April 25, 2019

Background: Although the debate over balanced (i.e. lactated ringers, PlasmaLyte) vs unbalanced (i.e. 0.9% saline) crystalloids has not been settled, fluid resuscitation continues to be a fundamental therapy given to critically ill patients.  0.9% saline is one of the most common fluids given in resuscitation of patients but the high chloride content may contribute to the development of acute kidney injury (AKI) [1]. Alternatives to 0.9% saline include crystalloids with electrolyte compositions that are more balanced and resemble that of plasma (i.e. Lactated Ringer’s Plasma-Lyte, etc). Theoretically use of more balanced crystalloids would result in less potential side effects when compared to 0.9% saline. The crux of the matter is does fluid choice affect any patient-oriented outcomes?

April 15, 2019

Background:Tracheal intubation is a common procedure performed on critically ill patients. In these patients, there is a high risk of life-threatening complications associated with the procedure, with severe hypoxemia being one of the more common. Development of severe hypoxemia, in turn, increases the risk of post-intubation cardiac arrest. Therefore, optimal preoxygenation is an essential part of tracheal intubation to help stave off subsequent complications.

Both NIV and HFNC can provide a higher fraction of inspired oxygen than standard oxygen therapies.  HFNC can provide continuous oxygen up to 70L/min via nasal prongs with the potential advantage of remaining in place for apneic oxygenation. NIV can also provide high flow oxygen but must be removed during the apneic phase of intubation.  To date there has not been a study comparing NIV vs HFNC to reduce the incidence of severe hypoxemia during intubation until now; the FLORALI-2 trial.

April 8, 2019

Screen-Shot-2019-03-19-at-5.32.30-AM.pngBackground: Multiple guidelines recommend tramadol or NSAIDs as 1stline treatment for patients with osteoarthritis (OA).  Tramadol is viewed as a weak opioid because it binds to the mu receptor at a significantly lower affinity than morphine.It also inhibits the reuptake of serotonin and norepinephrine.  Tramadol is converted in the liver via CYP2D6 which can cause some issues.  The big issue is that CYP2D6 activity varies among patients and this is important because you don’t know how much opiate the patient is actually receiving (i.e. the same dose of tramadol will have widely different effects from patient to patient).  Not only is tramadol potentially not giving pain relief, but patients often return to the ED for common side effects of tramadol including nausea/vomiting, dizziness, constipation, etc. Because of it’s multiple mechanisms of action, potential drug-drug interactions, and lowering of the seizure threshold, the safety of tramadol has been brought to question.

April 4, 2019

Background: Computed tomography (CT) scans using IV contrast agents are one of the most common imaging modalities used in the emergency department (ED). The reason for this is no secret. CT scans with IV contrast offer a large amount of information on patients when limited information is available, they are diagnostic of many conditions with good performance characteristics, and they are often requested by consultants.   Many patients get suboptimal studies without IV contrast due to fear of contrast induced nephropathy (CIN). However, more recent studies suggest that with the use of iso- and low-osmolar contrast agents (almost universally used today) this concern is unwarranted.  Most studies on this topic have focused on unselected populations, and not focused on patient groups at higher risk for AKI, including those with sepsis.

April 1, 2019

Background: No matter which side of the debate you sit on in regard to systemic thrombolysis in acute ischemic stroke (AIS), there is one truth: systems have undergone major changes to ensure tPA is offered to patients in the ≤4.5-hour window.  The debate surrounding tPA in AIS lies in the equipoise surrounding benefits while there are very real harms.  Advocates of tPA in AIS hang on to two trials that have never been replicated (i.e. NINDS and ECASS-III), and both have major methodological issues. Skeptics of tPA in AIS appropriately argue that there are 11 other randomized clinical trials which have shown almost no benefit, but come at the cost of early increased early mortality and symptomatic intracranial hemorrhage (sICH) (Nice breakdown of individual trials of thrombolysis in stroke can be found at First10EM).  Now there is a push to extend the window of tPA out to 9 hours in AIS with newer imaging modalities such as MRI diffusion-weighted studies in patients with unknown onset of symptoms. The push for this stems from the fact that patients with a visible ischemic lesion on diffusion-weighted imaging, combined with the absence of a clearly visible hyperintense signal in the same region on fluid-attenuated inversion recovery (FLAIR) is predictive of symptom onset within 4.5 hours before imaging.