Are we Missing Acute MIs with Clinical Risk Scores?

13 Apr
April 13, 2017

Background: In 2011, we saw 7 million patients in the emergency department (ED) complaining of chest pain. Most of these patients did NOT have an acute coronary syndrome (ACS) or an acute myocardial infarction (AMI). Missing an AMI is one of the biggest fears we have in the ED. By using validated risk scores, we can help decrease the risk of missing AMI and the resultant adverse events. There are multiple scores available for our use. Thrombolysis in Myocardial Infarction (TIMI) predicts risk of adverse outcomes in the next 14 days. Global Registry of Acute Coronary Events (GRACE) predicts outcomes at 6 months. ED specific scores include HEART and Emergency Department Assessment of Chest Pain (EDACS). But, how well do these scores actually perform? Are we missing AMIs by using these clinical risk scores? Read more →

Low-Dose Ketamine for Acute Pain in the ED: IV Push vs Short Infusion?

10 Apr
April 10, 2017

Background: Ketamine’s role in the ED has expanded in recent years.  The clinical reasons for this make it easy to understand why, and include analgesia, amnesia, and anesthesia. Amazingly, ketamine does not only reduce acute pain, but it also decreases persistent chronic and neuropathic pain as well. More importantly, use of low-dose ketamine (0.1 – 0.3 mg/kg IV) has been demonstrated to be opioid sparing.  Some of the major issues with IV push low-dose ketamine include its adverse effects, such as feelings of unreality, nausea/vomiting, and dizziness. Many emergency medical providers have anecdotally noticed a decrease in adverse effects when ketamine is given slowly. In the paper we are reviewing today, the authors tried to see if increasing the duration of the ketamine from IV push (3 – 5 min) to a slow infusion (10 – 15 min) could mitigate some of these effects, while maintaining analgesic efficacy. Read more →

The Marik Protocol: Have We Found a “Cure” for Severe Sepsis and Septic Shock?

07 Apr
April 7, 2017

Background: The overall mortality in sepsis has decreased quite a bit in the last decade or so, however for a subset of patients, like those with Septic Shock, the mortality still remains high (as high as 50%).  There have been hundreds of studies trying to identify the holy grail to decrease mortality further, but one has not been found thus far.  Marik PE et al [1] published a study in Chest 2016 that has found a potential front runner.  In addition, the authors go on to say, in order to have an impact on a global scale, treatments would not only need to be effective, but also cheap, safe, and readily available; the authors of the following paper may have found just that..
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Is the Future of Non-Invasive Hemodynamic Monitoring Here and Ready for Primetime?

06 Apr
April 6, 2017

Background: Many physicians struggle with monitoring accurate continuous blood pressures, cardiac output, and response to fluids in patient resuscitation. Also, due to the invasive nature of most methods presently available (i.e. arterial lines, etc) few patients get this monitoring. Ultrasound has been an amazing addition to our armamentarium, but many, I am sad to say, still don’t feel comfortable with this modality. Recently, finger cuff, non-invasive technology was brought to my attention by Bob Frolichstein (Twitter: @frolichstein), one of my colleagues in San Antonio, TX. Specifically, it has been stated that, finger cuff technology, allows hemodynamic monitoring with both BP and CO continuously available in patients without the need for an arterial line. Read more →

Urinary Retention: Rapid Drainage or Gradual Drainage to Avoid Complications?

04 Apr
April 4, 2017

Background: The treatment of urinary retention is pretty straightforward; place either a Foley catheter or suprapubic catheter to decompress the bladder.  What is less clear, and more often debated, is if we need to clamp the catheter after 200 – 1000mLs of urine output or just allow complete drainage.  Historic teaching has been to do intermittent volume drainage to avoid complications such as hematuria, circulatory collapse, and worsening renal failure.  I distinctly remember being taught this as a resident, but not sure that I ever evaluated the literature until recently.  Read more →

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