Trick of the Trade: Persistent paracentesis leakage

Dr. Matt Borloz (Carilion Clinic) recently emailed me his recent trick in fixing a persistently leaking paracentesis site. Read about his experience:

A patient with advanced alcoholic cirrhosis with ascitic fluid leaking from a paracentesis puncture site from a procedure done 2 days prior. Dermabond had initially been applied post-procedure, but it had come loose, and ascitic fluid had been saturating dressing after dressing.

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By Michelle Lin, MD|2016-11-11T18:43:16-08:00Nov 6, 2012|Gastrointestinal, Tricks of the Trade|

Mythbuster: Urgent dialysis following IV contrast?

Have you ever had to promise the radiologist that you would arrange emergent dialysis for your end-stage renal disease (ESRD) patient after receiving IV contrast?

This myth is even perpetuated in the field of nursing. In fact, what prompted this post was overhearing this very topic discussed between a nurse and a recent graduate nurse trainee.
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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2019-02-19T18:47:01-08:00Oct 31, 2012|Renal, Tox & Medications|

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|

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|

Is this coin in the esophagus or the trachea?
The classic teaching for the Boards exam is:

Esophageal coins appear in the coronal plane, as shown above.
Tracheal coins appear in the sagittal plane because of the cartilaginous tracheal rings.

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By Michelle Lin, MD|2016-11-11T18:43:31-08:00Sep 28, 2012|Pediatrics, Radiology|

PV Card: Electrolytes and ECG changes

The electrocardiogram can pick up all sorts of electrolyte abnormalities. The most common abnormalities revolve around high and low levels of potassium and calcium. Magnesium derangements typically have nonspecific findings. How do you keep things straight? To make things more complicated, multiple electrolyte derangements can occur at the same time, making ECG interpretation challenging.

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By Michelle Lin, MD|2021-10-08T09:38:57-07:00Sep 21, 2012|ALiEM Cards, ECG, Endocrine-Metabolic|

Tricks of the Trade: Calcium gel for hydrofluoric acid burns

A 41 y/o m presents to your ED after an occupational exposure to 30% hydrofluoric acid (HF). The thumb and index finger of his right hand were affected. Upon visual examination, the site of exposure looks relatively benign but the patient is complaining of extreme pain. Beyond giving opioids, what can you do?