The 2014 Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections (SSTI) recommend sulfamethoxazole-trimethoprim (SMX-TMP) for purulent infections where methicillin-resistant S. aureus (MRSA) is a likely pathogen. 1 But, what dose of SMX-TMP should we be prescribing? Both the SSTI and MRSA guidelines say 1-2 double strength tablets twice a day. 1,2 So, which is it, 1 tablet or 2?
There is so much literature to sift through each year, it becomes nearly impossible to stay abreast of it. Here is a quick summary of the 6 must-know Emergency Medicine pharmacotherapy articles from 2014, in my humble opinion.
At the 2014 American College of Emergency Physicians Scientific Assembly, ACEP passed Resolution 44, officially recognizing Emergency Medicine Pharmacists as valuable members of the EM team. Nadia Awad (@Nadia_EMPharmD) summarized the importance of the resolution’s passage on the EMPharmD blog. The role of an EM Pharmacist has been outlined by the American Society of Health-System Pharmacists (ASHP). In addition, Zlatan Coralic (@ZEDPharm), one of ALiEM’s regular contributors, framed the EM Pharmacist as the ‘ultimate consult service.’ The intent behind this post is not to discuss the role of the EM Pharmacist, but to highlight the rigorous training process through which most EM Pharmacists have traversed to work in this amazing specialty.
This ALiEM-Annals of EM Global Journal Club features the Annals of EM journal club by Schwartz et al. entitled “Lack of Association Between Press Ganey Emergency Department Patient Satisfaction Scores and Emergency Department Administration of Analgesic Medications.” We hope you will participate in an online discussion based on the clinical vignette and questions below from now until Dec 5 2014. Please respond by commenting below or tweeting using the hashtag #ALiEMJC. In a few months, a summary of this journal club will be published in Annals of EM.
On Dec 4, 2014 at 1300 PST (1600 EST), we will host a live Google Hangout with the authors Drs. Tayler Schwartz and Kavita Babu.
You are resuscitating a hypotensive patient with severe sepsis and have just hung your 4th liter of crystalloid. On the fluid bags, you wrote the numbers 1 through 4 in permanent marker to help keep track of your resuscitation. As you finish placing your central line the charge nurse enters the room. He informs you that according to the Institute for Safe Medical Practices (ISMP), writing directly on IV bags with permanent marker is not recommended due to concerns that the ink will leach into the bag and potentially cause harm to your patient.1–4
This situation raises several questions:
Traditional teaching recommends naloxone doses of at least 0.4 mg IV to reverse opioid toxicity. Drs. Lewis Nelson (@LNelsonMD) and Mary Ann Howland (@Howland_Ann) co-authored the opioid antagonist chapter in Goldfrank’s Toxicologic Emergencies.1 They write:
“However, this dose [0.4 mg] in an opioid-dependent patient usually produces withdrawal, which should be avoided if possible. The goal is to produce a spontaneously and adequately ventilating patient without precipitating significant or abrupt opioid withdrawal. Therefore, 0.04 mg is a practical starting dose in most patients, increasing to 0.4 mg, 2 mg, and finally 10 mg.”
Ceftriaxone is a broad-spectrum antibiotic that is frequently administered intramuscularly (IM) in emergency medicine. However, these injections hurt — A LOT! Can we do anything to minimize the pain?