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Paucis Verbis: Overanticoagulation and supratherapeutic INR

I find it amazing that I know more non-emergency physicians virtually in the social media world rather than in person. Primarily through Twitter, I follow and am followed by medical educators from various specialties. If you haven’t joined Twitter yet, I think it might be time. There is a whole world of collaboration and conversation going on in this virtual community, which crosses specialties and geography.

Last week, Dr. Javier Benítez (@jvrbntz) was tweeting a Question of the Day, referencing a 2010 Paucis Verbis card on overanticoagulation, which was based on the 2008 American College of Chest Physicians (ACCP) guidelines. About 8 minutes after I retweeted his question, Dr. Roy Arnold (@cholerajoe), a pulmonary/critical care physician kindly informed me that the 2012 ACCP guidelines have been out since February.

So this PV card is replacing the 2010 card with revised recommendations. For more in-depth discussion, definitely take a look at Dr. Scott Weingart’s great podcast over at EMCrit. He helps to clarify holes which the 2012 ACCP guidelines don’t really address such as:

What if the patient is minorly bleeding with a high INR?

  • Oral vitamin K and 15 mL/kg FFP

What if you only have the 3-factor PCC (factors II, IX, X) and not the recommended 4-factor PCC (factors II, IX, X plus factor VII)?

  • If PCC is indicated, add recombinant factor VIIa or FFP to the 3-factor PCC to cover for factor VII.

PV Card: Overanticoagulation and Supratherapeutic INR


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

Reference

  1. Holbrook A, Schulman S, Witt D, et al. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e152S-84S. [PubMed]
By |2021-10-10T08:47:06-07:00Aug 10, 2012|ALiEM Cards, Heme-Oncology, Tox & Medications|
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Mythbuster: The 10% cephalosporin-penicillin cross-reactivity risk

RedSirenTo give or not to give a cephalosporin in penicillin-allergic patients?

I remember back to my days in pharmacy school when I learned that there was approximately a 10% risk of cross-reactivity, if a cephalosporin was given to a penicillin-allergic patient. They probably said something about the risk being less with 3rd and 4th generations cephalosporins, but lets be honest… who remembers anything but that magic 10%? When I started working more with physicians, I found that they also learned the same 10% rule in medical school. Well, I guess that means it’s fact, right? Not so fast!

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By |2018-05-28T22:12:57-07:00Aug 9, 2012|Tox & Medications|
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Trick of the Trade: Converting % to mg/mL

MedicationSyringe

Medication error is something that we all fear in Emergency Medicine and do our best to avoid. Here’s a scenario and simple approach for you, provided by Zlatan Coralic, PharmD (Assistant Clinical Professor in the UCSF School of Pharmacy).

You are an emergency physician working in an underserved country. You are presented with an asthmatic kid with severe retractions and tight wheezes. Multiple nebulizers and corticosteroids have failed. You want to try some magnesium sulfate before risking intubation in a place with no reliable access to ventilator equipment. You know the dose should be 1 gm IV over 20 minutes.

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By |2016-11-11T18:44:27-08:00Jul 17, 2012|Tox & Medications, Tricks of the Trade|
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Paucis Verbis: Toxic alcohols – Isopropyl alcohol

isopropyl alcohol Rubbing Alcohol

 

Continuing on the theme of Toxic Alcohols (osmolal gap, ethylene glycol, methanol), this Paucis Verbis card focuses on isopropyl alcohol toxicity, which is commonly found in rubbing alcohols. In this toxic alcohol, fomipezole is actually NOT indicated because you want to have alcohol dehydrogenase convert the toxic parent compound (isopropyl alcohol) into the nontoxic metabolite (acetone).

Note that these are merely guidelines and you should tailor management plans with your toxicologist and nephrologist.

PV Card: Isopropyl Alcohol Toxicity


Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.

References

  1. Kraut J, Kurtz I. Toxic alcohol ingestions: clinical features, diagnosis, and management. Clin J Am Soc Nephrol. 2008;3(1):208-225. [PubMed]
  2. Jammalamadaka D, Raissi S. Ethylene glycol, methanol and isopropyl alcohol intoxication. Am J Med Sci. 2010;339(3):276-281. [PubMed]
By |2021-10-10T08:56:50-07:00Jun 22, 2012|ALiEM Cards, Tox & Medications|
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Paucis Verbis: Toxic alcohols – Methanol

MethanolContinuing on the theme of Toxic Alcohols (osmolal gap, ethylene glycol), this Paucis Verbis card focuses on methanol toxicity. Useful are the American Academy of Clinical Toxicologists recommendations on when to administer an antidote (fomipezole) and when to perform hemodialysis. I redrew the flowchart based on what’s relevant to the ED in the initial stages.

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By |2021-10-19T19:44:59-07:00Jun 15, 2012|ALiEM Cards, Tox & Medications|
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Paucis Verbis: Toxic alcohols – Ethylene glycol

Ethylene glycol

Following last week’s Paucis Verbis card on calculating the osmolal gap, here is the first installment of the Toxic Alcohols cards. First up — ethylene glycol. There are useful American Academy of Clinical Toxicologists recommendations on when to administer an antidote (fomipezole) and when to perform hemodialysis.

Here’s a quick review of the metabolism of the different toxic alcohols. The parent compounds for ethylene glycol and methanol are innocuous and the metabolites are toxic.

PV Card: Ethylene Glycol Toxicity


Adapted from [1-3]
Go to ALiEM (PV) Cards for more resources.

See Dr. Leon Gussow’s great review on The Poison Review and tips of a recent Annals of EM4 paper on identifying a small subset of patients with ethylene glycol who did well despite NOT receiving hemodialysis.

References

  1. Kraut J, Kurtz I. Toxic alcohol ingestions: clinical features, diagnosis, and management. Clin J Am Soc Nephrol. 2008;3(1):208-225. [PubMed]
  2. Jammalamadaka D, Raissi S. Ethylene glycol, methanol and isopropyl alcohol intoxication. Am J Med Sci. 2010;339(3):276-281. [PubMed]
  3. Marraffa J, Cohen V, Howland M. Antidotes for toxicological emergencies: a practical review. Am J Health Syst Pharm. 2012;69(3):199-212. [PubMed]
  4. Levine M, Curry S, Ruha A, et al. Ethylene glycol elimination kinetics and outcomes in patients managed without hemodialysis. Ann Emerg Med. 2012;59(6):527-531. [PubMed]
By |2021-10-10T08:59:56-07:00Jun 8, 2012|ALiEM Cards, Tox & Medications|
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Paucis Verbis: Approach to increased osmolal gap

MindTheGap Osmolal gapWe often talk about calculating the anion gap in the evaluation of patients. What about the osmolal gap? When do you calculate this? What’s the differential diagnosis for an increased gap?

I recently came upon a nice 2011 review in the American Journal of Kidney Disease called “Approach to the evaluation of a patient with an increased serum osmolal gap and high-anion-gap metabolic acidosis”. It’s always nice to revisit and review this concept. You’ll always learn something new. For instance, I didn’t know that salicylates cause anion gaps as well as osmolal gaps.

So don’t forget to calculate an osmolal gap for patients with an unexplained metabolic acidosis anion gap.

PV Card: Approach to Osmolal Gap


Adapted from [1]
Go to ALiEM Cards for more resources.

Reference

  1. Kraut J, Xing S. Approach to the evaluation of a patient with an increased serum osmolal gap and high-anion-gap metabolic acidosis. Am J Kidney Dis. 2011;58(3):480-484. [PubMed]
By |2021-10-10T18:55:20-07:00Jun 1, 2012|ALiEM Cards, Tox & Medications|
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