Let us say you have a patient, SH, who presents to the emergency department with the following chief complaint: "It's happening again- I just need to be intubated." This seems to be more than a little interesting and you think to yourself, "What the heck? Let me check this out." You then begin to recall that the patient looks a little familiar to you. In fact, SH has been to the ER more than a [...]
A few days ago I read a few tweets about evidence versus eminence-based medicine and the ensuing discussions. I started to think of a number of examples of eminence based medicine I practice; but not out of old habits, or limited knowledge – but because there’s simply a lack of evidence. Diltiazem dosing for AFIB rate control was one of them. So sayeth the drug reference; the initial weight based diltiazem dose for rate control [...]
We are all familiar with this label on the vials and packages of antimicrobials that have been prescribed to us over the course of the years: How often is this to likely occur among patients discharged from the emergency department? The most challenging part of providing patients with prescriptions for antimicrobials to be filled once they are discharged from the emergency department is the fact that (a) there is no guarantee that the prescription will [...]
Vancomycin dosing in EDs has been on a journey from “a gram” for everyone towards a weight based dosing scheme. This shift has been driven by a number of sources, but namely by the Infectious Disease Society of America, American Society of Health-System Pharmacists and Society of Infectious Disease Pharmacists' (IDSA/ASHP/SIDP) guideline recommendations for vancomycin therapeutic monitoring.1 The change in dosing strategy is similar to other ID discussion nowadays; resistance and multidrug resistant pathogens are [...]
Ingestion of cyclopeptide mushrooms can lead to irreversible hepatotoxicity that may potentially be life-threatening. The mechanism by which hepatotoxicity occurs is through the activity of α-amanitin, which is taken up by hepatocytes and inhibits DNA-dependent RNA polymerase II, preventing DNA transcription into mRNA, which consequently halts the process of protein production. This causes injury of organ systems that are highly dependent on protein synthesis, such as the gastrointestinal mucosa, kidneys, and liver, which eventually leads [...]
When it comes to drug therapy in cardiac arrest, we just can’t get it right. Granted, the heterogeneity of the causes of cardiac arrest as well as patient population characteristics make it difficult to find a drug (or combination of drugs) that will improve survival. But that doesn’t stop us from looking for one. Take for instance, aminophylline. Yes, aminophylline.The ethylenediamine salt of theophylline, aminophylline is thought to counteract the effects of adenosine on the [...]
A few weeks ago, we received an interesting question from one of the ED attending physicians regarding the immunogenicity of alteplase. Providing him with an answer made me realize to not take for granted the information available regarding the differences between the various thrombolytic agents, and reading more about this topic made me a bit humbled by the years of research and clinical experience that went into what we currently know today about these agents. [...]
While I’m not a huge fan of nitroglycerin paste, I understand it’s clinical usefulness. The ability of slapping on an inch of paste to relieve chest discomfort is certainly non-invasive and can achieve effective results. With this simplicity, a degree of randomness exists with regard to the ability to titrate the dose. If the desired clinical effect is not achieved, how much more can we apply safely? Conversely, if hypotension results, how long will the [...]
Since starting my residency, nicardipine has become one of the drugs that I have grown to love…maybe even becoming one of my favorite drugs to use for blood pressure control, especially in neurological emergencies such as acute ischemic stroke and subarachnoid hemorrhage. Time and time again, it has never failed me in these settings. It’s like a best friend who shows up at the right place and at the right time who knows exactly what [...]
Extended infusion beta-lactam antibiotic administration is a growing trend in US hospitals. This dosing strategy takes advantage of the pharmacodynamics properties of drugs like Zosyn (piperacillin/tazobactam), improving time over the MIC (T>MIC) to susceptible bacteria while providing cost savings. Based on computer Monte-Carlo simulations, dosing Zosyn 3.375g IV q8 infused over 4 hours, the same probability of achieving a therapeutic T>MIC is reached as dosing Zosyn 3.375g IV q6 infused over 30 minutes. It’s a [...]