August 26, 2019

Normal saline started being used based on work done in the 1830s with cholera.  We are still doing the same thing the same way and it’s not until recently we have begun to ask the hard questions about why we are doing things the same way 150 years later.  In this debate, titled "What the Fluid," from Rebellion in EM 2019, Scott Wieters, MD and Rob J. Bryant, MD debate the pros and cons of balanced and unbalanced crystalloids.

August 22, 2019

Background: Unwarranted use of antibiotics has several deleterious effects which include, antimicrobial resistance, wasted resources, adverse effects, negative affect on the microbiome of patients, and distracts from potentially more effective interventions. There has recently been a huge push for tests such as procalcitonin to help in curtailing the use of antibiotics when it is not warranted.  Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend only prescribing antibiotics in moderately or severely ill patients with acute COPD exacerbations, increased cough, and/or sputum purulence [2]. The authors of this trial wanted to test another such marker, point of care CRP in patients with acute COPD exacerbations.  Along with bronchodilators and steroids, antibiotic prescriptions seem to be a common treatment modality as well. CRP is an acute-phase protein that is readily available and can be measured quickly with point of care testing.  The authors of this trial hypothesized that the results of POC CRP may help inform prescribing decisions for acute COPD exacerbations, however RCTs regarding clinical effectiveness of this test are lacking.

August 19, 2019

Background: Antibiotics are one of the cornerstones of therapy in the treatment of sepsis/septic shock, however according to the Surviving Sepsis Campaign (SSC) guidelines, time to antibiotics is a core measure, though there is weak evidence in support of this.  Most of the evidence supporting this is based off retrospective studies that showed delays in the administration of antibiotics after the development of septic shock is associated with an increase in mortality of almost 7.6% per hour [3]. The major issues with retrospective studies are that they are uncontrolled, chart quality may be inaccurate, baseline status of patients may be unbalanced and thus allow selection bias that can affect the results. Although, prospective observational studies have failed to consistently show an association between early antibiotics and mortality benefit, the guidelines still recommend early antibiotic administration within an hour of sepsis recognition.

August 12, 2019

Background:  In patients with ICH, antiplatelet therapy is withheld due to the perceived risk of hematoma expansion.  Often, these medications are either not restarted or there is prolonged delays until they are restarted, but the risk of occlusive vascular events might be higher without resumption of antithrombotic therapy. A meta-analysis of observational studies found no difference in the risk of hemorrhagic events and a lower risk of occlusive vascular events associated with antiplatelet therapy resumption after any type of intracranial hemorrhage (ICH); however, randomized trials for antiplatelet efficacy in occlusive vascular disease have excluded patients with a history of intracerebral hemorrhage. Due to the paucity of evidence, no guidelines have strong recommendations about long-term anti-platelet therapy after ICH. The RESTART Trial [1] aimed to address the question of whether or not to start antiplatelet therapy following an intracerebral hemorrhagic stroke.

August 8, 2019

Background: Trauma patients can be a rather difficult patient population to treat with multiple ongoing issues.  There is always a balance of hemorrhage control vs prophylaxis for venous thromboembolism (VTE), as both can cause increased morbidity and mortality.  One method to balance this challenging issue is retrievable inferior vena cava (IVC) filters, which at face value sound like a nice solution (Prevent VTE while avoiding worsening hemorrhage).  The main issue with IVC filters is there is limited high quality data to support the use of these devices and IVC filters are not without their own long-term complications as well. Finally, there are also conflicting recommendations depending on which guidelines you choose to read [3][4][5].