The REASON Trial: POCUS in Cardiac Arrest

08 Dec
December 8, 2016

the-reason-trialBackground: For many emergency providers, POCUS has become a critical modality in the resuscitation of patients with cardiac arrest. The authors of this paper (The REASON Trial) state that <8% of all OHCA’s survive to hospital discharge; a dismal number.  We already know that shockable rhythms, early defibrillation, early bystander CPR, and ROSC in the field are all associated with increased survival. What we don’t have is large scale evidence that the use of POCUS improves survival with good neurologic outcomes. Read more →

IV Lidocaine for Renal Colic: Another Opioid Sparing Option?

06 Dec
December 6, 2016

renal-colicBackground : For anyone who has taken care of a patient with renal colic, the agony they experience is indelible.  I have had several female patients even tell me that the pain is worse than child birth.  Treatment of renal colic comes down to two key components: treatment of pain and expediting passage of the stone.  Many medications have been tested for the former, and we have discussed the latter on our blog before (HERE and HERE). We had a recent resident journal club discussing a trial comparing IV lidocaine (1.5mg/kg) vs IV morphine (0.1mg/kg) for treatment of pain. Read more →

Should I Stay or Should I Go: Outpatient Treatment of Venous Thromboembolism

05 Dec
December 5, 2016

venous-thromboembolismBackground: The care of venous thromboembolism (VTE) is currently undergoing a paradigm shift in the US with an increasingly large percentage of patients being discharged home from the Emergency Department (ED).  It wasn’t too long ago that all patients diagnosed with deep vein thrombosis (DVT) and pulmonary embolism (PE) would be admitted for anticoagulation.  Some of the reasons for this were lack of literature to support outpatient therapy in the US, inability to arrange outpatient follow up, and, of course, medicolegal concerns.  Dr. Jeff Kline, one of the thought leaders in VTE, advocates for the outpatient treatment of “low-risk” patients using a modified Hestia criteria supplemented with additional criteria (POMPE-C) for patients with active cancer.  This publication is the initial results of his rivaroxaban-based treatment protocol. Read more →

Mythbuster: Glucose Levels Must be Below a “Safe” Threshold Before Discharge

01 Dec
December 1, 2016

discharge-glucoseBackground: Anyone who works in the Emergency Department has seen patients brought in by EMS or sent from the clinic with a chief complaint of “high blood sugar.”  Now, we are not talking about patients with diabetic ketoacidosis, but just simple hyperglycemia. This is a common complaint with no real consensus on optimal blood glucose levels before safe discharge. Read more →

Does Targeted Temperature Management Actually Work?

28 Nov
November 28, 2016

targeted-temperature-management-logoThe use of therapeutic hypothermia (TH) has become part of the routine care of patients after return of spontaneous circulation (ROSC) from cardiac arrest (Use of the phrase Targeted Temperature Management has become more accepted). It became much more accepted after two separate trials were published in the New England Journal of Medicine in 2002 showing a survival benefit and improved neurologic outcome with use of TH. (1,2) The use of TH has even been given a Level One recommendation by the American Heart Association for comatose post-arrest patients. (3) Uncertainties still remain, however, such as what optimal temperature to use, and most recommendations on specifics related to TH are based on observational studies and expert opinion. So what is the actual evidence behind the use of TH? Read more →

Treatment of Submassive Pulmonary Embolism (PE): Full Dose, Half Dose, or No Dose?

03 Nov
November 3, 2016

submassive-peSubmassive pulmonary embolism (PE) is responsible for approximately 20% of all PEs.  Although the in-hospital mortality has been reported as about 5%, there is significant morbidity associated with this diagnosis such as chronic pulmonary hypertension, impaired quality of life, persistent right ventricular disfunction, and recurrent venous thromboembolism.  The literature suggests that systemic thrombolytics can improve morbidity and maybe mortality, but this comes at the risk of increased major bleeding and intracranial hemorrhage (2 – 3%) when compared to anticoagulation alone. Read more →

The HYPRESS Trial: Early Steroids to Prevent Septic Shock

31 Oct
October 31, 2016

hypress-trialBackground: The most recent surviving sepsis campaign recommends the use of hydrocortisone in patients with refractory septic shock (i.e. vasopressor dependent).  However, the use of hydrocortisone in severe sepsis without shock still remains a very controversial topic. Recommendations for hydrocortisone are mostly based on 2 randomized clinical trials (i.e. Annane et al [2] and CORTICUS [3]), but subsequent meta-analyses had more mixed results.  Shock reversal was consistently improved irrespective of disease severity; however, mortality outcomes were not as consistent.  Therefore, it has been hypothesized that early hydrocortisone administration could prevent shock by attenuating patient’s inflammatory response. Read more →

Baclofen Withdrawal

27 Oct
October 27, 2016

Baclofen WithdrawalDefinition: A dysfunctional condition in which removal of baclofen, an inhibitory neurotransmitter, from the central nervous system (CNS) causes CNS excitation. Read more →

The PESIT Trial: Do All Patients with 1st Time Syncope Need a Pulmonary Embolism Workup?

24 Oct
October 24, 2016

the-pesit-trialBackground: Syncope is a very frustrating chief complaint for many in the medical field.  There is no gold standard test and no validated decision instrument. It represents about 3 – 5% of ED visits, 1 – 6% of hospital admissions, and in patients over the age of 65 years it is the 6th most common cause of hospitalization [2][3]. Additionally, both ED and inpatient work ups are notoriously low yield for finding significant pathology. Pulmonary embolism is one of the myriad of diagnoses included in the differential diagnosis of syncope, but there is little information looking at its prevalence amongst hospitalized patients. Fast forward to Oct. 20th, 2016 and there is now some evidence just published in the NEJM: The PESIT Trial. Read more →

American College of Emergency Physicians (ACEP) Conference 2016

20 Oct
October 20, 2016

acep-2016This years ACEP 2016 conference took place in Las Vegas, NV from Oct 16th – 19th.  There was greater than 350 courses, labs, and workshops given throughout the week.  It was impossible to make all of these great lectures, but I was able to take away some very important clinical pearls that I wanted to share with our readers.  Read more →

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