Zlatan Coralic

Prediction of Vancomycin Pharmacodynamics in Children With Invasive Methicillin-Resistant Staphylococcus aureus Infections: A Monte Carlo Simulation

BACKGROUND Due to the emergence of community-associated strains, the prevalence of invasive methicillin-resistant Staphylococcus aureus (MRSA) infections has increased substantially in pediatric patients. A vancomycin AUC(0-24)/MIC index >400 best predicts treatment outcomes for invasive MRSA infection in adults. Data on whether recommended vancomycin doses in children achieve this break point are lacking. OBJECTIVE This study aimed to assess the likelihood that currently recommended vancomycin doses in children achieve AUC(0-24)/MIC >400. METHODS Vancomycin AUC(0-24)/MIC predictions were conducted across a range of dosages (40-70 mg/kg/d) using a Monte Carlo simulation (n = 5000). AUC(0-24) was calculated as daily dose divided by vancomycin clearance, and daily dose was fixed for a given simulation. Three literature-reported estimates in children were used to define vancomycin clearance and its variance. For the MIC distribution of MRSA isolates, susceptibility data were obtained from the University of California, San Francisco Childrens Hospital, San Francisco, California (n = 180; 40% < or =0.5 mg/L; 59% = 1 mg/L; and 1% = 2 mg/L). RESULTS Using the recommended empiric dosage of 40 mg/kg/d, 58% to 66% of children were predicted to achieve AUC(0-24)/MIC >400. Increasing the vancomycin dosage to 60 mg/kg/d substantially increased the likelihood (88%-98%) of achieving this pharmacodynamic target. On sensitivity analysis, a dosage of 40 mg/kg/d was more strongly influenced by small changes in MIC compared with 60 mg/kg/d. CONCLUSIONS Recommended empiric vancomycin dosing in children (40 mg/kg/d) was not predicted to consistently achieve the pharmacodynamic target of AUC(0-24)/MIC >400 for invasive MRSA infections. A vancomycin dosage of 60 mg/kg/d was predicted to optimize achievement of this target in children.

Simple Text-Messaging Intervention Is Associated With Improved Door-to-Needle Times for Acute Ischemic Stroke

Background and Purpose— Timely administration of intravenous tissue-type plasminogen activator (IV tPA) is associated with improved outcomes for acute ischemic stroke; yet, developing processes to consistently provide prompt treatment remains a challenge. We developed and evaluated a simple quality improvement intervention designed to improve door-to-needle (DTN) times for resident-led Code Stroke teams at an academic medical center. Methods— We evaluated a simple text-messaging based intervention with real-time feedback to improve DTN times for intravenous tissue-type plasminogen activator. We used the rank-sum test and linear regression to evaluate for a change in DTN times that was temporally associated with the rollout of the intervention. Results— A total of 202 patients received intravenous tissue-type plasminogen activator; 94 preintervention and 108 postintervention. The median DTN time was significantly lower in the postintervention period (56 minutes [interquartile range 44–71] versus 82 minutes [IQR 68–103], P<0.0001) and a significantly higher proportion of patients were treated within 60 minutes (61% versus 16%, P<0.001). Conclusions— A simple real-time text-messaging intervention was associated with a significant improvements in DTN times for acute ischemic stroke.

Staff Perceptions of an On-site Clinical Pharmacist Program in an Academic Emergency Department after One Year

Introduction Emergency department clinical pharmacists (EPh) serve a relatively new clinical role in emergency medicine. New EPh may still face barriers prior to working in the emergency department (ED), including staff acceptance. We aimed to assess staff perceptions of a university hospital EPh program 1 year after implementation. Methods We sent an electronic survey consisting of 7 multiple-choice questions, 17 5-point Likert-scale questions, and 1 free-text comment section to ED providers and nurses. The qualitatively validated survey assessed staff’s general perceptions of the EPh and their clinical work. Results We received responses from 14 attending physicians, 34 emergency medicine residents, 5 mid-level providers, and 51 nurses (80% response rate). Overall, the ED staff strongly supported the presence of an EPh. All of the respondents consulted the EPh at least once in their previous 5 ED shifts. Most respondents (81%) felt the EPh’s availability for general consultation and aid during resuscitations served as the major contribution to medication and patient safety. The participants also expressed that they were more likely to consult a pharmacist when they were located in the ED, as opposed to having to call the main pharmacy. Conclusion The EPh model of practice at our institution provides valuable perceived benefit to ED providers.

Root Cause Analysis of Ambulatory Adverse Drug Events That Present to the Emergency Department.

Background Adverse drug events (ADEs) among patients self-administering medications in home/community settings are a common cause of emergency department (ED) visits, but the causes of these ambulatory ADEs remain unclear. Root cause analysis, rarely applied in outpatient settings, may reveal the underlying factors that contribute to adverse events. Study Objectives To elicit patient and provider perspectives on ambulatory ADEs and apply root cause analysis methodology to identify cross-cutting themes among these events. Methods Emergency department clinical pharmacists screened, identified, and enrolled a convenience sample of adult patients 18 years or older who presented to a single, urban, academic ED with symptoms or diagnoses consistent with suspected ADEs. Semistructured phone interviews were conducted with the patients and their providers. We conducted a qualitative analysis. We applied a prespecified version of the injury prevention framework (deductive coding), identifying themes relating to the agent (drug), host (patient), and environment (social and health systems). These themes were used to construct a root cause analysis for each ADE. Results From 18 interviews overall, we identified the following themes within the injury prevention framework. Agent factors included high-risk drugs, narrow therapeutic indices, and uncommon severe effects. Host factors included patient capacity or understanding of how to use medications, awareness of side effects, mistrust of the medical system, patients with multiple comorbidities, difficult risk-benefit assessments, and high health-care users. Environmental factors included lack of social support, and health systems issues included access to care, encompassing medication availability, access to specialists, and a lack of continuity and communication among prescribing physicians. Root cause analysis revealed multiple underlying factors relating to agent, host, and environment for each event. Conclusion Patient and physician perspectives can inform a root cause analysis of ambulatory ADEs. Such methodology may be applied to understand the factors that contribute to ambulatory ADEs and serve as the formative work for future interventions improving home/community medication use.

Levamisole contaminated cocaine induced cutaneous vasculitis syndrome.

A 40-year-old woman presented to the emergency department with a chief complaint of a painful rash. She had noticed lesions on her skin accompanied by burning pain that intensified over a 24-hour period. The patient admitted to smoking “crack” cocaine 4 days prior to presentation. She reported having similar symptoms previously. Her complicated past medical history was significant for hepatitis C, anti-phospholipid antibody syndrome, migraine headaches, and chronic lower back pain. She endorsed smoking cigarettes and polysubstance abuse (marijuana, heroin, and daily cocaine use). The patient’s exam was notable for retiform purpuric skin lesions with eschar on her left external pinnae (Figure 1), tongue, roof of her mouth, and bilaterally on her upper and lower extremities (Figure 2). Pus was expressible on palpation of the tibial skin lesions. Laboratory evaluation revealed a white blood cell count of 3.1×109 cells/L and a positive urine toxicology screen for cocaine. A biopsy obtained from her right thigh during a prior similar presentation showed luminally-thrombosed fibrin-containing small vessels surrounded by neutrophils and nuclear dust. The adjacent dermis contained extravasated erythrocytes. Figure 1. Retiform purpuric skin lesions with eschar on pinnae. Figure 2. Retiform purpuric skin lesions with eschar on lower extremities. A vasculitic syndrome associated with levamisole-adulterated cocaine has become increasingly recognized. This syndrome is characterized by purpuric lesions in a retiform pattern that may become necrotic and are commonly distributed on the ears, face, and extremities,1 as evidenced by our patient. Typical laboratory findings include agranulocytosis, leukocopenia, and the production of anti-neutrophil cytoplasmic antibodies.1 There is no evidence for the optimal treatment of levamisole-induced cutaneous vasculitis syndrome. Steroids have been used, but have an unclear benefit. 2 Permanent discontinuation of levamisole-adulterated cocaine use should be advocated. When appropriate, surgical debridement has been used to contain the progression of necrotic tissue spread.2

Detection of Acute Pulmonary Embolism by Bedside Ultrasound in a Patient Presenting in PEA Arrest: A Case Report

Optimal management of the critically ill patient in shock requires rapid identification of its etiology. We describe a successful application of an emergency physician performed bedside ultrasound in a patient presenting with shock and subsequent cardiac arrest. Pulmonary embolus was diagnosed using bedside echocardiogram and confirmed with CTA of the thorax. Further validation and real-time implementation of this low-cost modality could facilitate the decision to implement thrombolytics for unstable patients with massive pulmonary embolism who cannot undergo formal radiographic evaluation.

Prochlorperazine-Induced Hemidystonia Mimicking Acute Stroke

Prochlorperazine is frequently used in the treatment of refractory nausea and migraines. Known side effects include extrapyramidal symptoms such as akathisia and dystonia. We report a pregnant patient taking prochlorperazine for hyperemesis gravidarum who developed hemidystonia, which triggered an acute code stroke response from prehospital, emergency medicine and neurology providers. We suspect this report to be the first case of prochlorperazine-induced hemidystonia as a stroke mimic.

Adie's Tonic Pupil

A 33-year-old woman with no past medical history presented to the emergency department with asymmetric pupils. At 7:30am while putting on makeup, she noted her pupils were equal in size. One hour later, she developed light sensitivity in her right eye, and soon after noticed her right pupil was significantly enlarged. She denied headache, facial or extremity weakness, dysarthria, or ataxia. On exam, her left pupil was reactive from 4 to 3 mm and her right pupil was sluggishly reactive and 8 mm (Figure). No abnormalities in her visual acuity, extraocular movement or fundoscopic exam were detected. Neurologic consultation was obtained, but the patient had an unremarkable brain computed tomography (CT)/CT-Angiography and magnetic resonance imaging. Figure. Photograph of 33-year-old female presenting with asymmetric pupils. A tonic pupil results from parasympathetic denervation at the level of the ciliary ganglion. It is characterized by a large, regular pupil with decreased response to light but preserved or enhanced constriction to accommodation, segmental iris constriction, vermiform movements of the pupillary border, and hypersensitivity to pharmacologic constricting agents.1–4 The diagnosis was established in consultation with ophthalmology and confirmed with rapid miotic response of the affected pupil to 0.125% pilocarpine drop.1,2 Most cases are idiopathic, occurring in women 20–40 years of age, and referred to as the Adie’s tonic pupil, though this disorder can be due to local disorders within the orbit, including tumor, inflammation, trauma, surgery, ischemia or infection. 3 Most patients do not require any treatment and can be reassured once the diagnosis is confirmed.

Ketamine procedural sedation in the emergency department of an urban tertiary hospital in Dar es Salaam, Tanzania

Study objective We describe ketamine procedural sedations and associated adverse events in low-acuity and high-acuity patients in a resource-limited ED. Methods This was a prospective observational study of ketamine procedural sedations at the Emergency Medical Department at the Muhimbili National Hospital in Dar es Salaam, Tanzania. We observed consecutive procedural sedations and recorded patient demographics, medications, vital signs, pulse oximetry, capnography and a priori defined adverse events (using standard definitions in emergency medicine sedation guidelines). All treatment decisions were at the discretion of the treating providers who were blinded to study measurements to simulate usual care. Data collection was unblinded if predefined safety parameters were met. For all significant adverse and unblinding events, ketamine causality was determined via review protocol. Additionally, providers and patients were assessed for sedation satisfaction. Results We observed 54 children (median 3 years, range 11 days–15 years) and 45 adults (median 33 years, range 18–79 years). The most common indications for ketamine were burn management in children (55.6%) and orthopaedic procedures in adults (68.9%). Minor adverse events included nausea/vomiting (12%), recovery excitation (11%) and one case of transient hypertension. There were nine (9%) patients who had decreased saturation readings (SpO2 ≤92%). There were three deaths, all in severely injured patients. After review protocol, none of the desaturations or patient deaths were thought to be caused by ketamine. No patient experienced ketamine-related laryngospasm, apnoea or permanent complications. Overall, ketamine was well tolerated and resulted in high patient and provider satisfaction. Conclusion In this series of ketamine sedations in an urban, resource-limited ED, there were no serious adverse events attributable to ketamine.