Vancomycin 1g for Everyone, Right?

From our very own ED pharmacist, Natalija Farrell:


The Issue

  • Methicillin-resistant Staphylococcus aureus (MRSA) infections and MRSA-related hospitalizations continue to increase.1
  • Vancomycin remains the cornerstone for the treatment of suspected or confirmed MRSA infections.
  • Its efficacy is measured by troughs (goal 10-20 mg/L) and troughs <10 mg/L foster vancomycin resistance.2
  • Due to the increased mortality in patients with vancomycin susceptible aureus with higher minimum inhibitory concentrations (“MIC creep”) and emergence of vancomycin intermediate or resistant S. aureus (VISA, VRSA),3-5 it is even more paramount to dose vancomycin correctly and target troughs 15-20 mg/L.
  • Emergency Departments are underdosing vancomycin in >70% of patients (especially in obese patients).
    • Most patients received vancomycin 1 g IV. 6-7

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CITW 5: A Close Shave

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: 20 y/o otherwise healthy male presents to the ED with a rash on his neck. He states he woke up with the rash. It burns, but is not pruritic. He’s never had it before. He endorses some chills, but no fevers.  He states these lesions all appeared in areas where he had been shaved yesterday at the Barber Shop.

Vitals: BP 132/76, HR 67, T 98.9 °F, RR 12, SpO2 99 % on RA

Notable exam findings: See below

PF 1

PF 2

What’s the diagnosis?

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CITW 4: Abdominal Pain and a Curious Rash

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: 20 year old female with no significant past medical history who presents to the ED with one week of severe, diffuse abdominal pain. She’s never had this pain before. It waxes and wanes. Nothing makes it better or worse. It is associated with nausea, intermittent joint pain and swelling, and a non-pruritic rash on her lower extremities. She states she had a head cold about three weeks ago, but has been otherwise well. She denies fevers, chills, headache, shortness of breath, chest pain, nausea, vomiting, diarrhea, or urinary symptoms. Of note, she was seen at an urgent care when her symptoms started and put on doxycycline for presumed Lyme, although she denies any tick bites.

Vitals: BP 126/81, HR 73, T 98.7 °F, RR 18, SpO2 100 % on RA

Notable physical exam findings: Mild, diffuse abdominal tenderness, but no rebound or guarding. She has scattered, raised, purpuric lesions on her bilateral lower extremities. They are non-painful and non-blanchable (see below).

Notable laboratory workup: Trace, microscopic hematuria and a mildly elevated creatinine (1.24).


What’s the diagnosis?

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CITW: Case 3

A 15 y/o male with a history of  diabetes mellitus and hypothyroidism presents to the ED with a diffuse rash. It is not painful or pruritic. Of note, he was seen at the at his primary care doctors office earlier that week and found to have hyperglycemia (400’s) and hypertriglyceridemia (>10,000 mg/dL):




What’s the diagnosis?

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CITW: Case 2

Two cases this week! Thank you to Dr. David Kaplan for submitting the first case, while the second case was one seen by myself and Dr. Paul Cheung.

Case 1:

58 y/o male sustained blunt force trauma to the lateral aspect of his right knee. On exam, there is a mild right knee effusion, but no obvious deformities. Pain with ROM. Neurovascularly intact. No ligamentous laxity appreciated. X-rays of the right knee are obtained:

Kap Knee

Case 2:

22 y/o male sustained a gunshot wound to the right knee. On exam, there is an entrance wound on the posterior-lateral aspect of the knee, but no exit wound. There is pain with ROM of the knee and a mild effusion is appreciated. No obvious deformities. Neurovasculary intact. No ligamentous laxity appreciated. Initial plain films demonstrate the bullet lodged in the mid-thigh. Physical exam findings and x-rays of the right knee:


TR Knee

Given concern for an open joint, an aspiration is performed prior to irrigation, and the following aspirate is obtained:


What’s the diagnosis?

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Clinical Image of the Week: Case 1

This is a case I saw in the ED. This case has been deliberately altered to protect the identity of the patient:

28 y/o patient presents to the ED after sustaining blunt trauma to the chest. An EKG is ordered as part of her workup:

Case 1 Upon further questioning, the patient endorses periods of palpitations over the past couple of months where her “heart was racing”. She denies chest pain, shortness of breath, dizziness, or syncope with these episodes.  What’s the diagnosis?

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Simple pneumothorax? Try a pigtail!

Why the 32 French?! It’s not 1970 anymore. Next time you’ve got a simple pneumothorax, consider the pigtail! Chana Rich and Kat Farmer will show you how:

For a more detailed, step by step process, see another great post by Dr. Jay Diamond: