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A Breath of Fresh Air: Nebulized TXA for Hemoptysis

An 80-year-old male arrived at the Emergency Department (ED) in a serious condition: he was coughing up blood. Although he coughed up about three tablespoons (50cc/hr), he was hemodynamically stable. A physician approached me with an unfamiliar question: “Could we give him nebulized TXA?” I looked at him for a moment, nonplussed. “What?!” I exclaimed, “Hold on—let me look it up and get back to you.” Questions flooded my mind: Is it effective? Is it [...]

By |2018-11-14T11:00:00-05:00November 14th, 2018|EM PharmD Blog|0 Comments

Nausea and Vomiting in the ED: There’s Something Fishy Going On

Nausea and vomiting is a common chief complaint in the ED, one I never really paid much attention to unless prompted (appropriate agent to use in pregnancy, which medication to use for a patient with a prolonged QTc, etc.) - at least, that was my practice before I began practicing in Miami. In one of the many unforgettable cases I have had in the ED, there was a young patient who presented with nausea and vomiting. [...]

By |2018-10-30T10:00:00-05:00October 30th, 2018|EM PharmD Blog|0 Comments

Fosfomycin: The Forgotten Treasure

We have all been there, a patient with so many complicating factors that it’s difficult to choose the least worst option to treat a urinary tract infection. For example: a patient with a CrCl ~22 ml/min, a prolonged QTc, sulfa allergy (described as immediate death), and amoxicillin allergy (also somehow described as immediate death) who absolutely refuses to try a cephalosporin. How is it this difficult to treat a simple urinary tract infection?!?!?! There is [...]

By |2018-08-27T11:11:00-05:00August 27th, 2018|EM PharmD Blog|0 Comments

BCPS Recertification: Follow Up

In two previous post, I outlined my impressions of High-Yield Med Reviews based on my experience going through the modules and webinar. While I still stand behind my evaluation of HYMR, my assessment was somewhat limited because it was all before the exam. Now that I have my scores, I feel I can give a more complete assessment of HYMR. In a nutshell: I passed, and highly recommend HYMR. In the final days before the exam, [...]

By |2018-07-25T14:41:00-05:00July 25th, 2018|EM PharmD Blog|0 Comments

Choosing NOACs in the ED

Patient Case:A 62-year-old female presents to the ED with left lower extremity pain and swelling and is diagnosed with a LLE deep vein thrombosis (DVT) on ultrasound. The patient’s past medical history is significant for hypertension and she takes amlodipine at home. Laboratory values, pulse oximetry, and vital signs are within normal limits. The ED physician approaches you about discharge anticoagulation options and asks for a recommendation. Which agent would you recommend for outpatient management [...]

By |2018-06-29T21:00:00-05:00June 29th, 2018|EM PharmD Blog|0 Comments

The plague that is vancomycin troughs

How important are vancomycin levels? Not very.... at least as a marker of efficacy. True, higher levels probably are associated with increased nephrotoxicity (above 15 mcg/mL) - Antimicrob Agents Chemother. 2013 ;57:734-44But the notion that troughs of 15-20 mcg/mL are the holy grail of therapeutic drug monitoring targets is simply not supported by data.What we know: vancomycin AUC/MIC in the mid 300 to 400s (let's just say > 400) or so range is likely the [...]

By |2018-05-29T16:30:00-05:00May 29th, 2018|EM PharmD Blog|0 Comments

Changing Paradigms in Stress Ulcer Prophylaxis

Obviously any patient that requires mechanical ventilation for 48 hours or has "coagulopathy" should get stress ulcer prophylaxis (SUP) right? maybe not....when the above risk factors where identified in 1994 by Deborah Cook (N Engl J Med. 1994;330(6):377-81.) and studies validating SUP as an effective means of preventing GI bleeding in critically ill patients were published (Crit Care Med.1993;21:1844-9. and Crit Care Med. 1993;21:19-30 - btw, cimetidine continuous infusion, really?) critical care was quite different [...]

By |2018-05-25T17:14:00-05:00May 25th, 2018|EM PharmD Blog|0 Comments

"What is the INR of FFP?"

I frequently encounter people touting that "The INR of FFP is like 1.6 or something". Indeed I learned something similar myself at some point. It turns out however that the mean INR of FFP is actually 1.1 (Transfusion 2005;45:1234-5.). So why does it seem like no matter how much FFP you tend to give, it is very difficult to get the INR much lower than 1.6 or so?As can be seen from the image below [...]

By |2018-05-21T13:56:00-05:00May 21st, 2018|EM PharmD Blog|0 Comments

“What is the INR of FFP?”

I frequently encounter people touting that "The INR of FFP is like 1.6 or something". Indeed I learned something similar myself at some point. It turns out however that the mean INR of FFP is actually 1.1 (Transfusion 2005;45:1234-5.). So why does it seem like no matter how much FFP you tend to give, it is very difficult to get the INR much lower than 1.6 or so?As can be seen from the image below [...]

By |2018-05-21T13:56:00-05:00May 21st, 2018|EM PharmD Blog|0 Comments

"Balanced Crystalloids" and Hyperkalemia

With the recent publication of the SMART and SALT-ED trials, the chloride rich vs poor (balanced/buffered) crystalloid debate is back in the spotlight after a break post the orginal Yunos JAMA 2012 and SPLIT JAMA 2015. Something I commonly hear from internal medicine residents however is that LR and plasma-lyte should DEFINITELY be avoided in the setting of hyperkalemia, since they contain 4 and 5 meq/L of potassium respectively.It turns out however that normal saline [...]

By |2018-05-15T14:22:00-05:00May 15th, 2018|EM PharmD Blog|0 Comments