Background: Since the publication of the before and after Marik trial  published in 2016, there have been six randomized clinical trials trying to answer the question of the utility of the metabolic cocktail (Vitamin C, thiamine, and hydrocortisone) in septic shock (See table below). Although, each was of various methodological rigor only one had a positive primary outcome (i.e. ORANGES). It is important to note that the primary outcome of the ORANGES trial was changed after full data collection (and likely analysis) was complete (See the REBEL EM analysis HERE). We now have our 7th RCT on this topic....Read More
Altered mental status has numerous possible etiologies. Splitting it into vital sign issues, toxic/metabolic, infectious processes, CNS issues (bleed, mass) and psych/dementia is a good way to organize your thoughts
Hypertensive encephalopathy is a diagnosis of exclusion - make sure you're not dealing with another process like meningitis or an intracranial hemorrhage
Once the diagnosis of hypertensive encephalopathy is made, shoot to lower the SBP by about 20-25% over the hour using a drug like nicardipine, clevidipine or labetalol
The use of corticosteroids in patients with pneumonia secondary to COVID-19 has been a controversially hot topic, particularly early on in the pandemic. Prior evidence seen in Severe Acute Respiratory Syndrome (SARS) and Middle Eastern Respiratory Syndrome have led some to argue against their use due to delayed viral clearance.1 More recent evidence related to SARS-Cov-2 has specifically shown reduced mortality and reduced need for mechanical ventilation with corticosteroids.2-4 More recently, the RECOVERY Trial showed an improvement in 28-day mortality among patients on oxygen therapy who received Dexamethasone.5 Little information exists in the literature about patients with moderate to severe disease who do not warrant ICU level of care but require hospital admission due to the extent of their illness. The authors of this study designed and conducted a pragmatic, partially randomized control trial to evaluate the possible benefit of methylprednisolone in hospitalized patients with moderate to severe COVID-19 pneumonia.
Background: Respiratory tract infections (RTIs) are a common reason for medical visits in kids. Most RTIs are self-limited and the addition of antibiotics rarely alters the course of disease. However, antibiotics are frequently prescribed for these conditions. Antibiotic overuse is one of the main drivers of resistance to antimicrobial agents. Additionally, antibiotic prescriptions place patients at risk for adverse events from the antibiotics themselves and makes parents believe they need to have their children seen for similar episodes in the future....Read More