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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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!
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 |
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.
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.
Original: October 9, 2012; Last Updated: December 24, 2021
Is this coin in the esophagus or the trachea?
The classic teaching for the Boards exam is:
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.
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?
A 40-year-old man presents with significant agitation and severe respiratory distress from a COPD exacerbation. His oxygen saturation is 75% on room air, and he has diffuse, tight wheezes on exam. You prepare to intubate the patient using a rapid sequence induction protocol: etomidate, succinylcholine, 8-0 endotracheal tube.
Or do you?
This pocket card discusses the delayed sequence intubation (DSI) protocol made famous by Dr. Scott Weingart and Dr. Rich Levitan.1 Thanks to Dr. Michelle Reina (EM resident at Univ of Utah) and Dr. Rob (Intermountain Medical Center in Utah) for designing this helpful card. Rob has even implemented a DSI protocol in his ED.
The card breaks down the reasoning and steps behind DSI. Anecdotally, ketamine has often calmed patients down enough during the preoxygenation phase to enhance oxygenation/ventilation so much so that intubation is not required.
Go to ALiEM (PV) Cards for more resources.