Author Archive for: Swami

The Ketorolac Analgesic Ceiling

19 Jan
January 19, 2017

Ketorolac Analgesic CeilingBackground: Ketorolac is a commonly used parenteral analgesic in the Emergency Department (ED) for a variety of indications ranging from musculoskeletal injuries to renal colic. This non steroidal anti-inflammatory drug (NSAID) is available in oral, intranasal and parenteral routes. Ketorolac has a number of side effects including nausea, vomiting, gastrointestinal bleeding and renal insufficiency. The risk of GI bleeding appears to be related to the use of higher doses and prolonged use. As with all NSAIDs, the drug has an analgesic ceiling – the dose at which additional dosing will not provide additional analgesia but can lead to more side effects. The current FDA dosing is 30 mg intravenously and 60 mg intramuscularly for patients < 65 years of age. However, the necessity of these doses is unclear and prior studies have demonstrated efficacy of considerably lower doses. The use of lower doses, if effective, may mitigate the potential for harm. Read more →

Alpha Blockers in Renal Colic: A Systematic Review

16 Jan
January 16, 2017

Renal ColicBackground: Ureteric (renal) colic is a common, painful condition encountered in the Emergency Department (ED). Sustained contraction of smooth muscle in the ureter as a kidney stone passes the length of the ureter leads to pain. The majority of stones will pass spontaneously (i.e. without urologic intervention). For over a decade, calcium channel blockers (i.e. nifedipine) and, more commonly, alpha adrenoreceptor antagonists (i.e. tamsulosin) have been employed in the treatment of ureteric colic for their potential ability to increase stone passage, reduce pain medication use and reduce urologic interventions. These interventions were mostly based on poor methodologic studies and meta-analyses of these flawed studies.

Over the past 3-4 years, a small number of higher-quality RCTs have been published (Ferre 2009, Pickard 2015, Furyk 2016). These studies have demonstrated a lack of benefit for routine use of alpha blockers. However, secondary outcomes suggest a possible benefit in larger stones (> 6 mm). In spite of recent multiple studies, the use of alpha blockers remains an area of active debate. Read more →

Intraosseous (IO) Needle Length in Obese Patients

09 Jan
January 9, 2017

intraosseousBackground: Intraosseous (IO) access can play an important role in the resuscitation of the critically ill patient to help expedite delivery of critical medications (i.e. RSI). Much like with peripheral or central access, obesity can present a challenge to placement of an IO as accurate placement relies on use of landmarks which may not be palpable in this group. Additionally, increased soft tissue depth may render standard needles ineffective. IO needles require 5 mm of excess length from skin to bony cortex to ensure successful placement (i.e. maximal depth of 20 mm for a 25 mm needle). Studies investigating these questions are necessary in order to understand how reliable IO access will be in obese patients. 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 →

Hyperthermia Syndromes

17 Oct
October 17, 2016

hyperthermia-syndromesDefinition: A life-threatening emergency in which there is a failure of the body’s thermoregulatory mechanisms to handle extrinsic and intrinsic heat. The failure of thermoregulation leads to multi-system organ dysfunction characterized by alteration of neurologic function. Unlike in fever, hyperthermia is not caused by endogenous pyrogens that change the thermoregulation set point in the brain. Hyperthermia results from excessive heat production and/or inadequate heat dissipation Read more →

October 2016 REBEL Cast: IDSA Pneumonia Update

10 Oct
October 10, 2016

pneumoniaEvery few years we get updates in the guidelines based on new evidence. Guidelines give us a framework to work with in the treatment of disease processes, such as pneumonia. The last Infectious Disease Society of America (IDSA) guidelines update on the treatment of pneumonia came from 2005, but recently, the new 2016 guidelines were just published. This was a massive 51 page summary that starts off by saying:

“It is important to realize that guidelines cannot always account for individual variation among patients.  They are not intended to supplant physician judgment with respect to particular patients or special clinical situations.  IDSA considers adherence to these guidelines to be VOLUNTARY, with the ultimate determination regarding their application to be made by the physician in the light of each patient’s individual circumstances.” 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 →

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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