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

Leadership Team, ALiEM
Creator and Lead Editor, Capsules and EM Pharm Pearls Series
Attending Pharmacist, EM and Toxicology, MGH
Associate Professor of EM, Division of Medical Toxicology, Harvard Medical School

Are Acetaminophen Levels Necessary in All Overdose Patients?

Intentional overdose patients are notorious for giving inaccurate histories. “I took 14 tablets of this and 8 capsules of that. No, wait. It was 3 tablets of this and a handful of capsules of that… This happened about 2 hours ago. Actually, I think it was last night.” Round and round the merry-go-round we go.

How should we risk-assess whether acetaminophen is involved?
If the patient provides no history of acetaminophen ingestion, do we need to order a level?

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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2016-11-11T19:02:49-08:00Sep 4, 2013|Expert Peer Reviewed (Clinical), Tox & Medications|

Safe dosing of nebulized lidocaine

Serum lidocaine levels correlate well with observed clinical effects. As the concentration increases, lightheadedness, tremors, hallucinations, seizures, and cardiac arrest can occur. Levels > 5 mcg/mL are associated with serious toxicity. With so many concentrations (1%, 2%, 4%) and routes of administration available, the total dose of lidocaine is always a concern.

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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2026-02-03T01:23:43-08:00Aug 6, 2013|ENT, Tox & Medications|

LET’S START WITH THE FACTS

We know that calcium chloride (CaCl₂) provides 3 times more elemental calcium than an equivalent amount of calcium gluconate.
So, CaCl₂1 gm = calcium gluconate 3 gm.

CLINICAL QUESTIONS

Does CaCl₂have better bioavailability than calcium gluconate?
Does calcium gluconate have a slower onset of action because it needs hepatic metabolism to release the calcium?

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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2016-11-11T18:39:24-08:00Jul 2, 2013|Tox & Medications|

Must We Avoid Nitrofurantoin with Impaired Renal Function?

Acute uncomplicated cystitis is becoming more difficult to treat in the setting of increasing antimicrobial resistance. In the 2010 IDSA Guideline, as summarized in a PV Card on Cystitis and Pyelonephritis in Women, nitrofurantoin is now listed as the first-line choice, surpassing ciprofloxacin and sulfamethoxazole/trimethoprim from the previous iteration.

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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2021-03-09T12:31:20-08:00Jun 17, 2013|Tox & Medications|

The Case

A 56 y/o man presents to the ED via ambulance. He was sent from clinic for ‘new onset afib.’ His pulse ranges between 130 and 175 bpm, while his blood pressure is holding steady at 106/58 mm Hg. He has a past medical history significant for hypertension and hypercholesterolemia. His only medications are hydrochlorothiazide and atorvastatin. The decision is made to administer an IV medication to ‘rate control’ the patient with a goal heart rate < 100 bpm.

Calcium channel blockers, such as diltiazem and verapamil, can both cause hypotension. In the case above, the patient has borderline hypotension.

The Clinical Question

What is the evidence behind giving IV calcium as a pre-treatment to prevent hypotension from calcium channel blockers?

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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2016-11-11T19:47:24-08:00May 22, 2013|Cardiovascular, Tox & Medications|

Trick of the Trade: Rapid Oral Phenytoin Loading in the ED

A 57-year-old male (75 kg) presents to the ED after a witnessed seizure. He describes a history of seizure disorder and is prescribed phenytoin, but recently ran out. A level is sent and, not surprisingly, results as < 3 mcg/mL (negative). After a complete workup, the decision is made to ‘load’ him with phenytoin 1 gm and discharge him with a prescription to resume phenytoin. An IV was not placed.

Can you rapidly load him orally?

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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2020-02-16T14:45:12-08:00Apr 16, 2013|Neurology, Tox & Medications, Tricks of the Trade|

Venous thromboembolism (VTE) is often treated with low molecular weight heparins (LMWH) such as enoxaparin. For patients with normal renal function, dosing is as follows:

Enoxaparin: 1 mg/kg subcutaneously every 12 hours, or 1.5 mg/kg every 24 hours
Dalteparin 200 IU/kg subcutaneously once daily
Tinzaparin: 175 IU/kg subcutaneously once daily

What about the obese patient? Is there a maximum dose for enoxaparin?