The ENCHANTED Trial: Is Low-Dose the Right Dose for Intravenous tPA in Acute Ischemic Stroke?

26 May
May 26, 2016

The ENCHANTED TrialBackground: Despite continued debate on the efficacy of alteplase (tPA), it currently remains one of the major interventions directed at patients presenting with acute ischemic stroke. The current standard dose of the drug is 0.9 mg/kg given over 1 hour. It is unclear whether lower doses would be equally effective in increasing good neurologic outcomes after stroke while simultaneously decreasing the rate of intracerebral hemorrhage (ICH); the most serious side effect. Evidence showing that lower doses of tPA are non-inferior to standard-dose tPA could lead to a shift in treatment.  Read more →

Changing Arm Position for Ultrasound Guided Subclavian Central Lines?

23 May
May 23, 2016

Changing Arm Position for Ultrasound Guided Subclavian Central Lines?The subclavian route is known to be the site for central line placement with the lowest risk of infection, but can also lead to many mechanical complications [2]. The biggest risk of subclavian line placement is an iatrogenic pneumothorax. The use of ultrasound for subclavian line placement can greatly reduce this risk by watching the needle enter the vein. But does arm position matter for ultrasound guided subclavian central lines? Read more →

Direct Oral Anticoagulants (DOACs): A Practical Guide for the EM Physician

12 May
May 12, 2016

Direct Oral Anticoagulants (DOACs)Over the past 5 to 6 years we have seen an explosion of new anticoagulant medications.  Since 2010, four new oral anticoagulant medications have arrived on the scene: dabigatran, apixaban, edoxaban, and rivaroxaban.  Their popularity amongst patients is no surprise as they have a fixed dosing, absence of dietary interactions, and a lack of laboratory monitoring unlike warfarin.  As EM physicians we often are the common point of entry into the hospital system.  Therefore, we not only deal with the complications of these medications, but also have to deal with patients with venous thromboembolism (VTE) and atrial fibrillation who may require these medications.  Also, with more and more push to discharge patients from the emergency department and the difficulties in arranging timely follow up (i.e. warfarin clinic), discharging patients with direct oral anticoagulants (DOACs) may be coming more en vogue.  This blog post will focus on three major points:

  1. How to Prescribe DOACs in the ED
  2. What are the Red Flags for not prescribing DOACs in the ED
  3. How to Manage Emergency Bleeding in Patients on DOACs

Read more →

Benzodiazepine-Refractory Alcohol Withdrawal

28 Apr
April 28, 2016

Alcohol WithdrawalBackground: Severe alcohol withdrawal syndrome (AWS) accounts for only 10% of the roughly 500,000 annual cases of AWS episodes that require pharmacologic treatment. AWS is characterized by an imbalance between inhibitory GABA and excitatory NMDA receptor stimulation secondary to chronic ethanol intake. Treatment is typically centered around supportive care and symptom-triggered benzodiazepines. However, some patients are refractory to benzodiazepines, defined as > 10 mg lorazepam equivalents in 1 hour or > 40 mg lorazepam equivalents in 4 hours. Doses exceeding this threshold provide little benefit and put patients at risk for increase morbidity and mortality, over sedation, ICU delirium, respiratory depression and hyperosmolar metabolic acidosis.  Read more →

ALPS: Amiodarone, Lidocaine or Placebo Study in OHCA

25 Apr
April 25, 2016

ALPSBackground: Many Out-of-Hospital Cardiac Arrest (OHCA) are attributable to ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). Both are said to be treatable presentations of OHCA, due to their responsiveness to defibrillation. VF and VT can persist or recur after defibrillation with an inverse relationship between the duration of OHCA, the recurrences of arrhythmias, and ultimately resuscitation outcomes.

Amiodarone and lidocaine are both recommended by the advanced cardiovascular life support (ACLS) guidelines to help promote successful defibrillation in refractory ventricular fibrillation or pulseless ventricular tachycardia and to prevent recurrences. In previous randomized controlled trials patients receiving amiodarone vs placebo or lidocaine in OHCA were more likely to have return of spontaneous circulation (ROSC) and to survive to hospital admission. However the effects of amiodarone on survival to hospital discharge or neurologic outcome still remain uncertain. Should we be using anti-dysrhythmic drugs in out-of-hospital cardiac arrest? Read more →

Succinylcholine vs Rocuronium for RSI in Traumatic Brain Injury

21 Apr
April 21, 2016

Succinylcholine vs Rocuronium v2Background: Airway management is a critical part of the management of patients presenting with traumatic brain injury (TBI). Emergency Physicians (EPs) have no ability to change the primary injury once it has occurred and so our focus is on preventing secondary brain injury. Hypoxemia and hypercarbia are major contributors to morbidity and mortality and management must focus on preventing them. Patients with TBI and depressed mental status frequently require definitive airway management in order to avoid these secondary insults. Rapid sequence intubation (RSI) with serial administration of a neuromuscular blocking agent (NMBA) and an induction agent is common practice. The most commonly used NMBAs are the depolarizing agent succinylcholine and the non-depolarizing agent rocuronium. There are strong proponents arguing for the dominance of one agent over the other based on qualities of the drugs but scant data investigating the question has led to clinical equipoise. Read more →

Advice to the Graduating Resident – Victoria Brazil

18 Apr
April 18, 2016

Advice to the Graduating ResidentSo this is the third installation of Advice to the Graduating Resident. Again, many 3rd year residents will be graduating in just a few short months and taking on their first jobs as attending physicians. I was lucky enough to sit down with the amazing Victoria Brazil and pick her brain. She gave some valuable words of wisdom, which I will try and summarize in this post, but for the full advice, be sure to checkout the podcast. Read more →

Hemophilia: What’s so Bloody Funny?

13 Apr
April 13, 2016

HemophiliaToday, I gave a lecture on Hemophilia to our residents in San Antonio, TX.  Now this was a core content lecture that I have actually never given before. As I was preparing the lecture I realized that this is a diagnosis that comes up frequently enough that it is important to know about, but also so infrequently that I always have to look up the factor replacement options and calculations.  So instead of being our typical evidence based evaluation of literature, this post will serve as a reminder of the basics of hemophilia and what are the essential elements one needs to know to appropriately treat a patient with Hemophilia. Read more →

Is It Necessary to Irrigate Abscesses After I&D?

11 Apr
April 11, 2016

Irrigate AbscessesBackground: Irrigation after incision and drainage (I&D) of an abscess in the ED is considered by some sources to be standard care but local practice varies considerably. There are no randomized controlled trials to date that look at the potential benefits of this procedure. Irrigation increases the time required for the procedure and increases pain experienced by the patient. Read more →

Should We Use Skin Glue to Secure Peripheral IVs?

07 Apr
April 7, 2016

v2 Peripheral IVsBackground: Peripheral venous cannulation is the most frequently performed procedure in the Emergency Department (ED). The vast majority of patients admitted to the hospital will leave the ED with an intravenous catheter (IV). While these devices typically have a “life-span” of 72 hours from placement, they often fail prematurely as a result of infection, phlebitis, occlusion or dislodgement. IV dislodgement is a particular bane to emergency providers and nurses because it often occurs during the patient’s ED stay requiring repeated cannulation and the associated expenditure of time and resources not to mention the additional pain/discomfort to the patient. Inadequate fixation of the catheter is a likely cause of dislodgement but may also contribute to infection and phlebitis due to small movements leading to microtrauma to the vein.

Medical-grade skin glue (cyanoacrylate) has been demonstrated to reduce peripheral arterial line failure rate in prior studies but has not been extensively studied for peripheral IV securing. Read more →

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