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

Diminishing Returns: The MIC Creep Dilemma with Vancomycin

The story of vancomycin all started when a missionary from Boreno sent a sample of dirt to a friend at Eli Lilly. The compound isolated had activity against most gram positive organisms. In fact, it got its name from the word ‘vanquish.’ Vancomycin was FDA-approved in 1958. [1]

Vancomycin is still a powerful tool against gram positive organisms, but there are some important learning points for using it properly in the critically ill ED patient.

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Is the 6-12-12 adenosine approach always correct?

AdenosineVialThe ACLS-recommended dosing strategy of 6 mg, 12 mg, and 12 mg for adenosine may not be appropriate in every situation. There are a few instances when lower or higher dosing should be considered.

Caveat: All recommendations are data-based, but many factors affect successful conversion of paroxysmal supraventricular tachycardia (PSVT) including proper line placement and administration technique.

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Losing faith in evidence-based medicine: Etomidate and sepsis

 
MagnifyingGlass3dIn an era where evidence-based medicine is the goal, it is vitally important for practitioners to understand how to prioritize and interpret the onslaught of data coming at us. 

This fact was driven home for me with a recent publication. Several weeks ago an article was published in Critical Care Medicine entitled “Etomidate is associated with mortality and adrenal insufficiency in sepsis: A meta-analysis.”

The point of this post is not to debate if etomidate should be used to intubate septic patients. Etomidate very well may kill people with sepsis. I just don’t know from the data currently available. Using this meta-analysis as an example, the goal is to point out two important areas where we could stand to sharpen our literature evaluation skills.

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Trick of the Trade: Searching for Comments to a Published Article

One day back in 2005 during my PGY-1 pharmacy practice residency, I remember a conversation with my residency director. He was a Surgical/Trauma ICU pharmacist. There had been a recent article published (I think it may have been one linking ‘tight’ glucose control to decreased mortality in ICU patients). Funny how times change…

Anyway, he mentioned all of the ‘discussion’ surrounding the article in terms of comments submitted to the journal. It was my first introduction to the idea that published literature could be challenged through an avenue provided by the journal.

Just this past week during EM residency journal club, we were discussing the recent Etomidate/Sepsis Meta-Analysis published in Critical Care Medicine (more to come on that soon in another post). I mentioned to my group how one could search for submitted comments. Most seem surprised to learn this trick of the trade.
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Mythbuster: Urgent dialysis following IV contrast?

Have you ever had to promise the radiologist that you would arrange emergent dialysis for your end-stage renal disease (ESRD) patient after receiving IV contrast?

This myth is even perpetuated in the field of nursing. In fact, what prompted this post was overhearing this very topic discussed between a nurse and a recent graduate nurse trainee.
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Tricks of the Trade: Calcium gel for hydrofluoric acid burns

HydrofluoricAcidA 41 y/o m presents to your ED after an occupational exposure to 30% hydrofluoric acid (HF). The thumb and index finger of his right hand were affected. Upon visual examination, the site of exposure looks relatively benign but the patient is complaining of extreme pain. Beyond giving opioids, what can you do?

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