Should You Prescribe Oral Thiamine for Chronic Alcoholics?

07 Sep
September 7, 2017

Background: Alcoholism is a chronic disease with a staggering impact on society, costing the nation approximately 100 billion dollars per year, an expenditure greater than the costs associated with all cancers and respiratory diseases combined (Whiteman 2000). Large public hospital emergency department studies have demonstrated the enormous strain of alcohol use on resources, and the disproportionate burden that the care of the alcohol abusing patient places on the emergency medical system and the ED (Zook 1980). In one observational cohort, 24% of adult patients brought to the ED by ambulance were determined to likely suffer from alcoholism, further underscoring the tremendous frequency of this disease (Whiteman 2000). Read more →

Button Battery Ingestion

04 Sep
September 4, 2017

Button Batteries: Small, disc shaped battery cells which are designed for use in small electronic devices. Common sources are kids toys, watches, calculators and hearing aids. Most batteries use lithium as a power source

Button Battery Ingestion Danger:

  • Contact with mucosal surfaces (oropharynx, esophagus, nasal passage) results in transmission of current
  • Current transmission causes chemical burns and necrosis via alkaline injury (sodium hydroxide)
  • Tissue damage can progress rapidly and result in devastating injuries
  • Nasal passage and esophagus are most susceptible to injury (narrow places for battery to become lodged)
  • Injury Patterns
    • Viscous perforation
    • Fistula formation
    • Erosion into blood vessels and resultant bleeding and possible catastrophic bleeding with erosion into aorta

Read more →

Safety of PE Treatment with Rivaroxaban

31 Aug
August 31, 2017

Background: The simplified PE Severity Index (sPESI) is one of several validated prognostic tools for acute pulmonary embolism (PE).  The European Society of Cardiology recommended the use of the sPESI to risk-stratify patients with acute PE into low risk (sPESI=0) and non-low risk (sPESI≥1) in order to guide treatment and disposition (Konstantinides 2014).  Systematic reviews and meta-analyses have found that outpatient management of low-risk PE patients with standard therapy is safe, effective, and cost-effective (Aujesky 2011, Zondag 2013, Kahler 2015).

Standard practice in the United States for treatment of acute PE over the last decade has been a parenteral agent (e.g. enoxaparin, fondaparinux) overlapping with a vitamin K antagonist (VKA) (e.g. warfarin). However, a paradigm shift has been brewing over recent years.  Direct oral anticoagulants  (DOACs) have demonstrated efficacy as initial and long-term treatment of PE compared to standard therapy in various trials (EINSTEIN-PE 2012, RE-COVER 2014, AMPLIFY 2013, Hosukai-VTE 2013).  The EINSTEIN-PE study found that rivaroxaban was noninferior to enoxaparin/VKA for the treatment of recurrent venous thromboembolism (VTE) without increased risk of bleeding.  Rivaroxaban and other DOACs are approved for treatment of VTE in the European Union, but use in the United States of DOACs for ED treatment of PE is more limited. Read more →

ATHOS-3: A New Vasopressor For Treatment of Vasodilatory Shock?

28 Aug
August 28, 2017

Background: As I walk to the bedside to re-examine my patient with refractory hypotension, I start thinking what else can I do? My patient came into the hospital with septic shock secondary community acquired pneumonia requiring me to intubate her due to impending respiratory failure. I subsequently placed a central venous catheter and an arterial line as I carefully volume resuscitated her.  I turned up her tidal volume momentarily on the ventilator to assess for pulse pressure and stroke volume variation, did a bedside echo, and attempted a passive leg raise, but it appears that she is volume replete. I started a norepinephrine infusion, and as the dose escalated, I added a vasopressin infusion, but she still remains hypotensive even after giving her stress dose steroids. As I contemplate my next move I am haunted by her bedside monitor alarming; MAP 50 mm Hg. What’s my next move? Read more →

Pacemaker Basics

24 Aug
August 24, 2017

Have you ever been confused by the alphabet soup of pacemakers? This post will serve as a pacemaker basics reference. Read more →

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