Author Archive for: Swami

Pediatric Septic Hip

06 Mar
March 6, 2017

Pediatric Septic Hip Definition: Bacterial infection of the hip joint space and synovial fluid

Background:

  • Causes
    • Hematogenous spread in bacteremia
    • Local spread (i.e. from osteomyelitis)
    • Direct inoculation (traumatic or surgical)
  • High-Risk Subgroups
    • Age < 2 years (peak incidence 6 – 24 months)
    • Immunocompromised state (i.e. AIDS, active cancer, etc)
    • Functional asplenia (i.e. sickle cell disease)
  • Complications
    • Sepsis
    • Osteomyelitis
    • Chronic arthritis
    • Osteonecrosis
    • Capsule damage

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Effectiveness of Diazepam Adjunct Therapy in Acute Low Back Pain

02 Mar
March 2, 2017

Background: Low back pain is an extremely common presentation to US Emergency Departments (EDs) representing 2.4% or 2.7 million visits annually. The vast majority of presentations are benign in etiology but can be time consuming and frustrating for both patients and physicians. For patients, most will have persistent symptoms a week after presentation and many will have continued functional impairment months after symptom onset. Physician frustrations are multifaceted – preoccupation for finding the rare dangerous back pain patient (the one with an epidural abscess or vertebral osteomyelitis), difficulty in relieving pain and concern for secondary gain (i.e. opiate abuse or diversion). Post-ED analgesia regimens range from NSAIDs and acetaminophen to muscle relaxants (i.e. cyclobenzaprine) to benzodiazepines and opiates. Previous work from this group demonstrated a lack of benefit for adjunct cyclobenzaprine or oxycodone/acetaminophen to naproxen. Now, they turn their eye to the use of diazepam in addition to naproxen. Read more →

Fluid Responsiveness and the Six Guiding Principles of Fluid Resuscitation

27 Feb
February 27, 2017

Background: Fluid resuscitation is a crucial aspect of emergency and critical care. Since the advent of the concept of early goal-directed therapy, we have placed a huge emphasis on aggressive fluid resuscitation in patients with severe sepsis and septic shock. From EGDT to PROCESS/ARISE/PROMISE to Surviving Sepsis Guidelines, we have seen a shift in how fluid resuscitation is monitored, but the idea of aggressive fluid resuscitation is still the crux of our hemodynamic management of these patients. Yet, the FENICE study showed that in 46 countries, there is a “huge variability in the current practice regarding an FC [fluid challenge]…and may reflect the controversies in current guidelines.” (Cecconi 2015) Read more →

Outcomes After Aggressive Management of Recent-Onset Atrial Fibrillation in the ED

13 Feb
February 13, 2017

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.

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The Ketorolac Analgesic Ceiling

19 Jan
January 19, 2017

Ketorolac Analgesic CeilingBackground: 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 →

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