IDSA Guideline on Seasonal Influenza Management 2018

14 Jan
January 14, 2019

Article: Uyeki TM et al. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenza. Clin Infect Dis 2018. PMID: 30566567

Background: Influenza is an Emergency Department scourge that we deal with every year. The vast majority of patients recover from uncomplicated influenza without anything more than supportive care but, influenza can cause serious complications. Young children, older adults, pregnant and postpartum women, people with neurologic disorders and patients with certain chronic medical conditions (i.e. COPD, CAD, Diabetes, Immunocompromised states) are at increased risk for these complications. Annual vaccination is the best method to reduce the impact of influenza on morbidity and mortality. Though antiviral medications for influenza are far from perfect, the indications for their use must be understood. Read more →

Journal Abstracts and Why You Should Continue to Use Phenobarbital in Alcohol Withdrawal Syndrome for Patients Requiring Admission

10 Jan
January 10, 2019

Background: The mainstay of treatment for alcohol withdrawal syndrome is a symptom-triggered approach using benzodiazepines. Phenobarbital, however, is an interesting agent in this scenario for several reasons. It is famous for  it is long duration of action. IV Phenobarbital has an onset of action of over 15 – 20 minutes, a duration of action of 10 – 12 hours and a half-life of 53 – 118 hours in adults [5]. But phenobarbital has several other characteristics that make it attractive in the treatment of alcohol withdrawal. Importantly, it works on the GABA receptor differently than benzodiazepines. First, it increases the duration (not frequency) the chloride channel is open. Also, chronic alcohol abuse can alter the GABA receptor making it less sensitive to benzodiazepines not barbiturates. And finally, at very high doses, phenobarbital can open the chloride channel independent of the presence of GABA. The authors of this paper sought to compare a phenobarbital-adjunct versus benzodiazepine-only approach for the management of alcohol withdrawal syndrome in the ED. Read more →

REBEL Core Cast 2.0 – Cardiotoxic Drugs

09 Jan
January 9, 2019

Take Homes

  1. Calcium Channel Blocker (CCB) toxicity usually present with bradycardia and hypotension, but with preserved mental status. This can help differential from Beta Blocker (BB) toxicity, where the patients often have altered mental status.
  2. Hyperglycemia is the other hallmark of CCB toxicity, which can help you differentiate from BB. This hyperglycemia may be a harbinger of impending circulatory collapse, so be on guard in a pt with CCB overdose, normal vitals and hyperglycemia
  3. Don’t be afraid to use and infuse hyperinsulinemia-euglycemia therapy for BB and CCB toxicity. Have a frank and open conversation with your team about how it works to get everyone on board before your start.
  4. TCA overdoses present with a a number of signs and symptoms including anticholinergic symptoms, AMS, hypotension and seizures. Once you identify the TCA toxicity, you’re going to start with fluids and pressors and then move on the antidote which is sodium bicarbonate 1-2 mEq/kg as a bolus followed by a drip. You want to keep pushing sodium bicarb until you see the QRS narrow

Read more →

SUP-ICU: Ending the Confusion About Stress Ulcer Prophylaxis in ICU. So I Don’t Give it Right, or do I?

07 Jan
January 7, 2019

Background: Stress related gastrointestinal mucosal damage is a commonly encountered problem in the critically ill patients admitted to the intensive care unit. The incidence ranges from 0.6-7% and is decreasing partly due to aggressive resuscitation strategies and focus on early enteral feeding1. Damage to the mucosal integrity occurs in conditions associated with increased inflammation and reduced mucosal perfusion 2. Despite its decreasing incidence, stress related GI bleed remains a major challenge for the intensivist with many studies showing increase in mortality and ICU length of stay in these patients3.

Stress ulcer prophylaxis is recommended for critically ill patients at risk for GI bleed; the major risk factors include need for prolonged mechanical ventilation, coagulopathy, hepatic and renal failure. There is high quality evidence supporting the use of H2 receptor antagonists (H2RA) and proton pump inhibitors (PPI) in these patients. Many international surveys show that PPIs are currently preferred for acid suppression4. Though many randomized controlled trials support the use of PPI over other acid suppressants, there is clearly no recommendation regarding benefits of one group over the other. Alhazzani et al5recently published a network meta-analysis of 57 trials enrolling over 7000 patients that showed moderate quality evidence that PPIs are more effective than H2 blockers, sucralfate or placebo in preventing clinically significant GI bleed though there is a possible increase in risk for pneumonia with similar mortality. Another meta-analysis by Alshamsi et al showed that PPIs were more effective than H2RAs in reducing the risk of clinically important GI bleeding and overt GI bleeding without a significant increase in risk for pneumonia, mortality and ICU length of stay6

Furthermore, there is growing concern that acid suppression predisposes patients to increased risk for nosocomial infections like pneumonia and Clostridium difficile as well as cardiovascular events. This was demonstrated in a few randomized clinical trials as well as a few observational studies7,8. The authors of the current study aimed to evaluate the benefits and adverse events associated with the use of pantoprazole for stress ulcer prophylaxis in patients at risk for gastrointestinal bleeding9 Read more →

30-Day Outcomes in Syncope vs Near-Syncope

07 Jan
January 7, 2019

Background: Syncope, defined as a transient loss of consciousness with spontaneous and complete recovery to pre-event status, is a common emergency department (ED) presentation. Near-syncope is frequently seen as well. Unlike syncope, near-syncope has a more nebulous definition often thought of as the feeling of oncoming syncope without a complete loss of consciousness. Regardless of definition, many providers consider syncope and near-syncope as two ends of a spectrum of disease with near-syncope being not as dangerous and syncope being more dangerous. The literature on this, however, is inconsistent with a 2009 study stating that near-syncope was a “low-risk” factor (Sun 2009) and a 2015 study showing the opposite (Thiruganasambandamoorthy 2015). Additional high-quality data in this area is needed to further elucidate the risk of near-syncope presentations in the ED. Read more →