I had an interesting discussions in the ED the otherday when I was talking about the importance of administering epi via IM for anaphylaxis.  Is there a diminished response to epi if a patients is on a beta-blocker?Let’s clarify: patients on chronic non-selective beta-blocker therapy may have a blunted effect of epinephrine in anaphylaxis but epinephrine administration may also result in profound hypertension and bradycardia or heart block.Non-selective beta-blockers will blunt the bronchodilatory effects of [...]

When the literature behind ticagrelor hit, there seemed to be a short-lived cheer. Where prasugrel (Effient) fell short, this drug excelled - superior (composite endpoint of vascular death, MI and stroke) to clopidogrel (Plavix) with no excess bleeding. What followed was a resounding thud since 10% of the population in PLATO, who were from North America, did not see this benefit. But the confusion didn’t end there.  Especially for pharmacists…In a mysterious turn of events, [...]

Epinephrine dosing and administration for anaphylaxis can be a tricky situation. In a strange, non-conformist type of stubbornness, the concentration parenteral epinephrine products are listed as a ratio (1:1000 vs 1:10,000 vs 1:100,000), rather than a percentage. There have been numerous reports, and personal experiences, where patients end up getting a significant overdose, or underdose of epi from miscommunication, dosing error or picking the wrong ampule/vial/syringe.An often-overlooked administration (won’t call it an error) issue is [...]

Ultrasound guided regional nerve block is an evolving trend in ED procedural sedation.  The thought being, local anesthetics could be used instead of benzodiazepines, ketamine or propofol, which could allow for earlier patient discharge from the ED and lower risk of complications (respiratory depression).Navigating the library of local anesthetics can be complex, particularly if your patient reports some allergy to lidocaine or prilocaine or if the drug is on shortage (an evolving problem in the [...]

This is a question that I’ve gotten a few times over the years.  You’ve got a patient in AFIB that has been rate controlled after a bolus of diltiazem and is now on a diltiazem drip.  The hospital has a policy stating a patient on a diltiazem drip must go to a cluster or ICU bed but the patient could go to a general medical floor, or even go home.  What can be done for [...]

An important, but all too often overlooked contraindication to thrombolytics for acute ischemic stroke is known bleeding diathesis including but not limited to current use of oral anticoagulants or an INR > 1.7 or a PT > 15 sec, heparin administration within 48 hours preceding stroke onset and an elevated aPTT at presentation, or platelet count less than 100,000 mm3.Including but not limited to… Very important, yet easily overlooked.  It also complicates matters, in that, [...]

I recently had a discussion about what makes a good EM pharmacist.  Below is a great essay by my EM pharmacy resident discussing just that. Being A Crystal Baller Nadia Awad, Pharm.D. There is one running theme that I have learned to appreciate and embrace since I started my emergency medicine pharmacy residency nearly three months ago. This theme can be summed up in one word: ANTICIPATION.Why is this important? For me, emergency medicine is [...]

I recently had a discussion about what makes a good EM pharmacist.  Below is a great essay by my EM pharmacy resident discussing just that. Being A Crystal Baller Nadia Awad, Pharm.D. There is one running theme that I have learned to appreciate and embrace since I started my emergency medicine pharmacy residency nearly three months ago. This theme can be summed up in one word: ANTICIPATION.Why is this important? For me, emergency medicine is [...]

"Evidence Based" Medicine - Ben GoldacreIt's amazing how fast ideas spread. I recently watched this TEDMED talk with the pharmacy students on my rotation as well as my pharmacy resident.  I've linked the Life In The Fast Lane post about it, since I've followed this site for a while and hope to see how the discussion grows.It's something we should all consider whenever interpreting data about new or old drugs... Are we getting the whole [...]

Fosphenytoin (fosPHT) is not a new drug. It was designed to improve the water solubility of phenytoin (PHT) thereby reducing the risk of cardiac arrhythmias and hypotension during administration (from lack of propylene glycol, although PHT is still a 1b antiarrhythmic). Improved water solubility also eliminates the risk of tissue necrosis if extravasation occurs. This allows for much more rapid infusion of fosPHT (150mg/min) as well as ability to administer IM.  Unfortunately, the drug failed [...]