Keeping It "Current": A Review of Treatment Options for the Management of Supraventricular Tachycardia.

OBJECTIVE: To review treatment options and updates that exist for the management of paroxysmal supraventricular tachycardia (PSVT). DATA SOURCES: A literature search of PubMed was performed including articles from 1974 to June 2023 using the terms: arrhythmias, adenosine, verapamil, diltiazem, esmolol, propranolol, metoprolol, beta-blockers, amiodarone, PSVT, synchronized cardioversion, methylxanthines, dipyridamole, pediatrics, heart transplant, and pregnancy. Primary literature and guidelines were reviewed. STUDY SELECTION AND DATA EXTRACTION: Studies were considered if they were available in English and conducted in humans. DATA SYNTHESIS: PSVT is a subset of supraventricular tachycardia (SVT) that presents as a rapid, regular tachycardia with an abrupt onset and termination. Due to frequent emergency department (ED) visits annually with symptoms of PSVT, appropriate and efficient management of these patients is vital. This review provides an overview of the pathophysiology of PSVT, while also describing the literature behind nonpharmacologic and pharmacologic management of PSVT. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: This review describes new literature regarding the improved success of the modified Valsalva maneuver as a nonpharmacologic therapy in PSVT. In addition, it describes a new technique in administration of adenosine that has improved outcomes, defines dose adjustments needed for drug interactions with adenosine, compares the utilization of nondihydropyridine calcium channel blockers with adenosine, and provides management recommendations for patients in special populations. CONCLUSIONS: With high annual rates of ED visits for SVT, providers should be aware of the data behind management and modifications of therapy based on patient-specific factors (ie, patient preference, pharmacokinetics/pharmacodynamics, drug interactions, and special populations).

Antimicrobial Stewardship Techniques for Critically Ill Patients with Pneumonia.

Pneumonia is common in the intensive care unit (ICU), infecting 27% of all critically ill patients. Given the high prevalence of this disease state in the ICU, optimizing antimicrobial therapy while minimizing toxicities is of utmost importance. Inappropriate antimicrobial use can increase the risk of antimicrobial resistance, Clostridiodes difficile infection, allergic reaction, and other complications from antimicrobial use (e.g., QTc prolongation, thrombocytopenia). This review article aims to discuss methods to optimize antimicrobial treatment in patients with pneumonia, including the following: procalcitonin use, utilization of methicillin-resistant Staphylococcus aureus nares testing to determine need for vancomycin therapy, utilization of the Biofire® FilmArray® pneumonia polymerase chain reaction (PCR), and microbiology reporting techniques.

D-Cycloserine-Induced Seizure Activity in the Emergency Department: A Case Report.

D-cycloserine (DCS) is an anti-tuberculosis medication that has been utilized for years for drug-resistant tuberculosis. DCS works via a centrally acting mechanism which can cause neurotoxic adverse effects which has limited its use. This centrally acting mechanism also allows for DCS to be utilized for various neuropsychiatric purposes. Our patient was on high-dose DCS for autism spectrum disorder and presented to the emergency department (ED) with a seizure. The seizure episode was managed with both anti-epileptics and pyridoxine. With increasing novel use of this older medication, it is imperative for ED clinicians to be aware of the different management strategies that may be required when a patient presents with a neurotoxic effect, specifically seizures, secondary to DCS.

Impact of Pulmonary Embolism Response Team on Anticoagulation Prescribing Patterns in Patients With Acute Pulmonary Embolism.

INTRODUCTION: Anticoagulation remains the mainstay pharmacotherapy for acute pulmonary embolism (PE), but multiple treatment options exist. The Pulmonary Embolism Response Team (PERT) is a multidisciplinary group that evaluates patients, formulates evidence-based treatment plans, and mobilizes resources. The objective of this study was to characterize the anticoagulation prescribing patterns made by PERT and to determine the clinical impact of anticoagulant selection. MATERIALS AND METHODS: This was a retrospective analysis of patients evaluated by PERT from 2016 to 2018. Multivariable linear regression was conducted to determine predictors of length of stay (LOS). RESULTS: A total of 209 patients were evaluated by PERT and received anticoagulation on discharge. Of those, 47% received a non-vitamin K oral anticoagulant (NOAC), 29% received warfarin, and 23% received low-molecular-weight heparin. Patient preferences and comorbidities were the most common reasons for NOAC omission. Patients who received NOACs had a shorter median LOS than warfarin (6.1 [4.6-7.6] days vs 10.9 [8.4-13.4] days; P < .05). Selection of NOAC upon discharge was the only factor independently associated with reduced LOS (ß coefficient: -0.6; 95% CI: -1.01 to -0.18; P < .01). CONCLUSION: The most common recommendation made by PERT was to initiate a NOAC upon discharge, resulting in shorter hospital LOS compared to patients who received warfarin.

Pharmacist Presence Decreases Time to Prothrombin Complex Concentrate in Emergency Department Patients with Life-Threatening Bleeding and Urgent Procedures.

BACKGROUND: Reversal of anticoagulation with four-factor prothrombin complex concentrate (4F-PCC) is critical, yet the optimal timing to 4F-PCC administration and whether quicker administration improves hemostasis remains unknown. OBJECTIVE: The objective of this study was to determine if pharmacist presence is predictive of faster time to 4F-PCC. METHODS: This retrospective cohort study included patients receiving 4F-PCC for life-threatening bleeding or urgent procedure in the emergency department (ED) from 2014 to 2018. Patients with pharmacists at bedside (PharmD group) were compared with physician teams alone (control group). The primary outcome was time from ED presentation to 4F-PCC administration. RESULTS: Of 252 patients evaluated, 116 patients (46%) were included (n = 50 PharmD group; n = 66 control group). Most patients presented on warfarin (68.1%), and of the life-threatening bleeds (94%), intracranial hemorrhage was most common (67.2%). The median time to 4F-PCC administration was significantly shorter in the PharmD group (66.5 vs. 206.5 min, p < 0.001). Pharmacist at bedside was the only factor independently associated with reduction in time to 4F-PCC (ß coefficient -163.5 min, 95% confidence interval -249.4 to -77.7). Although there was no difference in hemostasis or mortality, patients in the PharmD group had a shorter intensive care unit length of stay (LOS) (2 vs. 5 days, p < 0.01) and hospital LOS (5.5 vs. 8 days, p = 0.02). CONCLUSION: A pharmacist at the bedside of patients who present to the ED with life-threatening bleeding or need for emergent procedure decreased time to 4F-PCC administration by 140 min, even after accounting for confounders. Faster time to 4F-PCC was associated with significantly shorter intensive care unit and hospital LOS.