The DETO2X Trial: Do Patients with AMI Need Supplemental O2?

21 Sep
September 21, 2017

Background: Each year approximately 790,000 Americans suffer an acute myocardial infarction (AMI) (Benjamin 2017). Traditional treatment for an acute myocardial infarction has included morphine, oxygen, nitroglycerine and aspirin (MONA) with interventions such as percutaneous coronary intervention providing more definitive management. There has been little data from randomized control studies that supports the use of oxygen in AMI. Recent studies such as the AVOID trial suggest that hyperoxia results in harm while a 2016 Cochrane Review suggest no benefit in supplemental oxygen. (Stub 2015, Cabello 2016). There has, however, not been a large randomized control study comparing supplemental O2 to ambient air with patient centered outcomes until the DETO2X-AMI trial. Read more →

Can We Agree on Cardiac Standstill?

18 Sep
September 18, 2017

Background: Point of Care Ultrasound (POCUS) has gained wider use in resuscitation of patients presenting with cardiac arrest. POCUS can play an important role in determining the etiology of arrest as well as being used to determine the presence or absence of mechanical activity. The REASON study demonstrated that patients with PEA or asystole without cardiac activity on POCUS are extremely unlikely to survive to hospital discharge though this study did not investigate the more important question of a survival with a good neurologic outcome. (Gaspari 2016). In light of this as well as other evidence, some have proposed that the absence of cardiac activity may be adequate to declare resuscitation futility and stop resuscitative efforts. However, there is a lack of agreement on what defines cardiac activity (see table 1). Due to this, and other factors, the level of agreement between physicians in interpretation of cardiac standstill is unknown. Read more →

Turn it (All the Way) Up: Flush Rate O2 for Pre-Oxygenation

14 Sep
September 14, 2017

Background: There has been a lot of buzz recently about the importance of pre-oxygenation in emergency airway management.  The recent publication of the ENDAO trial [2], a randomized clinical trial of ApOx vs no ApOx also emphasized this point.  In the review article accompanying this trial by John Sackles [3] he brought up the point that most patients in this study were intubated in less than 1 – 2 minutes.  In this scenario, preoxygenation alone would likely provide an adequate oxygen reservoir to prevent hypoxemia and that apneic oxygenation would only be helpful in the patients who exhausted their oxygen reserves (i.e. prolonged intubations). Although, apneic oxygenation has recently come into favor in emergency intubation, the issue that should maybe warrant greater consideration is proper preoxygenation. The optimal method of pre-oxygenation however, is often debated: bag-valve mask (BVM), nonrebreather (NRB), or simple face mask.  Read more →

Predicting Dysrhythmias After Syncope

11 Sep
September 11, 2017

Background: Syncope, the sudden, brief loss of consciousness followed by spontaneous, complete recovery is a common presentation to the Emergency Department (ED). It represents a significant portion of overall admissions to the hospital because while many cases are benign (i.e. vasovagal syncope), some may result from a life-threatening cause (ventricular tachydysrhythmia, myocardial ischemia, gastrointestinal bleeding etc). Admission or 24 hour observation is often sought for continuous dysrhythmia monitoring but they are infrequently found. A decision instrument directed at stratifying patients to high or low risk for a dysrhythmia causing syncope (and thus subsequent risk for a recurrent dysrhythmia) would be useful in managing patients with syncope. Read more →

Should You Prescribe Oral Thiamine for Chronic Alcoholics?

07 Sep
September 7, 2017

Background: Alcoholism is a chronic disease with a staggering impact on society, costing the nation approximately 100 billion dollars per year, an expenditure greater than the costs associated with all cancers and respiratory diseases combined (Whiteman 2000). Large public hospital emergency department studies have demonstrated the enormous strain of alcohol use on resources, and the disproportionate burden that the care of the alcohol abusing patient places on the emergency medical system and the ED (Zook 1980). In one observational cohort, 24% of adult patients brought to the ED by ambulance were determined to likely suffer from alcoholism, further underscoring the tremendous frequency of this disease (Whiteman 2000). Read more →

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