Section 1.1: The Emergency Department (ED): The Unscheduled Front Door

Triage: The Science of Sorting

In your retail pharmacy, triage is often an informal process. The technician answers the phone and decides if the call requires a pharmacist’s immediate attention, can be handled later, or is a routine refill request. In the ED, triage is a formal, evidence-based science. It is the process of rapidly assessing every patient who arrives to determine the severity of their condition and the urgency with which they need to be seen. The universal language for this process in most U.S. hospitals is the Emergency Severity Index (ESI), a five-level triage scale.

Understanding ESI is non-negotiable for an ED pharmacist. The ESI level assigned to a patient is a powerful signal that tells you, at a glance, how sick they are and how quickly you may need to act on their medication orders. An order for a patient with an ESI of 2 requires a fundamentally different level of urgency and scrutiny than an order for an ESI 5 patient.

Deep Dive: The 5 Levels of the Emergency Severity Index (ESI)

ESI Level	Patient Description & Required Intervention	Classic Clinical Examples	Implications for the Pharmacist
ESI 1 (Most Urgent)	Critically Ill / Requires Immediate Life-Saving Intervention. This patient is actively dying or circling the drain. They require immediate, simultaneous evaluation and treatment by the entire team (physician, nurse, pharmacist). Think airway, breathing, circulation (ABCs).	Cardiac Arrest (Code Blue) Severe Respiratory Distress (requiring intubation) Major Trauma (e.g., gunshot wound) Unresponsive / Overdose with respiratory depression	Action Stations. Drop everything. You are physically needed at the bedside or preparing critical meds. Your role is hands-on: drawing up ACLS drugs, preparing RSI kits, calculating pressor drip rates. Verification happens verbally and in real-time.
ESI 2	High-Risk / Confused, Lethargic, or Severe Pain/Distress. This patient is not actively dying but is very sick and has the potential to decompensate quickly. They need to be seen within 10 minutes. Their situation is time-critical.	Active Chest Pain, suspected MI (STEMI) Stroke symptoms (FAST positive) Sepsis with hypotension/tachycardia Femur fracture causing severe pain	High Priority. These orders jump to the top of your queue. Anticipate time-sensitive protocols: “door-to-balloon” for STEMI (antiplatelets, anticoagulants), “door-to-needle” for stroke (tPA workup), “sepsis bundles” (STAT antibiotics, fluids). Your speed and accuracy directly impact patient outcomes.
ESI 3	Stable / Requires Multiple Resources. This is the “workup” patient. They are stable but need significant resources (labs, imaging, IV fluids/meds) to determine a diagnosis and disposition. They should be seen within 1 hour.	Abdominal pain needing a CT scan Pneumonia in an adult who is breathing comfortably Ankle fracture needing x-ray and reduction Migraine needing IV antiemetics and fluids	Standard Workflow. These orders constitute the bulk of your day. The urgency is lower than ESI 2, but standard ED turnaround times apply. This is where your clinical skills in dose adjustments, allergy checks, and initial medication reconciliation shine.
ESI 4	Stable / Requires One Resource. This patient has a minor issue that requires one simple diagnostic or procedure (e.g., stitches, an x-ray, a prescription).	Simple laceration needing sutures Sore throat needing a strep test Sprained ankle needing an x-ray Urinary Tract Infection needing a urinalysis	Low Priority / “Fast Track”. Your involvement is often minimal. You might verify a single order for a pain medication or an antibiotic prescription to be filled at an outpatient pharmacy. These orders should not distract you from sicker patients.
ESI 5 (Least Urgent)	Stable / Requires No Resources. This patient essentially needs a conversation, an examination, or a simple prescription refill. They could have been seen at an urgent care or primary care clinic.	Prescription refill request Work note request Poison ivy rash Toothache	Minimal Involvement. Your role is almost exclusively verifying discharge prescriptions. These are the lowest priority in your verification queue.

Resuscitation & Stabilization: From Chaos to Control

While triage sorts patients, resuscitation and stabilization are the active processes of treating them. These two concepts are intertwined and represent the core function of emergency medicine.

• Resuscitation is the act of reversing a life-threatening condition. It’s the “R” in RSI (Rapid Sequence Intubation), the epinephrine in a cardiac arrest, the naloxone in an overdose. It is immediate, aggressive, and focused on restoring vital functions.
• Stabilization is the broader process of taking a critically ill patient from a state of high risk to a state of relative safety, allowing for further diagnostics and transfer to an inpatient unit. This includes controlling blood pressure, managing pain, starting antibiotics for sepsis, and giving fluids.

The pharmacist’s role in this phase is direct and profound. You are the medication expert in the resuscitation bay, ensuring the right drug, right dose, and right route are used under extreme pressure. You are the safety net, the calculator, and the drug information resource, all in one. When the team is focused on chest compressions or securing an airway, they are relying on you to manage the entire medication side of the equation with precision and speed. This is where your training, your composure, and your systematic approach to verification become life-saving skills.

Mastery 1: The Art of the STAT Medication

In the rest of the hospital, a “STAT” order means “as soon as possible.” In the ED, STAT means NOW. It implies that a delay in administration could lead to a significant negative outcome. This fundamental difference in philosophy requires a complete rewiring of your prioritization skills. An ED STAT order for diltiazem for a patient in rapid atrial fibrillation takes precedence over nearly every other task.

Your role is twofold: clinical verification and logistical facilitation.

• Clinical Verification: This is your core function, but accelerated. You must rapidly assess the appropriateness of the drug, dose, and route in the context of the patient’s presentation. Is this weight-based dose of ketamine for procedural sedation correct? Does this patient with chest pain have any contraindications to nitroglycerin? Your verification is the final safety check before a potent medication is given.
• Logistical Facilitation: Where is the drug? Is it in the automated dispensing cabinet (ADC) in the ED? Does it need to be tubed from the central pharmacy? Does it need to be compounded? A verified order is useless if the nurse can’t get the drug. A huge part of your job is knowing the location of critical medications and ensuring the supply chain is uninterrupted.

Masterclass Table: Common ED STAT Medications & The Pharmacist’s Verification Checklist

This table is not exhaustive, but represents the bread-and-butter of ED pharmacy. Your goal is to internalize this information so your verification process becomes second nature.

Drug Class & Name	Common ED Indications	Pharmacist Verification Checklist
Analgesics Morphine, Hydromorphone, Fentanyl, Ketorolac	Acute, severe pain (e.g., fractures, kidney stones, sickle cell crisis)	Dose: Is it appropriate for the indication and patient’s age/size? Is the patient opioid-naive? Fentanyl is dosed in mcg, not mg! Allergies: Verify true opioid allergy vs. intolerance (itching, nausea). Renal Function: Avoid morphine/hydromorphone in severe renal dysfunction (active metabolites). Fentanyl is generally preferred. Avoid ketorolac in renal impairment or GI bleed risk. Last Dose: Check the MAR. Has the patient received a dose recently? Avoid dose stacking.
Anxiolytics / Sedatives Lorazepam, Midazolam, Diazepam	Seizures, status epilepticus, acute agitation, alcohol withdrawal, procedural sedation.	Route: IV is preferred for speed in emergencies like seizures. IM is an option for agitation. Respiratory Status: High doses can cause respiratory depression. Is the patient on a monitor? Is airway equipment nearby? Synergistic Effects: Is the patient also receiving opioids or other CNS depressants? High risk for over-sedation.
Antihypertensives (IV) Labetalol, Hydralazine, Esmolol, Nicardipine	Hypertensive emergency (with end-organ damage), aortic dissection, pre-eclampsia.	Heart Rate: Labetalol is a beta-blocker and will lower HR. Avoid in bradycardia. Hydralazine is a direct vasodilator and can cause reflex tachycardia. Contraindications: Avoid beta-blockers like labetalol in patients with severe asthma/COPD or decompensated heart failure. Goal: The goal is controlled lowering of BP (e.g., by 25% in the first hour), not normalization. Rapid drops can cause ischemia. Drips (nicardipine, esmolol) are preferred for tight control.
Antiarrhythmics Amiodarone, Diltiazem, Adenosine, Digoxin	Atrial fibrillation with RVR, Supraventricular Tachycardia (SVT), Ventricular Tachycardia (VT).	Rhythm Confirmation: Ensure the rhythm has been confirmed on an EKG. Rate vs. Rhythm Control: In the ED, the initial goal is almost always rate control (e.g., with diltiazem). Adenosine: For stable, narrow-complex SVT only. Requires extremely rapid IV push (“slam”) followed by a saline flush. Warn the patient about the impending sense of doom! Blood Pressure: Diltiazem and amiodarone can cause hypotension. Use with caution if the patient is already borderline hypotensive.
Antibiotics (Sepsis) Vancomycin + Pip/Tazo or Cefepime, Ceftriaxone	Suspected sepsis or septic shock. Community-acquired pneumonia. Meningitis.	TIMING IS EVERYTHING. The sepsis bundle goal is antibiotics within 1 hour of recognition. Your verification is the rate-limiting step. Dosing Weight: Use actual body weight for loading doses of vancomycin. Doses must be aggressive. Broad Spectrum: The initial regimen must be broad (covering gram-positives, gram-negatives, and often pseudomonas). Do not question the breadth of the initial combo; the goal is to cover all likely pathogens. Cultures First: Verbally confirm with the nurse that blood cultures have been drawn *before* the first antibiotic dose is administered.
Thrombolytics Alteplase (tPA)	Acute Ischemic Stroke (within 3-4.5 hours of symptom onset). Massive Pulmonary Embolism.	CHECKLIST IS MANDATORY. This is the highest-risk drug you will handle. You MUST run through the formal inclusion/exclusion checklist with the physician. Every item. Every time. Hemorrhage Ruled Out: Confirm a non-contrast head CT has been read and shows NO bleeding. Weight-Based Dosing: Dose is 0.9 mg/kg (max 90 mg). 10% given as a bolus over 1 minute, the rest infused over 1 hour. Double-check your calculation. Anticoagulants: Ensure patient has not recently received heparin, LMWH, or a DOAC.