Neil Jasani

A Randomized Trial of Loading Vancomycin in the Emergency Department

Background: Optimizing vancomycin dosing may help eradicate bacteria while avoiding resistance. The guidelines recommend loading doses; however, there are no data to demonstrate that this may result in a more rapid achievement of therapeutic troughs. Objective: To evaluate the percentage of troughs reaching therapeutic levels at 12, 24, and 36 hours following an initial vancomycin dose of 30 mg/kg compared with 15 mg/kg. Methods: This prospective, randomized study was performed in a community academic medical center. Patients who were to receive vancomycin in the emergency department were randomized to an initial traditional dose of 15 mg/kg or a 30-mg/kg loading dose followed by 15 mg/kg every 12 hours for 3 doses. Patients weighing >120 kg or with creatinine clearances <50 mL/min were excluded. Results: In total, 99 patients were enrolled; 12 hours after the initial dose of vancomycin, there was a significantly greater proportion of patients reaching target trough levels of 15 mg/L among the patients who received a loading dose as compared with a traditional dose (34% vs 3%, P < 0.01). This trend continued at 24 hours but was not statistically significant. At 36 hours, there was no difference in the percentage of patients reaching target levels between the 2 groups. No statistically significant difference in nephrotoxicity or adverse events among the 2 groups was demonstrated. Conclusion: A loading dose of 30 mg/kg of vancomycin achieved a higher percentage of therapeutic levels at 12 hours when compared with the traditional dose of 15 mg/kg, without increased nephrotoxicity or adverse events.

Ultrasound-Guidance Can Reduce Adverse Events During Femoral Central Venous Cannulation

BACKGROUNDnUltrasound-guidance for internal jugular central venous cannulation (CVC) has become the recommended best practice and has been shown to improve placement success and reduce complications. There is a dearth of studies that evaluate emergency point-of-care ultrasound guidance of femoral CVC.nnnOBJECTIVEnOur aim was to determine if point-of-care ultrasound guidance for femoral CVC decreases adverse events and increases the likelihood of successful placement when compared with the landmark technique.nnnMETHODSnWe conducted an Institutional Review Board-approved, prospective, observational study of consecutive patients who required CVC. Physicians who performed CVC completed a standardized, web-based data sheet for a national CVC registry. We evaluated single-institution data regarding CVC site, ultrasound usage, CVC indication, and mechanical complications (e.g., pneumothorax, arterial puncture, failed access, catheter misdirection, and hematoma). The study period was between January 2006 and June 2010. Analysis using Pearsons χ(2) and Agresti-Coull binomial confidence intervals was performed; significance was defined as p < 0.05.nnnRESULTSnWe evaluated data for 143 patients who had femoral CVC in our institution. Sixty CVCs (42%) were performed under ultrasound guidance, 83 (58%) via landmark technique (p = 0.0159); 3.3% of femoral central venous lines placed by ultrasound guidance had recorded adverse events compared with 9.6% for the landmark technique (p = 0.145). There was no statistically significant difference in complications between ultrasound-guidance and landmark techniques. Our data showed a trend toward decreased rates of arterial puncture and reduced cannulation attempts resulting in improved placement success.nnnCONCLUSIONSnOur experience shows that ultrasound guidance for femoral CVC might decrease complications and improve placement success, although we cannot recommend this approach without additional data. We recommend a larger study to further evaluate this technique.

Prescribing Habits of Vancomycin in the Emergency Department: Are We Dosing Appropriately?

BACKGROUNDnTo prevent the development of bacterial resistance, current guidelines recommend vancomycin dosages of 15-20 mg/kg based on actual body weight.nnnOBJECTIVEnOur aim was to determine if two community teaching Emergency Departments followed the new recommendations for a weight-based dosing regimen for vancomycin.nnnMETHODSnA retrospective cohort study was conducted on the prescribing habits of vancomycin in the Emergency Department. During a 6-month time period, 1,734 doses of vancomycin were dispensed and a subsequent random sample of 240 doses was reviewed. Data collection included age, gender, weight, creatinine clearance, vancomycin dose, and indication for vancomycin therapy. Mean values, standard deviations, and ranges were computed to illustrate current prescribing practices.nnnRESULTSnThe mean vancomycin dose was 1,117 ± 325 mg. Based on actual body weight, the calculated mean dose was 14.6 ± 5.7 mg/kg. Only 19.6% (47 of 240) of all patients received an appropriate dose based on the recommended 15-20 mg/kg vancomycin dose.nnnCONCLUSIONSnOur Emergency Department is inappropriately dosing vancomycin in the majority of patients. Educating clinicians regarding appropriate vancomycin dosing is recommended to achieve compliance with the latest consensus guidelines.

Computerized provider order entry improves compliance of vancomycin dosing guidelines in the emergency department

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Seizure as a Presentation of Pulmonary Embolism

BACKGROUNDnSeizure is estimated to be the presenting symptom of pulmonary embolism (PE) < 1% of the time. A review of the available literature on the subject indicates that many of the reported cases are postmortem findings, and invariably, are examples of delayed diagnosis and treatment.nnnOBJECTIVESnTo heighten physician awareness of the possibility of a PE in patients initially presenting with seizures, and to bring to light some key aspects of the history and physical examination that may assist in the final diagnosis.nnnCASE REPORTnA 76-year-old man presented to the Emergency Department (ED) after suffering from two tonic-clonic seizures at home. He had a history of one isolated seizure 4 years prior, for which he was not prescribed any medication after full evaluation, including a negative electroencephalogram. In the ED, he was noted to have a resting tachycardia and a room air oxygen saturation of 92%. This prompted further evaluation in the ED. Electrocardiography and D-dimer were ordered, and both were found to be abnormal. Computed tomography scan was positive for multiple large pulmonary emboli. The patient was given an appropriate dose of enoxaparin and admitted to the internal medicine service.nnnCONCLUSIONnDespite an atypical presentation, the authors were able to diagnose the patient due to a high level of suspicion for the disease. Our goal is to make physicians more attuned to the possibility of a PE as a final diagnosis in patients who present with new-onset seizures.

Recidivism among ED super users after implementation of a pain protocol

Super users who frequent the emergency department (ED) with recurring pain complaints pose a number of challenges for ED staff. Our system defines super users as patients with greater than 20 ED visits annually. In 2013, there were 144 super users in our 2 hospital system, accounting for 4405 visits. The diagnosis of pain has been shown to be a driver of ED use. The more frequently a patient visits the ED annually, the higher likelihood there is a diagnosis of pain (chronic, musculoskeletal, neuropathic, generalized, etc) [1]. The routine use of intravenous (IV) or intramuscular (IM) opiates for the management of chronic pain may actually worsen chronic pain syndromes [2]. Unfortunately, this is often the strategy ED providers adopt when caring for the recidivist patient with chronic pain. This highlights the need for successful chronic pain management strategies [3–7] within the super user population. Therefore, a restrictive pain protocol was implemented to minimize the overuse of the ED and potentially decrease cost and hospital admissions among a super user cohort. An interdisciplinary committee reviewed super user charts from our system (160 000 ED visits) to determine if pain and the routine administration of IV or IM opiates was the predominant factor driving ED use. The 14 patients with the highest ED visits were notified of their enrollment in the pain management protocol which recommended oral as opposed to IV and IM opiates for treatment of chronic pain (Figure). The study was a prospective cohort trial. To investigate protocol effectiveness, ED visits, ED charges, inpatient days, and total charges per patient per month were recorded. These data were divided into 3 distinct time periods: a “preprotocol” period lasting 16 months and 2 distinct “follow-up” periods of 6 months (short term or “follow-up 1”) followed by an additional 23 months (long term or “follow-up 2”). Differences in ED use, inpatient days, ED costs, and total costs over time were examined using a multivariate repeated measures analysis of variance. Protocol compliance was determined through measurement of the percentage of visits where patients received IV or IM hydromorphone and number of doses/visit for the preprotocol and follow-up periods. For cohort demographics, see Table 1. After implementation of our pain protocol, there was a statistically significant decrease in ED use and ED costs, but not inpatient days or total cost (Table 2). Protocol compliance measures also showed a statistically significant decrease for both study periods (Table 3). Our goal was to determine the impact of a restrictive pain protocol implemented among an ED super user cohort. Theoretically, the implementation of a consistent restrictive pain management strategy that discourages the use of parenteral medications for the treatment of chronic pain will dissuade patients from using the ED and encourage outpatient follow-up. Data at follow-ups 1 and 2 demonstrated a statistically significant reduction in ED visits per patient per month. When the 2 follow-up periods were compared, there was no degradation of effect. Through the entire duration of the protocol, ED charges decreased by more than

Immediate Stress Echocardiography for Low-Risk Chest Pain Patients in the Emergency Department: A Prospective Observational Cohort Study

200 000. It therefore appears that our pain protocol was effective in establishing a long-term reduction of ED visits and charges. However, this did not translate into decreased inpatient days or total charges (Table 2). Use of ED is driven by a number of factors, and institutions are approaching the super user population in varied fashion. This study demonstrates that a targeted restrictive approach can easily be implemented to reduce excessive ED visits in patients with recurrent pain. This study is limited by several factors. A small sample size, lack of a control group, unknown ED usage outside our system, and implementationwithin a single hospital systemmakes it difficult to extrapolate these results. Also, the administration of even small quantities of opiates may have encouraged ED usage. Finally, this study did not take into account the natural variability in the usage patterns among this patient population. Often super users with greater than 20 visits per year do not maintain their frequent usage patterns on a year-over-year basis [8]. The implementation of a restrictive pain protocol within our 2hospital system resulted in both a shortand long-term reduction in ED visits and total charges among a cohort of 14 super users with recurrent pain complaints. A statistically significant reduction in ED visits seen at 6 months was sustained during an additional 23-month follow-up period. This study suggests that a consistent restrictive approach to pain management in super users with pain as their primary complaint may dissuade against excessive ED use.

Emergency Department Evaluation of Chest Pain Using Exercise Stress Echocardiography

BACKGROUNDnEvaluation and disposition of low-risk chest pain (CP) patients in the emergency department (ED) is time consuming and expensive. Low-risk CP often results in hospital admission to rule out myocardial infarction, which leads to additional costs and delays.nnnOBJECTIVEnOur aim was to assess whether an immediate exercise stress echocardiogram (IESE) in the ED will allow safe, efficient, and cost-effective evaluation and discharge of patients with low-risk CP.nnnMETHODSnLow-risk CP patients (TIMI [Thrombolysis in Myocardial Infarction] score 0-1) presenting to the ED with normal electrocardiogram, no history of coronary artery disease, and negative troponin T received IESE. We followed these patients for major adverse cardiac events and compared them to a control cohort of similar-risk patients admitted with traditional care at 1 and 6xa0months.nnnRESULTSnWe enrolled 216 patients, 117 IESE and 109 control. We obtained follow-up at 1 and 6xa0months in 94% of the IESE group and 88% in the control group. There was no difference in diagnostic catheterization or percutaneous coronary intervention between the 2 groups (6.0% and 1.7% vs. 6.4% and 1.8%; pxa0=xa00.89). Median time from triage to discharge was significantly shorter with IESE (572.6xa0min vs. 1466.0xa0min), resulting in significantly lower cost (

Comparison of Hydromorphone and Meperidine for Ureteral Colic

4380.50 vs.

928: COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE) INCREASES WEIGHT-BASED DOSING COMPLIANCE WITH VANCOMYCIN PRESCRIBING IN THE EMERGENCY DEPARTMENT

6191.70). There were no adverse events related to IESE or early discharge.nnnCONCLUSIONSnIn our study, IESE for low-risk CP patients presenting to the ED has the potential to be equally safe, more expeditious, and morexa0cost effective than admission to an observation unit.