We’re all pretty familiar with the banana bag: intravenous (IV) fluids with the addition of thiamine, folic acid, multivitamins, and sometimes magnesium. Banana bags are commonly utilized in patients at risk for alcohol withdrawal symptoms or those who present to the emergency department (ED) acutely intoxicated.
A 71 year old female presents to the ED with lethargy, fever (39.5 C), and tachypnea (RR 28 rpm). She has a long-standing history of myasthenia gravis (MG) for which she receives periodic IVIG infusions. She is accompanied by her son, who informs you that she had a recent 10-day hospital stay for weakness. A CXR reveals an infiltrate in the left lower lobe.
The decision is made to initiate antimicrobial therapy for presumed healthcare-associated pneumonia. But, which antibiotics are safe to use in a patient with severe MG?
Valproic acid is used for a variety of clinical indications including seizures, migraine prophylaxis and treatment, and bipolar disorder. A metabolite of valproic acid, thought to be propionic acid, has the ability to increase ammonia levels by inhibiting a step in the hepatic urea cycle, which may lead to valproic acid-induced hyperammonemic encephalopathy. As a result, patients treated with valproic acid presenting with signs and symptoms of acute mental status changes, increased seizure frequency, and/or gastrointestinal symptoms should be evaluated for elevated ammonia concentrations.
Carbon monoxide (CO) poisoning may be the most common cause of fatal poisonings worldwide. 1 The majority of poisonings occur in the Fall and Winter. It is that time of year when heaters that have lain dormant all summer are flicked on, sometimes in enclosed areas, introducing CO fumes into homes. The pathophysiology is complex, and not fully understood, but all ED physicians should be aware of the signs and symptoms of CO toxicity, and know how to treat it.
With several new diabetes medications available, it is important to know which ones are likely to cause hypoglycemia after overdose. Based on mechanism of action and reported cases, the likelihood of hypoglycemia after overdose is listed below by drug class. 1
Keep in mind that other drugs can interact with antidiabetic medications resulting in hypoglycemia. The following table applies only to single agent ingestion/administration.
Intravenous beta blockers and non-dihydropyridine calcium channel blockers are recommended first-line for atrial fibrillation (AF) with rapid ventricular rate (RVR) [1]. In a previous post, Bryan Hayes (@PharmERToxGuy) provided an overview of the data comparing beta blockers to calcium channel blockers for atrial fibrillation rate control in the ED. Here is part 2 of our two-part AF series. (more…)
Prochlorperazine is a commonly used medication in EM. In certain patients prochlorperazine does wonders for migraines, and remains a great antiemetic choice for undifferentiated nausea/vomiting when ondansetron is ineffective. However, prochlorperazine has antidopinamergic activity increasing the chances of extrapyramidal symptoms (EPS), such as akathisia, dystonia, parkinsonism, and rarely tardive dyskinesia. A common practice in the ED is to give diphenhydramine with prochlorperazine to attenuate EPS. Does this really work? What is the evidence?