Background: In elderly patients on chronic anticoagulation (i.e. warfarin and clopidogrel), falls have been shown to increase the incidence of intracranial hemorrhage (ICH) versus those not on anticoagulation (8.0% vs 5.3%). Mortality in those with ICH on anticoagulation is also higher than those who are not (21.9% vs 15.2%). Patients >65 years of age account for almost 10% of ED visits and 30% of admissions for traumatic brain injury. Even more frustrating is clinical decision rules on who to scan and not scan (i.e. Canadian CT Head Rule, New Orleans Criteria, and NEXUS-II criteria) do not apply to anticoagulated patients, because these patients were excluded in many of these studies. To date studies on patients taking warfarin who suffer minor head injuries have shown an incidence of ICH from 6.2 – 29%, suggesting that physicians should have a low threshold to scan these patients. Finally, several European guidelines suggest that all anticoagulated patients with head trauma should be admitted for observation, even if the initial head CT is negative, based on limited data. Unfortunately, the risk of traumatic intracranial hemorrhage after blunt head trauma for patients on warfarin and clopidogrel, has never really been studied in a large generalizable cohort or under a rigorous, prospective, multicenter designed studies. Therefore, knowledge of the true prevalence and incidence of immediate and delayed traumatic ICH in patients on anticoagulation would allow for evidence based decisions to be made about initial patient evaluation and disposition instead of admitting all patients for observation for concern of delayed ICH . Read more →
Author Archive for: srrezaie
Background: Out-of-hospital cardiac arrest (OHCA) occurs in the United States at a rate of nearly 300,000 individuals per year. Even more concerning is the high mortality rate which is associated with this. The majority of OHCA is due to cardiac etiology with the most common initial rhythm being ventricular fibrillation (VF). What we all know is that high-quality, limited interruption cardiopulmonary resuscitation (CPR) and early defibrillation are the hallmarks of successful neurologic outcomes in OHCA. For many who have heard me speak about ACLS, you have heard me say that these guidelines are created for the providers who do not perform resuscitation as part of their daily routine. For those of us in the trenches of the emergency department, we have to think beyond ACLS at times. Although VF typically responds very well to the standard energies of defibrillation, maybe in patients with higher body mass index or morbid obesity we need higher energies to achieve successful defibrillation. Read more →
Welcome to the July 2015 REBELCast, where Swami, Matt, and I are going to talk oxygen. It is important to remember that oxygen is a drug, and just like any drug we prescribe to patients it has potential side effects. Although there is a paucity of clinical trial data to support routine use of supplemental oxygen, most health care providers still put oxygen on patients for possible physiological benefits. So with that introduction today we are going to specifically tackle:
- Topic #1: The AVOID Trial – Supplemental O2 vs Room Air for STEMI
- Topic #2: The FLORALI Trial – High Flow Nasal Cannula (HFNC) for Acute Hypoxemic Respiratory Failure Read more →
This year I was fortunate enough to attend the 3rd annual Social Media And Critical Care (SMACC) conference from June 23rd – 26th, 2015 in Chicago, IL. This year the conference was dubbed as SMACC Chicago and followed by the hashtag #smaccUS on twitter. I tried to keep track of all the great take home messages while at the conference for those not lucky enough to make it or who have not heard of it. For those of you who have not heard of SMACC, it is a modern, academic meeting, mixed with on-line technologies to deliver innovation in education in the fields of emergency medicine and critical care. This conference addresses important clinical issues in a format that is energetic, cutting edge, and yet reputable. If you wanna see what the conference was about last year checkout this link: smaccGOLD. So what did I learn this year? Well, a lot more than one post can give justice to, but some of the highlights are listed below. Read more →
Welcome back to a special edition, or should I say “bootcamp edition” of REBELCast. We have started to do something new by inviting guests onto the show to discuss papers in the literature they find interesting. This month I had the pleasure of working with Steve Carroll, an emergency room physician in my neck of the woods, down in San Antonio, TX. Today, Steve and I are going to specifically discuss how to manage the hypoxic and agitated patient, and the topic we are discussing:
Delayed Sequence Intubation (DSI) of the Hypoxic and Agitated Patient
Background: Intravenous morphine use has been reported in nearly one of seven patients hospitalized with acute decompensated heart failure (ADHF). I have anecdotally, even seen physicians giving morphine as a “first-line” agent: Nitroglycerine, Non-Invasive Positive Pressure Ventilation (NIPPV), and Morphine. There is surprisingly little evidence supporting routine use of morphine in ADHF, and no major American cardiology or emergency medicine society has really endorsed or published any recommendations on the treatment of ADHF with morphine.
Most of us were taught the acronym “MONA,” Morphine, Oxygen, Nitroglycerin, and Aspirin for treatment of acute pulmonary edema and commonly, quoted physiologic/clinical beliefs for the use of morphine in ADHF are: beneficial hemodynamic effects, managing anxiety/agitation in air hunger, reduction in preload, and maybe to a lesser extent, afterload, and finally, decreasing heart rate. We should also consider the use of morphine in a framework of risk and benefit. For example intravenous morphine can also have some deleterious effects like causing central nervous system suppression, ventilatory depression, and hypotension.
The Acute Decompensated Heart Failure National Registry (ADHERE) is a large multicenter registry that records data from patients hospitalized with ADHF with more than 175,000 hospitalizations from over 250 hospitals across America. To be included in this registry patients must be >18years of age, admitted to an acute care hospital and receive a discharge diagnosis of ADHF. Data for this registry are collected by retrospective chart review and entered via an electronic web-based case report form for all consecutive eligible patients. Read more →
Background: In 2010, 5.4% of all emergency department (ED) visits in the United States were for chest pain. Admission or observation of such patients cost about $11 billion dollars in the United States in 2006. The majority of these admissions are commonly determined to be non-cardiac in etiology. Many physicians and patients believe that a hospital admission or extended observation after a “negative” ED workup has a safety benefit for patients. Previous studies have looked at 30-day mortality, but no current large trials have looked the short-term risk for clinically relevant adverse cardiac events, including inpatient STEMI, life-threatening arrhythmias, cardiac or respiratory arrest, or death. Other things to keep in mind is that one of the pitfalls of hospitalization of chest pain patients can lead to false-positive testing, hospital-acquired infections, venous thromboembolism, and other iatrogenic events, and can have greater than a 2% rate of adverse events at 30 days often cited as the upper boundary estimate for low-risk chest pain patients.
The purpose of the current study was to quantify the incidence of short-term clinically relevant adverse cardiac events (CRACE), or more simply put, life-threatening events in patients admitted to the hospital after a “negative” ED evaluation of ischemia. The definition of “negative” was negative serial cardiac biomarkers, normal vital signs, and non-ischemic electrocardiograms (ECGs).
And by the way, checkout the authors: Scott Weingart and David Neman…. Read more →
Acute severe asthma, formerly called status asthmaticus, is defined as severe asthma unresponsive to repeated courses of beta-agonist therapy or subcutaneous epinephrine. It is a medical emergency that requires immediate recognition and treatment. Recently, Anand Swaminathan (Twitter: @EMSwami) gave a lecture to the residents at the University of Texas Health Science Center at San Antonio (UTHSCSA) February 2015. This post is a summary of that lecture on how to manage the crashing asthmatic. Read more →
Background: Vasopressors are frequently used in critically ill patients with hemodynamic instability both in the emergency department (ED) as well as intensive care units (ICUs). Typically, vasopressors are given through central venous catheters (CVCs) as opposed to peripheral intravenous (PIV) access due to the concerns about adverse events (i.e. tissue ischemia/necrosis) associated with extravasation through PIVs. In a truly hypotensive, critically ill patient the use of a PIV to administer vasopressors will allow the medication to stabilize the patient sooner and reduce the time to hemodynamic stability. The requirement to start vasopressors through a CVC may delay administration of pressors. Also, performing the insertion of a CVC in a hypotensive patient in an emergency circumstance versus an elective circumstance may increase the risk of adverse events from the procedure itself (i.e. bacteremia, pneumothorax, arterial puncture). Finally, most of the evidence cited for avoiding PIV administration of pressors is a sparse collection of case studies and expert opinion. Read more →
Patients with pulseless electrical activity (PEA) account for almost 1/3 of cardiac arrest and even more troublesome is that the survival rate is significantly worse than patients with shockable rhythms. Both the European and American ACLS guidelines stress the importance of quickly finding and addressing the cause of PEA. This is traditionally done with recalling the 5 to 6 H’s and T’s, but during cardiopulmonary resuscitation it is difficult to recall all 13 causes of PEA by trying to recall this list. In 2014 a review article was published that was developed by several departments from the Carolinas Medical Center in Charlotte, NC that tried to simplify the diagnostic approach to PEA. Read more →