Take the case of a 34-year-old female with a psychiatric history who presents to your emergency department with a chief complaint of lightheadedness. As you, the pharmacist, and the emergency medicine physician are at the bedside examining the patient and asking her questions about her present symptoms and past medical history, you observe that the patient becomes short of breath, and you notice that the EKG monitor suddenly changes from normal sinus rhythm to ventricular [...]

A physician I work with in the ED makes it his personal mission to send me on a literature search at least once during each of his shifts. He recently told me that he had “heard something on a podcast” about giving corticosteroids for symptomatic relief in pharyngitis, and wanted to know if there was any validity to it. I wasn’t immediately familiar with the podcast in question, so I set out to do some [...]

Four-factor prothrombin complex concentrate (4FPCC) has been available in the United States for the past two years. We first broke news of its approval by the FDA in the branded form of Kcentra on this blog, and now that we have had clinical experience with it in its use for warfarin-associated bleeding (as well as its off-label use for management of target specific oral anticoagulants as we await the highly anticipated pipeline antidotes of these [...]

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 [...]

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 [...]