compression support/wrap to secure the injured joint and add support. This may also help reduce swelling and blood loss with acute injuries.

Raise the affected limb above the heart to promote good circulation. This position also helps reduce swelling and pain in the limbs.

Medication therapy for knee injuries includes anti-inflammatory medication (both steroidal and nonsteroidal antiinflammatory drugs), prescription and OTC pain medication, and topical analgesics and liniments.

(eg, ACL surgery or arthroscopic surgery)

(eg, physical therapy and/or occupational therapy)

For patients with knee injuries, the resulting pain can range widely, from mild and acute to severe and chronic. Pharmacists can be instrumental in helping these patients find appropriate methods to reduce the inflammation and pain from knee injuries.

1. Reynolds, G. The complete guide to your knee. March 2010; 53-63.

2. Koopman, William, et al., eds. Clinical Primer of Rheumatology. Philadelphia: Lippincott Williams & Wilkins, 2003.

3. Kelley's Textbook of Rheumatology, W B Saunders Co, edited by Shaun Ruddy, et al., 2000.

4. Kastrup EK. Facts and Comparisons. Facts and Comparisons (Firm), St. Louis, MO. 2010.

5. Safe use of OTC topical anesthetics. Pharmacist’s Letter/Prescriber’s Letter 2009;25(3):250314.

6. Lambertz CK, Johnson CJ, Montgomery PG, Maxwell JR.  Premedication to reduce discomfort during screening mammography. Radiology 2008;248:765-725.

Mr. Brown is a clinical pharmacist at Clarian Arnett Hospital and professor emeritus of clinical pharmacy at the Purdue University School of Pharmacy in West Lafayette, Indiana. 

Knee Injuries: Helping Patients Treat the Pain

Pharmacists are often the first health care providers to make contact with patients needing medical advice for ocular disorders such as allergic conjunctivitis (AC), especially in the spring and summer months. A review of AC and counseling points are presented here. 

It is springtime, and a young regular client of the pharmacy comes in and asks the pharmacist for eye medicine to relieve acute, severe eye itching and irritation, tearing, redness, and watery discharge. Is this allergic conjunctivitis or a bacterial or viral eye infection? What can the pharmacist recommend for this patient

oth younger and older people with acute ocular conditions may ask a pharmacist about purchasing a nonprescription medicine to relieve painful signs and symptoms of ocular discomfort. Often pharmacists are the first health care providers to make contact with patients needing medical advice for ocular disorders such as allergic conjunctivitis (AC). This overview of AC and major eye structures will prepare pharmacists to better counsel patients with the condition.

The visible external portion of the eye is composed of the cornea and sclera. The cornea is enervated, whereas the sclera is not. The sclera is a white, tough, caliginous layer that gives the eye rigidity and encases internal eye structures. The conjunctiva is a thin, clear mucous membrane consisting of cells that covers the sclera and lines the inside of the eyelids. It consists of the nonkeratinizing squamous epithelium. One of the conjunctiva’s primary functions is to help lubricate the eye by producing mucus and tears, although the volume of tears it produces is less than that of the lacrimal gland. It also contributes to immune surveillance and helps to prevent the entrance of microbes into the eye.

AC is one of the most common seasonal ocular allergies. This condition involves inflammation of the conjunctiva, usually due to an allergy.

 Most individuals develop AC when their eye is exposed to an allergen—a substance that makes the body’s immune system overreact. As a result, the eye can become sore and inflamed.

The ocular allergic response results from a cascade of events mediated by mast cells.

Beta chemokines (ie, eotaxin and macro-phage inflammatory protein 1 alpha) have been implicated in the priming and activation of mast cells on the ocular surface. When an allergen is present, sensitization takes place and launches an antigen-specific response. Th2-differentiated T-cells release cytokines, which promote the production of antigen-specific immunoglobulin E (IgE). IgE binds to IgE receptors on mast cell surfaces. This process initiates the release of histamine, which leads to release of cytokines, prostaglandins, and platelet activation factor. Mast cell intermediaries cause allergic inflammation and symptoms through the activation of inflammatory cells. As histamine is released, it binds to H

 receptors on nerve endings and causes ocular itching. Histamine also binds to H

 receptors of the conjunctival vasculature and causes vasodilation. Mast cell—derived cytokines recruit neutrophils and eosinophils, which promote increased sensitivity.

Pollen is the most common allergen to cause conjunctivitis. It is referred to as seasonal allergic conjunctivitis (allergic rhinoconjunctivitis), because it occurs most often in the spring and summer months when plants, especially grass, trees, and flowers, are in pollen. Some individuals may have symptoms in early autumn or fall. In a normal season, a pollen count of 120 is considered high. During peak times, the pollen count may rise to 6000 or more. Common allergens include:

When an allergen contacts and irritates the conjunctiva, AC symptoms often occur quickly.

 Many individuals with AC have problems with both eyes. At least 20% of the nation’s population is affected by pollen, and about 5% have a strong enough reaction that they need see an allergy specialist. Some individuals will have only mild symptoms, while others state that it is like having a bad cold for 2 to 3 months. Symptoms occur because the overreacting immune system makes the body release histamine and other active substances from mast cells. These substances cause dilation of blood vessels, which irritates the nerve endings and causes increased tearing. The following symptoms are the most typical for AC:

• Red/pink, watery eyes—this is one of the most common symptoms. The eyes become irritated as the small capillaries in the conjunctiva membrane dilate.

• Pain—some individuals may have pain in one or both eyes. Individuals with painful, red eyes, photophobia (sensitivity to bright light), and impaired vision should see a physician immediately.

• Itching—about 75% of individuals experience itching. Rubbing them may worsen the problem.

• Swollen eyelids—as the conjunctiva become inflamed or if the individual has been rubbing them consistently, the eyelids may puff up.

• Soreness—as the conjunctiva become more inflamed, soreness/tenderness or burning may occur.

The patient should try to identify and avoid the allergens that seem to cause symptoms. If the patient is allergic to pollen or mold, he or she should try to stay indoors when pollen and mold levels are high outdoors when possible. Several sources—including television and radio weather reports, as well as newspapers and Web sites (eg, 

)—will include daily allergen count reports. As much as possible, the patient should keep doors and windows closed and use an air conditioner during the spring and summer months. Air filters on the furnace or air conditioner should be changed often. When possible, filters that trap pollen or have a high pollen-filtering code should be used.

The goals in treating allergic conjunctivitis include

: (1) avoid or remove the allergens, (2) reduce the severity of allergic reaction, (3) provide symptomatic relief, and (4) protect the ocular surface. A number of different types of eye medicines are available to treat AC. In general, they help relieve itchy, watery eyes and may keep symptoms from returning, but do not cure the allergy. Eye drops are often used and may contain an antihistamine, a nonsteroidal anti-inflammatory drug (NSAID) called a mast cell stabilizer, or a combination of these ingredients. Individuals will often begin taking an oral antihistamine product and a mast cell stabilizer eye drop. Corticosteroid eye drops are rarely needed unless symptoms are especially severe or are left untreated for a long period of time.

Antihistamines taken orally work quickly by blocking the effects of histamines produced when the immune system reacts to an allergen. The most commonly used oral antihistamines include cetirizine (Zyrtec), fexofenadine (Allegra), and loratadine (Claritin). These products are classified as low-sedating antihistamines and are dosed once or twice daily. Diphenhydramine (Benadryl) may also be used, but often causes significantly more drowsiness, dry mouth, and dry eyes. Diphenhydramine is dosed 3 or 4 times daily, every 4 to 6 hours. Adverse drug effects of antihistamines most commonly include headache, somnolence, vomiting, and dry mouth. Dosage reduction is suggested in patients with renal impairment and in the elderly.

Mast cell stabilizers take much longer than antihistamines to begin therapeutic effects, but their effects last much longer. A mast cell stabilizer is a class of NSAIDs that reduces the release of inflammation-causing chemicals from mast cells. They block a calcium channel essential for mast cell degranulation, stabilizing the cell, thus preventing the release of histamine. The most commonly used mast cell stabilizer eye drops include ketotifen (Zaditor), lodoxamine (Alomide), and neodocromil (Alocril). These drugs are dosed twice daily, every 10 to 12 hours, except for lodoxamine, which is dosed 3 to 4 times daily. Adverse effects of mast cell stabilizers include burning or stinging, dry eyes, eye pain, tearing, itching, and photophobia.

Many medicated eye drops cause minor burning/stinging when first applied, but this discomfort usually resolves in a few minutes. Contact lenses should not be worn while a patient has AC and is receiving treatment. The use of decongestant eye drops is not recommended. These products only constrict blood vessels in the conjunctiva and do not treat the allergy.

This individual appears to have classic AC. The first-line treatment of AC is to instill nonmedicated artificial tears as needed and start the patient on an oral antihistamine, cetirizine 10 mg once daily. If symptoms persist, the patient may add an ophthalmic mast cell stabilizer product, such as ketotifen or ketotifen fumarate eye drops, twice daily. These products do not require a prescription, are safe to use in individuals 3 years of age and older, and are very effective in relieving the signs and symptoms of AC. If symptoms are not resolved, an oral antihistamine may be added. 

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