June 22, 2020

Ear, nose, and throat (ENT) complaints are commonly seen in the emergency department. When you hear “ENT emergencies,” you probably think about epistaxis, sinusitis, and possibly foreign body removal (either from the ear or nose). While not as common, auricular hematomas are equally important to both understand and know how to manage. As a former wrestler, I can attest to the importance of 1) knowing how to accurately diagnose and 2) how to treat this injury to prevent future development of “cauliflower ear”. An auricular hematoma is a collection of blood underneath the perichondrium of the ear that typically occurs secondary to trauma. Common mechanisms of injury include an ear-piercing gone wrong or blunt trauma in contact sports (wrestling, boxing, and martial arts). Inadequate treatment of an auricular hematoma can lead to the development of an auricular deformity commonly known as “cauliflower ear,” which develops from permanent cartilage destruction.

June 18, 2020

Background: Here we go again with another “Time is Brain,” acute ischemic stroke study.  The authors start out by saying that earlier administration of intravenous tPA in acute ischemic stroke is associated with reduced mortality by the time of hospital discharge and better functional outcomes at 3 months.  These statements are based on flawed studies [3][4] (Check out Ken Milne discussing these issues HERE). Additionally, tPA has not been demonstrated to decrease mortality in any randomized clinical trial though it does increase early mortality. If you can’t tell, I am very skeptical about the spin of this trial.

June 15, 2020

Background: Factor Xa inhibitors have gained more use over the past several years due to the ease of administration and easier monitoring. However, bleeding, namely intracranial hemorrhage (ICH) is still a risk and the lack of a proven antidote is a cause for concern. Guidelines for the treatment of ICH published in 2016 recommended the administration of prothrombin complex concentrates (PCCs, both activated [aPCC] and 4 factor) [2]. In 2018 andexanet alfa gained accelerated approval by the FDA for the reversal of factor Xa inhibitors. Despite this new antidote, many organizations such as the American Society of Hematology and the European Stroke Organization still recommend the use of PCCs.  Research thus far has been performed in healthy volunteers, or small (<100 total patients with ICH) trials leaving a gap in the literature of what agent to use at the bedside.

June 11, 2020

Background: In end-stage renal disease (ESRD) patients on hemodialysis (HD), infection is the second most common cause of mortality after cardiovascular disease (Sarnik 2000). Because of the systemic inflammation and increased capillary permeability, septic patients are at significant risk for fluid imbalances and frequently require large volumes of crystalloids. The Surviving Sepsis Campaign guidelines provide a strong recommendation with low quality of evidence for administering a 30mL/kg fluid bolus within 3 hours of recognition of sepsis-induced hypoperfusion (Rhodes 2016). Further fluid administration should be guided by hemodynamic assessment (bedside echocardiography, passive leg-raise, etc.). In the general population, this early administration of fluids to patients with hypotension or sepsis-induced hypoperfusion has been associated with improved outcomes. However, there is significant confusion regarding the effects of a large 30mL/kg bolus on ESRD patients due to a lack of studies. While these patients may appear, volume overloaded on physical exam, they may be intravascularly volume deplete. Physicians may be hesitant to administer a large fluid bolus in ESRD patients because of the risk of precipitating cardiogenic shock, pulmonary edema, and respiratory failure. In fact, multiple studies show that patients who have ESRD are less likely to receive the full 30mL/kg fluid bolus compared to non-ESRD patients (Lowe 2018, Truong 2019, Dagher 2015). Furthermore, some studies show equivalent outcomes between ESRD patients who receive the full bolus and those who do not. We will review two studies that examined this topic.

June 6, 2020

Background: Convalescent plasma therapy is not a new or novel therapeutic option.  It involves taking the plasma from patients who have recovered from an illness and using it to treat patients who currently have the same illness. This approach has been evaluated in the treatment of SARS, MERS, and ebola but, none of the studies in these disease showed definitive results.  Thus far, the amount of evidence on convalescent plasma therapy in COVID-19 is also limited.  There was a case series of 5 patients [2] and a systematic review of 5 trials with 27 patients [3]. Neither study was earth-shattering. However, both showed  improved weaning from mechanical ventilation and no adverse events in the convalescent plasma group.  With a total of 32 patients, we should not put any weight in either of these trials.  We now have our first randomized clinical trial on convalescent plasma therapy.