Acute, uncomplicated cystitis (in the non-pregnant female):
· The drug of choice is SMX/TMP (provided the resistance rate is <20%) X 3 days.
· An alternative is nitrofurantoin X 5 days.
Acute, uncomplicated pyleonephritis (in the non-pregnanct female) may be treated with:
· Levofloxacin X 5 days, or ciprofloxacin X 7 days (provided resistance rate is <10%).
· Alternatively, SMX/TMP may be used X 14 days.
No one treatment has demonstrated consistency of pain relief from jellyfish stings over all species; conversely, a treatment for one species may worsen an envenomation from another.
Deionized water, seawater, meat tenderizer, and urea treatment do not appear to produce any improvement in pain sensation.
Ammonia, acetic acid, and ethanol may cause an increased stinging sensation, and in most species vinegar may cause nematocyst discharge.
Application of topical lidocaine reduced the local sensation of pain (10% and 15% produced immediate pain relief), and hot water results in pain relief in the majority of patients tested.
It may not be necessary to give oral vitamin K to patients that are not bleeding that have INRs between 4.5 and 10.
Patients who were supratherapeutic on warfarin were randomized to vitamin K 1.25 mg (n=355) versus placebo (n=369).
In the 90 days after enrollment, 15.8% of patients allocated to vitamin K and 16.3% allocated to placebo had a bleeding event. Major bleeding events occurred in 9 patients in the vitamin K group and 4 in the placebo.
Thromboembolic events occurred in 1.1% of patients in the vitamin K group, compared to 0.8% of patients in the placebo group. An equal number of patients died in each group (n=7).
If vancomycin resistance is suspected with MRSA infections, there are several other antibiotic choices. They are all extremely expensive.
| Antibiotic | ORAL | Indication | Precaution |
| Telavancin | N | SSTI | May cause QT prolongation: Caution with azole antifungals, class III antiarrhythmics, antidepressants, antipsychotics. Interferes with coagulation tests. |
| Daptomycin | N | SSTI Bacteremia Endocarditis | Not for pneumonia. May cause rhabdomyolysis; Discontinue statins. |
| Linezolid | Y | VAP SSTI | Not for bacteremia. May cause serotonin syndrome; Caution with antidepressants, antipsychotics, tramadol, methadone. |
| Tigecycline | N |
Intrabdominal infections SSTI | Not for bacteremia. Inhibits clearance of warfarin. Reserve for polymicrobial infections. |
Skin and soft tissue infection (SSTI); ventilator acquired pneumonia (VAP)
Protamine for enoxaparin overdose
Resistance is expected to be limited, with the exception of VRE, and VSE (vanco resistant or sensitive enterococcus faecalis)
Renally excreted
Common side effects: diarrhea, nausea, headache
Serious side effects: anaphylaxis, renal failure, hepatitis, seizure
Low incidence of C. difficile
Dose : 600 mg IV (over 1 hour) q12 hours X 5-7 days
High dose insulin is recommended in treatment of beta-blocker and calcium channel blocker overdose. In a recent observational case series of cardiogenic shock, high dose insulin was evaluated for efficacy and safety.
Salicylates:
Overall, this results in a mixed respiratory alkalosis and metabolic acidosis.
There are an increasing number of intranasal medications commercially available for use, which is opportune as more and more intravenous medications become scarce.
These now include:
| Generic name | Brand Name | Usage |
| Fentanyl | Instanyl | Opiate analgesic |
| Ketorolac | Sprix | NSAID analgesic |
| Desmopressin (DDAVP) | Stimate | Bleeding |
| Vitamin B12 | Nasobal | Anti-migraine (yes!) |
| Sumatriptan | Imitrex | Anti-migraine |
| Zolmitripran | Zomig | Anti-migraine |
*******In addition, you can administer glucagon, midazolam and narcan intranasally as well.
o The FDA is now asking manufacturers to limit the amount of acetaminophen in combination products to 325 mg per dose.
o The higher dose formulations will be phased out by 2014.
o The FDA is also considering lowering the maximum total to 3 gm per day, and a maximum dose of 650 mg per dose
o This does not pertain to OTC, but this is likely to change in the near future; Johnson & Johnson (manufacturer of Tylenol) has already adopted these recommendations.
Animal studies show high doses of caffeine produces catecholamine triggered activity
Small studies in high risk patients (recent MI, malignant arrhythmias) have shown no increase in frequency or severity of arrhythmia
No large scale human studies exist evaluating caffeine's effects on patients with malignant arrhythmias (VF/VT)
Overall, the data suggest that caffeine is well tolerated in moderate doses in most patients, even those with known or suspected arrhythmias
In patients who claim sensitivity to caffeine, or in those with known arrhythmias where catecholamines are felt to drive the arrhythmia, caffeine may be discouraged by physicians.
IV acetaminophen has been approved for use since November 2010
It is indicated for the:
The results of studies demonstrating opoid sparing effects have been mixed; some studies have not demonstrated either a reduction in opioid dose or opioid side effects.
The dose is the same for acetaminophen administered by other routes.
It must be administered over 15 minutes, and onset of activity is 15 minutes. Peak effect occurs at one hour.
The MAJOR drawback is the cost, which is $13 dollars per vial. This is compared to oral acetaminophen and ibuprofen, which are pennies.
· In the event a nuclear power plant accident, people may be exposed to a mixture of radioactive products. The main radionuclides representing health risk are radioactive caesium and radioactive iodine.
· Iodine-131 is concentrated in the thyroid gland and may eventually lead to development of thyroid nodules and thyroid cancer.
· Radioiodine uptake by the thyroid can be blocked by taking potassium iodide (KI) pills or solution, preventing these effects.
· KI should not be taken in the absence of a clear risk of exposure to a potentially dangerous level of radioactive iodine because KI can cause allergic reactions, skin rashes, salivary gland inflammation, hyperthyroidism or hypothyroidism.
· Since radioactive iodine decays rapidly, current estimates indicate there will not be a hazardous level of reaching the United States from this accident.
· There are three FDA approved KI products: Iosat, Thyrosafe and ThyroShield.
Recently a case report was published in which a child was incorrectly diagnosed with MRSA. He actually had systemic loxoscelism from a Brown Recluse spider bite.
A patient who has been bitten by brown recluse spider bite may present with pruritis, pain and swelling. The classic lesion has a bluish-purple central region, surrounded by concentric rings of pale ischemia and erythema. (“red, white and blue”) Bites may progress over days to a bleb with necrosis and eschar formation, followed by ulceration.
Systemic loxoscelism presents with a scarlatiniform rash that spreads dependently. It may have the classic purple lesion surrounded by concentric rings of pale ischemia and erythema. The patient may be uncomfortable but is usually stable. Treatment is supportive care.
