Author Archive for: Swami

Classic Journal Review: The OPALS Study

14 Jan
January 14, 2016


The Ontario Prehospital Advanced Life Support (OPALS) Study

Background: Sudden cardiac arrest is common and, obviously, very bad. In the US, there are about 500,000 cardiac arrests each year. About half of these cardiac arrests are OHCA and the survival rate is pretty poor. The most recent survival estimates put it at 7 – 9.5% in most communities. About 10-12 years ago, the American Heart Association built the 4-step “chain-of-survival.”

  • Step One – Early access to emergency care
  • Step Two – Early CPR
  • Step Three – Early defibrillation

There is little debate about these three steps as the sum of the data supports that they lead to better outcomes.

The 4th step in the chain, however, is slightly more controversial; early advanced care. This basically means rapid access to ACLS type resuscitation skills (intubation and intravenous drug therapy). Despite it being the 4th step, ACLS has little evidence to defend it.  Read more →

The Role of TEE in Cardiac Arrest

04 Jan
January 4, 2016

TEEBackground: Sudden cardiac arrest has very poor outcomes; less than 11% of patients in cardiac arrest in the Emergency Department survive to discharge from the hospital. The management of cardiac arrest is algorithmic because providers have limited tools at their disposal and limited knowledge of the patient’s past medical history. EKG is limited in its evaluation of cardiac function. Pulses are often difficult to palpate. The blood pressure cuff is often unreliable. As a result, there is a sense of futility when running resuscitations.

Transthoracic echocardiography (TTE) in the Emergency Department gave providers another tool to help guide management through direct visualization of cardiac activity, tamponade physiology, right heart strain, etc . It also offers prognostic value if there is no cardiac activity upon arrival to the Emergency Department on TTE, there is a near 0% chance of survival. However, TTE has its limitations: obesity, emphysema, poor windows, interrupts compressions, gel gets everywhere.

Transesophageal echocardiography (TEE) provides significant benefits when compared to TTE in the management of cardiac arrest in the emergency department. Read more →

Should We Give Fingertip Amputations with Exposed Bone Prophylactic Antibiotics?

14 Dec
December 14, 2015

FingertipBackground: Fingertip amputations are not an uncommon injury seen in the emergency department. Treatment options range from healing by secondary intention to flap coverage or replantation. Selection of the appropriate treatment modality depends on the nature of the injury, the physical demands of the patient, and the patient’s co-morbidities. Prophylactic antibiotic use in patients with fingertip amputations is controversial. The routine use of prophylactic antibiotics is universally recommended on grossly contaminated wounds, in immunocompromised patients, and in injuries with extensively destroyed/devitalized tissue as it is thought the infection risk is high in these circumstances. However, many reflexively prescribe antibiotics prophylactically in all distal tip amputations. Moreover, there is often an underlying tuft fracture and we reflexively give these patients antibiotics because we were all taught that any open fractures require antibiotics in addition to usual fracture care. Prior studies on distal fingertip amputations and the use of prophylactic antibiotics suggest no change in infection risk with the routine use of antibiotics but these studies were small and have done little to inspire an antibiotic-restrictive approach universally. Read more →

What Is the Role of Muscle Relaxants or Opiates in the Treatment of Acute Non-Traumatic LBP?

07 Dec
December 7, 2015

LBPBackground: Acute, non-traumatic low back pain (LBP) is a common chief complaint and has been estimated to lead to more than 2.7 million ED visits annually nationwide. It affects a broad range of individuals and can be painful and debilitating long after an initial ED visit. Often times in clinical practice, evidence based decisions on medical management of acute lower back pain seem to be thrown out the window; rather medications are prescribed on a gestalt medicament do jour. NSAIDs, muscle relaxants, and opioids have all been used in isolation and in combination for treating acute LBP but trials investigating the efficacy of these medications combined have produced heterogeneous results. Read more →

Is Too Much Supplemental O2 Harmful in COPD Exacerbations?

03 Dec
December 3, 2015

Title SlideBackground: It’s common practice to give carefully titrated supplemental oxygen therapy for patients in COPD exacerbation. We give enough O2 to prevent hypoxemia, but not so much that it causes hypoventilation or dangerous hypercarbia. If you’re like me then you’ve probably heard a number of conflicting theories as to WHY overzealous supplemental oxygen leads to bad outcomes in these patients.

Does hyperoxia suppress a COPD patient’s respiratory drive? Does it cause V/Q mismatching? Does it change the chemistry of the patient’s blood through the Haldane effect? It’s enough to make you want to give up and page respiratory therapy. Well lucky for you we sifted through the primary literature to bring you the myths and facts, and the short answer is…it’s complicated. Read more →

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