About Bryan D. Hayes, PharmD, 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

Is FOAM to blame when a medical error occurs?

SadFaceWhat if a resident-physician attempted a technique she read on a blog or listened to on a podcast, but the procedure didn’t go as planned and the patient was harmed? Is Free Open Access Meducation (FOAM) to blame for medical errors? What about the blog site? If the site has a disclaimer (like most medical databases), is it enough to limit liability?

These are challenging questions, but ones that deserve discussion, especially in light of the recent post on St. Emlyn’s blog about a theoretical scenario just like this.

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Are Acetaminophen Levels Necessary in All Overdose Patients?

pills SS (1)ExpertPeerReviewStamp2x200Intentional 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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Safe dosing of nebulized lidocaine

NebulizersmSerum 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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2016-11-11T19:02:35-07:00

Mythbuster: Calcium Gluconate Raises Serum Calcium as Quickly as Calcium Chloride

CalciumG and ClsmLET’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, CaCl1 gm = calcium gluconate 3 gm.

CLINICAL QUESTIONS

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

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2016-11-11T18:39:24-07:00

Must We Avoid Nitrofurantoin with Impaired Renal Function?

UrineBacteriaAcute 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 Womennitrofurantoin is now listed as the first-line choice, surpassing ciprofloxacin and sulfamethoxazole/trimethoprim from the previous iteration.

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2016-11-11T18:37:09-07:00

Calcium before Diltiazem may reduce hypotension in rapid atrial dysrhythmias

 

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

A 57 y/o, 75 kg male 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 ED 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?