OBJECTIVES

• CLASS FORMAT
• EMERGENCY MEDICINE PHARMACY
• DIFFERENTIAL DIAGNOSIS
• LABORATORY TESTS
• DIAGNOSTICS
• PRACTICE
• ROUTES OF MEDICATION ADMINISTRATION
CLASS FORMAT
• OH, COVID…PLEASE FOLLOW APPROPRIATE ONLINE ETIQUETTE
• LECTURE (SOME SYNCHRONOUS, SOME PRE-RECORDED- SEE SYLLABUS AND SCHEDULE ONLINE]
• ANSWER QUESTIONS OR WORK-UP PATIENT CASES AS INDICATED BY YOUR INSTRUCTOR IN CLASS
• 3 OTHER DAYS:
• JOURNAL CLUB
• FINAL PRESENTATIONS
• JEOPARDY / RESIDENCY QUESTIONS
GRADES
• CLASS/PATIENT CASE PARTICIPATION: 5 POINTS, CLASS PARTICIPATION DUE ON BLACKBOARD BY 23:59 EACH FRIDAY
• EM PHARMACIST CONSULT QUESTIONS: 5 POINTS, DUE ON BLACKBOARD BY 23:59 EACH FRIDAY
• JOURNAL CLUB: 20 POINTS, CREATE HANDOUT, EDUCATION BOARD, & PRESENT AS A GROUP IN CLASS, ASK QUESTION
• GROUPS OF 8-9, 15 MINUTE PRESENTATION

• FINAL PRESENTATION: 30 POINTS, CREATE PRESENTATION & PRESENT AS A GROUP IN CLASS, ASK QUESTION
• GROUPS OF 8-9, 15 MINUTE PRESENTATION

• INSTRUCTOR EVALUATIONS: NO POINTS, NOT REQUIRED, BUT HELPFUL

SEE CALENDAR & RUBRICS IN SYLLABUS

CLASS RULES
• ATTEND CLASS
• PARTICIPATE
• BE PROFESSIONAL
• BE RESPECTFUL
• CLASSMATES
• INSTRUCTORS
• TIME
• LEARN SOMETHING NEW
EMERGENCY MEDICINE
PHARMACY

• NOT NEW, POSITIONS HAVE EXISTED SINCE THE

1970’S
• VARIED TRAINING
• VARIED SETTINGS
• VARIED ROLES
 ASHP Patient care

POSITION Emergency preparedness planning

STATEMENT
ON Quality-improvement initiatives

PHARMACY ED-based research

SERVICES TO Education
THE ED

American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 2008;65:2380–3.

 PATIENT CARE
• RESUSCITATION EFFORTS • MODIFYING MEDICATION REGIMENS BASED ON
COLLABORATIVE-PRACTICE AGREEMENTS FOR THE
• CONSULTATIVE SERVICES MANAGEMENT OF SPECIFIC PATIENT POPULATIONS THAT
• PHYSICIANS RETURN TO THE ED
• NURSES • PROVIDING VACCINATION SCREENING, REFERRAL, AND
• OTHER ADMINISTRATION
• MONITORING ALLERGIES AND DRUG INTERACTIONS • OFFERING PATIENT AND CAREGIVER EDUCATION,
• MONITORING THERAPEUTIC RESPONSES INCLUDING DISCHARGE COUNSELING AND FOLLOW-UP
• GATHERING OR REVIEWING MEDICATION • PROVIDING INFORMATION ON OBTAINING MEDICATIONS
HISTORIES AND RECONCILING MEDICATIONS THROUGH PATIENT ASSISTANCE PROGRAMS, CARE FUNDS,
AND SAMPLES

American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 2008;65:2380–3.

 EMERGENCY PREPAREDNESS PLANNING

• PARTICIPATE IN HOSPITAL EMERGENCY-PREPAREDNESS PLANNING

• PARTICIPATE AS MEMBERS OF HEALTH CARE TEAM PROVIDING CARE TO VICTIMS
• ENSURING EFFICACY AND SAFETY OF MEDICATION-USE PROCESS
• TREATMENT OF DISASTER VICTIMS GENERALLY INVOLVES USE OF PHARMACOLOGIC AGENTS

American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 2008;65:2380–3.

 QUALITY-IMPROVEMENT INITIATIVES
• DEVELOPMENT OF EVIDENCE-BASED TREATMENT PROTOCOLS, ALGORITHMS, AND CLINICAL PATHWAYS
• DEVELOPMENT, IMPLEMENTATION, AND ASSESSMENT OF VARIOUS TECHNOLOGIES USED THROUGHOUT
THE ED MEDICATION-USE PROCESS
• ANALYZING ERROR-PRONE ASPECTS OF THE MEDICATION-USE PROCESS
• PARTICIPATING IN COMMITTEES WHOSE DECISIONS AFFECT MEDICATION USE IN THE ED
• MAINTAINING COMPLIANCE WITH STANDARDS OF NATIONAL ACCREDITING BODIES
• SURVEILLANCE AND REPORTING OF ADVERSE DRUG REACTIONS

American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 2008;65:2380–3.

 ED-BASED RESEARCH

• RESEARCH ON AND PUBLICATIONS ABOUT ED PHARMACY

• VARIED SCOPE AND RANGE OF ED PHARMACY PRACTICES
• MEDICATION USE IN THE ED
• ED-BASED PHARMACY ACTIVITIES
• THERAPEUTIC, SAFETY, HUMANISTIC, AND ECONOMIC OUTCOMES OF PHARMACIST-MEDIATED PROCESS CHANGES

American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 2008;65:2380–3.

 EDUCATION

• CONDUCTING EDUCATIONAL FORUMS FOR HEALTH CARE PROFESSIONALS AND STUDENTS

• PROVIDING EDUCATION TO PATIENTS AND CAREGIVERS REGARDING MEDICATION USE, DISEASE-STATE
MANAGEMENT, AND PREVENTION STRATEGIES
• OFFERING ED-BASED EDUCATIONAL OPPORTUNITIES TO PHARMACY STUDENTS AND RESIDENTS

American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 2008;65:2380–3.

 Management of critically ill
patients
3 TOP
EMERGING
ROLES OF EM Antimicrobial stewardship

PHARMACIST
(AJHP 2018) Involvement in generating orders
for home medications to be
administered by nurses in the ED

Roman C, et al. Am J Health-Syst Pharm 2018;75:796-806.

THE PATIENT

ANY PATIENT, ANY UNDIFFERENTIATED SECURE ABC’S IDENTIFY POTENTIAL

TIME LIFE THREATS
 THE DIAGNOSTIC PROCESS
Constructing a Choosing
Interpreting
differential diagnostic
results
diagnosis tests

• COMPLEX
• USES CLINICAL REASONING
• DIAGNOSTIC ERRORS: FAULTY KNOWLEDGE, DATA GATHERING, OR INFORMATION PROCESSING

Stern SDC, et al. Diagnostic process. McGraw-Hill; 2014.

 CONSTRUCTING A DIFFERENTIAL
DIAGNOSIS
1. IDENTIFY THE PROBLEM
2. FRAME THE DIFFERENTIAL DIAGNOSIS
3. ORGANIZE THE DIFFERENTIAL DIAGNOSIS
4. LIMIT THE DIFFERENTIAL DIAGNOSIS
5. USE THE H&P EXAM FINDINGS TO EXPLORE POSSIBLE DIAGNOSES
6. RANK THE DIFFERENTIAL DIAGNOSIS

Stern SDC, et al. Diagnostic process. McGraw-Hill; 2014.

 EXAMPLE
VT IS A 58 YO F PRESENTING TO ED WITH PAINFUL SWELLING OF HER LEFT CALF X 2 DAYS. SHE FEELS FEVERISH
BUT HAS NO OTHER SYMPTOMS SUCH AS CP, SOB, OR ABDOMINAL PAIN.
PMH: HTN, OSTEOARTHRITIS OF HER KNEES, AND A CHOLECYSTECTOMY, WITH NO HISTORY OF OTHER MEDICAL
PROBLEMS, SURGERIES, OR FRACTURES. SHE HAD A NORMAL PELVIC EXAM AND PAP SMEAR 1 MONTH AGO.
HOME MEDS: HYDROCHLOROTHIAZIDE
PHYSICAL EXAM: CIRCUMFERENCE OF HER LEFT CALF IS 3.5 CM GREATER THAN HER RIGHT CALF, AND THERE IS
1+ PITTING EDEMA. THE LEFT CALF IS UNIFORMLY RED AND VERY TENDER, AND THERE IS TENDERNESS ALONG THE
POPLITEAL VEIN AND MEDIAL LEFT THIGH. THERE IS A HEALING CUT ON HER LEFT FOOT. HER TEMPERATURE IS
37.7°C. THE REST OF HER EXAM IS NORMAL.

Stern SDC, et al. Diagnostic process. McGraw-Hill; 2014.

 CONSTRUCTING A DIFFERENTIAL
DIAGNOSIS
1. IDENTIFY THE PROBLEM
1. Problem list: Acute problems,
2. FRAME THE DIFFERENTIAL DIAGNOSIS chronic problems, inactive
3. ORGANIZE THE DIFFERENTIAL DIAGNOSIS problems
-Painful left leg edema w/
4. LIMIT THE DIFFERENTIAL DIAGNOSIS erythema
5. USE THE H&P EXAM FINDINGS TO EXPLORE POSSIBLE DIAGNOSES -HTN
-OA of knees
6. RANK THE DIFFERENTIAL DIAGNOSIS -S/P cholecystectomy

Stern SDC, et al. Diagnostic process. McGraw-Hill; 2014.

 CONSTRUCTING A DIFFERENTIAL
DIAGNOSIS
1. IDENTIFY THE PROBLEM
2. FRAME THE DIFFERENTIAL DIAGNOSIS
3. ORGANIZE THE DIFFERENTIAL DIAGNOSIS 2. Type of edema?
4. LIMIT THE DIFFERENTIAL DIAGNOSIS Gerneralized vs. Unilateral
Limb vs. Local
5. USE THE H&P EXAM FINDINGS TO EXPLORE POSSIBLE DIAGNOSES
6. RANK THE DIFFERENTIAL DIAGNOSIS

Stern SDC, et al. Diagnostic process. McGraw-Hill; 2014.

 CONSTRUCTING A DIFFERENTIAL
DIAGNOSIS
1. IDENTIFY THE PROBLEM
2. FRAME THE DIFFERENTIAL DIAGNOSIS
3. ORGANIZE THE DIFFERENTIAL DIAGNOSIS 3. Not necessary to organize for
this specific example because
4. LIMIT THE DIFFERENTIAL DIAGNOSIS framing the edema organized it
5. USE THE H&P EXAM FINDINGS TO EXPLORE POSSIBLE DIAGNOSES for us

6. RANK THE DIFFERENTIAL DIAGNOSIS

Stern SDC, et al. Diagnostic process. McGraw-Hill; 2014.

 CONSTRUCTING A DIFFERENTIAL DIAGNOSIS
1. IDENTIFY THE PROBLEM
4. Acute unilateral leg edema:
2. FRAME THE DIFFERENTIAL DIAGNOSIS - Skin: Stasis dermatitis
3. ORGANIZE THE DIFFERENTIAL DIAGNOSIS - Soft tissue: Cellulitis
- Calf veins: Distal DVT
4. LIMIT THE DIFFERENTIAL DIAGNOSIS - Knee: Ruptured Baker cyst
5. USE THE H&P EXAM FINDINGS TO EXPLORE POSSIBLE DIAGNOSES - Thigh veins: Proximal DVT
- Pelvis: Mass causing
6. RANK THE DIFFERENTIAL DIAGNOSIS lymphatic obstruction

Stern SDC, et al. Diagnostic process. McGraw-Hill; 2014.

 CONSTRUCTING A DIFFERENTIAL DIAGNOSIS
1. IDENTIFY THE PROBLEM
2. FRAME THE DIFFERENTIAL DIAGNOSIS
5. Consider risk factors for the
3. ORGANIZE THE DIFFERENTIAL DIAGNOSIS diagnostic possibilities
4. LIMIT THE DIFFERENTIAL DIAGNOSIS *Cellulitis follows skin injury (pt
has cut on foot)
5. USE THE H&P EXAM FINDINGS TO EXPLORE POSSIBLE DIAGNOSES *Can use clinical decision rules
6. RANK THE DIFFERENTIAL DIAGNOSIS

Stern SDC, et al. Diagnostic process. McGraw-Hill; 2014.

 CONSTRUCTING A DIFFERENTIAL DIAGNOSIS
1. IDENTIFY THE PROBLEM 1. Soft tissue: Cellulitis
2. FRAME THE DIFFERENTIAL DIAGNOSIS 2/3: Calf veins: Distal DVT
2/3: Thigh veins: Proximal
3. ORGANIZE THE DIFFERENTIAL DIAGNOSIS DVT
4. LIMIT THE DIFFERENTIAL DIAGNOSIS 4/5: Knee: Ruptured Baker
cyst
5. USE THE H&P EXAM FINDINGS TO EXPLORE POSSIBLE DIAGNOSES 4/5: Pelvis: Mass causing
6. RANK THE DIFFERENTIAL DIAGNOSIS lymphatic obstruction
6. Skin: Stasis dermatitis

Stern SDC, et al. Diagnostic process. McGraw-Hill; 2014.

 ROLE OF DIAGNOSTIC TESTING
• TEST YOUR HYPOTHESIS
• DETERMINE PRETEST PROBABILITY
• *CLINICAL DECISION RULES (WELL’S SCORE FOR DVT RISK)
• CONSIDER POTENTIAL HARMS
• DETERMINE LIFE-THREATS ARE NOT PRESENT OR HAVE VERY LOW PROBABILITY BEFORE
EXCLUDING WITHOUT TESTING
• SOME TREATMENTS ARE HIGHER RISK THAN OTHERS (THROMBOLYTICS VS. ANTIBIOTICS

Stern SDC, et al. Diagnostic process. McGraw-Hill; 2014.

 PRETEST PROBABILITY
• CONCEPTUALIZING PRETEST PROBABILITY
• *19 YO F W/ 30 SEC SHARP RIGHT SIDED CP AFTER LIVING A HEAVY BOX

• *60 YO M W/ 15 MIN OF CRUSHING SUBSTERNAL CP. PMH: DM, HTN, SMOKING. EKG SHOWS ST SEGMENT
ELEVATION IN ANTERIOR LEADS

Stern SDC, et al. Diagnostic process. McGraw-Hill; 2014.

 LABORATORY TESTS
BLOOD: URINE: OTHER:
• BMP • DRUG LEVELS • PREGNANCY • WOUND CULTURE
• CMP • THYROID FUNCTION • URINE DRUG ANALYSIS • SYNOVIAL CULTURE
• CBC (W/, W/O DIFF) • LIPASE • CSF CULTURE
• URINALYSIS
• PT/INR • BLOOD GAS • EYE CULTURE
• MAGNESIUM • D DIMER • CULTURES
• STOOL (PARASITE, C. DIFF,
• AMMONIA • CK CULTURE)
• LFT’S • ESR • GAS SWAB
• LACTATE • CULTURES
• VIRUS SWAB (VARIOUS)
• TROPONIN • *SOME POINT OF CARE*
• STD TESTS
*NOT ALL ENCOMPASSING* SWAB/URINE/BLOOD
 RADIOLOGICAL TESTING
• X-RAY (CAN BE BEDSIDE)
• ULTRASOUND (CAN BE BEDSIDE)
• COMPUTED TOMOGRAPHY (CT SCAN) – CAN BE W/ OR W/O IV OR ORAL CONTRAST
• MAGNETIC RESONANCE IMAGING (MRI) – CAN BE W/ OR W/O CONTRAST
• NUCLEAR

*NOT ALL ENCOMPASSING*

 OTHER DIAGNOSTICS
• VITALS • PHYSICAL EXAM
• EKG • PSYCHOLOGICAL EXAM
• CAPNOGRAPHY • PAST MEDICAL HISTORY
• INTRACRANIAL PRESSURE • SOCIAL HISTORY
• URINE OUTPUT • MEDICATIONS
• MANY MORE… • SCALES: GLASGOW COMA SCORE, NATIONAL
INSTITUTE OF HEALTH STROKE SCALE, MANY MORE…

*NOT ALL ENCOMPASSING*

PATIENT CASE EXAMPLE!
ROUTES OF MEDICATION
ADMINISTRATION
• INTRAVENOUS (IV): PERIPHERAL
• MANY POSSIBLE LOCATIONS
• MANY POSSIBLE GAUGES
• *COLORS MAY NOT BE CONSISTENT
THROUGH ALL BRANDS
 ROUTES OF MEDICATION
ADMINISTRATION
• INTRAVENOUS (IV): CENTRAL
• TYPES:
• NON-TUNNELED
• TUNNELED
• IMPLANTED PORTS
• PERIPHERALLY INSERTED CENTRAL CATHETERS
DIALYSIS CATHETERS
• NON-TUNNELED MOST COMMON LOCATIONS:
SUBCLAVIAN, JUGULAR, FEMORAL
• COMPLICATIONS: THROMBOSIS, INFECTIONS, LOCAL
COMPLICATIONS (PNEUMOTHORAX, ETC)

Akaraborworn O. Chinese J Trauma 2017;20:137-140.

PUMPS
 PRIMARY &
SECONDARY
INFUSIONS
 ROUTES OF MEDICATION ADMINISTRATION
• INTRAOSSEOUS (IO)
• FLUIDS AND DRUGS ENTER THE VENOUS SINUSOIDS
OF THE MEDULLARY CAVITY, DRAIN INTO THE
CENTRAL VENOUS CHANNEL, AND LEAVE THE BONE TO
THE SYSTEMIC CIRCULATION
• SITES: PROXIMAL OR DISTAL TIBIA, HUMERAL HEAD,
DISTAL FEMUR, STERNUM, CALCANEUS, STYLOID OF
THE RADIUS, ANTERIOR-SUPERIOR ILIAC SPINE

Dev SP, Stefan RA, Saun T, et al. N Engl J Med 2014;370:e35.

 ROUTES OF MEDICATION ADMINISTRATION
• CONTRAINDICATIONS:
• FRACTURES OR CRUSH INJURIES NEAR THE SITE
• CONDITIONS THAT MAKE BONE FRAGILE: OSTEOGENESIS
IMPERFECTA, ETC
• PREVIOUS ATTEMPTS IN THE SAME BONE
Available Drill-assisted
Mechanical Devices
• FAST-1 Intraosseous Infusion
System (Pyng Medical) - Sternal
• EZ-IO Drill (Vidacare)
• Bone Injection Gun (Waismed)

• OVERLYING BURN OR INFECTION

• COMPLICATIONS: EXTRAVASATION, INFECTION, FRACTURE,
DAMAGE TO GROWTH PLATE
• LIDOCAINE IF PATIENT IS AWAKE

Dev SP, Stefan RA, Saun T, et al. N Engl J Med 2014;370:e35.

ROUTES OF MEDICATION ADMINISTRATION
• ENDOTRACHEAL (ET)
• FOR EMERGENCY DRUG ADMINISTRATION
N Naloxone
• NOT PREFERRED (ONLY IF IV OR IO IS NOT
AVAILABLE)
A Atropine

• ABSORPTION VIA ALVEOLAR-CAPILLARY V Vasopressin

MEMBRANE
• AHA SUGGESTED DOSE: 2-2.5X THE IV DOSE E Epinephrine

L
DILUTED IN 5-10 ML OF NS OR SWFI
Lidocaine
ROUTES OF MEDICATION ADMINISTRATION
• INTRANASAL (IN)
• CONVENIENT WHEN NO IV ACCESS AVAILABLE OR NEEDED
• *PEDIATRIC PATIENTS
• *NARCAN
 INTRANASAL

Corrigan m, Wilson SS, Hampton J. Am J Health-Syst Pharm 2015;72:1544-54.

 INTRANASAL
• QUICK ACTING
• OLFACTORY MUCOSA (LOCATED BELOW THE
CRIBRIFORM PLATE) CONTAINS OLFACTORY
CELLS THAT THAT CROSS THE CRIBRIFORM PLATE
AND EXTEND DIRECTLY INTO THE CRANIAL CAVITY
• MEDICATIONS CAN BE CARRIED BY THE
OLFACTORY NERVE PATHWAY DIRECTLY TO THE
CSF AND BRAIN

Corrigan m, Wilson SS, Hampton J. Am J Health-Syst Pharm 2015;72:1544-54.

 Medication IN Dose Other INTRANASAL
Naloxone 2-4 mg • MINIMIZE PRODUCT VOLUME
• 0.2-0.3 ML/NARE IDEAL
Fentanyl 1.5-2 mcg/kg Available generic • > 1 ML/NARE NOT RELIABLY ABSORBED
(max 100 mcg) concentration 50
mcg/mL • MAXIMIZE DRUG CONCENTRATION
Midazolam 0.1-0.5 mg/kg Concentrated
• ADEQUATE DOSING
(sedation);
0.2 mg/kg (seizures)
product 5 mg/mL;
Burning sensation
• UTILIZING BOTH NARES
(max 10 mg) • ATOMIZE PARTICLES
Ketamine 0.5-1 mg/kg
(analgesia);
Sedation by IN route
may not ne practical
• INCOMPLETE AND SLOWER ABSORPTION THAN IV
3-9 mg/kg (sedation) especially in adults (GENERALLY NEED LARGER DOSES)
• NOT FOR USE WITH NASAL TRAUMA, ETC

Wolfe TR, Braude DA. Pediatrics 2010;126(3):532-7.

 ROUTES OF MEDICATION ADMINISTRATION

Oral Sublingual Rectal Topical

Slow acting. Quick acting Highly vascularized, fast acting *Anesthetics,
Most common method. *Nitroglycerin… *APAP, ASA, Promethazine, antibiotics,
Various formulations: oral DiaStat, Vancomycin, patches…
disintegrating tablets, Lactulose…
solutions, suspensions, tablets,
capsules…
 ROUTES OF MEDICATION ADMINISTRATION

Intramuscular {IM} Subcutaneous Intracavernous Intra-articular

Common: acute agitation, seizures,
anaphylaxis, STDs, injury, overdose
*Tdap, Rabies (Immunization and Immune
Globulins), Ceftriaxone, Haldol,
Olanzapine, Lorazepam, Midazolam,
Naloxone, Ketorolac, Epinephrine…(lots)
Not generally preferred For priapism *Steroids
for immediate effect *Phenylephrine
(erratic absorption)
*Insulin, enoxaparin,
anesthetics, fluids…
 ROUTES OF MEDICATION ADMINISTRATION

Inhalation Intranasal (topical) Eye Ear

Inhalers, nebulized medications Topical agents utilized *Antibiotics, anesthetics, *Antibiotics, anesthetics,
*Albuterol, ipratropium, racemic frequently for epistaxis steroids, fluorescein, steroids, carbamide
epinephrine… *Phenylephrine, oxymetazoline, cycloplegics… peroxide…
thrombin, tranexamic acid, silver
nitrate (systemic intranasal
discussed separately)…
 NEXT WEEK…
DR. LAUREN BEAUCHAMP
IU HEALTH BLOOMINGTON
&
DR. KRISTIN BUECHLER
IU HEALTH ARNETT

RAPID SEQUENCE INTUBATION (RSI) & PROCEDURAL SEDATION

 RESOURCES
• AKARABORWORN O. A REVIEW IN EMERGENCY CENTRAL VENOUS CATHETERIZATION. CHINESE J TRAUMA 2017;20:137-140.
• AMERICAN SOCIETY OF HEALTH-SYSTEM PHARMACISTS. ASHP STATEMENT ON PHARMACY SERVICES TO THE EMERGENCY DEPARTMENT.
AM J HEALTH-SYST PHARM. 2008;65:2380–3.
• CORRIGAN M, WILSON SS, HAMPTON J. SAFETY AND EFFICACY OF INTRANASALLY ADMINISTERED MEDICATIONS IN THE EMERGENCY
DEPARTMENT AND PREHOSPITAL SETTINGS. AM J HEALTH-SYST PHARM 2015;72:1544-54.
• DEV SP, STEFAN RA, SAUN T, ET AL. INSERTION OF AN INTRAOSSEOUS NEEDLE IN ADULTS. N ENGL J MED 2014;370:E35.
• ROMAN C, EDWARDS G, DOOLEY M, ET AL. ROLES OF THE EMERGENCY MEDICINE PHARMACIST: A SYSTEMIC REVIEW. AM J HEALTH-SYST
PHARM 2018;75:796-806.

• STERN SDC, CIFU AS, ALTKORN D. DIAGNOSTIC PROCESS. SYMPTOM TO DIAGNOSIS: AN EVIDENCE-BASED GUIDE, 3E. NEW YORK, NY:
MCGRAW-HILL; 2014.
• WOLFE TR, BRAUDE DA. INTRANASAL MEDICATION DELIVERY FOR CHILDREN: A BRIEF REVIEW AND UPDATE. PEDIATRICS
2010;126(3):532-7.