May 26, 2014

Typically, the treatment of acute pulmonary embolism consists of administration of unfractionated heparin or low molecular weight heparin (i.e. enoxaparin) overlapped with vitamin K antagonists (i.e. warfarin).  This can be a very effective treatment regimen, but also very complex.  New direct Xa inhibitors are being used more and more in clinical practice with prevention of venothromboembolism (EINSTEIN-DVT Trial), after major orthopedic surgery (RECORD1 Trial), prevention of stroke in patents with atrial fibrillation (ROCKET-AF Trial) , and in the treatment of acute coronary syndromes.  Recently, the EINSTEIN-PE Trial evaluated oral rivaroxaban for treatment of symptomatic pulmonary embolism.

May 1, 2014

Frequently, patients with acute alcohol intoxication are brought to the emergency department (ED) for evaluation and treatment.  Although practice patterns vary, it is not an uncommon practice to give normal saline to these patients in the hopes that the saline will cause a dilution effect on the level of alcohol helping patients sober faster and therefore having a shorter length of stay in the ED.  At the end of 2013 a study was published evaluating intravenous fluids and alcohol intoxication.

April 28, 2014

D-dimer testing is sensitive for thrombus formation, and in patients who are not high risk, this test is used to rule-out venous thromboembolism. D-dimer has been shown to increase with age, which can cause a lower specificity (i.e. more false positive tests) in older patients.  Specificity can range from 49 - 67% in patients ≤ 50 years of age, but in older patients (i.e. ≥ 80 years of age) the specificity is quoted as 0 - 18%. The result of this is, older patients often have more diagnostic imaging, but a higher cut-off may lead to increased false negative cases (i.e. missed VTE) and make this strategy less safe. So could age adjusted d-dimer testing increase specificity without affecting sensitivity?

April 21, 2014

Patients with corneal abrasions typically come to the emergency department for eye pain.  Most physicians treat these with topical antibiotics, oral analgesia, and for those who are lucky enough 48 - 72 hour follow up with ophthalmology. Oral analgesia does a poor job of controlling these patients pain. Tetracaine is an esterase type anesthetic with a onset of action of 10 - 20 seconds and a duration of action of 10 - 15 minutes.  Use of topical anesthetics are very effective at reducing pain, but there use is discouraged secondary to poor wound healing of the corneal epithelium.  So what is the evidence for topical anesthetic use on corneal abrasions?

April 17, 2014

Hyperkalemia is an electrolyte abnormality seen in the emergency department as well as in hospitalized patients and it can be associated with adverse clinical outcomes and death if not treated appropriately. It is important to remember that the electrophysiologic effects of hyperkalemia are directly proportional to both the absolute plasma potassium and its rate of rise. However, neither the ECG nor the plasma potassium alone are an adequate index of the severity of hyperkalemia, and therefore providers should have a low threshold to initiate therapy. Classic teaching of the chronological ECG changes of hyperkalemia include:
  1. Peaked T waves
  2. Prolongation of PR interval
  3. Widening QRS Complex
  4. Loss of P wave
  5. "Sine Wave"
  6. Asystole
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