December 19, 2019

Background: E-cigarettes or “vapes” are now the most popular tobacco product among US teens and are used by 20% of all high-schoolers2. Vapes are used to heat and vaporize a liquid (e-juice or vape juice) that may contain nicotine, tetrahydrocannabinol (THC), cannabidiol (CBD), or ultraconcentrated THC resin (hash oil, wax, or dabs.)3. Since their introduction, vaping devices have been studied for the numerous potentially harmful chemicals they can introduce into users, including: heavy metals (cadmium, nickel, lead), plastic-related toxic gases (like cyanide and phosgene), volatile organic compounds, ultrafine particles, and diacetyl flavoring (linked to a chronic pulmonary syndrome known as ‘popcorn lung,’ which is not as appealing as it sounds)4. More recently, a spectrum of lung illnesses related to vaping have become the focus of a national public health investigation. These cases have been described in almost every US state since early summer 2019; as of November 2019, there have been over 2000 cases of ‘Vaping-Associated Lung Injury’ (VALI) reported to the CDC, with 42 associated deaths. The article discussed below is a large case series from the Midwest depicting the clinical characteristics and outcomes of patients with VALI from April to August 2019.  Since then, several more epidemiological and analytical investigations have been published, and studies are ongoing to clarify the causes and best treatments for this disorder. We chose this article for REBEL EM because it represents a well-done early investigation of an emerging epidemic which contributed valuable clinical insights for emergency medicine practice.

December 12, 2019

Background: The 2015 American Heart Association guidelines for Adult Advanced Cardiac Life Support recommend adenosine in non-hypotensive patients in regular narrow-complex supraventricular tachycardia (SVT).  Adenosine has a rapid onset and a half-life that is <10 seconds, which makes it an ideal agent for hemodynamically stable SVT. Typically, adenosine is administered as an initial 6mg rapid IV bolus over 1 – 2 seconds followed by a rapid 10 – 20mL saline flush.  If SVT is not terminated and normal sinus rhythm maintained within 1 – 2 minutes, a repeat dose of 12mg is given followed by a 10 – 20mL saline flush, and this can be repeated for a total of 3 doses. Because of the short half-life of adenosine, several advocate for a two-way stopcock, where adenosine and a 10 – 20mL saline flush are given in tandem. The logistics and timing with using a two way stopcock can be challenging and can result in less rapid flush than intended.

December 5, 2019

Background: Saline (0.9% sodium chloride) has historically been one of the most common intravenous fluids administered in critically ill adults.  However, the supraphysiologic chloride concentration can cause hyperchloremia, metabolic acidosis, renal vasoconstriction and alter immune function.  There is nothing normal about normal saline. Balanced crystalloids (i.e. lactated Ringer’s solution, Plasma-Lyte A, etc) contain electrolyte compositions that are closer to physiologic levels.  Recently, the Isotonic Solutions and Major Adverse Renal Events Trial (SMART) [2] compared balanced crystalloids to saline among critically ill adults and found that balanced crystalloids decreased the composite outcome of death, new renal replacement therapy, or persistent renal dysfunction (This composite outcome was primarily driven by mortality benefit).  Interestingly, in the subgroup analyses of septic patients, balanced crystalloids seemed to have its biggest benefit in MAKE30 compared to saline.

December 2, 2019

Background: Recently there have been some observed trends in decreasing susceptibility among Strep pneumoniae isolates to antimicrobials used to treat community acquired pneumonia (CAP) (Resistance to oral penicillin and macrolides for Strep pneumoniae & macrolides and fluoroquinolones for Staph aureus).  New antibacterials are therefore needed to treat CAP because of growing antibacterial resistance. Lefamulin is the first pleuromutilin antibiotic approved for intravenous and oral use in humans. Both the intravenous and oral formulations were approved in August 2019 by the US Food and Drug Administration (FDA) to treat CAP.  It is active against the most common CAP-causing pathogens, including bacteria resistant to other antimicrobial classes. Lefamulin Evaluation Against Pneumonia 1 (LEAP 1) [1] looked at IV Lefamulin vs IV Moxifloxacin in adult patients with moderate to severe CAP and demonstrated noninferiority in that trial.   Given those results, LEAP 2 was performed to compare oral Lefamulin to oral Moxifloxacin in adult patients with moderate to severe CAP.

November 25, 2019

Background: In 2016, Paul Marik published a study in Chest [2] demonstrating a decrease in hospital mortality of 32% for sepsis patients treated with vitamin C, thiamine and hydrocortisone.  The Marik protocol(as it has come to be known), entails IV vitamin C 1.5g q6hr for 4d + IV hydrocortisone 50mg q6hr for 7d + IV thiamine 200mg q12hr x4d. The authors’ hypothesis was that vitamin C, hydrocortisone, and thiamine have synergistic effects that reverse vasoplegic shock and potentially limit the duration of vasopressor treatment resulting in a reduction in organ and limb ischemia from vasopressors themselves.  Although the results of the study are promising, it is important to remember that this was only a hypothesis generating study.  We have been waiting for a randomized clinical trial to recreate the results of this study and finally we have our first of many… CITRIS-ALI. This randomized trial looks to see if high-dose vitamin C could reduce organ failure and biomarkers of inflammation and vascular injury in patients with sepsis and ARDS.
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