Antibiotics, Myasthenia Gravis, and Risk of Weakness

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?

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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2026-06-16T16:06:23-07:00Oct 20, 2014|Rheumatology, Tox & Medications|

Valproic Acid-Induced Hyperammonemic Encephalopathy

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.

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By Jill Logan, PharmD BCPS|2016-11-16T09:41:30-08:00Oct 16, 2014|Tox & Medications|

Blunt Chest Trauma: Validation of the NEXUS Chest Rule

We commonly see patients who have some form of blunt chest trauma. This is the result of motor vehicle collisions, falls, and a myriad of other traumatic events. The decision to perform thoracic imaging can be difficult. Chest xray (CXR) and/or chest CT? In fact, studies have shown that emergency and trauma physicians often disagree 28-40.9% of the time about which patients require a chest CT following blunt trauma. ^1,2

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By Eric Morley, MD|2016-11-11T19:22:53-08:00Oct 14, 2014|Expert Peer Reviewed (Clinical), Radiology, Trauma|

Carbon Monoxide Poisoning – It’s That Time of Year Again

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.

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By Christina Shenvi, MD, PhD, MBA|2016-11-11T19:22:45-08:00Oct 8, 2014|Tox & Medications|

Top 10 Reasons NOT to Order a CT Pan Scan in a Stable Blunt Trauma Patient

The pendulum has swung one way with CT for trauma, but has it gone too far? Liberal use of CT raises concerns over resource utilization, cost, and the consequences of radiation exposure [1,2]. No-one can seem to agree, including trauma surgeons, on guidelines for a more selective use of imaging studies [3-6].

“CT pan scan” is the term, source unclear, which describes the whole body CT (WBCT) imaging strategy used in blunt trauma management. It consists of the following CT studies:

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By Daniel Firestone, MD RDMS|2017-03-05T14:18:47-08:00Oct 6, 2014|Radiology, Trauma|

Trick of the Trade: Insect removal from the ear

Insect removal from the ear is a foreign body removal procedure with unique considerations. First, insects are friable. Have you ever squashed a house centipede? It’s like their 700 legs are spring-loaded to fall off instantly when touched. This characteristic makes mechanical removal by alligator forceps or cerumen loops less reliable. Second, they are alive which means they can move during your attempted extraction procedure.

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By Mitchell Li, MD|2017-05-06T20:32:25-07:00Oct 2, 2014|ENT, Tricks of the Trade|

AIR Series: Endocrinology Module 2014

Welcome to the third ALiEM Approved Instructional Resources (AIR) Module! In an effort to reward our readers for the reading and learning they are already doing online, we have created an Individual Interactive Instruction (III) opportunity utilizing FOAM resources for U.S. Emergency Medicine residents. For each module, the board curates and scores a list of blogs and podcasts. A quiz is available to complete after each module to obtain residency conference credit. Once completed, your name and institution will be logged into our privatedatabase, which participating residency program directors can access to provide proof of completion.

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By Andrew Grock, MD|2017-03-05T14:18:40-08:00Oct 1, 2014|Approved Instructional Resources (AIR series), Endocrine-Metabolic|