Background: Atrial fibrillation (AF) is one of the most common dysrhythmias encountered in the ED. The management of recent-onset AF and atrial flutter (AFl) in the ED continues to be debated. The discussion centers on whether patients with recent-onset AF should be rhythm controlled (e.g. converted back to sinus rhythm) or rate controlled only. This debate was showcased in a point-counterpoint in Annals of Emergency Medicine in 2011 (Stiell 2011, Decker 2011). The rhythm control supporters argue that AF/AFl is abnormal, worsens quality of life, leads to cardiac remodeling and, in may patients, requires medications for rate control and anticoagulation. The rate control group argues that cardioversion runs the risk of causing a thromboembolic event (i.e. CVA, peripheral arterial occlusion). Thus, it should not be performed until the absence of clot in the left atrium is confirmed (by TEE) or appropriate anticoagulation has occurred. It has long been taught that if the patient has been in AF/AFl for < 48 hours, the risk of developing a clot in the left atrium is negligible and cardioversion may be pursued. However, some recent literature has called this classic teaching into question (Nuotio 2014). Prospective studies looking at outcomes of recent-onset AF/AFl patients after aggressive treatment in the ED are needed to further evaluate the risks of aggressive treatment.
Author Archive for: Swami
Background: 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 →
Background: 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 →
Background: 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 →
Definition: A dysfunctional condition in which removal of baclofen, an inhibitory neurotransmitter, from the central nervous system (CNS) causes CNS excitation. Read more →