Lessons Learned and Take Home Messages From dasSMACC – Day 1

27 Jun
June 27, 2017

The 2017 edition of the Social Media And Critical Care (SMACC) conference was held in Berlin, Germany this year (#dasSMACC). Over 2000 emergency physicians, intensivists, anesthetists, EMS providers, and nurses piled into the Tempodrom for three days of inspiring lectures and an all-around good time. This conference is truly a leader in innovation and continues to push the boundaries of medical education and entertainment. Here are some of the lessons learned and take home messages from the first day of the conference. Read more →

Icatibant Doesn’t Improve Outcomes in ACE-I Induced Angioedema

22 Jun
June 22, 2017

Angiotensin Converting Enzyme Inhibitors (ACE-I) are prescribed to millions of patients in the US. Though they are relatively safe, upper airway angioedema is one of the life-threatening adverse effects that we see frequently in the Emergency Department. Though this disorder is routinely treated with medications for anaphylaxis (i.e. epinephrine, histamine blockers, corticosteroids) the underlying mechanism of action predicts that these medications will fail. There is no well established treatment algorithm other than airway control if the angioedema is severe and appears to be causing a mechanical obstruction and cessation of the medication. A 2015 phase 2 study published in the NEJM touted the role for Icatibant in the treatment of these patients. Despite being heralded as “the cure,” the data set in this article was small questioning the validity of the findings. Enter the CAMEO study which attempts to further elucidate the benefits of this medication. Read more →

Targeted Temperature Management in Out-of-Hospital Cardiac Arrest: 33°C or 36°C?

19 Jun
June 19, 2017

Background: In 2002, the New England Journal of Medicine published two studies that changed the management of post-cardiac arrest patients by showing improved outcomes in patients treated with therapeutic hypothermia (32°C-34°C) for at least 24 hours. (Bernard 2002, Hypothermia 2002).  The landscape changed again in 2013 with the publication of the Targeted Temperature Management (TTM) trial in the New England Journal, which compared post-cardiac arrest hypothermia at 32-34°C and at 36°C and found no difference in outcomes (Nielson 2013). After the publication of the TTM trial, many hospitals changed their cooling protocols to a target temperature of 36°C, however, recently it has been shown that this may pose an increased risk of fever. (Cassamento 2016). Read more →

Alternative Headache Therapies

15 Jun
June 15, 2017

Background: Presentations to the Emergency Department for acute headache are remarkably common, with more than 2 million visits each year in the United States (Goldstein 2006). Emergency clinicians are tasked with dual roles of excluding life-threatening pathology while rendering effective pain relief and symptomatic care. Treatment patterns for isolated benign headache are widely variable, reflecting the array of symptoms and diversity of therapeutic response among patients presenting for care. One observational cohort of ED patients reported the routine use of 36 different medications for the treatment of headache, with most patients receiving more than one parenteral agent, as well as frequent use of opioid therapy despite recommendations to avoid the same except as a last resort (Vinson 2002). While a variety of effective medications are available for treatment of primary headache in the Emergency Department, including NSAIDs, neuroleptics, anti-emetics, anti-epileptics, and more, there is a growing interest in alternative headache therapies that offer rapid relief without the side effects and time investment of more traditional agents. Read more →

Is Amiodarone Dead?

12 Jun
June 12, 2017

Background: Amiodarone is a class III antidysrhythmic first released for human use in 1962. As with other drugs in this class, amiodarone acts by blocking potassium channels thus prolonging the action potential. This, in turn, leads to a lengthening of depolarization of the atria and ventricles. The drug spread rapidly through US hospitals as it was touted as “always works, and no side effects,” by it’s pharmaceutical manufacturer (Bruen 2016).

Of course, nothing comes free and soon after the drug became widely used, a multitude of adverse effects became apparent. These included minor issues – sun sensitivity and corneal deposits – to major ones – thyroid dysfunction (hypo- and hyperthyroidism), pulmonary toxicity and liver damage. Additionally, the medication’s mechanism of action wasn’t clean and simple – amiodarone is no known to have sodium-channel blocking (Class I), beta-blocking (Class II) and calcium-channel blocking (Class IV) effects.

Despite the multitude of issues, the drug continued to be used extensively because of it’s purported benefits. The drug was most commonly applied in the Emergency Department (ED) for conversion of atrial fibrillation, conversion of stable ventricular tachycardia and in refractory VF/VT cardiac arrest.

This post dives into the three most common places amiodarone is employed in the ED: cardioverion of atrial fibrillation, cardioversion of VT and in refractory VF/VT cardiac arrest and demonstrates that superior evidence points to better options for management. Read more →

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