January 16, 2020

Background: Computed tomography pulmonary angiography (CTPA) is the current gold standard for diagnosing acute pulmonary embolism in the ED.  It has a high sensitivity, and specificity, is readily available, and can establish analternative diagnoses.  One issue with CTPA is that many hospital protocols create barriers for patients with chronic kidney disease or acute kidney injury (AKI) protocols in place from getting the necessary IV contrast.  There are several studies [2][3][4] that have evaluated the causal relationship between contrast exposure and nephrotoxicity. However, most of these studies are observational and retrospective in nature. The issue with retrospective studies is that they often cannot control for confounders and observational studies cannot give us causation, only association. We now have another retrospective observational study asking the same question, which has the inherent issues of previous studies.

January 9, 2020

Background: Rapid sequence intubation (RSI) is the most widely utilized approach for patients requiring emergency tracheal intubation.  RSI typically requires the use of a induction agent followed by the use of a neuromuscular blocking agent (NMBA) to improve the overall intubation conditions and therefore improve first-attempt intubation success rate. Historically, succinylcholine has been the preferred NMBA, due to its fast onset (45 – 60 seconds) and fast offset (6 – 8 minutes of paralysis). Recent studies, however, show that rocuronium is an effective agent (similar timing of onset for ideal intubating conditions) as well.  When used at a dose of 1.2mg/kg, rocuronium has a similar onset time to succinylcholine of about 1 minute. Additionally, succinylcholine has several contraindications (see bottom of the post) while rocuronium has no contraindications (except for hypersensitivity) which has increased the debate about the paralytic agent of choice for RSI.

January 2, 2020

Background: Traditionally, vasopressors have been given through central venous catheters (CVCs) in the critically ill.However, the time it takes to place a CVC is time a patient could potentially remain hypotensive. Early initiation of vasopressors may be associated with reduced mortality by increasing end-organ perfusion. Therefore, there has been a growing trend to use vasopressors through peripheral IVs (PIVs).  Running pressors through a peripheral IV has a couple of important benefits including faster time to pressor initiation and no need for invasive procedures (i.e. CVC). There islittle evidence to support the safety of this practice other than one systematic review which included case reports and small case series. Now we have two more papers that evaluate this very question…are peripheral pressors safe?

December 30, 2019

Background: One of my favorite ED superstitions is that if someone says the word “quiet,” all hell is going to break loose. Many believe this superstition and as the ED inevitably gets busier as the day goes on, the person who said the Q word gets blamed for the volume; classic association being confused with causation.  I have never heard the opposite…“oh it’s busy,” and when it slows down, no one ever gets upset for someone saying the B word.  This is our own bias of work aversion in my humble opinion.  In this day and age of evidence-based medicine, we finally have a tongue-in-cheek study that proves my point.

December 23, 2019

Background: Dealing with a patient in status epilepticus, refractory to treatment with benzodiazepines, can be a sphincter tightening ordeal.  While most seizure activity responds to appropriately dosed benzodiazipines, some will not respond. The choice of second line medication has been hotly debated (i.e. Levetiracetam, fosphenytoin, and valproate).  One of the key aspects of management of status epilepticus is early termination.  The longer the seizure continues, the more likely patients can have cardiac/respiratory complications, brain injury, rhabdomyolysis, hyperkalemia, and acidosis. Thus, prompt termination of seizure activity with second line agents is critical. Despite recent pediatric studies (ConSEPT, ECLIPSE etc) there is limited guidance on the efficacy or safety of second line mediations for status epilepticus.