Miscellaneous

Rapid Review

• Mechanism of Action: Simple carbohydrate that increases serum blood glucose concentrations
• Indications: Hypoglycemia. When used with insulin, can treat hyperkalemia by allowing for uptake of potassium into cells
• Contraindications: Intracranial/intraspinal hemorrhage, delirium tremens (if patient is already dehydrated)
• Dosage: 25 grams in several different formulations; D50 comes in 50mL sterile water amp, D10 comes in 250mL sterile water bag, D5W comes in 500mL sterile water bag)
• Onset: Less than 10 minutes
• Duration: Variable
• Adverse Reactions: Tissue necroses, hyperglycemia, cerebral ischemia/hemorrhage
• Special Considerations: Can only be given via IV route (due to tissue necrosis)

Pearls

• A full ampule of D50 typically increases blood sugar by approximately 150mg/dL, which is often more than what’s required and can be harmful in critically ill  patients. Consider D10 infusions or only giving part of the D50 ampule. 
• Dextrose can cause significant tissue necrosis if extravasated, especially in the D50 formulation. D10 is a safer option when giving through a peripheral IV.

Deep Dive

• D50 vs D10 for Severe Hypoglycemia in the Emergency Department (ALiEM)

Rapid Review

• Mechanism of Action: Loop diuretic; inhibits sodium and chloride reabsorption in the loop of henle and proximal/distal convoluted tubule. Promotes excretion of sodium, water, chloride, and potassium.
• Indications: Fluid overload, hypertension, hypercalcemia
• Contraindications: Allergy to class/drug, anuria
• Dosage: Usual dosage in ED is 20-40mg IV; titrate to effect. 
• Onset: 5 min (IV); 20-30 min (PO)
• Duration: 2 hours (IV); 6-8 hours (PO)
• Adverse Reactions: Hypokalemia, hypovolemia, urinary frequency, dizziness, weakness

Pearls

• For patients with volume overload that are already on PO furosemide at home, increase the IV dosage by 2X the total daily home dosage.
• Furosemide should be used carefully, as it has several boxed warnings including risk for significant electrolyte depletion, hypovolemia, and prerenal AKI

Deep Dive

• Myths in Emergency Medicine: Rethinking Furosemide in Acute Pulmonary Edema (Emergency Medicine News)

Rapid Review

• Mechanism of Action: Hormone/Anti-diabetic agent; increases peripheral glucose uptake, increases inotropy, and shifts potassium intracellularly
• Indications: DKA/HHS, hyperkalemia, calcium-channel blocker overdose
• Contraindications: None
• Dosage: Hyperkalemia (5-10 units IV x 1); DKA/HHS (0.1 unit/kg bolus followed by 0.1 unit/kg/hour infusion)
• Onset: 30-60 minutes
• Duration: 3-6 hours
• Adverse Reactions: Hypoglycemia, hypersensitivity reactions
• Special Considerations: For hyperkalemia, insulin should be used in conjunction with dextrose.

Pearls

• Because insulin shifts potassium intracellularly, you should not initiate insulin until serum potassium is at least > 3.3 mEq/L.
• Intravenous boluses of insulin are typically not necessary for DKA unless the patient has severe acidosis (ph < 7) or concurrent hyperkalemia. Subcutaneous dosing can help minimize precipitation of hypoglycemia/hypokalemia.

Deep Dive

• Pharmacology of Insulins (CORE EM)

Rapid Review

• Mechanism of Action: Antifibrinolytic agent; competitively inhibits the activation of plasminogen to plasmin, thus preventing clot breakdown during blood loss. 
• Indications: Massive hemorrhage, postpartum bleeding, epistaxis, 
• Contraindications: Greater than 3 hours from injury, previous DVT/PE, allergy to drug
• Dosage: 1 gram IV over 10 minutes (Initial bolus); followed by 1 gram IV over 8 hours. 
• Onset: 5-15 min
• Duration: 3 hours
• Adverse Reactions: Thrombotic events, hypotension, nausea/vomiting
• Special Considerations: None

Pearls

• As an antifibrinolytic agent, tranexamic acid increases the risk of venous thromboembolism. Be cautious using this medication in patients with a history or high risk of blood clots.
• Tranexamic acid can be applied topically (typically gauze soaked in IV solution) format for a variety of situations, including lacerations and epistaxis. 

Deep Dive

• The Evidence for TXA – Should Tranexamic Acid Be Routine Therapy in the Bleeding Patient (EM Cases)