Background: 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 →
Author Archive for: dhughes
The newly published 2015 AHA guidelines recommend that:
“In IHCA, the combination of Vasopressin, Epinephrine, and Methylprednisolone and post-arrest Hydrocortisone as described by Mentzelopoulos et al. maybe considered; however, further studies are needed before recommending the routine use of this strategy (Class IIb, LOE C-LD)”
Mentzelopoulos et al.  have published two separate randomized, double-blind, placebo-controlled studies out of Greece examining the role of this Vasopressin, Steroid, and Epinephrine (VSE) cocktail. These studies looked at in-hospital cardiac arrest for patients and enrolled patients immediately with non-shockable rhythms or patients in refractory VFib/VTach. The first study included 100 patients from a single center, while the second study included 268 patients from multiple centers. Read more →
Recently, there has been a lot of buzz about the use of topical tranexamic acid for epistaxis or oral bleeds on multiple social media platforms. Everyone seems so happy that it works so well, but we thought we would look through the literature and see what the evidence for use of topical tranexamic acid (TXA) is and how best to compound it for these clinical dilemma. We performed a PubMed, and Ovid search using the terms “topical” AND/OR “oral solution” AND/OR “intranasal” PLUS “tranexamic acid” to answer our questions at hand. Read more →
In a prior post, we discussed the use of an initial insulin bolus in the management of diabetic ketoacidosis (DKA). Today we will address another facet of DKA management, for which there is less than optimal evidence and that is: Any benefit to sodium bicarbonate in DKA? Consensus guidelines for the management of DKA recommended administering sodium bicarbonate to DKA patients who present with an initial blood gas pH of < 7.0. That recommendation was updated and changed in 2009 to limit sodium bicarbonate use to DKA patients with blood gas pH of < 6.9. More recently, Chua et al. published a systematic review of 44 articles discussing bicarbonate administration and Duhon et al. published the largest retrospective review of DKA patient with presenting pH of < 7.0.
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Diabetic ketoacidosis (DKA) is a common endocrine emergency encountered in the emergency department. DKA associated mortality is relatively low in adults, but in children with type 1 diabetes, the elderly, and adults with concomitant illnesses have a mortality rate is > 5% (19564476). Guidelines for the management of hyperglycemic crisis in adults provide recommendations for intravenous fluid administration, correction of electrolyte abnormalities, insulin and bicarbonate therapy. While the recommendations made in the American Diabetes Association (ADA) consensus statement are intended to be evidence based, there are two recommendations which have less than optimal supporting evidence which results in controversy in the emergency department: 1. Use of regular insulin boluses of 0.1 units/kg and 2. patients with a pH < 6.9 should receive sodium bicarbonate therapy. Today we will attempt to answer the question, is there any benefit to an initial insulin bolus in DKA?