June 7, 2021

Background: Droperidol came onto the market in 1967 and, over time, became a frequently employed treatment of headache, nausea, agitation, acute pain, chronic pain, pain in the context of opioid-tolerance and refractory abdominal pain.  Unfortunately, in December 2011, the US Food and Drug Administration placed a black box on droperidol due to surveillance data showing increased prevalence of QT prolongation.  Most of these cases were due to high doses of droperidol ranging from 50 to 100 mgs. It’s also important to point out that QTc prolongation is not a patient centered outcome. A trial published by Nuttall et al of over 20,000 patients found ZERO cases of polymorphic VT or death at low doses of droperidol (0.625mg) [3].  Additionally, the Clinical Guidelines Committee of the American Academy of Emergency Medicine (AAEM) reviewed the literature in 2014 and found no evidence that low dose droperidol (under 2.5mg) was unsafe for use [4].

June 3, 2021

Background: Oral sweet solutions have been used for some time as a pain-reducing agent for procedures in the neonatal population.  However, there has been some mixed results in its effectiveness, especially in the <12 months of age group. Nasopharyngeal aspiration (NPA) is a common procedure performed especially during seasonal upper respiratory tract infection. A study performed in 2005 by Macfarlane et al [2], demonstrated that NPA had a Face, Legs, Activity, Cry, and Consolability pain scale (FLACC) score of 6 out of 10.

May 27, 2021

Background: We have all seen the wide spectrum of illness caused by COVID-19 ranging from asymptomatic disease on one extreme all the way up to critical illness, acute respiratory disease and ultimately death at the other extreme.  In the most critically ill there are thoughts that a viral-induced hyperinflammatory immune response (i.e. cytokine storm) is the culprit.  The main gatekeeper of the cytokine storm is, granulocyte-macrophage colony-stimulating factor (GM-CSF) which in turn can stimulate increases in inflammatory markers such as IL-6, CRP, d-dimer, and ferritin.  Medications that can inhibit or slow down upstream effects of GM-CSF could have beneficial effects. However, there is a lack of robust evidence to support this claim. Now we have the newest kid on the block…Lenzilumab. Lenzilumab is an anti-human GM-CSF monoclonal antibody that directly binds to GM-CSF and prevents signaling through its receptor.

May 24, 2021

Background: It’s no surprise that unplanned, emergency intubations are significantly different from intubations in the operating room (OR). Unplanned intubations on the floors and in the ED and ICU settings are highly unlikely to be “physiologically optimized:” they have underlying shock, respiratory failure, metabolic acidosis, as well as other pathophysiological changes that can substantially increase the risks of adverse peri-intubation events.  Historically, we focused more on the anatomically challenging airway instead of the physiologically challenging airways. Fortunately for our patients, this has changed in recent years. There is increased attention on physiologic challenges including hypotension, hypoxemia, and metabolic acidosis.  Taking care of critically ill patients that require intubation can be a high stress situation with very little room for error.  Having a large evaluation of routine clinical practice and occurrence of adverse events could help establish which high-priority interventions could reduce risk in this already risky situation.

May 20, 2021

Background: Coronary pathology in patients with NSTEMI can range from structurally normal vessels to varying degrees of nonobstructive coronary artery disease (CAD) to extensive obstructive CAD affecting the coronary tree.  The current diagnostic pathway to differentiate these different coronary pathologies is invasive coronary angiography (ICA).  A routine invasive strategy, however, can be associated with an increased risk of bleeding, iatrogenic injury from cath, and prolonged hospital stay.  Coronary computed tomography angiography (CCTA) is a simple, low-risk noninvasive test that can potentially rule out CAD and is gaining more popularity in the evaluation of NSTEMI patients. However, the prognostic information about obstructive CAD and/or the extent of CAD defined by CCTA in patients with NSTEMI compared to ICA is unknown.