Acute Severe Asthma
EM PharmD Core - Acute Severe Asthma
Ten years a pharmacist
Reflections on 10 years as a pharmacist.
Acute Decompensated Heart Failure
Warm and wet just sounds weird to me. Not only does it allow the mind to drift to undesirable places, it also isn’t reflective of real practice. Whenever I open a pharmacy based text or review article regarding acute decompensated heart failure (ADHF), the first section invariably begins to discuss the Forrester Classification.[1] While it’s a useful visual learning tool, the routine dropping of Swan-Ganz catheters is no more. And who knew Frank Starling is [...]
Acute coronary syndromes
Sir William Osler said it best, that learning medicine without books is like going to sea without a map, but learning medicine without patients is like not going to sea at all. Learning any aspect of medicine without the proper context of a real patient, is just learning facts then having to figure out how they fit together later. Similarly, without proper framing of what your role is, a given subject can become overwhelming. Breaking [...]
A Breath of Fresh Air: Nebulized TXA for Hemoptysis
An 80-year-old male arrived at the Emergency Department (ED) in a serious condition: he was coughing up blood. Although he coughed up about three tablespoons (50cc/hr), he was hemodynamically stable. A physician approached me with an unfamiliar question: “Could we give him nebulized TXA?” I looked at him for a moment, nonplussed. “What?!” I exclaimed, “Hold on—let me look it up and get back to you.” Questions flooded my mind: Is it effective? Is it [...]
Nausea and Vomiting in the ED: There’s Something Fishy Going On
Nausea and vomiting is a common chief complaint in the ED, one I never really paid much attention to unless prompted (appropriate agent to use in pregnancy, which medication to use for a patient with a prolonged QTc, etc.) - at least, that was my practice before I began practicing in Miami. In one of the many unforgettable cases I have had in the ED, there was a young patient who presented with nausea and vomiting. [...]
Fosfomycin: The Forgotten Treasure
We have all been there, a patient with so many complicating factors that it’s difficult to choose the least worst option to treat a urinary tract infection. For example: a patient with a CrCl ~22 ml/min, a prolonged QTc, sulfa allergy (described as immediate death), and amoxicillin allergy (also somehow described as immediate death) who absolutely refuses to try a cephalosporin. How is it this difficult to treat a simple urinary tract infection?!?!?! There is [...]
BCPS Recertification: Follow Up
In two previous post, I outlined my impressions of High-Yield Med Reviews based on my experience going through the modules and webinar. While I still stand behind my evaluation of HYMR, my assessment was somewhat limited because it was all before the exam. Now that I have my scores, I feel I can give a more complete assessment of HYMR. In a nutshell: I passed, and highly recommend HYMR. In the final days before the exam, [...]
Choosing NOACs in the ED
Patient Case:A 62-year-old female presents to the ED with left lower extremity pain and swelling and is diagnosed with a LLE deep vein thrombosis (DVT) on ultrasound. The patient’s past medical history is significant for hypertension and she takes amlodipine at home. Laboratory values, pulse oximetry, and vital signs are within normal limits. The ED physician approaches you about discharge anticoagulation options and asks for a recommendation. Which agent would you recommend for outpatient management [...]
The plague that is vancomycin troughs
How important are vancomycin levels? Not very.... at least as a marker of efficacy. True, higher levels probably are associated with increased nephrotoxicity (above 15 mcg/mL) - Antimicrob Agents Chemother. 2013 ;57:734-44But the notion that troughs of 15-20 mcg/mL are the holy grail of therapeutic drug monitoring targets is simply not supported by data.What we know: vancomycin AUC/MIC in the mid 300 to 400s (let's just say > 400) or so range is likely the [...]