Background: The most feared complication in the clinical course of children with diabetic ketoacidosis (DKA) is the development of cerebral edema. Cerebral edema is rare (<1%) but is the leading cause of death in pediatric DKA. Many of the details about the risk factors as well as the mechanisms leading to DKA related cerebral edema are not well understood. Before we review the recent, groundbreaking study by Kupperman et al (1), examining the relationship between intravenous fluid content and rate of fluid administration in the development of DKA related cerebral edema, it’s important that we review the associated risk factors as well as the proposed mechanisms. It is important to know that the available data we are about to review comes from retrospective studies as well as case reports and case series and not from randomized control trials. Read more →
Background: Critically ill patients come to the ED all the time and it is almost reflexive to liberally administer oxygen in these acutely ill patients. Many providers may consider supplemental oxygen a harmless and potentially beneficial therapy in these patients, irrespective of the presence or absence of hypoxemia (i.e. hyperoxia). There have been several trials (Stroke Oxygen Study, Oxygen in AMI, & Oxygen in the ICU) that have shown harm with hyperoxia in the critically ill. This paper is a systematic review and meta-analysis evaluating the evidence base for liberal versus conservative oxygen therapy in this patient population. Read more →
Background: Community acquired pneumonia (CAP), defined as lower bronchial tree infection in a patient that has not been hospitalized in the last 90 days is a commonly diagnosed disease. There are between 2-4 million episodes per year in the US with roughly 500,000 hospital admissions (Rosen’s). Most outpatients are treated with azithromycin (or another macrolide antibiotic) as this drug gives a simple treatment regimen (single drug, simple dosing, short course). However, the efficacy of this regimen has been questioned in recent years as resistance patterns shift. Read more →
Background: In recent years, ketamine use has dramatically increased in the Emergency Department (ED). There are four major indications for the use of ketamine in the ED: analgesia with low dose ketamine (LDK), induction for rapid sequence intubation, procedural sedation and sedation of the agitated patient. A number of relative contraindications for ketamine exist though many of them have been debunked through analysis of the evidence. This includes the dogma that ketamine cannot be used in patients with head trauma (for fear of increasing the ICP) or in patients with hypertension or tachycardia.
One contraindication that persists, though, is that of a history of psychiatric illness. Ketamine is an N-methyl-D-aspartic acid (NMDA) receptor antagonist and it can produce a broad range of cognitive and behavioral disturbances including psychosis. These disturbances are short-lived in the majority of individuals but there is a fear that ketamine can cause decompensation of psychiatric illness. The ACEP Clinical Policy lists psychiatric illness as an absolute contraindication for dissociative sedation with ketamine (Green 2011). Read more →
Refractory Hypoxemia: Now maybe you have intubated a patient secondary to hypoxemic respiratory failure who is at high risk for the development of acute respiratory distress syndrome (ARDS). These patients, and really all patients, with exception of severe obstructive disease, I set up the ventilator to deliver 6mL/kg based on ideal body weight (not actual weight). Regardless if this is a pediatric or adult patient, I am setting up the ventilator to target 6 mL/kg of IBW. I can accomplish this with either pressure mode, where you set the pressure, but closely monitor the tidal volumes the patient is receiving. Read more →