Calcium before Diltiazem may reduce hypotension in rapid atrial dysrhythmias

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?

(more…)

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?

(more…)

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?

(more…)

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:

Minimal adverse effects
Rapid onset and offset of action
Pharmocokinetic predictability across a spectrum of patients

(more…)

By Salim Rezaie, MD|2021-03-01T09:32:06-08:00Mar 20, 2013|Tox & Medications|

What’s the Code Dose of tPA?

Suppose you have a patient in whom you highly suspect a pulmonary embolism (PE) that devolves into PEA arrest while awaiting a CT angiogram. Or, what about a patient with an ECG showing clear STEMI that loses pulses?

(more…)

By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2018-02-17T01:56:47-08:00Mar 14, 2013|Tox & Medications|

Lytics for sub-massive PE: Ready for primetime?

There was recently a great study published in the American Journal of Cardiology (2012) by Sharifi et al¹, questioning whether we should be considering tPA in patients other than those patients with massive pulmonary embolism (PE)? You know the big “Saddle Embolus” we all fear? Well it turns out this is only about 5% of all PEs.