Epinephrine dosing and administration for anaphylaxis can be a tricky situation. In a strange, non-conformist type of stubbornness, the concentration parenteral epinephrine products are listed as a ratio (1:1000 vs 1:10,000 vs 1:100,000), rather than a percentage. There have been numerous reports, and personal experiences, where patients end up getting a significant overdose, or underdose of epi from miscommunication, dosing error or picking the wrong ampule/vial/syringe.An often-overlooked administration (won’t call it an error) issue is [...]

Ultrasound guided regional nerve block is an evolving trend in ED procedural sedation.  The thought being, local anesthetics could be used instead of benzodiazepines, ketamine or propofol, which could allow for earlier patient discharge from the ED and lower risk of complications (respiratory depression).Navigating the library of local anesthetics can be complex, particularly if your patient reports some allergy to lidocaine or prilocaine or if the drug is on shortage (an evolving problem in the [...]

This is a question that I’ve gotten a few times over the years.  You’ve got a patient in AFIB that has been rate controlled after a bolus of diltiazem and is now on a diltiazem drip.  The hospital has a policy stating a patient on a diltiazem drip must go to a cluster or ICU bed but the patient could go to a general medical floor, or even go home.  What can be done for [...]

An important, but all too often overlooked contraindication to thrombolytics for acute ischemic stroke is known bleeding diathesis including but not limited to current use of oral anticoagulants or an INR > 1.7 or a PT > 15 sec, heparin administration within 48 hours preceding stroke onset and an elevated aPTT at presentation, or platelet count less than 100,000 mm3.Including but not limited to… Very important, yet easily overlooked.  It also complicates matters, in that, [...]

I recently had a discussion about what makes a good EM pharmacist.  Below is a great essay by my EM pharmacy resident discussing just that. Being A Crystal Baller Nadia Awad, Pharm.D. There is one running theme that I have learned to appreciate and embrace since I started my emergency medicine pharmacy residency nearly three months ago. This theme can be summed up in one word: ANTICIPATION.Why is this important? For me, emergency medicine is [...]

I recently had a discussion about what makes a good EM pharmacist.  Below is a great essay by my EM pharmacy resident discussing just that. Being A Crystal Baller Nadia Awad, Pharm.D. There is one running theme that I have learned to appreciate and embrace since I started my emergency medicine pharmacy residency nearly three months ago. This theme can be summed up in one word: ANTICIPATION.Why is this important? For me, emergency medicine is [...]

"Evidence Based" Medicine - Ben GoldacreIt's amazing how fast ideas spread. I recently watched this TEDMED talk with the pharmacy students on my rotation as well as my pharmacy resident.  I've linked the Life In The Fast Lane post about it, since I've followed this site for a while and hope to see how the discussion grows.It's something we should all consider whenever interpreting data about new or old drugs... Are we getting the whole [...]

Fosphenytoin (fosPHT) is not a new drug. It was designed to improve the water solubility of phenytoin (PHT) thereby reducing the risk of cardiac arrhythmias and hypotension during administration (from lack of propylene glycol, although PHT is still a 1b antiarrhythmic). Improved water solubility also eliminates the risk of tissue necrosis if extravasation occurs. This allows for much more rapid infusion of fosPHT (150mg/min) as well as ability to administer IM.  Unfortunately, the drug failed [...]

We use IV bisphosphonates in acute hypercalcemia with theunderstanding that they’ll help achieve a normal calcium level in about 72hours.  Aside from the importantcomponents of this treatment that will have more of an immediate effect (fluid,diuretics, steroids, calcitonin); which bisphosphonate is best?Since oral bisphosphonates have extremely low bioavailablity(1-2%), IV agents like pamidronate and zoledronic acid become the two leadingcandidates.Even though these drugs do reach their peak effect for days,we do want to administer them as [...]

It's an interesting dilemma when considering how exactly to safely integrate hyperosmolar sodium chloride products into the emergency department.  Stocking vials of 23.4% sodium chloride in the ED, whether in a Pyxis/Omnicell or a locked cabinet, creates an unnecessary risk for significant medication errors. Though no specific threshold exists for what is considered a 'concentrated sodium chloride' product by the joint commission, the decision must be made by the hospital P&T committee. Lower concentrations (3% [...]