Patwari Academy videos: Toxicology
What is your approach to the poisoned patient? Listen to these 4 videos by Dr. Rahul Patwari to build your foundation of knowledge in toxicology.
- Introduction
- Toxidromes
- Testing
- Decontamination
One-dose vancomycin for SSTIs: Just don’t do it
You are managing an otherwise healthy patient with cellulitis but no abscess to poke. You decide this patient needs antibiotics but is stable enough to go home.
“Give em’ a dose of vanc before they go,” right?
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.
Paucis Verbis: Composition of intravenous fluids
There has been a lot of discussion on the ideal intravenous fluids (IVF) for resuscitation in the Emergency Department and ICU. This was highlighted by the landmark study in JAMA on ICU patients who received chloride-rich versus chloride-restricted IVFs. This got me to thinking, what exactly comprises the common IVFs that we order? We so often take for granted what’s in 1 liter of normal saline. As it turns out, normal saline is not really “normal”. Dr. Scott Weingart has a great podcast on “chloride poisoning” using IVFs.
This PV card helps remind me what’s in each liter bag of fluids we order (composition of intravenous fluids). At the bottom half of the card is a brief summary of the JAMA findings.
PV Card: IV Fluid Formations
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
Update 1/4/13
After the posting of this PV card, there was intense discussion about why the D5W osmolarity was 252 mOsm/L instead of 272 mOsm/L, which is found on various medical calculators. See the discussion by Dr. Joel Topf.
@kidney_boy @M_Lin @BrianJL @PharmERToxGuy
Great story.
It's not what we know/don't know, it's what we don't know that we don't know.— David Y.T. Chen (@dytcmd) January 4, 2013
Has this JAMA study changed your approach to ED intravenous fluid management?
It sure has for me. After 2 liters of normal saline, I consider switching patients to a more chloride-restrictive fluid (we have Plasma-Lyte in our ED). Examples include patients with DKA, AKA, sepsis, and severe dehydration.
Reference
- Yunos N, Bellomo R, Hegarty C, Story D, Ho L, Bailey M. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012;308(15):1566-1572. [PubMed]
MIA 2012: Campagna JD, et al. The use of cephalosporins in penicillin-allergic patients: a literature review. J Emerg Med. 2012 May;42(5):612-20
Bottom Line 1
- For patients with penicillin (PCN) allergies, it is safe to administer third- and fourth-generation cephalosporins (CPN) with no fear of cross reaction.
- Use of first- and second-generation CPN should only be avoided when the penicillin antibiotic shares structurally similar R1 side chains.
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MIA 2012: Nishijima DK et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med. 2012 Jun;59(6):460-8.e1-7.
Bottom Line 1
CREST study: Patients presenting to the emergency room with blunt head trauma and preinjury warfarin or clopidogrel use have a high incidence of immediate intracranial hemorrhage, but a very low incidence delayed intracranial hemorrhage. Thus, if the initial head CT is negative, you should be able to discharge the patient home…
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Is the 6-12-12 adenosine approach always correct?
The 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.