Accelerated Diagnostic Protocol for Chest Pain Not Useful in a US Population?

16 Apr
April 16, 2015

Accelerated Diagnostic ProtocolThere are approximately 8 to 10 million patients coming to Emergency Departments (EDs) in the United States annually. In the US, we use a very liberal testing strategy in order to avoid acute coronary syndrome (ACS) in patients presenting with chest pain. This results in over 50% of ED patients with acute chest pain receiving serial cardiac biomarkers, stress testing, and cardiac angiography at an estimated cost of $10 to $13 billion annually and yet fewer than 10% of these patients are diagnosed with ACS.

The 2-hour accelerated diagnostic protocol (ADAPT) combines  0 and 2 hour cardiac troponin (cTn), electrocardiograms (ECGs), and an adapted Thrombolysis in Myocardial Infarction (TIMI) score to help identify ED patients safe for early discharge. Previous studies show that this strategy can identify as many as 20% of patients for early discharge with a high sensitivity of 97.9% to 99.7% for major adverse cardiac events (MACE) at 30 days. This ADP has yet to be tested in a US population until now.

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Do Patients with Posterior Epistaxis Managed by Posterior Packs Require ICU Admission?

13 Apr
April 13, 2015

Epistaxis MythsThis post is part 2 of epistaxis dogma. In the first post, we discussed the (dis)utility of prophylactic antibiotics in patients with epistaxis who require nasal packing. Here, we will take on dogma #2:

Dogma #2: Patients with posterior packs for epistaxis should be admitted to the ICU for continuous monitoring due to the risk of life-threatening bradydysrhythmias.

Unfortunately, the literature here is even sparser than with prophylactic antibiotics. An extensive literature search (paging research librarian) turned up two articles that were repeatedly cited. Read more →

Lidocaine + Bupivacaine vs Bupivacaine Alone for Digital Nerve Blocks

09 Apr
April 9, 2015

Digital Nerve BlocksWhen I first learned digital nerve blocks in the late 1990’s I was taught to mix Lidocaine and Bupivacaine 50/50 to provide faster onset (Lidocaine) and a longer duration of action (Bupivacaine). My use of two agents for digital nerve blocks was recently questioned by one of my colleagues.

Any time additional medications are drawn up into a syringe there is opportunity for error, and there is additional time added to the procedure. A review of the (limited) literature will try to answer the following questions:

  1. Does the addition of Lidocaine to Bupivacaine decrease the time to onset of anesthesia?
  2. Does the addition of Lidocaine to Bupivacaine decrease the pain of injection?
  3. Does the use of Lidocaine with Epinephrine prolong the duration of digital block long enough to obviate the need for Bupivacaine?

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April 2015 REBELCast

06 Apr
April 6, 2015

April 2015 REBELCastWelcome to the April 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of articles just published this year. Today we are going to specifically tackle:

  • Topic #1: Basic Life Support (BLS) vs Advanced Cardiac Life Support (ACLS) in Out of Hospital Cardiac Arrest (OHCA)
  • Topic #2: PROMISE Trial – Anatomic vs Functional Testing for Coronary Artery Disease (CAD)

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Do Patients with Epistaxis Managed by Nasal Packing Require Prophylactic Antibiotics?

30 Mar
March 30, 2015

EpistaxisEpistaxis is a common Emergency Department (ED) complaint with over 450,000 visits per year and a lifetime incidence of 60% (Gifford 2008, Pallin 2005). Posterior epistaxis is considerably less common than anterior epistaxis and represents about 5-10% of all presentations. Many patients with posterior epistaxis will be managed with a posterior pack and admitted for further monitoring. Traditional teaching argues that:

  1. Patients with nasal packs should be given prophylactic antibiotics to prevent serious infectious complications.
  2. Patients with posterior packs should be admitted to the ICU for cardiac monitoring as they are at risk for serious bradydysrhythmias.

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