Author Archive for: srrezaie

Acute Salicylate Toxicity, Mechanical Ventilation, and Hemodialysis

25 May
May 25, 2017

Background: Salicylates are common substances that can be purchased over the counter. They are readily available, and in the setting of an overdose, can be fatal [1]. Initially, as salicylates are metabolized, they can induce a respiratory alklalosis. This is then followed by an anion gap metabolic acidosis.

Due to the metabolic derangements induced by salicylates as well as salicylate’s direct stimulation on the respiratory centers of the brain, patients can present with profound tachypnea, fever and even altered mental status. As the severity of toxicity increases, the need for airway protection through intubation and mechanical ventilation becomes more profound.

Intubation has unique implications in patients with acute salicylate toxicity [1]. Patients with  tachypnea are able to compensate for the profound metabolic acidosis that can develop from salicylate poisoning. Once intubated, the peri-intubation minute ventilation, typically, cannot be matched by the ventilator, thus taking away the patient’s physiologic mechanism of compensation for the metabolic abnormalities associated with salicylate toxicity leading to further clinical deterioration. Despite this, intubation in many cases of severe salicylate toxicity is necessary.

In addition to ventilation management, other therapeutic options to help manage acute salicylate toxicity include alkalization of the serum to prevent conversion of salicylates to its non-ionized form, which easily crosses the blood brain barrier and can lead to cerebral edema and end organ damage. Hemodialysis is another option in management of salicylate toxicity to help correct acid-base abnormalities and directly remove salicylates from the blood stream [3]. Read more →

Episode 38 – Do All Submassive PE’s Require Treatment with Thrombolysis?

15 May
May 15, 2017

Background: There has been very little robust evidence published on the long-term outcomes of systemic thrombolysis in acute submassive PE.  Many advocate for the use of systemic thrombolysis to reduce morbidity (complications from chronic pulmonary hypertension) and mortality. The PEITHO trial compared systemic thrombolysis (with tenecteplase + heparin) vs no systemic thrombolysis (placebo + heparin) in just over 1000 patients with confirmed PE, RV dysfunction, and positive troponins.  The primary outcome of all-cause death or hemodynamic decompensation within 7 days occurred less frequently in the thrombolysis arm. This statistically significant difference was driven by differences in hemodynamic decompensation, not mortality – a non-patient centered outcome. Additionally, the benefit was at the risk of increased intracranial hemorrhage.  In this current study, 70% of the patients from the original PEITHO trial were followed for a 2-year follow up period, giving us some information about long-term sequelae of systemic thrombolysis in patients with submassive PE. Read more →

More on the Easy IJ

04 May
May 4, 2017

Background: IV access is one the most important interventions that must be performed in effectively managing patients in the Emergency Department.  It is part of “Circulation” in the ABCs acronym and is even first in the “IV, O2, Monitor” phrase that we have become accustom to hearing.  Although experienced ED nurses can obtain access quickly and without much difficulty in most patients, there remain a handful of patients that will present to the ED where standard peripheral access is unable to be obtained after multiple attempts.  What is the next step? Peripheral placement of an IV using ultrasound can be a great next step if timing permits, but this too can be troublesome in patients who are difficult to access, especially if dehydration is present.  IOs have become more popular but are painful when medications are given through them, thus making management more difficult in patients who are alert.  Also IOs are limited in regards to what lab testing can be performed.  Central lines are not worth the risk if IV access does not need to be central or if access is only needed temporarily.   External Juglar IV placement can have similar difficulties as traditional peripheral access especially, in patients with a large body habitus or who have had repeated EJ cannulations. What if a peripheral IV was placed into the internal jugular vein (Easy IJ)?  It is an easily visualized structure on ultrasound and cannulating it is a skill that is familiar to most Emergency physicians.  Is this a safe approach? Read more →

Episode 37 – Definitions and Identification of Sepsis: Sepsis 2.0 vs Sepsis 3.0

01 May
May 1, 2017

Background: Just a few months ago the surviving sepsis campaign published their international guidelines for management of sepsis and septic shock [1].  There has been a lot of talk in the FOAM world about sepsis 3.0 and this is the first update since the introduction. This was a 67 page document that made a total of 93 statements on the early management and resuscitation of patients with sepsis or septic shock.  1/3 of the statements were strong recommendations and just over 1/3 were weak recommendations. Instead of going through every component of this document, we thought we would discuss one of the potentially biggest components of sepsis care that  would affect clinical practice for those of us on the front lines.

One of the main reasons we have seen a mortality decrease in sepsis overtime is due to the proactive nature health care professionals have taken in sepsis management.  The so called ABC’s of sepsis management: Early identification, Early fluids, and Early antibiotics. One of the biggest components of this is early identification of these patients.

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In-Hospital Cardiac Arrest: The First 15 Minutes

27 Apr
April 27, 2017

Background: Over the past few years there has been a shift in cardiac arrest from the mantra of ABC (Airway, Breathing, Circulation) to CAB (Circulation, Airway, Breathing).  There has been increased emphasis on circulation and a de-emphasis of airway management in cardiac arrest.  Physiologically, this makes sense as the only two interventions in cardiac arrest that have been shown to make a difference in neurological outcomes are early, high quality CPR and defibrillation.  The reason for this is increased coronary and cerebral perfusion pressure, which improve oxygenation to ischemic tissue.  The less ischemic cardiomyocytes are the more likely they will convert to a perfusing rhythm.  Similarly, the less ischemic neurons are, the more likely we will have a better neurologic outcome for our patients.  It has been fairly well established in the peer reviewed literature that advanced airway management in the prehospital setting is associated with decreased survival with good neurologic outcome.  There is considerably less literature exploring this area in in-hospital cardiac arrest. Read more →

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