On the Horizon: Propofol for Migraines

Propofol for the treatment of migraines in the ED might be on the horizon. This will possibly be a new practice in emergency medicine, although it has been known for some time. Propofol, when given at procedural sedation doses, seems to miraculously terminate migraines refractory to usual treatment. Patients awake with minimal to no headache and may be discharged from the ED much quicker than traditional treatment with possibly less side effects. The proposed mechanism of action is described in below papers, but in short, propofol seems to “reboot” the brain and terminate the migraine.

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By Zlatan Coralic, PharmD|2016-11-11T18:37:24-08:00May 25, 2013|Neurology, Tox & Medications|

PV Card: Contraindications to Thrombolytics in Stroke

This Paucis Verbis (PV) card is an updated version of the PV card on Contraindications to Thrombolytics for CVA from September 10, 2010, based on the Stroke 2013 AHA/ASA new guidelines that were just published.¹ Some changes include…

There is new mention of new anticoagulants in the market with additional absolute exclusion criteria.
A blood glucose < 50 mg/dL has been upgraded from a relative exclusion to an absolute exclusion criteria. There is no more mention of glucose > 400 mg/dL as an exclusion criteria.
Seizure at onset of presentation has moved from an absolute to a relative risk.
Post-AMI pericarditis is no longer a relative exclusion criteria.

PV Card: Contraindications for Thrombolytics in Stroke

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

Jauch E, Saver J, Adams H, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870-947. [PubMed]

By Michelle Lin, MD|2021-10-06T19:58:38-07:00May 23, 2013|ALiEM Cards, Neurology, 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|

With Dr. Jeff Tabas giving a lecture on the perennially hot topic of pulmonary embolism (PE) at the upcoming UCSF High Risk EM Conference (main link, PDF Brochure) in San Francisco May 22-24, 2013, I thought I would get a sneak peek into his discussion points.

Rivaroxaban for Pulmonary Embolism: One pill and done?
By Prathap Sooriyakumaran, MD and Jeffrey Tabas, MD
UCSF-SFGH Emergency Medicine (more…)

By Michelle Lin, MD|2018-08-23T19:16:55-07:00Apr 3, 2013|Cardiovascular, Pulmonary, Tox & Medications|

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?

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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2016-11-11T18:39:24-08:00Mar 27, 2013|Tox & Medications|

Ketofol: Is this the “Game Changer” of Procedural Sedation and Analgesia?

When talking about procedural sedation and analgesia, our goal is to minimize pain and anxiety, with the appropriate agent that matches the needs of our patient and the clinical scenario. So what are some qualities of this “ideal agent?”

In a perfect world, it would have: