I have always been envious of the residents who carry around the Continuous Infusions cheat-sheet card, which was created by the UCSF Critical Care Units as part of a campaign for Safe Medication Prescriptions. I want one! So I finally managed to wrangle one away for a few minutes and xerox copy it. Here is the abbreviated card, after paring down the list to just ED-focused medications.
Go to ALiEM (PV) Cards for more resources.
“Ow, that burnnnnssss… ow! ow! ow! … zzzzzz…
As many as 60% of patients report significant pain with the injection of IV propofol. Once a patient experiences pain, it’s too late to reverse it. Often all you can do is to tell them that the pain will subside in a few seconds. What can you do preemptively to minimize the pain of propofol injection?
Serotonin syndrome is caused by the excess of serotonin and presents classically as:
Fortunately, there’s a nice algorithm (Hunter’s decision rule) which helps you decide whether it is serotonin syndrome or not. I also include a table, which I adapted from a New England Journal of Medicine review article, which helps you to differentiate it from its mimickers, such as anticholinergic syndrome, neuroleptic malignant syndrome, and malignant hyperthermia.
Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.
A video to remind you what clonus looks like:
Thanks to Dr. Steve MacDade (Univ of Florida, Jacksonville EM resident) for the idea!
Did you know that the American Association of Poison Control Centers reports that 10% of poison center calls are related to acetaminophen ingestions? That’s a lot. This Paucis Verbis card reviews the basics of acetaminophen toxicity. I included the Rumack Matthew nomogram to help you plot out the patient’s risk for hepatotoxicity.
In the Emergency Department, we often screen for acetaminophen toxicity for patients who may have ingested substances as a suicide attempt. We check the serum acetaminophen level 4 hours post-ingestion. Occasionally, we are surprised by a toxic level because in the first 24 hours, because symptoms are can be mild and nonspecific (abdominal pain, nausea, lethargy).
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
Overdoses of long-acting opiates, such as oxycodone and methadone, are challenging to manage, especially if these patients are chronically on opiates.
On the one hand, you want to reverse some of the sedative effectives with naloxone so that they aren’t near-apneic and hypoxic. You also want to be able to take a history from them. On the other hand, you don’t want to abruptly withdraw them with naloxone such that they become violent and agitated. It is a fine balancing act.
Long-acting opiates present a separate challenging because naloxone wears off fairly quickly in 30-45 minutes. These patients may require repeat dosings and/or a naloxone IV drip.
Do no harm.
We so often recommend and give NSAIDs to patients for various painful conditions. We also commonly administer ketorolac (toradol) in the ED, because it works so amazingly well for renal colic. When giving various NSAIDs, what is the relative risk (RR) for an upper GI bleed or perforation in the first year?
Ketorolac has the highest upper GI complication RR (14.54) for all of the studied NSAIDs. Compare this with the overall risk of traditional COX-1 NSAIDS (RR=4.5) and COX-2 inhibitors (RR=1.88). So before giving ketorolac, first check that patients don’t have a history of a GI bleed or peptic ulcer.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
Haldol, Ativan, and Versed… oh my.
In the Emergency Department, some patients present very acutely and aggressively agitated. This is usually the result of illicit drug use or a schizophrenic who hasn’t been taking medications (or both!). Fortunately, we have an arsenal of medications to help sedate the patient.
One study looked to answer the question of what single IM sedation agent is most effective, as measured by the shortest time to sedation and time to arousal.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.