August 18, 2016

Background: Diabetic ketoacidosis (DKA) is traditionally defined as a triad of hyperglycemia (>250mg/dL), anion gap acidosis, and increased plasma ketones. There is another entity that providers must be aware of known as euglycemic DKA (euDKA), which is essentially DKA without the hyperglycemia (Serum glucose <200 mg/dL). Euglycemic DKA is a rare entity that mostly occurs in patients with type 1 diabetes, but can possibly occur in type 2 diabetes as well. The exact mechanism of euDKA is not entirely known, but has been associated with partial treatment of diabetes, carbohydrate food restriction, alcohol intake, and inhibition of gluconeogenesis. euDKA, can also be associated with sodium-glucose cotransporter 2 (SGLT-2) inhibitor medications.  These medications first came onto the market in 2013 and are FDA approved for the treatment of type 2 diabetes, however many physicians use them off-label for type I diabetes due to their ability to improve average glucose levels, reduce glycemic variability without increasing hypoglycemia, and finally promote weight loss.

August 15, 2016

Background: In the ACLS guidelines stable Ventricular Tachycardia (VT) can be treated with either IV amiodarone or IV procainamide, as the drugs of choice. This has been given a class II recommendation, but there has not been a controlled prospective trial to base the use of one drug over the other in the clinical setting. Despite both medications having a class II recommendation, both clinically and anecdotally it appears that amiodarone is the preferred agent in clinical practice.

August 11, 2016

Background: Acute asthma presentations account for more than 2.1 million Emergency Department (ED) visits annually. In the US, 8.4% of the population is affected by the disease. Current guidelines from the National Heart, Lung, and Blood Institute recommend a minimum of 5 days of oral prednisone to treat moderate to severe asthma exacerbations (NHLBI Guidelines 2007). Oral and parenteral dexamethasone have similar bioavailability, with a duration of action of 72 hours. There has been promising data on dexamethasone for acute asthma from the pediatric literature, as well as a 2-dose regimen in adults. However, due to the strong association with low patient adherence and poor outcomes, a single dose of a long acting oral medication in the ED may help prevent relapse of symptoms.

August 8, 2016

Background: When it comes to treating community acquired respiratory tract infections, macrolide antibiotics (azithromycin, clarithromycin, and erythromycin) are a common choice of agent. In 2010, 57.4 million macrolide prescriptions were written in the U.S. with azithromycin being the most commonly prescribed individual antibiotic agent overall with ~51.5 million prescriptions (Hicks 2013).

With more and more patients being prescribed macrolide antibiotics, an increasing amount of research has been put forth dealing with the safety concerns regarding these medications; specifically the thought that azithromycin use can lead to fatal ventricular arrhythmias. In addition to case reports a 2012 observational study published in the New England Journal of Medicine highlighted an association between  azithromycin use and higher rate of both cardiovascular death and all-cause mortality (Ray 2012). This prompted the US Food and Drug Administration to issue warnings about the use of azithromycin and potential QT-interval prolongation and fatal ventricular dysrhythmias.

However, recent studies suggest that these concerns and warnings may not be accurate. A retrospective cohort study comparing older patients hospitalized with pneumonia that were treated with azithromycin to those who received other guideline appropriate antibiotics actually showed a lower risk of 90-day mortality in the azithromycin group. Further, there was no significant difference between the 2 groups in regards to risk of arrhythmia, heart failure or any cardiac event. (Mortensen 2014).

August 4, 2016

ATACH-2Background: Hemorrhagic stroke accounts for only 11-22% of all strokes but up to 50% of all stroke mortality. Additionally, there is significant disability associated with the disease in survivors. Much of our attention in the Emergency Department (ED) is guided towards preventing expansion of bleeding and secondary injury after the initial insult. Physiologically, controlling blood pressure has always appeared to be a reasonable goal as it may decrease hematoma expansion and thus mortality. However, there is little high-quality evidence to guide clinicians in determining what the goal blood pressure should be and whether there’s truly a patient centered benefit to aggressive blood pressure management. The recently published INTERACT-2 trial demonstrated no benefit for death or disability for aggressive blood pressure control when started within 6 hours of symptom onset (though the authors touted benefits seen only after ordinal analysis) but some critics have argued that treatment should be started earlier.