Author Archive for: Swami

Procalcitonin: Useful Test or Useless Pest to Improve Antibiotic Stewardship with Acute Respiratory Infections in the ED?

27 Jul
July 27, 2018

Background: In patients with an acute respiratory illness (ARI), it is often difficult to determine whether a bacterial infection is the underlying etiology and whether antibiotics are warranted. Excess antibiotic use carries risk of bacterial resistance, medical costs, and adverse drug effects. However, underuse of antibiotics risks inadequate treatment and progression of disease. In the setting of a bacterial infection, cytokines stimulate procalcitonin production and release. The serum procalcitonin level increases with the progression of bacterial infection and decreases upon recovery. Procalcitonin production is actually blocked in the setting of viral infection, resulting in low serum levels. Numerous studies have investigated the use of procalcitonin for the determination of initiating antibiotics as well as for aiding in decisions to terminate their use.

This Evidence-Based Emergency Medicine (EBEM) article reviews the following systematic review:

Schuetz P et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev 2017. PMID: 29025194 Read more →

Neutropenic Fever

20 Jul
July 20, 2018

Neutropenia: An absolute neutrophil count less than 500 cells/mm3 or less than 1000 cells/mm3 with a predicted decline to less than 500 cells/mm3

ANC = WBC x (neutrophil% + band%)

  • Mild: 1000 – 1500
  • Mod: 500 – 1000
  • Severe: 100 – 500
  • Profound: <100

Read more →

How Do You FEEL About Echo in Cardiac Arrest?

13 Jul
July 13, 2018

Background: Focused use of ultrasound in resuscitation of patients with shock and cardiac arrest has become increasingly embraced in both the emergency department (ED) as well as in the prehospital setting. Application of ultrasound, particularly of echocardiography, has the potential to identify treatable causes of shock and arrest, identify shockable rhythms and identify the presence of mechanical activity. All of these can affect management decisions and, potentially effect outcomes. Recent studies have led to concerns that integration of point of care ultrasound (POCUS) in cardiac arrest increases pauses in compressions. Thus, it is important to establish what POCUS adds to shock and arrest management. Read more →

Update in Community Acquired Pneumonia (CAP) Treatment: Macrolide Resistance

06 Jul
July 6, 2018

Background: Community acquired pneumonia (CAP), defined as lower bronchial tree infection in a patient that has not been hospitalized in the last 90 days is a commonly diagnosed disease. There are between 2-4 million episodes per year in the US with roughly 500,000 hospital admissions (Rosen’s). Most outpatients are treated with azithromycin (or another macrolide antibiotic) as this drug gives a simple treatment regimen (single drug, simple dosing, short course). However, the efficacy of this regimen has been questioned in recent years as resistance patterns shift. Read more →

Is Ketamine Contraindicated in Patients with Psychiatric Disorders?

03 Jul
July 3, 2018

Background: In recent years, ketamine use has dramatically increased in the Emergency Department (ED). There are four major indications for the use of ketamine in the ED: analgesia with low dose ketamine (LDK), induction for rapid sequence intubation, procedural sedation and sedation of the agitated patient. A number of relative contraindications for ketamine exist though many of them have been debunked through analysis of the evidence. This includes the dogma that ketamine cannot be used in patients with head trauma (for fear of increasing the ICP) or in patients with hypertension or tachycardia.

One contraindication that persists, though, is that of a history of psychiatric illness. Ketamine is an N-methyl-D-aspartic acid (NMDA) receptor antagonist and it can produce a broad range of cognitive and behavioral disturbances including psychosis. These disturbances are short-lived in the majority of individuals but there is a fear that ketamine can cause decompensation of psychiatric illness. The ACEP Clinical Policy lists psychiatric illness as an absolute contraindication for dissociative sedation with ketamine (Green 2011). Read more →