March 14, 2019

Background: Chest pain is a complaint commonly seen in the emergency department.  Getting a good history is an essential part of working up patients with chest pain, as the history may guide us to be concerned for the cause of life-threatening chest pain including, pulmonary embolism, aortic dissection, tension pneumothorax, or acute coronary syndrome. In regard to acute coronary syndrome, many of us learned that the classic description of ischemic chest pain was chest pressure radiating to the left arm.  But as sometimes is the case, classic teachings are based on antiquated evidence and simply not correct.

March 11, 2019

Background: Based on the Surviving Sepsis Campaign, hemodynamic resuscitation of sepsis patients is done by repeating serum lactic acid levels every 2 – 4 hours until normalization. The issue with this strategy is that there are other things that may elevate lactate levels other than sepsis and hypoperfusion.  Another, potentially useful marker to guide hemodynamic resuscitation could be capillary refill time.  Its easy-to-use, requires no resources, and costs nothing.  To answer this question the ANDROMEDA-SHOCK randomized controlled trial tried to evaluate the use of a peripheral perfusion-targeted resuscitation strategy during septic shock in adults.

March 7, 2019

Background: 1st trimester vaginal bleeding and abdominal pain is a common complaint seen in the ED.  As EM physicians it is important to make the diagnosis of ectopic pregnancy early in the clinical course as it can prevent rupture, difficulty with future fertility, and even death.  Typically, when non-ruptured, hemodynamically stable, ectopic pregnancy is diagnosed, our Ob/Gyn colleagues get consulted and the usual first-line treatment is methotrexate initiated in the ED with 24 - 72hours follow-up in an ideal world. Unfortunately, this does not always happen, and some patients will return to the ED for increased pain. It is important to be aware of methotrexate outcomes and have suspicion for failure of methotrexate in patients returning to the ED.

March 4, 2019

Background: Over the past few years we have seen a surge in the use of oral Factor Xa inhibitors (apixaban, rivaroxaban etc) for anticoagulation.  The reason for this is the ease of use, standard dosing with no levels to check and no injections needed. Despite these advantages, the risk of bleeding remains a concern.  These agents unfortunately do not have any specific reversal agents.  In May of 2018, Andexanet alfa gained accelerated approval by the FDA for the reversal of these agents, but robust evidence in its support have been lacking.

February 28, 2019

Background: Standard management of septic shock has included, IV fluids until optimal intravascular volume is achieved, appropriate early antibiotics, and source control.  Typically, only after all these measures have been undertaken is vasopressor infusion initiated if a MAP of ≥65mmHg is not achieved. There have been some animal and human studies that have advocated for early norepinephrine administration in septic shock improving hemodynamics and mortality.  The issue, with these trials is that they were retrospective which means these studies suffer from the limitations of this type of methodology (i.e. convenience sampling, recall bias, confounding, and ultimately cannot determine causation, only association).