Author Archive for: Swami

Occult Causes of Non-Response to Vasopressors

13 Jul
July 13, 2017

Intro: Vasoactive substances are powerful therapeutic medications that can boost a patient’s blood pressure and perfusion to target organs. They are often used in resuscitation to support tissue perfusion though their benefits are mostly unproven and may be harmful in certain circumstances (i.e. hypovolemia, hemorrhage). The cognitive response to hypotension should not be reaching for a pressor. The primary therapy for any sick hypotensive patient is treatment of the underlying pathology.

While many patients will respond to these medications, we occasionally encounter non-responder-patients who despite substantial doses do not show hemodynamic parameter improvements. Absence of response can result from a number of causes including misidentification of the underlying pathology (i.e. I missed the massive PE or pericardial tamponade thinking the patient was in septic shock). Premature diagnostic closure can lead us to simply push on with higher doses of pressors and adding additional pressors. However, there should be a cognitive pause at this point where the clinician reassesses the situation, considers alternate causes and therapeutics. Below is a list of pathologic conditions that complicate other diagnoses and are frequently missed as causes of non-response to vasopressors. This is the list I consider during my cognitive pause. Read more →

Icatibant Doesn’t Improve Outcomes in ACE-I Induced Angioedema

22 Jun
June 22, 2017

Angiotensin Converting Enzyme Inhibitors (ACE-I) are prescribed to millions of patients in the US. Though they are relatively safe, upper airway angioedema is one of the life-threatening adverse effects that we see frequently in the Emergency Department. Though this disorder is routinely treated with medications for anaphylaxis (i.e. epinephrine, histamine blockers, corticosteroids) the underlying mechanism of action predicts that these medications will fail. There is no well established treatment algorithm other than airway control if the angioedema is severe and appears to be causing a mechanical obstruction and cessation of the medication. A 2015 phase 2 study published in the NEJM touted the role for Icatibant in the treatment of these patients. Despite being heralded as “the cure,” the data set in this article was small questioning the validity of the findings. Enter the CAMEO study which attempts to further elucidate the benefits of this medication. Read more →

Is Amiodarone Dead?

12 Jun
June 12, 2017

Background: Amiodarone is a class III antidysrhythmic first released for human use in 1962. As with other drugs in this class, amiodarone acts by blocking potassium channels thus prolonging the action potential. This, in turn, leads to a lengthening of depolarization of the atria and ventricles. The drug spread rapidly through US hospitals as it was touted as “always works, and no side effects,” by it’s pharmaceutical manufacturer (Bruen 2016).

Of course, nothing comes free and soon after the drug became widely used, a multitude of adverse effects became apparent. These included minor issues – sun sensitivity and corneal deposits – to major ones – thyroid dysfunction (hypo- and hyperthyroidism), pulmonary toxicity and liver damage. Additionally, the medication’s mechanism of action wasn’t clean and simple – amiodarone is no known to have sodium-channel blocking (Class I), beta-blocking (Class II) and calcium-channel blocking (Class IV) effects.

Despite the multitude of issues, the drug continued to be used extensively because of it’s purported benefits. The drug was most commonly applied in the Emergency Department (ED) for conversion of atrial fibrillation, conversion of stable ventricular tachycardia and in refractory VF/VT cardiac arrest.

This post dives into the three most common places amiodarone is employed in the ED: cardioverion of atrial fibrillation, cardioversion of VT and in refractory VF/VT cardiac arrest and demonstrates that superior evidence points to better options for management. Read more →

Initial Antibiotic Choice in Uncomplicated Cellulitis

08 Jun
June 8, 2017

Background: Cellulitis is a common emergency department (ED) presentation. Despite the fact that diagnosis remains relatively straight forward, complexity remains in management in terms of the causative agent and appropriate antibiotic regimen. Though beta-hemolytic Streptococci are the most common causative agents there is increasing prevalence of community acquired methicillin-resistant Staphylococcus aureus (MRSA). Cephalexin has long been used to treat uncomplicated cellulitis because of it’s activity against streptococci and methicillin-sensitive S. aureus (MSSA). Despite the current Infectious Disease Society of America (IDSA) recommendations against routine coverage of MRSA, trimethoprim-sulfamethoxazole (TMP-SMX) is often added to cephalexin (Stephens 2014). While there are other single options for coverage, they either have suboptimal MRSA coverage (i.e. clindamycin and doxycycline) or are more expensive (i.e. linezolid). Without reliable ways to determine which patients need MRSA coverage, it is unclear which patients with uncomplicated cellulitis need to be discharged with MRSA coverage and which will do fine with a single agent.

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Should You Give Albumin in Spontaneous Bacterial Peritonitis (SBP)?

05 Jun
June 5, 2017

The Background: Nearly 50% of patients in the U.S. with cirrhotic liver disease develop ascites over a 10-year period of observation, placing them at risk for developing spontaneous bacterial peritonitis (SBP) (Runyon 2012). It is estimated that 12-25% of patients with ascites in the ED will have spontaneous bacterial peritonitis (SBP) but the classic triad of fever, abdominal pain, and worsening ascites is often absent (Borzio 2001)(Runyon 1988). With a mortality rate approaching 40%, rapid diagnosis and evidence-based treatment is critical in the management of patients presenting with SBP (Salerno 2013).

SBP is diagnosed via cell count and differential of ascitic fluid obtained by paracentesis demonstrating an elevated polymorphonuclear leukocyte (PMN) count ( 250 cells/mm3). Treatment focuses on appropriate antibiotic therapy. A third-generation cephalosporin is the treatment of choice as they are typically effective in covering the three most common isolates from infected ascitic fluid: Escherichia coli, Klebsiella pneumonia, and Streptococcus pneumonia (Runyon 2012). Intravenous albumin administration is often added to the management of these patients but the utility for improving morbidity and mortality is questionable. The benefit of albumin infusion in SBP is not entirely known, although multiple possible mechanisms have been identified. Albumin has been demonstrated to mitigate endotoxemia, block lipopolysaccharide-stimulated neutrophil activity, and modulate nitric oxide activity, mitigating systemic vasodilation and capillary leak (Salerno 2013). Read more →

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