Say you have a patient who consumed almost an entire gallon of antifreeze over a span of 24 hours. Even Animal House’s Blutowski would be concerned, given that an adult who inadvertently sips 10-30 mL of antifreeze should be referred to the emergency department for evaluation of potential toxicity [1]. Initial lab results reveal an ethylene glycol (EG) level of 76 mg/dL, arterial pH of 6.9, and a serum bicarbonate level of 7 mmol/L. The [...]

Tramadol is a commonly prescribed analgesic that is used to treat a wide variety of painful conditions. Through a somewhat unique mechanism of action, tramadol acts as a mu-opioid receptor agonist and serves as an antagonist to serotonin and norepinephrine receptors. When compared to traditional opioids, tramadol, and its active metabolite M1 (O-desmethyltramadol) bind the mu-opioid receptor with 10 times less affinity than codeine and approximately 100 times less affinity than morphine. While the weak [...]

Over the past week, this article, which was published online ahead of print in JAMA Pediatrics (1), has made its rounds through the Twitter-verse: The investigators of this study aimed to assess the readiness of emergency departments across the United States in the provision of care to pediatric patients. This was based on the joint policy statement put forth by the American Academy of Pediatrics (AAP) related to guidelines for the care of children in [...]

If you ask 5 cardiologists and 5 toxicologists about the best way to predict the risk of Torsade de Pointes (TdP) in a patient with a prolonged QT, you will likely get 11 different answers. Here is what we know: A corrected QT (QTc) interval > 500 msec is associated with an increased risk of TdP (1). Not every patient with a QTc interval > 500 msec develops TdP (1). Not every patient with TdP has a QTc > [...]

A middle-aged male with no known history of hereditary angioedema (HAE) and a questionable medication history presents to your ED with oropharyngeal angioedema. He has received the usual cocktail of intramuscular epinephrine along with an intravenous antihistamine, H2-receptor antagonist, and corticosteroid with no improvement in symptoms. The EM resident asks you for the correct dose of C1-esterase inhibitor (C1-INH). Oh, and it is needed STAT because the decision has been made to perform rapid sequence [...]

Flying in under the radar recently were the changes to the Alteplase (rt-PA) prescribing information. These changes pertain to the contraindications to use of the drug in acute ischemic stroke. It's hard to find anything on the particulars about why the FDA authorized such changes, and more puzzlingly, why.The updated contraindications now read as follows: LinkDo not administer Activase to treat acute ischemic stroke in the following situations in which the risk of bleeding is [...]

When I began pharmacy school several years ago the thought of pursuing a residency wasn’t even on the radar. Like most other students at the time, I had a community pharmacy background and when the topic of post-graduate education was introduced I questioned its utility. I asked the important questions. Do I see myself working in a clinical setting? Is the extra year(s) of work and countless projects really worth it? Seriously you guys, who [...]

With increasing prevalence of antimicrobial resistance among bacteria coupled with the lack of novel antimicrobial development, multi-drug resistant bacteria will continue to be problematic [1]. Due to this increased prevalence, it is likely that even in the emergency department, we will see more and more patients with prior cultures or past medical history documentation of multi-drug resistant bacteria, such as vancomycin resistant Enterococcus (VRE). Once we are aware of this information, how should this affect [...]

Note: This is the introduction of a series of posts on Emergency Medicine PharmD called "Throwback Drug Thursdays" (#TBDT). It will feature medications that were once available for routine use in the emergency department, but are no longer on the market.   I work with some awesome providers within my emergency department, many of whom have been practicing for quite some time. Sometimes, they will reminisce back to their time during residency, especially the interesting [...]

I watched TRON over the weekend (yes, both the original and re-boot). If you’re familiar with the story, TRON was born in technology and “fights for the User.” I feel that the community of FOAM is taking on the role of TRON, and is fighting for the User/consumer/student of medical education. Often times, we are quite literally fighting (albeit minus a light cycle).It’s pretty easy now to get a colleague in the emergency department (pharmacist, [...]