Author Archive for: Swami

The WOMAN Trial: Early TXA in Post-Partum Hemorrhage

22 May
May 22, 2017

Background: Post-partum hemorrhage (PPH) is the leading cause of maternal death worldwide. It is typically defined as > 500 ml of blood loss within 24 hours of giving birth. However, PPH encompasses a broad spectrum of disease from mild oozing over hours to rapid exsanguination and death. The burden of mortality from PPH is shouldered mainly by developing countries thus requiring cost-effective treatment modalities. Tranexamic acid (TXA) is one such possibly modality. TXA works by inhibiting the breakdown of fibrinogen and fibrin by plasmin. In essence, it stabilizes clot that the body naturally forms. TXA has a well established role in reducing death in trauma patients as demonstrated in the CRASH-2 trial (CRASH-2 2010) and is already used by many performing resuscitations in resource strapped locations due to its availability and low cost. Whether early TXA in post-partum hemorrhage reduces mortality while avoiding significant clotting complications (DVT, PE, ACS, CVA) is unknown. Read more →

Local Anesthetic Systemic Toxicity (LAST)

18 May
May 18, 2017

Definition: A life-threatening adverse reaction resulting from local anesthetic reaching significant systemic circulating levels. Local Anesthetic Systemic Toxicity (LAST) is rare and almost always occurs within minutes of injection of the local anesthetic.

Causes:

  • Injection of local anesthetic into the systemic circulation (either errantly as part of a regional block i.e. Bier block)
  • Rapid absorption of local anesthetic injected into a highly vascular area
  • Use of local anesthetic doses in excess of the maximum dose (typically occurs with multiple subcutaneous injections)
  • Common implicated procedures: bronchoscopy, circumcision, tumescent liposuction. Consider diagnosis in any patient coming from outpatient surgical center with cardiac arrest

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Validation of the Step-By-Step Approach to Febrile Infants

11 May
May 11, 2017

Background: Fever without source in infants less than three months old presents a difficult diagnostic dilemma for ED physicians.  Over the past 25 years several algorithms have been developed to help guide clinicians, most notably the Rochester, Philadelphia and Boston Criteria, in determining which infants require admission vs. outpatient management.  These studies were designed published between 1992 and 1994 prior to the wide spread use of HiB and pneumococcal vaccines in children, maternal GBS screening and the development of many new biomarkers. 

The Step-by-Step approach to febrile infants was developed by a European group of pediatric emergency physicians with the objective of identifying low risk infants who could be safely managed as outpatients without lumbar puncture or empiric antibiotic treatment. The algorithm was designed using retrospective data and this study attempts to prospectively validate it. Read more →

Etomidate vs Ketamine in Trauma RSI

16 Mar
March 16, 2017

Background: Etomidate and ketamine are both routinely used as induction agents during rapid sequence intubation (RSI) in trauma patients. It is well established that etomidate transiently suppresses the adrenal gland through inhibition of the 11-beta hydroxylase enzyme. Though adrenal suppression in theory can cause deleterious outcomes, there is no high-quality evidence demonstrating a change in patient centered outcomes with it’s use in comparison to alternate agents. Ketamine has long been an alternative induction agent to etomidate but historical concerns, though disproven in more recent literature, limited it’s use due to concerns over increasing intracranial pressure. Read more →

The Benefit of Lung Protective Ventilation in the ED Should be LOV-ED

13 Mar
March 13, 2017

Background: Intubation and mechanical ventilation are commonly performed ED interventions and although patients optimally go to an ICU level of care afterwards, many of them remain in the ED for prolonged periods of time. It is widely accepted that the utilization of lung protective ventilation reduces ventilator-associated complications, including acute respiratory distress syndrome (ARDS). Additionally, it is believed that ventilatory-associated lung injury can occur early after the initiation of mechanical ventilation thus making ED management vital in preventing this disorder. Despite this, intubated ED patients are not optimally ventilated used lung-protective strategy on a routine basis. Read more →

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