Trick of the Trade: Avoiding a straight-needle needlestick injury

You are finishing up a successful subclavian line procedure. You insert the straight-needle suture needle through the skin to secure the line. When trying to pull it out, you accidentally poke yourself!

This is actually a common scenario for a needlestick injury. Although many central line kits now have curved suture needles, many still have straight needles. How can you avoid a needlestick?

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By Michelle Lin, MD|2019-01-28T22:11:48-08:00Oct 23, 2012|Tricks of the Trade|

PV Card: Predictors of a Difficulty Airway

See ALiEM (PV) Cards for other resources

By Michelle Lin, MD|2021-10-19T19:33:37-07:00Oct 19, 2012|ALiEM Cards|

Where’s the best place to suffer cardiac arrest? Seattle? Las Vegas? Who’s going to give me mouth-to-mouth resuscitation? Will someone know how to use an automatic external defibrillator (AED)?

Where is the BEST place to experience a cardiac arrest???

As luck would have it, the best place would be at the ACEP Scientific Assembly. On the first day of Scientific Assembly, an exhibitor collapsed in the convention center without a pulse. At a conference with thousands of emergency physicians, several Good Samaritans immediately sprung into action. An attendee used a CPR mask while another operated an AED. They were able to revive their patient, where he is reportedly doing well at a local hospital.

Congratulations to Drs. David Pigott, Jared Shell, Jerry Edwards and everyone else involved on a job well done!

By Fred Wu, MHS, PA-C|2019-02-19T18:05:51-08:00Oct 17, 2012|Cardiovascular|

Trick of the Trade: High volume irrigation of abscesses

Large-sized abscess often have pus trapped in deep crevices and pockets. Irrigation can help express the pus. How can you set up a high-volume irrigation system?

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By Michelle Lin, MD|2016-11-11T18:43:24-08:00Oct 16, 2012|Tricks of the Trade|

How many times have you given your patient IM ceftriaxone for that presumed gonococcal infection? … still counting? Many of us learned (or at least thought we learned) that ceftriaxone has to be administered IM to get the ‘depot’ effect.

Myth Busted

There doesn’t appear to be a true depot effect. IV and IM ceftriaxone have very similar pharmacokinetic profiles. Let me prove it to you, straight from the FDA-approved ceftriaxone package insert.

Table 1: Average plasma concentration (mcg/mL) as measured over time after 500 mg of ceftriaxone administration

Ceftriaxone route	0.5 hr	1 hr	2 hr	4 hr	6 hr	8 hr	12 hr	16 hr	24 hr
IV	82	59	48	37	29	23	15	10	5
IM	22	33	38	35	30	26	16	unknown	5

Table 2: Average urine concentration (mcg/mL) as measured over time after 500 mg of ceftriaxone administration

Ceftriaxone route	0-2 hrs	2-4 hrs	4-8 hrs	8-12 hrs	12-24 hrs	24-48 hrs
IV	526	366	142	87	70	15
IM	115	425	308	127	96	28

The plasma concentrations are almost identical after IM and IV administration through 24 hours (Table 1).
Even the urinary concentrations are similar up to 24-48 hours after a dose (Table 2).
The volume of distribution is the same for both parenteral routes, too. This means that its penetration into the “affected area” is similar.
According to a 2012 CDC Report the minimum inhibitory concentration (MIC) for N. gonorrhoeae strains to ceftriaxone is 0.125 mcg/mL. IV therapy provides concentrations above this resistance cutoff well after 24-48 hours, similar to IM therapy.

Trick of the Trade

If the patient already has an IV line, we can give IV ceftriaxone for gonorrhea instead of IM.

In fact, the Japanese Society for Sexually Transmitted Diseases has recommended monotherapy with a single IV dose of 1 g ceftriaxone since 2008. (Aoki 2021)

While most of the time patients with STD (or STI, if you prefer) complaints don’t have an IV line established, occasionally they do. My hospital stocks 1 gm and 2 gm premixed IV bags of ceftriaxone, so we could potentially just give 1 gm IV in these rare cases to ensure adequate levels (even 500 mg might be just fine).

Of course, the other way to avoid the painful injection is to mix the ceftriaxone with lidocaine… or avoid contracting gonorrhea altogether.

Disclaimer

This post is intended for educational purposes to explore the kinetic data for IM and IV therapy. The CDC guidelines should be followed for treatment of STDs.

References

Product Information: ROCEPHIN(R) IV, IM injection, ceftriaxone sodium IV, IM injection. Genentech USA, Inc. (per Manufacturer), South San Francisco, CA, 2010.
Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010;59(RR-12):1-110. [PMID: 21160459]. Free MMWR PDF download.

Original: October 9, 2012; Last Updated: December 24, 2021

By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2022-02-03T10:29:27-08:00Oct 9, 2012|Infectious Disease, Tox & Medications, Tricks of the Trade|

Trick of the Trade: Don’t miss the pneumothorax in needle thoracostomy

A patient arrives in PEA arrest and you note that her left chest has no breath sounds or lung sliding on bedside ultrasound. You suspect a tension pneumothorax.

You insert a standard 14g angiocather in the left 2nd intercostal space (ICS). You don’t hear a rush of air. The patient’s clinical condition deteriorates to impending asystole. How sure are you that your angiocatheter actually reached the pleural space?