The Fragility Index: Assessing Usefulness of Randomized Clinical Trials

22 Aug
August 22, 2016

Fragility IndexBackground: In the pyramid of evidence based medicine randomized controlled trials (RCTs) are considered to be one of the most reliable study designs when evaluating the cause and effect of treatment modalities. When evaluating randomized controlled trials, we often look for statistical significance of a study to determine if a treatment has an effect.  Statistical significance means that the result of a study is unlikely to occur by chance alone.  The value assigned to a statistically significant result is typically a p-value less than 0.05. Read more →

Euglycemic DKA: It’s not a Myth

18 Aug
August 18, 2016

Euglycemic DKABackground: Diabetic ketoacidosis (DKA) is traditionally defined as a triad of hyperglycemia (>250mg/dL), anion gap acidosis, and increased plasma ketones. There is another entity that providers must be aware of known as euglycemic DKA (euDKA), which is essentially DKA without the hyperglycemia (Serum glucose <200 mg/dL). Euglycemic DKA is a rare entity that mostly occurs in patients with type 1 diabetes, but can possibly occur in type 2 diabetes as well. The exact mechanism of euDKA is not entirely known, but has been associated with partial treatment of diabetes, carbohydrate food restriction, alcohol intake, and inhibition of gluconeogenesis. euDKA, can also be associated with sodium-glucose cotransporter 2 (SGLT-2) inhibitor medications.  These medications first came onto the market in 2013 and are FDA approved for the treatment of type 2 diabetes, however many physicians use them off-label for type I diabetes due to their ability to improve average glucose levels, reduce glycemic variability without increasing hypoglycemia, and finally promote weight loss. Read more →

REBELCast: The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia

15 Aug
August 15, 2016

The PROCAMIO TrialBackground: In the ACLS guidelines stable Ventricular Tachycardia (VT) can be treated with either IV amiodarone or IV procainamide, as the drugs of choice. This has been given a class II recommendation, but there has not been a controlled prospective trial to base the use of one drug over the other in the clinical setting. Despite both medications having a class II recommendation, both clinically and anecdotally it appears that amiodarone is the preferred agent in clinical practice. Read more →

Single Dose Dexamethasone or 5 Days of Prednisone in Adult Asthmatics?

11 Aug
August 11, 2016

Single Dose DexamethasoneBackground: Acute asthma presentations account for more than 2.1 million Emergency Department (ED) visits annually. In the US, 8.4% of the population is affected by the disease. Current guidelines from the National Heart, Lung, and Blood Institute recommend a minimum of 5 days of oral prednisone to treat moderate to severe asthma exacerbations (NHLBI Guidelines 2007). Oral and parenteral dexamethasone have similar bioavailability, with a duration of action of 72 hours. There has been promising data on dexamethasone for acute asthma from the pediatric literature, as well as a 2-dose regimen in adults. However, due to the strong association with low patient adherence and poor outcomes, a single dose of a long acting oral medication in the ED may help prevent relapse of symptoms. Read more →

Macrolide Antibiotics, Prolonged QTc, and Ventricular Dysrhythmias

08 Aug
August 8, 2016

Macrolide AntibioticsBackground: When it comes to treating community acquired respiratory tract infections, macrolide antibiotics (azithromycin, clarithromycin, and erythromycin) are a common choice of agent. In 2010, 57.4 million macrolide prescriptions were written in the U.S. with azithromycin being the most commonly prescribed individual antibiotic agent overall with ~51.5 million prescriptions (Hicks 2013).

With more and more patients being prescribed macrolide antibiotics, an increasing amount of research has been put forth dealing with the safety concerns regarding these medications; specifically the thought that azithromycin use can lead to fatal ventricular arrhythmias. In addition to case reports a 2012 observational study published in the New England Journal of Medicine highlighted an association between  azithromycin use and higher rate of both cardiovascular death and all-cause mortality (Ray 2012). This prompted the US Food and Drug Administration to issue warnings about the use of azithromycin and potential QT-interval prolongation and fatal ventricular dysrhythmias.

However, recent studies suggest that these concerns and warnings may not be accurate. A retrospective cohort study comparing older patients hospitalized with pneumonia that were treated with azithromycin to those who received other guideline appropriate antibiotics actually showed a lower risk of 90-day mortality in the azithromycin group. Further, there was no significant difference between the 2 groups in regards to risk of arrhythmia, heart failure or any cardiac event. (Mortensen 2014). Read more →

Intensive Blood Pressure Control Doesn’t Benefit Patients with Acute Cerebral Hemorrhage (ATACH-2)

04 Aug
August 4, 2016

ATACH-2Background: Hemorrhagic stroke accounts for only 11-22% of all strokes but up to 50% of all stroke mortality. Additionally, there is significant disability associated with the disease in survivors. Much of our attention in the Emergency Department (ED) is guided towards preventing expansion of bleeding and secondary injury after the initial insult. Physiologically, controlling blood pressure has always appeared to be a reasonable goal as it may decrease hematoma expansion and thus mortality. However, there is little high-quality evidence to guide clinicians in determining what the goal blood pressure should be and whether there’s truly a patient centered benefit to aggressive blood pressure management. The recently published INTERACT-2 trial demonstrated no benefit for death or disability for aggressive blood pressure control when started within 6 hours of symptom onset (though the authors touted benefits seen only after ordinal analysis) but some critics have argued that treatment should be started earlier. Read more →

The POKER Trial: Go All in on Ketofol?

01 Aug
August 1, 2016

The POKER TrialBackground: Procedural sedation and analgesia is a frequently performed procedure in the emergency department to help facilitate care of patients in an effective manner. Our goal should be to minimize pain and anxiety while minimizing adverse effects. We have discussed the complications associated with procedural sedation and analgesia on REBEL EM before HERE.  Ketamine and Propofol are two agents commonly used for this and each agent has its own theoretical advantages and disadvantages. Due to this, it has been hypothesized that the combination of the two agents may result in fewer adverse events because of each agent counteracting the disadvantages of the other. Despite this, to date, no RCTs have really shown a reduction in adverse events with the combination of propofol and ketamine. Read more →

Predicting Fluid Responsiveness by Passive Leg Raise (PLR)

23 Jun
June 23, 2016

passive leg raiseBackground: The best way to resuscitate critically ill patients with fluids has been a hotly debated topic in the FOAMed and Critical Care worlds. Fluids are important to optimize stroke volume and distal tissue perfusion, however, the administration of excessive fluids for shock can increase a patient’s morbidity and mortality by causing volume overload, which may lead to tissue edema and subsequently inadequate blood flow to tissues [1]. Accurately predicting when, whom, and how much fluid to administer remains a very challenging clinical question as only half of critically ill patients increase their cardiac output in response to the administration of fluids (i.e. the patient is preload or fluid responsive) [1].

Clinical signs and pressure/volumetric static variables are unreliable predictors of fluid responsiveness [1]. Ventilator-induced dynamic variables such as stroke volume variation and pulse pressure variation, however, have been shown to be more accurate in predicating fluid responsiveness. These tests can only be applied when several criteria are present (e.g., sinus heart rate, mechanical ventilation with a tidal volume of 8-10cc/kg of ideal body weight).

Passive leg raise (PLR) is another method to assess preload responsiveness. PLR produces a temporary and reversible increase in ventricular preload through an increase in venous return from the lower extremities, which mimics fluid administration without actually having to give exogenous fluids. This sounds great in theory, but PLR requires a hemodynamic assessment to be made during the maneuver to determine if the patient is preload responsive or not. There are multiple techniques for assessing changes in stroke volume but the diagnostic performance of each method still remains unknown. The two most commonly described methods are changes in pulse pressure variation and variables of flow. Read more →

The PATCH Trial: Hold the Platelets in Spontaneous Intracerebral Hemorrhage?

15 Jun
June 15, 2016

PATCH TrialBackground: Hemorrhagic stroke accounts for 11 – 22% of strokes, half of all stroke deaths, and a significant amount of disability in many of the remaining survivors. Spontaneous, non-traumatic, intracerebral hemorrhage (ICH) accounts for 2/3 of hemorrhagic strokes; estimated at > 2 million ICHs each year. To date several studies have suggested that antiplatelet therapy use before ICH might worsen outcomes by increasing the risk of early ICH volume growth, due to platelet dysfunction, and pathophysiologically this makes sense. Platelet transfusion has been used therapeutically in many clinical settings for acute ICH, but there is a paucity of randomized trials investigating its effectiveness for reducing death or dependence.  Read more →

Forget the PediaLyte and Just use Dilute Apple Juice in Mild Gastroenteritis

02 Jun
June 2, 2016

Dilute Apple JuiceBACKGROUND: Every year in the United States there are an estimated 178.8 million episodes of acute gastroenteritis resulting in 473,832 hospitalizations.  Most of the evidence surrounding oral rehydration centers around Oral Rehydration Therapy (ORT) studies in low-income countries where children suffer from more extensive gastrointestinal losses.  Theoretically, electrolyte maintenance solutions are recommended in order to prevent increasing diarrheal losses through the osmotic diuresis that can occur with glucose-rich drinks like juice.  However, these electrolyte maintenance solutions can cost up to $10 for a 1-liter bottle and are unpalatable to some children.  Refusal to drink often results in the need for IV hydration and can potentially result in disease progression and hospitalization.  This study attempted to look at whether a dilute apple juice solution or preferred fluids was equal to, if not superior to oral hydration with an electrolyte maintenance solution. Read more →

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