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I am giving prochlorperazine. Should I give diphenhydramine too?

BenadrylProchlorperazine is a commonly used medication in EM. In certain patients prochlorperazine does wonders for migraines, and remains a great antiemetic choice for undifferentiated nausea/vomiting when ondansetron is ineffective. However, prochlorperazine has antidopinamergic activity increasing the chances of extrapyramidal symptoms (EPS), such as akathisia, dystonia, parkinsonism, and rarely tardive dyskinesia. A common practice in the ED is to give diphenhydramine with prochlorperazine to attenuate EPS.  Does this really work? What is the evidence?

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By |2019-02-19T18:41:26-08:00Sep 3, 2014|Tox & Medications|
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The Opioid Prescription Epidemic: Annals of EM Resident Perspectives article

opioid prescription epidemicMisuse of prescription opioids is one of the defining health problems of our generation.  The dramatic rise of opioid analgesic prescriptions in the US and Canada has been well documented, and opioids represent the most common cause of fatal prescription overdoses. On every shift, in every emergency department in the country, physicians struggle with the concerns of patients presenting with common pain complaints. Seeking to manage their patients’ symptoms in the face of dramatically rising prescription opioid misuse and fatal overdose, emergency physicians are  challenged to distinguish those who are simply seeking pain relief, those who are seeking opioid prescriptions due to addiction, and those who fit both categories. Emergency care providers are also charged with balancing the pressures of meeting clinical care and patient satisfaction goals while fulfilling our moral obligation to provide primary and secondary prevention of opioid misuse.

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By |2018-12-20T15:09:25-08:00Aug 11, 2014|Tox & Medications|
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SimLIFE-EM Challenge: Add to the conversation

simLIFE-EM

Debriefings in medical simulation are meant to be the bow on top of the gift that is medical simulation. It is the ultimate delicious dessert, served after a grueling dinner course. All analogies aside, debriefings are meant to drive home the teaching points, to gain a deeper understanding of medical resuscitation as a group, and create mental frameworks of the approach to various patients. But this is often easier described than actually done. We here at ALiEM paired with Dr. Henry Curtis to come up with a creative way of developing debriefing skills and gain deeper understanding of mental frameworks.

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By |2016-11-07T12:40:10-08:00Aug 4, 2014|Medical Education, Simulation, Tox & Medications|
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PV Card: Pediatric Ingestion Dose Thresholds for ED Referral

Clinical Toxicology has published guidelines for out-of-hospital management of 16 distinct overdoses and their dose thresholds, above which, pediatric patients should be referred to the Emergency Department for evaluation. Clinical Toxicology is the official journal of the American Academy of Clinical Toxicology (AACT, @AACTinfo), the American Association of Poison Control Centers (AAPCC, @AAPCC), and the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT). There are two caveats to be aware of regarding these guidelines.

  1. They were developed between 2005 and 2007. New medications have been approved since that time and there may be more recent data available.
  2. As with any poisoning, dose is only one factor when determining disposition. Consideration should also be given to intent, underlying medical conditions, co-ingestion of other medications, presence of symptoms, and drug formulation.

This PV Card summarizes the pediatric ingestion dose thresholds for referral to an ED.

PV Card: Pediatric Dose Thresholds


Adapted from [1–16]
Go to ALiEM (PV) Cards for more resources.

Thanks to Zlatan Coralic, PharmD (@ZEDPharm) for his excellently detailed expert peer review and suggestions for revisions for this important card.

References

  1. Wax P, Erdman A, Chyka P, et al. beta-blocker ingestion: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005;43(3):131-146. [PubMed]
  2. Caravati E, Erdman A, Christianson G, et al. Ethylene glycol exposure: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005;43(5):327-345. [PubMed]
  3. Manoguerra A, Erdman A, Booze L, et al. Iron ingestion: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005;43(6):553-570. [PubMed]
  4. Olson K, Erdman A, Woolf A, et al. Calcium channel blocker ingestion: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005;43(7):797-822. [PubMed]
  5. Dart R, Erdman A, Olson K, et al. Acetaminophen poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2006;44(1):1-18. [PubMed]
  6. Scharman E, Erdman A, Wax P, et al. Diphenhydramine and dimenhydrinate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2006;44(3):205-223. [PubMed]
  7. Manoguerra A, Erdman A, Wax P, et al. Camphor Poisoning: an evidence-based practice guideline for out-of-hospital management. Clin Toxicol (Phila). 2006;44(4):357-370. [PubMed]
  8. Caravati E, Erdman A, Scharman E, et al. Long-acting anticoagulant rodenticide poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(1):1-22. [PubMed]
  9. Chyka P, Erdman A, Christianson G, et al. Salicylate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(2):95-131. [PubMed]
  10. Woolf A, Erdman A, Nelson L, et al. Tricyclic antidepressant poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(3):203-233. [PubMed]
  11. Nelson L, Erdman A, Booze L, et al. Selective serotonin reuptake inhibitor poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(4):315-332. [PubMed]
  12. Chyka P, Erdman A, Manoguerra A, et al. Dextromethorphan poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(6):662-677. [PubMed]
  13. Scharman E, Erdman A, Cobaugh D, et al. Methylphenidate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(7):737-752. [PubMed]
  14. Cobaugh D, Erdman A, Booze L, et al. Atypical antipsychotic medication poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(8):918-942. [PubMed]
  15. Caravati E, Erdman A, Christianson G, et al. Elemental mercury exposure: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2008;46(1):1-21. [PubMed]
  16. Manoguerra A, Erdman A, Woolf A, et al. Valproic acid poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2008;46(7):661-676. [PubMed]
By |2021-10-06T10:12:48-07:00Jul 9, 2014|ALiEM Cards, Expert Peer Reviewed (Clinical), Tox & Medications|
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Anxiolytics and Hypnotics: Are They Doing Harm?

insomnia clockA patient presents to the emergency department complaining of increasing insomnia due to anxiety. She states that she is not actively suicidal nor homicidal but she has trouble “turning off her brain” at night in order to sleep and her insomnia is worsening her anxiety. She has a history of morbid obesity and smokes 1 pack of cigarettes per day. In order to help you consider writing her a prescription for 5 mg of zolpidem as you presume it to be a benign way to deal with her current sleep disorder. But what does the evidence say about these drugs and the risks of harm? (more…)

By |2016-11-11T19:21:16-08:00Jul 2, 2014|Psychiatry, Tox & Medications|
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tPA Administration: Don’t Forget the Leftover Volume in the Pump Tubing

LeftoversWhether alteplase (tPA) is given for ischemic stroke, pulmonary embolism, or STEMI, there is an important practical issue to be aware of during administration. Dr. Charles Bruen (@resusreview) published a great step-by-step pictorial tPA Mixing Tutorial. Once the tPA is mixed, it will invariably be infused via a smart pump through its corresponding tubing. At my institution we use Alaris® CareFusion smart pumps, through the principle applies irrespective of which brand pump is used.

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By |2016-11-11T19:21:16-08:00Jun 23, 2014|Tox & Medications|
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