In light of the JAMA and NEJM articles that have been recently published regarding outcomes associated with therapeutic hypothermia (TH) status post-cardiac arrest, I figured this would be a good time as any to cover complications associated with this phenomenon- namely, shivering. As we all know, the goal in TH status post-cardiac arrest is to reach a goal core body temperature between 32 and 34 degrees Celsius for a period of 12 to 24 hours in [...]

In a story featured on NPR yesterday, news of additional warning information on labeling for oral emergnecy contraception in Europe has raised questions as to why similar label changes have not yet occured in the USA. The story focuses on a recent meta-analysis [1] that describes the effectiveness of the oral emergency contraceptives levonorgestrel (Plan B) and ulipristal acetate (Ella). In this case, I must agree with the FDA, that there is not enough data [...]

With all the controversy surrounding the questionable association of mortality associated with the use of etomidate for the purposes of induction in the septic patient, it only seems reasonable to recommend alternative agents in this setting...or design therapeutic analogues. Enter carboetomidate. Carboetomidate is a derivative of etomidate that contains a pyrrole ring in its structure, as opposed to an imidazole ring that is found in etomidate. What is the significance of this? It has been [...]

The first drug that I ever had clinical experience with was flumazenil. It was as a student during my final year of pharmacy school, and it occurred while I was on my clinical practice rotations. We had a patient on our ward service who had an MRI and was extremely lethargic following the procedure. We soon discovered that our patient received more lorazepam than he could tolerate prior to the procedure, which seemed to be [...]

Expanding on a previous post where we discussed the importance of IM administration of epinephrine for anaphylaxis (vs subcutaneous), I wanted to discuss epinephrine auto-injectors for in hospital use.The mechanism and effects of epinephrine for anaphylaxis is several fold.[1]  Through alpha-1 agonism, vasoconstriction followed by increased peripheral vascular resistance leads to increased blood pressure as well as limiting the degree of mucosal edema. Beta-1 agonism increases the inotropy and chronotropy, and beta-2 agonism leads to [...]

In an earlier post, the nuances associated with the administration of Kcentra was discussed. One point of contingency was associated with the dilution and rate of infusion of Kcentra. The package insert provides the following information with regards to the rate of administration: "Administer by intravenous infusion at a rate of 0.12 mL/kg/min (approximately 3 units/kg/min) up to a maximum rate of 8.4 mL/min (approximately 210 units/min)." The package insert also provides additional information with [...]

In an earlier post, I discussed some of the nuances associated with the administration of opioid analgesics (particularly morphine and hydromorphone) in the emergency department. This post will review some of the studies that have been recently conducted to evaluate the safety and efficacy of these agents for acute pain management in patients who present to the emergency department.  Hydromorphone:Chang AK et al.; Ann Emerg Med 2013: This was a prospective study that evaluated the safety and [...]

Very quietly, an article that many EM clinicians have been waiting for was recently e-published in the journal Circulation and with no fanfare and no fancy acronym in the title. I am referring to the new [to the United States] and hot drug that has gotten a lot of press in terms of its potential for use in the emergency department that has been cited in the package insert since it first was approved by [...]

After the inclusion of Kcentra to the armamentarium for acute reversal of anticoagulation, a few practical issues have come up that are worth sharing. 1) Product contents:Depending on the products previously used at a given institution (here it was Profilnine), there are several differences in the contents compared to Kcentra. One particular of note is that Kcentra contains approximately 40 units of heparin for every 500 FIX units.  Therefore a patient could receive anywhere from [...]