July 12, 2021

Background: Hypertensive acute heart failure is a subgroup of acute congestive heart failure (CHF) patients.  Physiologically there is increased afterload and decreased venous capacitance both leading to fluid shifts resulting in pulmonary vascular congestion.  Sympathetic crashing acute pulmonary edema (SCAPE) is a severe form of hypertensive acute CHF.  The rapidity and severity of this illness leaves a very narrow period of time for therapeutic intervention before subsequent deterioration. Therapeutic intervention includes vasodilators such as, high-dose nitroglycerin (NTG) and non-invasive ventilation (NIV). Both therapies can result in reduced work of breathing, decreased preload/afterload, and prevention of endotracheal intubation, and ventilation.  There is a paucity of high level literature on this topic. However, many resuscitation-minded clinicians advocate for this therapy.

July 8, 2021

Background Information:

The Canadian Syncope Risk Score (CSRS) is one of several clinical decision tools used in the emergency department (ED) following a syncopal episode. (Figure 1) It was derived from one of the largest datasets currently available and its ability to predict the probability of adverse events from a score increases its clinical utility with flexibility when applied as a continuous risk assessment.1 One benefit it has over other risk-stratification tools is the score’s ability to address the risk of these serious adverse events over 30 days as opposed to 7-30 days after the syncopal episode. The CSRS is not without its disadvantages, of which one item on the score is the clinical diagnosis. The initial clinical picture may not be clear enough to immediately discern this. Furthermore, there’s difficulty in discerning where arrhythmia falls in the score (ie. adverse event or part of the final diagnosis). While CSRS has been previously validated in a multicenter Canadian study,2 the authors of the following paper wanted to externally validate it and compare it to clinical judgement.

July 5, 2021

Background: Intravenous sub-dissociative dosed ketamine has gained an expanded role in the management of a variety of acute painful conditions in the ED (REBEL EM).  When IV access is not readily available or unobtainable, sub-dissociative dosed ketamine can be given through the intranasal route as well.  Another non-invasive route of ketamine administration could be the nebulized route.  Inhaled ketamine has a bioavailability of about 20 to 40% (compared to the IV route) and a duration of action of 20 to 40 minutes. There is currently no high-quality literature in the ED that evaluates or compares the analgesic efficacy and safety of nebulized ketamine.

July 1, 2021

Background: Atrial fibrillation and atrial flutter are two of the most common dysrhythmias seen in the emergency department (ED). Rarely does a shift go by that you don't see one or the other. For decades, there has been a debate between rate and rhythm control in patients presenting with recent-onset AF. In recent years there has been an increased use of rhythm control in managing episodes of <48 hours of duration. The major concern with rhythm control is the potential for thromboembolic events after cardioversion. Recent observational data has led to various recommendations on post-cardioversion anticoagulation. The 2018 Canadian Cardiovascular Society Guideline (2) recommends all patients be anticoagulated for 4 weeks following cardioversion, including those without risk factors for stroke while the 2019 American and 2020 European guidelines (3,4) recommend that patients with CHADS2VASc scores above 2 receive anticoagulation. However, these recommendations are considered Class IIb or “weak based upon low-quality evidence.”  In order to best care for our patients, it is important to understand the true risk of thromboembolic events post cardioversion based on whether anticoagulation is prescribed or not.

June 30, 2021

Take Home Points

- Unexplained tachycardia (or any abnormal vital sign) warrants investigation.
- Pain, induration, "woody" feel of any muscle group should raise suspicion of infection in that muscle group that has spread hematogenously especially in those with predisposing factors (e.g HIV, trauma, IVDA)
- Early pyomyositis will not necessarily have abscess formation
- Treatment consists of IV antibiotics, possible drainage or surgery for source control.