August 5, 2019

Background Information: Non-steroidal Inflammatory drugs (NSAIDs) such as Ibuprofen are of the one of the most commonly used oral analgesics in the emergency department. 1 These medications work by inhibiting the enzymes cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2). These are two enzymes which lead to prostaglandin production and ultimately promote pain, fever and inflammation. Prostaglandins also serve to line the stomach epithelium and protect it from the digestive acids. The COX-1 enzyme also plays a role in platelet activation through the production of Thrombaxane-2. Understanding the physiology behind these important enzymes helps us better anticipate the expected adverse effects that may occur when prescribing NSAIDs, especially at higher doses or over an extended period of time. Due to its linear kinetic effects, higher doses of ibuprofen results in longer duration of analgesia and not necessarily more effective pain control. 3, 4 The authors of this study sought to identify the analgesic effects of three different doses of ibuprofen. Furthermore, they hypothesized that a lower dose had comparable analgesic effects when compared to higher doses.

June 13, 2019

Background Information: Syncope is defined as a sudden transient loss of consciousness (LOC) followed by complete resolution. It represents 1-3% of all emergency department (ED) visits. 1 1% of all hospitalizations are due to syncope as it may have resulted from a serious underlying condition, such as arrhythmia, acute cardiac ischemia, pulmonary embolism or internal hemorrhage. 2,3 Prior studies have demonstrated that up to a half of these serious conditions, particularly arrhythmias, are missed during ED evaluation and become evident after disposition. 1 Several risk stratification tools, such as the Canadian Syncope Risk Score (CSRS; Figure 1) and the San Francisco Syncope Rule (SFSR; Figure 2) have been developed to help identify serious outcomes. 4,5 The authors of this study sought to describe the time to occurrence of serious arrhythmias relative to when the patient arrived in the ED and based on their CSRS risk category. Furthermore, their goal was to use the results of this study to provide guidance for decision making regarding duration and location of cardiac monitoring.

May 9, 2019

Background Information: The sequential administration of a sedative and neuromuscular blocking agent (NMBA) to facilitate the passage of an endotracheal tube is a common method of intubating in both the emergency department (ED) and intensive care unit (ICU). In fact, 85% of ED intubation and 75% of ICU intubations are performed using RSI. 1 It has been shown that the NMBA not only provides muscle relaxation to improve laryngeal view but has also reduced intubation associated complications, ultimately improving the likelihood of intubation success.2-4 While the early use of a sedative leads to hypoventilation and apnea, the patient has an increased risk of hypoxemia and delaying optimal intubation conditions.1 Use of an NMBA was associated with a lower prevalence of hypoxemia, however the order of its administration before the sedative remains controversial for fear of patient awareness and its use has been limited to the operating room (OR) setting. 1,2 The authors of this study sought to identify whether the order of RSI drugs was associated with increased apnea time during intubation. They defined this interval as the time elapsed from administration of the first RSI drug to the end of a successful first intubation attempt.

January 31, 2019

Background Information: The successful placement of an endotracheal tube (ETT) is a necessary skill all emergency physicians must possess. Performing life-saving interventions are understandably stressful as their failure can lead to morbid consequences and expedited patient death.1,2 The intensive training of emergency physicians, the availability of multiple alternative airway adjuncts and the use of rapid-sequence intubation has helped reduce the intubation complication rate among trauma and medical patients.3-5 Confirmatory methods to ensure the placement of the endotracheal tube are ever changing with no single method being infallible.6. Physical exam findings such as auscultation of the chest and epigastrium, visualization of thoracic movement and fogging of the ETT are not sufficiently reliable to confirm placement.7,8 The use of end-tidal CO2 detection has been shown to have a cumulative false-positive and false-negative failure rate of 10% in accurately confirming the ETT’s location according to the authors of this paper (The paper referenced is a bit dated)­.6 Furthermore, the usage of these devices may contribute to the complications as they frequently require up to 5 ventilations to obtain an accurate reading.9-11 This puts the patient at risk for aspiration especially if the tube is in the esophagus. No.12 Despite a post-intubation CXR taking time, exposing the patient to more radiation and adding to the cost of treatment, it still continues to remain the standard of care.12-14  The authors of this study wished to better understand the test characteristics of utilizing ultrasound to confirm ETT placement. They conducted a systematic review and meta-analysis to quantify the accuracy of this ETT confirmatory method.

January 21, 2019

Background Information: In 2017, more than two-thirds of the 70,000 drug overdose deaths in the United States involved an opioid.1 Many emergency departments are affected as opioid overdoses increased 30% from July 2016 through September 2017 in 52 areas in 45 states.2 With the half-life of naloxone being between 60-90 minutes the appropriate disposition and observation time of these patients following naloxone reversal continues to be debated in the literature.3,4, A study on heroin overdose patients treated and released by pre-hospital providers showed no deaths in the one-year period studied.5 While this only applies to isolated heroin use, other studies have shown no increased incidence of death within 48 hours of patients treated with naloxone for non-fentanyl opioid overdoses.6,7 Many of these studies, however, suffer from poor follow up which is unsurprising given the difficulty in tracking patients with opiate use disorders. It is important to note that the increased presence of synthetic and long-acting opioids further complicates this topic. A systematic review of a clinical prediction rule known as the St. Paul’s Early Discharge Rule, concluded that ambulatory patients with normal vital signs, and a Glasgow Coma Scale (GCS) of 15 only needed 1 hour of observation prior to discharge.8,9 The authors of this study sought to validate this single center derived rule and its six criteria.

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