July 13, 2020

Background Information:

Headache is a common chief complaint that emergency physicians encounter almost every day and sometimes multiple times in each shift. In fact, headache is the fifth leading cause of patients presenting to the emergency department (ED).1 Current first-line treatment consists of a dopamine antagonist such as prochlorperazine or metoclopramide which are given in addition to diphenhydramine to mitigate any potential adverse effects. A recent study has shown that IV haloperidol, another dopamine antagonist, was equivalent to IV metoclopramide in the successful treatment of headaches in the ED.2 Additionally, haloperidol has been shown to be an effective rescue medication in the treatment of refractory migraine-pain.3 Unfortunately, the cardiovascular effects and reported QTc prolongation associated with haloperidol has limited its use in the ED. The authors of the following study sought to determine the effectiveness of low-dose IV haloperidol in the ED treatment of acute benign headache among patients aged 13 to 55 years old

May 28, 2020

Background Information:

Physicians have and continue to heavily contribute to the current opioid epidemic in the United States and Canada.1 Although much of the focus has been opioid prescriptions given to patients in the emergency department,2,3 not much attention has been paid to critically ill patients who survive to hospital discharge. The long-term sequelae of these opioids is concerningly overlooked especially when physicians utilize these medications as part of an “analgesia first” approach to sedating critically ill patients for the purposes of invasive mechanical ventilation (IMV).4 Previous observational studies in Canada found that approximately 85% of critically ill patients receiving IMV were exposed to opioids.1 Furthermore, the average daily opioid dosing for 2-7 days was 63 milligrams of morphine equivalent (MME), increasing to 106 MME per day for patients receiving IMV for greater than 7 days. The authors of this study performed a retrospective chart review of population-based data from Ontario Canada to investigate the frequency of new opioid initiation and persistent opioid use among critically ill patients who received mechanical ventilation. They compared this to patients who were hospitalized but not critically ill.

April 20, 2020

Background Information: The presentation of a patient with syncope to the Emergency Department (ED) can pose a challenge to clinicians as the identification of a serious underlying condition is the priority. Often the original cause of the syncope is difficult to determine in the ED and ultimately results in unnecessary hospitalization. Of all syncope patients evaluated in the ED, 3-5% of them will be found to have a serious condition after ED disposition.1 Furthermore, the literature has shown that hospital admissions due to syncope were associated with low mortality or the need for procedures.2 Emergency physicians are then also posed with the task of determining which patients may be considered low, medium and high risk for a serious outcome. Several risk stratification tools have been developed to help with the identification of these patients, however many of these tools are not validated and very complex, therefore they are not used clinically. The Canadian Syncope Risk Score (CSRS) is among these decision tools, however it has yet to be validated. The authors of this paper sought to conduct a multicenter ED based prospective study to validate this tool and advocate its superior use over some of the other risk stratification tools that currently exist.

April 16, 2020

Background Information: Nausea and vomiting during pregnancy most commonly occurs during the first trimester. If left untreated, the development of hyperemesis gravidarum can lead to further complications characterized by dehydration and electrolyte abnormalities.1 Ondansetron, a 5-HT3 receptor antagonist has quickly become the most frequently prescribed drug in the United States for nausea and vomiting during pregnancy.2 With the creation of an oral dissolving tablet in 2006, Ondansetron’s popularity as an antiemetic continues to rise. In fact, a study from 2014 shows that nearly a quarter of all pregnant women in the United States are using it.3 There is uncertainty in the literature as to the association between Ondansetron and birth defects. While some studies report there is no increased risk in congenital abnormalities among women who took this antiemetic early in pregnancy, other evidence suggests it may be associated with cleft palate and cardiac malformations.2 The authors of this study sought to investigate the association between exposure to Ondansetron during the first trimester of pregnancy and risk of congenital malformations in newborns using a national cohort of publicly insured pregnant women.

March 26, 2020

Background Information: Refractory ventricular fibrillation (RVF) is a complication of cardiac arrest defined as ventricular fibrillation (VF) that does not respond to three or more standard defibrillation attempts.1,2 Patients with RVF during their cardiac arrest have a mortality of up to 97%.3,4 Double external defibrillation (DED) involves the use of a second defibrillator providing an additional shock in a sequential or simultaneous manner. The left ventricle (LV), being the most posterior part of the heart and the furthest away from the anterolateral electrode pads, have led some to hypothesize that utilizing an anterior-posterior pad placement (ie. Changing the vector) is what accounts for DED’s success. Some theorize that the increase in amount of energy from two defibrillations as opposed to one is what’s needed to reach the LV. There are also theories suggesting that the sequential administration of the shocks, more effectively lowers the defibrillation threshold of the cardiac myocytes and thus leads to a more successful conversion of VF. In spite of these many theories, the intervention of DED has been studied for decades in the electrophysiology lab and widely discussed in the literature through case reports and meta-reviews. These case reports have shown success and a recent meta-review of 39 patients who received DED showed that 25% of them were discharged neurologically intact with Cerebral Performance Category (CPC) scores of 2 or less indicating normal recovery/mild disability or moderate disability but able to independently perform activities of daily living.5-10 While this literature is promising, DED is a highly variable intervention and there are still many unknown factors which continue to cause debate and controversy. The role of vector direction via pad placement, the role of a pulse interval in energy deliverance and the efficacy in method of delivering DED sequentially vs simultaneously continues to remain unclear. 6-11 The authors of this pilot RCT (DOSE VF) wished to answer some of these questions by first determining the feasibility and safety of performing a full RCT.  In doing so, they used alternate defibrillation strategies such as vector changes and double external sequential defibrillation (DSED) in treating RVF.12
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