About Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP

Leadership Team, ALiEM
Creator and Lead Editor, Capsules series, ALiEMU
Attending Pharmacist, EM and Toxicology, MGH
Assistant Professor of EM, Harvard Medical School

Trick of the Trade: Combine Adenosine with the Flush

2019 literature update from this original 2012 Trick of the Trade post!
The success of adenosine depends as much on the administration technique as it does the mechanism of action. The 2010 Advanced Cardiac Life Support (ACLS) Guidelines recommend the following when administering adenosine:

“6 mg IV as a rapid IV push followed by a 20 mL saline flush; repeat if required as 12 mg IV push”

This recommendation remained in the 2015 iteration.

While most drugs are metabolized in the liver, adenosine doesn’t even make it that far, being metabolized in the erythrocytes and vascular endothelial cells. With this extremely short half-life (10 seconds), it is important to help it reach the heart before it’s metabolized and excreted without being effective.

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Top 10 ALiEM Clinical Posts in 2018

Happy 2019 from the ALiEM team. We have published so many posts this year that you may have missed a few. Did you at least catch the top 10 ALiEM clinical posts in 2018? These are the most-viewed posts in the past calendar year. From can’t-miss ECGs, to common splint techniques, and new strategies for managing alcohol withdrawal – check these out as you keep celebrating the New Year!

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ALiEMU Capsules Module 11: Acute Agitation

We are proud to present Capsules Module 11: Acute Agitation, now published on ALiEMU. We present a summary of the module with key points from a stellar module by PharmDs Jenny Koehl, Kyle DeWitt, Gabrielle Procopio, and Zlatan Coralic. When you’re finished, head over to the Capsules page for even more practical pharmacology for the EM provider.
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Reversing Anticoagulation to Administer Systemic Fibrinolytics for Ischemic Stroke: Pump the Brakes

Care of acute ischemic stroke patients is a complex and time-sensitive team effort. There is a potentially dangerous trend in the medical literature over the past few years that seems to be increasing as of late: reversing anticoagulation in order to administer systemic thrombolytic therapy. The purpose of this post is to highlight the available literature on this topic, specifically related to the direct acting oral anticoagulants (DOACs), and discuss why we should not support this practice (at least as of today).

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Ketamine for Severe Ethanol Withdrawal: A New Hope?

Ketamine for severe ethanol withdrawalEthanol withdrawal is a complex disease state. Two of the main players are GABA (an inhibitory neurotransmitter) and glutamate (an excitatory transmitter that can act on NMDA receptors). Simplistically, chronic ethanol use leads to a down-regulation of GABA receptors and an up-regulation in glutaminergic receptors, such as NMDA. When ethanol is abruptly discontinued, we are left with a largely excitatory state with less ability for GABA-mediated inhibition and more capacity for NMDA/glutamate-mediated excitation. While much of the treatment of severe ethanol withdrawal is focused on GABA, there are agents, such as phenobarbital and propofol, that can suppress the glutaminergic response. Ketamine seems like it should confer benefit, as well, due to its NMDA antagonist properties. Until recently there was only one clinical study using ketamine for severe ethanol withdrawal.1 Now there are three.2,3

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ALiEMU Capsules Module 10: Concepts in Infectious Disease

We are proud to present Capsules Module 10: Concepts in Infectious Disease, now published on ALiEMU. Here is a summary of the key points from a stellar module by Drs. Meghan Groth and Paul Takamoto. When you’re finished, head over to the Capsules page for even more practical pharmacology for the EM provider.

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12 Must-Know EM Pharmacotherapy Articles of 2017

Welcome to the 4th annual installment of our must-know Emergency Medicine pharmacotherapy articles post, this time for 2017. We summarize some important EM pharmacotherapy articles from the last 12 months. We have tried to focus on articles that you may have missed, but are potentially high-impact for improving clinical practice in the ED. Without further ado, we present the 12 must-know EM pharmacotherapy articles of 2017.

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