Perspective is everything. Changing your perspective when learning can help gain a higher understanding; likewise in teaching, altering your perspective can help make a point. Take for, example, this recent article in NEJM[1] regarding the true incidence of bleeding associated with dabigatran.  Take a step back from the usual perspective of dabigatran being the spawn of Satan, if only for a moment. In this article, the authors propose that the reported incidence of bleeding as [...]

Very early on in my residency when I had my first experiences with rapid sequence intubation, my program director emphasized the importance of knowing the pregnancy categories and safety of these medications to "prevent getting burned" should such a situation arise. Here is a chart that I made adapted from two references1,2 that I have kept handy ever since: A previous post discussed the potential benefits of suggamadex as a reversal agent for vecuronium and [...]

The threat of multi-drug resistant pathogens is nothing new. Over the years, as we’ve developed antimicrobial agents to attack these pathogens, they’ve responded by evolving and mounting resistance mechanisms to stay alive.  Either alone or in combination, the mechanism are typically altering the binding site for the antimicrobial drug, reducing the intracellular antimicrobial concentration through efflux pumps, modifying the antimicrobial agent itself or altering one or more metabolic pathways to circumvent the action of the [...]

The case: A 65-year-old male presents to the emergency department today after a witnessed fall on his head by his wife. He was diagnosed with non-valvular atrial fibrillation two months ago and was placed on dabigatran 150 mg PO BID. He has fallen several times in the past week. His last dose of dabigatran was 6 hours ago. CT scan of the head shows a small right subdural hematoma with a 6-mm leftward midline shift. [...]

Deaths related to the abuse of prescribed opioid analgesics are undoubtedly a momentous concern in North America.  A recent article published in JAMA (JAMA. 2013;309(7):657-659) highlights the scope of the problem: seventy-five percent of deaths related to pharmaceutical overdoses are attributed to opioid analgesics.  While troubling, this figure has, in fact, been steadily rising over the past 11 years with no end in sight. Complicating the matter is a new focus in health care in the USA; [...]

I made a comment once on Twitter that if I ever became a physician, the specialty I would go into would be anesthesiology. Why? Anesthesiologists have time and again done such innovative things with medications in the operating room that have made their way into the practice of emergency medicine. One example that comes to mind is the use of intravenous lipid emulsion therapy for the treatment of various toxicological emergencies. Another instance is the [...]

It's one of those things that gets hammered into the head of nearly every EM resident by their attendings during their training. That little nugget of information related to rapid sequence intubation (RSI) that is woven into the curriculum and gets passed on from class to class of EM residents who will go on to advocate it when they become EM attending physicians. We cannot help it...it just IS. Yet, when we stare at it [...]

If anyone remembers studying for their SAT’s back in the day, complete this sequence:If SUX sucks, and ROC rocks, then Sugammedex _________.In a word, “unavailable.”  Sugammadex is a selective muscle relaxant-binding agent. As a result of its chemical structure, modified cyclodextrin compound with a hydrophilic outer surface and a lipophilic central cavity, sugammadex encapsulates both rocuronium and vecuronium.  This encapsulation creates a concentration gradient by which rocuronium or vecuronium leaves the neuromuscular junction for the [...]

An elderly female patient rolls into the emergency department as a trauma. The story from the paramedics is that she had a witnessed fall, and she was initially alert and answering questions appropriately. However, en route to the hospital, her mental status became altered and she began to go "in and out." She became combative and because the paramedics feared that her airway would become unprotected, the decision was made to intubate the patient. Her [...]

The empiric use of two antimicrobial agents with similar spectrum of coverage (aka double coverage) is often fancied for a few reasons:Synergy, either clinical or pharmacokinetic, between two antimicrobial agents.Differing resistance patters to increase likelihood of adequate coverage of the suspected organism.Prevention of the development of resistance.  Often, the second agent to be considered is either a fluoroquinolone (cipro/levo/moxi) or an aminoglycoside (amikacin/gentamicin/tobramycin). There is little, if any, data to steer towards one class or [...]