February 2017 REBEL Cast: The All Hyperoxia Edition

20 Feb
February 20, 2017

Background: Many providers and health care workers place oxygen on patients as a way to overcome hypoxemia or for patient comfort. Also in STEMI patients, many of us have learned the mnemonic “MONA” to remember the treatments for acute coronary syndrome. MONA stands for morphine, oxygen, nitroglycerin, and aspirin. It is however important to remember that oxygen is a drug; just like any other drug, there are side effects.  Some of the best known side effects of hyperoxia are direct lung toxicity, peripheral vasoconstriction, and increase in production of reactive oxygen species.  The PROXI Trial (Perioperative Oxygen Fraction-Effect on Surgical Site Infection and Pulmonary Complications After Abdominal Surgery) and the AVOID Trial (Air Versus Oxygen in Myocardial Infarction) showed increased long-term mortality and larger myocardial infarction size respectively in patients with supra-normal oxygen levels (hyperoxia). In this episode we will explore the effect of higher oxygen levels through in ICU and STEMI patients by reviewing two trials:

The Oxygen ICU Trial
The SOCCER Trial Read more →

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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Outcomes After Aggressive Management of Recent-Onset Atrial Fibrillation in the ED

13 Feb
February 13, 2017

Background: Atrial fibrillation (AF) is one of the most common dysrhythmias encountered in the ED. The management of recent-onset AF and atrial flutter (AFl) in the ED continues to be debated. The discussion centers on whether patients with recent-onset AF should be rhythm controlled (e.g. converted back to sinus rhythm) or rate controlled only. This debate was showcased in a point-counterpoint in Annals of Emergency Medicine in 2011 (Stiell 2011, Decker 2011). The rhythm control supporters argue that AF/AFl is abnormal, worsens quality of life, leads to cardiac remodeling and, in may patients, requires medications for rate control and anticoagulation. The rate control group argues that cardioversion runs the risk of causing a thromboembolic event (i.e. CVA, peripheral arterial occlusion). Thus, it should not be performed until the absence of clot in the left atrium is confirmed (by TEE) or appropriate anticoagulation has occurred. It has long been taught that if the patient has been in AF/AFl for < 48 hours, the risk of developing a clot in the left atrium is negligible and cardioversion may be pursued. However, some recent literature has called this classic teaching into question (Nuotio 2014). Prospective studies looking at outcomes of recent-onset AF/AFl patients after aggressive treatment in the ED are needed to further evaluate the risks of aggressive treatment.

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Normalization of Vital Signs Does Not Reduce the Probability of Pulmonary Embolism

09 Feb
February 9, 2017

Background: In patients with symptoms of pulmonary embolism (PE), we often turn to vital signs, including heart rate, respiratory rate and pulse oximetry, as part of our initial impression of the patient.  Before even considering further testing, such as d-dimer or CTPA, we look first at the vital signs to form our gestalt impression of the patient.  Clinical decision making tools are utilized in one static point in time, but gestalt decision-making occurs over the course of the patient’s entire stay in the Emergency Department (ED).  Because of this, clinicians may use changes in vital signs to augment their differential diagnosis or to justify their belief that a PE work up is not necessary.  

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The Ketorolac Analgesic Ceiling

19 Jan
January 19, 2017

Ketorolac Analgesic CeilingBackground: Ketorolac is a commonly used parenteral analgesic in the Emergency Department (ED) for a variety of indications ranging from musculoskeletal injuries to renal colic. This non steroidal anti-inflammatory drug (NSAID) is available in oral, intranasal and parenteral routes. Ketorolac has a number of side effects including nausea, vomiting, gastrointestinal bleeding and renal insufficiency. The risk of GI bleeding appears to be related to the use of higher doses and prolonged use. As with all NSAIDs, the drug has an analgesic ceiling – the dose at which additional dosing will not provide additional analgesia but can lead to more side effects. The current FDA dosing is 30 mg intravenously and 60 mg intramuscularly for patients < 65 years of age. However, the necessity of these doses is unclear and prior studies have demonstrated efficacy of considerably lower doses. The use of lower doses, if effective, may mitigate the potential for harm. Read more →

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