Author Archive for: Swami

Journal Update – Beta Blocker vs. Calcium Channel Blocker for Rate Control in Atrial Fibrillation

09 Jul
July 9, 2015

Atrial FibrillationBackground: Atrial fibrillation (AF) is a commonly encountered dysrhythmia in the Emergency Department (ED). Atrial flutter is less common but its management is very similar to that of AF. In patients with chronic AF or unknown time of onset and a rapid ventricular response (RVR), rate control and consideration and initiation of anticoagulation therapy are the standard ED approach. Both beta-blockers and calcium channel blockers are commonly used for rate control in the ED but it is unclear whether one of these agents is superior to the other as there is scant high-quality data on the topic (Demircan 2005). Read more →

Cardiogenic Shock

25 May
May 25, 2015

Cardiogenic ShockAuthor’s Note: This post is one of the first written for a new site sponsored by the NYU/Bellevue Emergency Department called Core EM. This is a FOAM site dedicated to core content Emergency Medicine featuring a blog, podcast and procedure video section. The Core EM Project launches on June 15th, 2015. Thanks to Salim and the REBEL EM editorial staff for posting this here. We’ll make sure to let you all know when Core EM is up and running at www.coreem.net

Definition: Tissue hypoperfusion that is primarily attributable to damage to the heart.

Criteria: The cardiology literature focuses diagnostic criteria based on systolic blood pressure (SBP) (Gowda 2008)

  • SBP < 90 mm Hg
  • Decrease in MAP by 30 mm Hg

It is more important, however, to look for evidence of hypoperfusion. In the acute setting, this will typically manifest as a change in mental status (lethargy, decreased responsiveness, agitation, decreased cap refill, cool extremeties etc.). Read more →

Do Patients with Posterior Epistaxis Managed by Posterior Packs Require ICU Admission?

13 Apr
April 13, 2015

Epistaxis MythsThis post is part 2 of epistaxis dogma. In the first post, we discussed the (dis)utility of prophylactic antibiotics in patients with epistaxis who require nasal packing. Here, we will take on dogma #2:

Dogma #2: Patients with posterior packs for epistaxis should be admitted to the ICU for continuous monitoring due to the risk of life-threatening bradydysrhythmias.

Unfortunately, the literature here is even sparser than with prophylactic antibiotics. An extensive literature search (paging research librarian) turned up two articles that were repeatedly cited. Read more →

Do Patients with Epistaxis Managed by Nasal Packing Require Prophylactic Antibiotics?

30 Mar
March 30, 2015

EpistaxisEpistaxis is a common Emergency Department (ED) complaint with over 450,000 visits per year and a lifetime incidence of 60% (Gifford 2008, Pallin 2005). Posterior epistaxis is considerably less common than anterior epistaxis and represents about 5-10% of all presentations. Many patients with posterior epistaxis will be managed with a posterior pack and admitted for further monitoring. Traditional teaching argues that:

  1. Patients with nasal packs should be given prophylactic antibiotics to prevent serious infectious complications.
  2. Patients with posterior packs should be admitted to the ICU for cardiac monitoring as they are at risk for serious bradydysrhythmias.

Read more →

Is Kayexalate Useful in the Treatment of Hyperkalemia in the Emergency Department?

02 Feb
February 2, 2015

BariumEnema_ORIGINAL_460x261Background: Hyperkalemia is the most common electrolyte disorder seen in the Emergency Department and treatment of hyperkalemia is core knowledge of EM training for interns and focuses on:

1) Stabilization of cardiac myocytes with calcium salts
2) Temporary shifting of potassium into cells (insulin, beta agonists, normal saline,
      magnesium, sodium bicarbonate)
3) Removal of potassium from the body (i.e. loop diuretics, cathartics)
4) Definitive Treatment (i.e. Hemodyalisis)

Although there is still some debate on the first two areas (i.e. is there truly a role for sodium bicarbonate?) our focus will be on the removal part of the algorithm, specifically, is there a role for kayexalate?

Read more →

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