Author Archive for: srrezaie

Chemical Sedation of the Agitated Patient

16 Feb
February 16, 2017

Background: Acutely agitated and aggressive patients have become an unfortunate commonality in emergency departments throughout the world.  They are often the most difficult patient encounters during a shift. Initially, when these patients’ present, medical providers are trying to figure out the underlying etiology including organic, psychiatric, or drug related illness.  Coaxing agitated patients out of an aggressive and often altered state with verbal and environmental modification is often fruitless.  When verbal de-escalation does not work, the next options are physical and/or chemical sedation.
Finding an ideal combination of medications for chemical sedation is critically important and the most ideal medication(s) need to work quickly and have a good safety profile. Over the last few years there is increasing literature evaluating different agents of chemical sedation, looking mainly at antipyschotic agents and benzodiazepines, in isolation and combination.

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The PEAPETT Trial: Half Dose tPA for PEA due to Massive Pulmonary Embolism

05 Jan
January 5, 2017

peapett-trialBackground: Anyone who has run a code, knows that pulseless electrical activity (PEA) during cardiac arrest has a worse prognosis compared to patients with shockable rhythms.  In patients with suspected massive PE as the cause of their cardiac arrest the Advanced Cardiac Life Support (ACLS) and American Heart Association (AHA) guidelines do recommend consideration of thrombolytics.  There is however, no uniform consensus on the type, dose, duration, timing, or method of administration.  The current study (PEAPETT Trial) was an attempt to do exactly that. Read more →

Question Tradition: Glucagon for Food Boluses

02 Jan
January 2, 2017

glucagon-and-esophageal-foreign-bodiesBackground: How many of you have had this scenario…patient comes into ED, just ate a big steak and now they can’t swallow.  You call gastroenterology, who asks… “Did you try glucagon yet?” OK, well maybe not exactly like that, but you get what I am asking.  Esophageal foreign body impactions are a rare entity, that cause quite a bit of discomfort to patients and have the potential for esophageal necrosis and perforation.  The definitive treatment for removal is endoscopy with direct visualization and removal of the object causing the obstruction.  This procedure is invasive, time consuming, requires a gastroenterologist, as well as procedural sedation.  Due to the time it takes to set up for this procedure, many consultants will ask to try medical therapy first.  There are several options including carbonated beverages, calcium channel blockers, sublingual nitroglycerin, proteolytic enzymes, benzodiazepines, and last but not least intravenous glucagon. This review will focus on the use of glucagon for esophageal foreign bodies. Read more →

December 2016 REBEL Cast: Obstructive Left Main Coronary Artery Disease

19 Dec
December 19, 2016

obstructive-left-main-coronary-artery-diseaseThe standard treatment for patients with obstructive left main coronary artery disease has typically been coronary-artery bypass grafting (CABG), however some newer trials have suggested that maybe drug-eluting stents may be an acceptable alternative to CABG in select patients. In this episode we will be reviewing the two most recent publications on this topic:

  1. The EXCEL Trial
  2. The NOBLE Trial

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Cardiac Arrest, Return of Spontaneous Circulation (ROSC) With No ST-Segment Elevation on ECG. Now What?

15 Dec
December 15, 2016

cardiac-arrestBackground: The American Heart Association/American College of Cardiology (AHA/ACC) give a Class I recommendation for activation of the cardiac catheterization lab in patients with out-of-hospital cardiac arrest (OHCA) whom ST-segment elevation myocardial infarction (STEMI) is present.  The evidence for early cardiac catheterization in patients after cardiac arrest, with ROSC and no STEMI is a bit more controversial.  The most recent 2015 AHA/ACC guidelines recommend, “it may be reasonable,” to perform an emergent cardiac catheterization in select patients without STEMI. Read more →

The CACTUS Trial: Anticoagulation for Symptomatic Calf Deep Vein Thrombosis?

12 Dec
December 12, 2016

cactus-trialBackground: The optimal management of isolated calf deep vein thrombosis (DVT) is not completely clear, based on the available evidence. The authors of this paper state up to 50% of all lower extremity DVTs are infra-popliteal. Because there is not a lot of robust evidence to guide us on the best diagnostic and therapeutic treatments, a huge variation in practice is seen. To help try and answer these questions the authors of this paper performed the Compression versus Anticoagulant treatment and compression in symptomatic Calf Thrombosis diagnosed by UltraSound – CACTUS Trial. Read more →

The REASON Trial: POCUS in Cardiac Arrest

08 Dec
December 8, 2016

the-reason-trialBackground: For many emergency providers, POCUS has become a critical modality in the resuscitation of patients with cardiac arrest. The authors of this paper (The REASON Trial) state that <8% of all OHCA’s survive to hospital discharge; a dismal number.  We already know that shockable rhythms, early defibrillation, early bystander CPR, and ROSC in the field are all associated with increased survival. What we don’t have is large scale evidence that the use of POCUS improves survival with good neurologic outcomes. Read more →

IV Lidocaine for Renal Colic: Another Opioid Sparing Option?

06 Dec
December 6, 2016

renal-colicBackground : For anyone who has taken care of a patient with renal colic, the agony they experience is indelible.  I have had several female patients even tell me that the pain is worse than child birth.  Treatment of renal colic comes down to two key components: treatment of pain and expediting passage of the stone.  Many medications have been tested for the former, and we have discussed the latter on our blog before (HERE and HERE). We had a recent resident journal club discussing a trial comparing IV lidocaine (1.5mg/kg) vs IV morphine (0.1mg/kg) for treatment of pain. Read more →

Should I Stay or Should I Go: Outpatient Treatment of Venous Thromboembolism

05 Dec
December 5, 2016

venous-thromboembolismBackground: The care of venous thromboembolism (VTE) is currently undergoing a paradigm shift in the US with an increasingly large percentage of patients being discharged home from the Emergency Department (ED).  It wasn’t too long ago that all patients diagnosed with deep vein thrombosis (DVT) and pulmonary embolism (PE) would be admitted for anticoagulation.  Some of the reasons for this were lack of literature to support outpatient therapy in the US, inability to arrange outpatient follow up, and, of course, medicolegal concerns.  Dr. Jeff Kline, one of the thought leaders in VTE, advocates for the outpatient treatment of “low-risk” patients using a modified Hestia criteria supplemented with additional criteria (POMPE-C) for patients with active cancer.  This publication is the initial results of his rivaroxaban-based treatment protocol. Read more →

Mythbuster: Glucose Levels Must be Below a “Safe” Threshold Before Discharge

01 Dec
December 1, 2016

discharge-glucoseBackground: Anyone who works in the Emergency Department has seen patients brought in by EMS or sent from the clinic with a chief complaint of “high blood sugar.”  Now, we are not talking about patients with diabetic ketoacidosis, but just simple hyperglycemia. This is a common complaint with no real consensus on optimal blood glucose levels before safe discharge. Read more →

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