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 [...]

In the past couple of months, we have had a number of patients present to our ED with acute overdose secondary to the ingestion of valproic acid (VPA). When reading further about toxicity secondary to VPA, I was surprised to find that on an annual basis, there are approximately 8,000 reported cases of VPA toxicity in the United States. There are a number of concerns with VPA toxicity that one should be mindful of: The [...]

In a departure from previous guideline recommendations for sedation, the new Pain, Agitation, and Delirium guidelines in CCM have moved away from benzodiazepines as first line sedatives.  Taking over are propofol or dexmedetomidine who now occupy the first line sedative of choice position.  While many of us in the ED are familiar with propofol and have amassed an understanding of its practical use, dexmedetomidine is equally unfamiliar. Dexmedetomidine is a central alpha-2 agonist, similar to clonidine, [...]