This is From Novice to Night Shift, an original production from the Emergency Nurses Association. This Audible series takes you into the world of emergency nursing, where experienced professionals share real-life scenarios, discuss critical cases, and reflect on the challenges and triumphs of working in this dynamic field. Whether you're just starting your journey or a seasoned pro, this series is your go-to for expert insights and relatable stories from the frontlines of healthcare. Now, here's From Novice to Night Shift. Welcome to ENA's Novice to Night Shift, Audible learning series where experienced emergency nurses like us talk and explore real-life nursing scenarios. We also discuss critical cases and share our experiences as healthcare professionals. I'm your host, Monica Escalante-Kobuk, Director of Novice Nurse Education here at ENA. I'm joined today by two incredible nurses with extensive experience in emergency nursing. Greta. Hi, I'm Greta Kumsel. I am a Program Development Specialist for the ENA. Hi, I'm Amy Toups, also a Program Development Specialist for the ENA. Today, we're going to talk about an interesting case that involves a patient who went into polymorphic ventricular tachycardia after taking a very commonly prescribed medication. But before we tackle this case, let's take some time out and pause to recognize the patients that we learn from. Our ability to care for patients that we encounter daily is really strengthened by our ongoing remembrance and respect for those we treated in the past. So let's make sure that we keep our hearts compassionate to help provide excellent care for our future patients. All right, I'll walk through the case and give you guys the patient presentation, and then we'll talk about treatment, pharmacological actions of medications, pathophys, and some EKG stuff today. All right, are you guys ready? So ready, always. This is one of those cases that really sticks with you. So I cared for this 11-year-old patient who's brought in to the ED by EMS. His mom was with him and he was having a lot of nausea and vomiting, and his mom decided to give him one of his sisters on dancetrons. So his sister suffers from migraines and mom had it on hand, so she figured, you know what, they're around the same age, it'll work, I'll give it to him, help with the nausea. Mom said the whole house had been having vomiting and diarrhea for the last couple of days and she really thought that her son was the next victim, I guess, of the virus that was going around the house. He said he felt better, so after she gave him the medication, he felt a lot better and he wanted to go play baseball. He had a game. Mom said he was there for like, well, we know how baseball games are, right? Like four or five hours. He was running around and then all of a sudden he fell. Bystanders said that it looked as if he had had a brief loss of consciousness, but there was really no trauma. They called EMS, EMS arrives. So baseball season, right? This is like summertime. Yeah, and plus he's been vomiting and had, sorry, did you say he had diarrhea? Yes, vomiting and diarrhea. And now he's at a baseball game. Yeah, running around, losing more fluid. Yeah, yeah. No, no, that's exactly what we thought initially was like, okay, they've got a virus going on. Everyone's vomiting, throwing up and diarrhea, all that stuff. Plus running around for four to five hours after you've been sick, likely what? Dehydration. Yeah. Was he alert when EMS got there? Yes, he was alert. So when he initially came in, the first thing we do is the pediatric assessment triangle, right? PATS. So the first assessment that you do, you'll kind of see exactly that general impression. What does he look like? Unlike adult patients, not all kids can express how they feel and help you out. And then that's, I think, what is the challenging part of taking care of pediatric patients. What I like about the pediatric assessment triangle is that it doesn't even involve touching the patient at first. It's a quick 30 second across the room assessment. So each side, for those that don't know, the pediatric assessment triangle, each side of the triangle represents a different area of assessment. So you have appearance. What would you look for when you're thinking appearance? Skin color. Work of breathing. Work of breathing is the other side of the triangle. And then circulation is the last part of the triangle. So you're looking at their appearance, the work of breathing and circulation. So as experienced nurses, when you're looking for work of breathing, what is it that you're looking for? Is there any retractions, nasal flaring? Chest rise and fall. Yeah, symmetrical, all that stuff. He's 11. Looking at him, he was breathing fine. He didn't look dusky or anything like that. What are some things that you look for in circulation? Color. Is there any hemorrhage for circulation? Yeah, yeah. Also, when we look at them, we're looking, is the child, especially when they're younger, are they limp? Are they flaccid? Are they stiff? Are they interacting with their caregiver, right? Younger children, the cry, it tells us a lot. The pitch of it. Are they old enough to speak? He's 11. But we also have to consider other things such as neurodiversity. Are they able to, just because they're 11, doesn't mean that there aren't other things going on as well. We can't just look at the patient, right? We have to break out our stethoscopes, listen to breath sounds, check work of breathing. You mentioned nasal flaring, retractions. Where else can we look to see retractions in the little one? Supraclavicular. And then we also look for... External retractions too, right? And... Entricles hugging. Yes. What are some other things we would look for? Accessory muscles. Exactly. Okay, so those are all examples of what we're looking for at a quick glance to know, you know, what's in it. All that stuff is going to come with experience, right? So for those novice nurses, you may have to have a framework in your head that you go through so you can remember to check this and to do that. But that will come with experience. The more times you do this, you know, the easier it gets to identify those red flags. So let's talk about the third part of the triangle, which is circulation. So Greta, tell me what you look for when you assess circulation. Certainly the overall color of the patient, but you do have to make sure you actually have the lights on in the room. Believe it or not, some people don't do that. And then skin tone actually can make a difference as well as where you look for circulation. Yes, skin tone has to do with the amount of melanin in a person's skin. So it has nothing to do with their race. So people of color experience health disparities. And we know in the literature and in practice, we see people of color experience poor quality of health care and outcomes. We do. And I think we can do a better job of educating ourselves on dark skin tones and what we need to do as health care providers to assess them appropriately. Yes. I know here at ENA, we're doing our best to ensure representation of dark skin tone in our educational material. Getting back, let's not get off track here. So getting back to circulation, detecting changes in skin color, pallor, cyanosis, jaundice, flushing can be challenging when you're assessing people with darker skin tones as well. What you want to look for when you have someone who has a darker skin tone, for cyanosis, you're going to be looking at their lips and tongue to see if they're cyanotic. But in darker skin tones, you would see more gray or white. The palms and soles, conjunctiva, nail beds, they're going to be more of a bluish tinge. So these are abnormalities that would indicate hypoxia in darker skin tone persons. But you also have to look at the inside of the mouth. The palate, actually, you can tell someone with darker skin tone is having circulation issues if you see more of a pale color. What's something else that's a little bit more difficult? Can you guys think of anything else? I think petechiae might be a bit difficult on dark skin tones. Yeah, you'd probably have to look inside the mouth as well. Mm-hmm. You're right. Or a mucosa or the conjunctiva to see in darker skin tones. So pallor is something that we look for. We talked about that. People with darker skin tones, you're going to have to look inside the mouth. Look at the mucous membrane for that ash gray color. Remember, lighting is really important. As Greta mentioned, ambient lighting or a halogen lamp would be ideal. But you're not going to like, oh, is there a halogen lamp in here? Do your best. But you may have to turn on all the lights in order to see better. Because of the decreased blood flow to the skin, brown actually appears more yellow-brown, and very dark brown or black can appear like an ash gray. So that's something for you, newer nurses, to think about when you're assessing people with darker skin tones. How would you assess somebody with darker skin tone for jaundice? Jaundice, the best place probably would be looking at their sclera, closest to the cornea, and also at their oral mucosa. Yes. Okay, so all of this is happening in that quick 10 seconds. Like, they're rolling in, and you can see that. I can see if someone is jaundiced. I can see if someone's cyanotic. Here's a documentation tip. Stop charting pink, warm, and dry. That drives me absolutely nuts. Words like red or mottled and skin blanching, all of those are better words that represent an assessment of lighter skin tones. But when you see, like, my skin tone, I'm pretty tan. I'm medium brown. I'm certainly not pink, am I? I'd be concerned if your skin was pink. Correct. It would cause concern. It would be, like, flushing or hot to touch if you were pink. Yes, that is a huge pet peeve when I see documentation on people with darker skin tones that says pink, warm, and dry. Skin color appropriate for ethnicity. Something like that would be more accurate than calling someone pink, warm, and dry. Any other tips for documenting? I was going to say for other documentation tips. Like, you actually have to assess the skin and touch the skin to be able to say, is it cool, clammy, yeah, warm, and dry. I mean, you could still chart pink, warm, and dry if they indeed are pink, warm, and dry. It's what you're seeing, and that's fine. And that may be accurate for someone who's got lighter skin tone. But don't do it for the darker skin tone people. If you're looking for more information on the assessment of darker skin tone persons, check out the episode notes for a list of references that we've provided for you to take a look at what you can be documenting and how to perform an assessment on different skin tone person. Ultimately, though, the Pediatric Assessment Triangle helps you determine sick versus not sick. So you'll know immediately what kind of resources and help you need to take care of your patient. And also, just a word of advice, you can't properly assess a child or any patient for that matter when they have their clothes on. A lot of times, children might come in wrapped up, bundled up. You need to remove the layers to properly assess them. Let's get back to the case. OK, so what did this 11-year-old patient look like? So awake, alert, tone was appropriate. He was looking around the room. He was talking to us. He was complaining of feeling weak and dizzy after playing baseball. He didn't have any increased work of breathing. I don't recall anything abnormal about his breathing at all. No retraction, nothing like that. He wasn't bleeding, and he looked pink and dry. Nice. I'm kidding. To be accurate, I would say his skin was fair. His face appeared flush, and his cheeks were a rosy red color. His vital signs were, let's say, heart rate was 118, BP 110 over 50, respiratory rate 23, 24, O2 stats, 98% on room air, started an IV, I put in a 22 gauge because I'm nice, a saline lock to his right AC, and we did an EKG right away. His EKG showed sinus tachycardia. He was saying at this point that he didn't feel good. He was tired. His stomach was upset. His mom said, he's never been like this before. I don't know what happened. He doesn't have any past medical history. He doesn't have any allergies. I mean, he was playing baseball earlier, right, and vomiting? Yeah, the vomiting was like way before, but yes, he was playing baseball. Did EMS give a glucose at all? Yeah, that's one of the different things. Did EMS give a glucose at all? Yeah, that's one of the differentials that was running in our head because, you know, when we have kids around that age, you're thinking, oh, is this a new onset diabetic kid or something like that? EMS said the sugar was 92. He wasn't hypoglycemic, so his blood sugar is normal. What would you guys think at this point? Give me some differentials. I'd still be pretty heavily thinking dehydration with sinus tach and not feeling well. Just the history of the GI upset. That brief loss of consciousness is weird. That is weird. Unless it was a vagal response from being out now. It's always hard when you hear that from bystanders, right? Correct. What does that mean? What does it mean? And it's always longer than it actually was, right? It's like, oh, he was out for 10 minutes. Really? Was it 10 minutes? 10 seconds, maybe? Yeah, so I don't feel like it feels like a long time. Yeah. So there's a lot of things we can be considering as well. And also, I mean, just because his blood sugar is normal doesn't mean there isn't something going on, right? Anyway, so EMS leaves the room. I noticed some changes on the cardiac monitor. And I was hoping, you know, when you see something on the monitor and you're like, that's probably artifact, right? You're hoping it's artifact. I was asking the patient, how are you feeling? Because that's the first thing. You see something on the monitor, then you look at your patient and you ask them, you know, how's it going? Trying to see if everything's okay. And he starts slurring his words and kept saying, I feel funny. Do you know how scary that is seeing a kid slurring their words? Like, it's just the most abnormal thing to see. I've seen it in adults. It's happened to me for adults, but I've never recalled that happening to me with a kid. It's almost like a heart drop moment. Like, something's happening. Yeah, it's a very uncomfortable feeling. And you're like, right? Like you want to get somebody else in the room with you. I reassess him. I'm taking his vitals, his heart rate. I'm looking at the monitor. It's 160 to 200. BP, 80 over 40. His respiratory rate now, he's like at 26. His SATS was 90% on room air. His central pulses were really weak. We had weighed him. So I already knew that he was about 80 pounds. He was on the little smaller end, which comes out to like 36 kilos. So just in these vitals that's happening right now, obviously these are red flags. Like, this is abnormal. So we got another EKG right away. So what was the EKG? What was the rhythm? So on the monitor, it looked like this progressing. It looked like, if you think of music as like crescendo, decrescendo, that's exactly what it looked like to me. And it just seemed wild. Like I'm looking at the monitor thinking, yeah, that's not normal. And I know that's not normal. And I have a feeling I know what this is, but let's get an EKG to confirm it. He was in polymorphic ventricular tachycardia with a long QT. So in other words, torsades de points. But I feel like I should say it like it was meant to be said, tor, right? Yes, that's excellent. Thank you. Actually, it is French. So I think I did a great job pronouncing it. You can correct me later. Anybody who is French, I'm sorry for, you know, whatever. Anyway, so it means translated literally is twisting of peaks. It's a specific type of abnormal heart rhythm, obviously, and it could lead to sudden cardiac death. Okay, so why don't you break down torsades for us then? Torsades, you will always remember it. So essentially the heart has a pacemaker and then two backup pacemakers. So in the case of torsades, neither of those pacemakers are working. They lose control and the ventricles take over, causing the heart to beat really, really fast. This can cause electrical impulses to travel around in loops known as reentrant pathways, producing the characteristic helix, you know, wave pattern of torsades. I like the word helix. Yeah, helix is good because you think of the DNA and that's exactly what it looks like is that twisting. Is a long QT syndrome, can that be a genetic disorder? Yeah, it definitely can be a genetic inherent mutation from their parents that can cause the disease or make them more susceptible to develop it later in life, or it can be triggered by electrolyte imbalances or certain medications. So this could be something, the patient had the long QT syndrome and maybe the family didn't know that they actually added energy. When you think about it, how many times do you, I mean, do you get EKGs on healthy children? Right. It's not standard in practice to have a baseline EKG on a child. Certainly an option to think about and something we were thinking like, did this kid have this and we just didn't know it or mom didn't know? Mom said no past history, but obviously this kid is getting a cardiac consult either way. The long QT syndrome is not super likely since it's not very common. It actually occurs in one in 2000 births. That actually seems a little bit more common. Like if I said one in a hundred thousand, then I'd be like, yeah, but I guess one in 2000 is a little bit more common, but let's put it on our differential. So possibly that he has some sort of long QT syndrome that maybe the family didn't know about. What else could have caused this? Any guesses? Actually. You do know this. We talked about this. Yeah. I actually read this. I think what I was reading about odansetron. Odansetron can actually cause a prolonged QT syndrome. We give odansetron to a lot of patients. I know it's crazy, right? Like everybody. A lot. So pretty much anyone with any sort of gastroenteritis receives it. You said you read about it. What did you learn about it? So there are some actual theories about different receptor antagonists that block the cardiac sodium channels, which can widen that QT interval, but the researchers aren't exactly sure that that's the main cause. Did you read anything else about other meds that can cause prolonged QT? Yes, actually certain antiarrhythmics, antibiotics, anti-medics, induction agents. There are some antipsychotics. If you've ever had to admit a patient to behavioral health unit, they always ask for the EPG. Oh, the EPG. Yes. And if that QT is prolonged. They want medical clearance first. They want medical clearance. Yeah. Or. Additional workup. Specific lab drawn to accept the patient. Ooh, that reminds me. In doing some research for today's case, I came across an interesting case of a seven-year-old with known congenital long QT syndrome. He was scheduled to have his tubes placed in his ears, so they gave him midazolam preoperative, and when they sedated him, they gave him nitrous oxide and sebofluoride. He was in sinus rhythm, and then shortly after anesthesia induction, EKG was showing bigeminy, then trigeminy, then VTAC. So they immediately stopped the sebofluorine, and then he went into torsades. It's a really interesting case. Sounds like a terrible progression. I mean, and that's kind of how, sometimes you see bigeminy, and then it's dry, and then you're like, yeah. You're like, this is not good. That's a whole other episode. And actually, the kid ended up being fine. I'll add a link to the article, so in the episode notes, so you guys can take a look at it if you're interested in reading about it. Okay, so at this point, the 11-year-old patient. Yes, let's go back to the kid. Heart rate's in the 160. They're hypotensive. They're obviously decompensation. What happened next? I mean, obviously we recognize this is abnormal, right? We noticed that there were changes in his mental status, this slurring of speech, his vital signs. So the management of torsades begins with first assessing the patient is hemodynamically stable. Was he? No. At this point, the heart rate's like 160, 220, BP 80 over 40, the heart rate is 26. We hooked him up to, end tidal CO2 was 45 to like 50. His O2 sats was 93%. We threw on 15 liters of oxygen, non-rebreather. Another nurse started an IV. I had already drew labs, so that was already cooking. We had a CBC and a CMP running. I initiated a bolus, and the physician ordered magnesium sulfate. Amy, do you want to explain why we use mag for torsades? I would love to. Magnesium sulfate acts as a calcium channel blocker by blocking calcium channels during repolarization. The magnesium suppresses the early after depolarizations that lead to torsades. So what's the dose of mag? So mag dose for peds is usually about 25 to 50 milligrams per kilogram, obviously dependent on the provider. Give an IV over about five to 20 minutes, and then typically it's followed by an infusion. Thanks, Amy. He was about 80 pounds. Physician ordered 25 milligrams per kg. So loading dose is 900 milligrams, and did he respond? Well, peds scare me. I'm not comfortable, I will admit that. So I'm always like triple-checking my medication. If you have a pharmacist in your ED, oh my God, that is like the best thing ever. If not, I always want to double-check my medications with other nurses just in case. So yes, I gave the loading dose over 10 minutes because mag can cause hypotension too rapid of an infusion. That was very smart, you gave slowly. Thank you. I reassessed the patient. He was more confused, heart rate 200 to 220. Rhythm still showed torsades. He was at this point now 70 over 30, respiratory rate 20-ish. His end title's 45, O2 stats was 93% on 15 liters non-rebreather, plus his pulses were very weak. He was clearly hemodynamically unstable. Yeah, torsades is never really stable. It's typically pretty short-lived and it'll usually flip back and forth into sinus rhythm or sometimes it can even go into V-fib. Even if the patient looks like they're okay, they're not stable. But in this case, he didn't really look okay. He actually declined pretty fast. So since the magnesium didn't work as your cardio version, did you consider electrical cardio version as the next step? Exactly, we ended up cardioverting him. He needed an electrical restart to correct that heartbeat that was like way too fast and irregular. So you try the mag, that's your first place to go is the chemical cardioversion. If that doesn't work, then the next step is electrical, especially because he was decompensating. So heart rate 200 to 220, this is a lethal arrhythmia that requires a really quick response. And cardioversion is, I mean, just from seeing it, appears very painful. It can cause a lot of anxiety, but I don't know what his mental status was. I assume it wasn't very- Yeah, for sure. And even then it's gonna cause pain. So we gave fentanyl and midazolam as a sedative, and you better believe I already had pads on him and connected him to the crash cart. Because the minute I saw that on the monitor, that's the first thing you do is get the crash cart in the room, put them on the pads. In circumstances like these, you really want sedation to have a quick onset, have a low cardiac effect, and you want the patient to recover quickly. So fentanyl is a potent opioid and its dosing should be really carefully titrated to achieve that level of pain control that you're going for, while minimizing the risk of any sort of respiratory depression due from its sedative effect. That's right. Fentanyl is administered by IV infusion, which we don't really do in the ED, right? Like I hope we're not really having to keep patients that long that we're putting them in PCA pumps and stuff. But anyway, we're used to giving fentanyl slow IV push. The dose is in micrograms per hour. Midazolam is a benzodiazepine, and that one is hemodynamically safe. And it's commonly used for kids who are undergoing any type of procedures because it causes drowsiness and it could be used for anxiety as well. But remember, if we think to ABC's here, Airway, he wasn't intubated at this point. And for those new nurses, make sure you have your equipment ready just in case, especially a case like this. Let's take a moment to walk through a cardio version. So you put the patient in supine position. Hopefully we know that. The patient already has an IV. They have fentanyl, midazolam are given. So make sure your attachments to the monitor leads are going to the crash cart and you actually see the rhythm on the defibrillator monitor. Yeah, that would be bad if we couldn't do that. Right. Then the pad should be placed on the anterior. So the front of the chest, one of them goes above the right upper third of the sternum, kind of below the clavicle. And the other is placed on the left of the nipple line below the axilla. So it's a small pediatric patient. You can also place one on the front of the chest and the second one on the back of the chest. So anterior posterior location. So don't place the pads, obviously on top of EKG leads. Essentially follow the recommendations of the defibrillator pads and the device you use for cardio version. Absolutely. But remember every hospital uses different equipment. So be sure that you are familiar with the monitors that your hospital uses. And sometimes we have to consider EMS doesn't always carry equipment that's compatible with your hospital. So you have to make sure that you know whether or not your pads are compatible with the EMS pads as well. So to be clear, this was a synchronized cardio version. So for that, we're switching the monitor on sync mode and you'll see the tick marks on the QRS peak. Synchronized cardio version is a low energy shock and it uses the sensor to deliver the electricity that is synchronized. Hence why we switch it over and we're looking for those tick marks. The machine has to know where the peak of the QRS is because that's the highest point of the R wave, right? So when we're in the sync option and that's engaged on the defibrillator, once we push the shock button, there'll be a delay in the shock. And what's happening is during this delay, the machine is ready and reading the rhythm to synchronize with the patient's EKG rhythm. So that's essentially what we do for a synchronized cardio version. And you're still making sure that everyone's clear of the patient. Yeah, correct. I'm not just like switching sync and being like, oh, shock. No, you still have to go through the whole, everyone, I'm clear, you're clear, everyone's clear. Nobody should be touching the patient. We're also prepared with respiratory at the bedside in case we need intubation as well. So you selected your proper energy level and sync cardioverted at what? Like 0.5 joules per kilogram? So about 18 joules? You're so good at math. Yes, that's exactly right. The pediatric patient and energy joules are different by weight. So make sure you're familiar with ACLS as well as pediatric advanced life support algorithms as well. So yes, Freda, the energy was at 18 joules. I cannot stress enough how necessary reassessing the patient is after each of the intervention. It's like one of my major pet peeves. Gotta always check breathing, circulation, pulse. There's a lot going on during cardioversion. After the first cardioversion, I reassessed the patient. I mean, we're all there, right? The physician's there. He didn't have any changes in vital signs. He remained like 200, 220. Rhythm still showed, torsades. BP was worse now. It was like 68 over 42. O2 sat like 93% and tidal was 45. Respiratory rate was like 20 and his central pulses were still weak. I'm assuming you cardioverted. Yeah, yeah, we did. At this point, the 18 joules doesn't work. So now we're gonna go up a level. The physician ended up increasing the energy level to one joule per kg. If you guys remember, he was 36 kilos, so 36 joules. Just be aware that many defibrillators default back to the unsynchronized mode after you provide a synchronized shock. Just be sure that you turn it back into sync mode and that you are visualizing the- The tics, the tics. And you know what? The funny thing is that's exactly what happened. How often are you cardioverting somebody in your nursing career? It's not super frequent. A couple times a year, maybe, if that. So that's actually what exactly would happen. I was like, I don't see the tics anymore. Then you have to hit the sync mode again. So that's exactly what I did. Hit the sync mode again. I gave a second synchronized shock, one joule per kg, so 36 joules. Drum roll. Did it work? Absolutely, it worked. He was more awake. He started to vocalize and ask for his mom. The monitor showed normal sinus rhythm with a heart rate of 110. BP was so much better, 100 over 65. His respiratory rate had increased. His end tidal was now 38. His O2 sats were much better, like 95, 96%. At that point, the physician wanted to repeat the EKG. And obviously, we were getting a PICU bed for this kid. So what's the process at your hospital to get a PICU bed? We notify the charge nurse, who then calls the bed coordinator and they request the PICU bed. I was lucky. I got a bed pretty quickly. And also, you have to know at this point, if you don't have a pediatric ICU, you're gonna be transferring out. So know what your policies and procedures are. So I got the bed quickly. I called report and we transferred the patient upstairs and did a bedside report. Nice job. Thank you. You're welcome. Yeah. As we wrap up, what are some of the key takeaways for our novice nurses out there? Well, for our new nurses, even our experienced nurses, you've got to know your lethal cardiac rhythms. Read about them, brush up on your skills, identifying them. It's not often that we may see them, but you need to know how to correctly identify them and know what to do. And in this case, getting a thorough medical history really made a difference too in identifying the cause. Yeah, I think something else important to take away is reassessment after each intervention. I always think of when you mess, reassess. When you mess, reassess? Yeah, when you mess with the patient, reassess. Oh, that's a cute one. Oh, that is a good one. Never heard of it. Never. But now you all have out there. Thank you, ladies, for your insight and your knowledge. And thank you, our listeners, for joining us. We hope you found this episode informative and remember to always follow provider orders in your individual hospital's policies and procedures. If you have any questions or want to share your own experiences or cases, please reach out to us at residency at ENA.org. Until next time, stay safe, stay compassionate, and remember, as nurses, we can play an essential role in saving lives and making a difference. Au revoir!

emergency nursing

torsades de pointes

pediatric assessment

cardiac rhythms

magnesium sulfate

nursing education

ondansetron