It seems as though the traditional "go-to" management of atrial fibrillation in the setting of rapid ventricular response in the emergency department involves rate control and anticoagulation. Can we break this tradition and consider alternative therapeutic management in certain subpopulations of patients with dysrhythmias? Recently, there has been some discussion regarding the use of rhythm control for new-onset atrial fibrillation, particularly procainamide, which used to be used back in the day and has started to [...]

Here is my attempt at a trick of the trade. This one is focused at the intubated STEMI patient in whom the EMS crew couldn’t get the 324mg of aspirin on board, and the cardiologist wants to load with clopidogrel 600mg as well as atorvastatin 80mg. Provided we can drop an OG tube before the patient gets sent to the cath-lab, this is how we get the meds into the patient:Grab a Toomey Tip 60mL [...]

My residency program director once made the following statement: "Pregnancy is the worst STD that anyone can get." At the time, I laughed when he said this, and I asked him to clarify this somewhat startling observation. We then had a brief discussion and came to the conclusion that pregnancy is associated with many comorbidities that otherwise would not typically occur in the non-pregnant patient. These include conditions of pregnancy that we commonly think of [...]

As I was preparing a post discussing antimicrobial double coverage, I was describing the utility of a hospital antibiogram in aiding in the selection empiric therapy.  Let’s just say I’m glad I have had teachers and mentors whose favorite question was “why.”  While trying to answer that simple question, I came across this article from 2007 [1] that did an excellent job describing the limitations of antibiograms. Although I was aware of certain limitations of [...]

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 [...]