Tag Archive for: Mythbuster

Mythbuster: Glucose Levels Must be Below a “Safe” Threshold Before Discharge

01 Dec
December 1, 2016

discharge-glucoseBackground: Anyone who works in the Emergency Department has seen patients brought in by EMS or sent from the clinic with a chief complaint of “high blood sugar.”  Now, we are not talking about patients with diabetic ketoacidosis, but just simple hyperglycemia. This is a common complaint with no real consensus on optimal blood glucose levels before safe discharge. Read more →

Diabetic Ketoacidosis (DKA) Myths

02 Nov
November 2, 2015

DKARecently, I was asked to give a lecture to both my residents and nurses at the University of Texas Health Science Center at San Antonio (UTHSCSA) on some common DKA myths. Now this topic was originally covered by my good friend Anand Swaminathan on multiple platforms and I did ask his permission to create this blogpost with the idea of improving patient care and wanted to express full disclosure of that fact. I specifically covered four common myths that I still see people doing in regards to DKA management:

  1. We should get ABGs instead of VBGs
  2. After Intravenous Fluids (IVF), Insulin is the Next Step
  3. Once pH <7.1, Patients Need Bicarbonate Therapy
  4. We Should Bolus Insulin before starting the infusion

Read more →

More Dogma: Epinephrine in Digital Nerve Blocks

03 Sep
September 3, 2015

Digital Nerve BlocksYou are working as an EM resident and have just evaluated a patient with a right long finger DIP joint dislocation. You perform a digital nerve block with 1% lidocaine with 1:100,000 epinephrine, and go to present to your attending before attempting the reduction. Your attending, on hearing about the epinephrine use goes berserk, and says “don’t you know that you shouldn’t use epi in fingers, noses, ears and toes?”.

When confronted with this situation we all like to have a one stop valid literature review to produce that validates our practice. Several social media authors have weighed in on this topic, however blogs sometimes don’t cut it for those unfamiliar with the current quality of peer reviewed online content.

The use of epinephrine in digital nerve blocks has been shown to increase duration of action for the anesthetic, and to allow the avoidance of bupivacaine, thereby decreasing the pain of the injection. (REBEL flashback) Read more →

Mythbuster: Administration of Vasopressors Through Peripheral Intravenous Access

28 May
May 28, 2015

VasopressorsBackground: Vasopressors are frequently used in critically ill patients with hemodynamic instability both in the emergency department (ED) as well as intensive care units (ICUs). Typically, vasopressors are given through central venous catheters (CVCs) as opposed to peripheral intravenous (PIV) access due to the concerns about adverse events (i.e. tissue ischemia/necrosis) associated with extravasation through PIVs. In a truly hypotensive, critically ill patient the use of a PIV to administer vasopressors will allow the medication to stabilize the patient sooner and reduce the time to hemodynamic stability. The requirement to start vasopressors through a CVC may delay administration of pressors. Also, performing the insertion of a CVC in a hypotensive patient in an emergency circumstance versus an elective circumstance may increase the risk of adverse events from the procedure itself (i.e. bacteremia, pneumothorax, arterial puncture). Finally, most of the evidence cited for avoiding PIV administration of pressors is a sparse collection of case studies and expert opinion. Read more →

Beyond ACLS: Epinephrine in Out-of-Hospital Cardiac Arrest Poll

15 Mar
March 15, 2015

epinephrineRecently, I wrote a post on the use of epinephrine in out-of-hospital cardiac arrest (OHCA) and this triggered some interesting discussion on twitter. Are we at a point that we can just stop using epinephrine in OHCA?  Has anyone stopped actually using epinephrine in OHCA and if so, why or why not? The evidence seems to point to no “good” neurologic benefit over basic life support (BLS).  I would love to hear more peoples thoughts on this. Read more →

Beyond ACLS: Is It Time to Abandon Epinephrine in Out-Of-Hospital Cardiac Arrest?

11 Mar
March 11, 2015

epinephrineEpinephrine is widely used and recommended by Advanced Cardiovascular Life Support (ACLS) in out-of-hospital cardiac arrest (OHCA), but its effectiveness in neurologic outcomes has never been truly established.  To verify effectiveness of epinephrine confounders, such as patients, CPR quality, CPR by bystanders, time from call to arrival at scene or hospital, and much much more, must be controlled for in a trial. This type of study is not easily performed due to ACLS being the current standard of care. Read more →

Is Kayexalate Useful in the Treatment of Hyperkalemia in the Emergency Department?

02 Feb
February 2, 2015

BariumEnema_ORIGINAL_460x261Background: Hyperkalemia is the most common electrolyte disorder seen in the Emergency Department and treatment of hyperkalemia is core knowledge of EM training for interns and focuses on:

1) Stabilization of cardiac myocytes with calcium salts
2) Temporary shifting of potassium into cells (insulin, beta agonists, normal saline,
      magnesium, sodium bicarbonate)
3) Removal of potassium from the body (i.e. loop diuretics, cathartics)
4) Definitive Treatment (i.e. Hemodyalisis)

Although there is still some debate on the first two areas (i.e. is there truly a role for sodium bicarbonate?) our focus will be on the removal part of the algorithm, specifically, is there a role for kayexalate?

Read more →

January 2015 REBELCast

10 Jan
January 10, 2015

REBELCastWelcome to the January 2015 REBELCast, where Swami and I are going to tackle a very important scenario that comes up in the daily practice of not only Emergency Medicine, but also in Medicine.  Today we are going to specifically tackle one topic:

Topic: Is the use of cephalosporin antibiotics in patients with a history of penicillin class antibiotics safe? Read more →

Do Patients with Strep Throat Need to Be Treated with Antibiotics?

05 Jan
January 5, 2015

Background: Streptococcal pharyngitis is a common presentation to primary care and Emergency Department physicians. Every year, 10 million patients in the United States are treated with antibiotics for pharyngitis. However, less than 10% of these patients actually have strep pharyngitis (Barnett 2013). Prescribing of antibiotics for these patients centers on three arguments:

  1. Antibiotics reduce symptomology
  2. Antibiotics reduce the rate of suppurative complications
  3. Antibiotics reduce the rate of non-suppurative complications (primarily Rheumatic Heart Disease).

So, do patients with strep throat need to be treated with antibiotics?

Read more →

Intravenous Fluids and Alcohol Intoxication

01 May
May 1, 2014

Intravenous Fluids and Alcohol IntoxicationFrequently, patients with acute alcohol intoxication are brought to the emergency department (ED) for evaluation and treatment.  Although practice patterns vary, it is not an uncommon practice to give normal saline to these patients in the hopes that the saline will cause a dilution effect on the level of alcohol helping patients sober faster and therefore having a shorter length of stay in the ED.  At the end of 2013 a study was published evaluating intravenous fluids and alcohol intoxication. Read more →

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