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: Rapid Oral Phenytoin Loading in the ED

rapid oral phenytoin loading

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?

Mythbuster: No Maximum Dose of Enoxaparin

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?

(more…)

Dexmedetomidine (Precedex) as an Adjunct to Benzodiazepines for Ethanol Withdrawal

Sometimes a question is posed on Twitter that generates a great discussion from colleagues ’round the globe. Such was the case for dexmedetomidine. Although benzodiazepines remain the standard of treatment for ethanol withdrawal, particularly seizures and delirium tremens, what’s all the hype about dexmedetomidine?

(more…)

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.

(more…)

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.

(more…)

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.

(more…)