May 3, 2021

Background: In 2019 the World Health Organization listed “Antimicrobial Resistance” as a top 10 threat to global health. This was echoed in a 2021 document. [WHO 2019, WHO 2021] The classic medical teaching regarding antimicrobial therapy pushed for longer treatment courses. There was a commonly held myth that premature cessation or prescription of a short course of antibiotics could select for more virulent pathogens thereby re-exacerbating and intensifying illness as well as hastening the development of antibiotic resistance. However, microbial stewardship is of paramount importance and we should embrace shorter courses of antibiotics when clinically appropriate.

May 1, 2021

Background: Head up (HUP) CPR is an emerging concept.  The theory behind HUP is it allows for venous blood to drain from the brain to the heart thereby decreasing intracranial pressure and lowering the arterial/venous pressure waves which concuss the brain with each compression.  Additionally, conventional CPR increases vascular pressure in both the venous and arterial sides of the heart simultaneously which in turn increases intrathoracic and intracranial pressure which can impede cerebral blood flow and compromise coronary circulation.  All of these theories were evaluated and confirmed in animal models with very limited human trials. In order for HUP to work however, we have to be able to effectively pump blood up to the brain which is not typically achieved with conventional CPR (C-CPR). Active Compression Decompression with Impedance Threshold Devices (ACD-ITD) are one way to improve C-CPR.  They can theoretically help by reducing intracranial pressure (ICP), reduce the potential for concussion with every compression, increase cerebral perfusion pressure (CerPP) and coronary perfusion pressure (CorPP). However, with any new approach, we should always temper enthusiasm, as the realities of implementing them may actually not be helpful, and maybe even harmful.

April 29, 2021

Background: Non-ST-elevation myocardial infarction (NSTEMI) is defined as acute coronary injury resulting in ischemia and myocardial infarction. The diagnosis is made based on clinical presentation and non-specific electrocardiogram (ECG) changes including ST-segment depression, T-wave inversions, or other nonspecific findings.1 Based on data from the NHS, most patients with NSTEMI are 70 years or older.2 This, coupled with an increasing aging population, raises the question, what is the best management in patients 80 years old or older with NSTEMI?

Previous studies have attempted to evaluate the best approach to elderly patients with NSTEMI, but the mean age of patients was 66 years old with few patients over 80 years old leaving few data to extrapolate these results to this specific population age.3 The best means of obtaining data to answer clinical questions is through prospective randomized trials and there is an upcoming trial to answer this question specifically, the SENIOR-RITA (cool name) will not be expected to complete enrolment prior to 2029. In the meantime, this trial (SENIOR-NSTEMI) was conducted to provide further data regarding the best management of patients older than 80 years old with a NSTEMI.

April 28, 2021

Background: It has long been thought that intravenous contrast can lead to acute kidney injury. Recent data, however, has called this dogmatic teaching into question.  Unfortunately, the data arguing against the association of contrast with AKI comes from observational trials and, thus, carry with it numerous biases.  One potential bias is baseline differences in the risk between exposure groups with patients not receiving contrast perceived to be at higher risk and those receiving contrast at lower risk of PC-AKI. Another example is selection bias due to requiring subsequent renal function testing in patients deemed to be higher risk and not those at lower risk.  Both of these can form a control group at high risk of kidney injury which creates a bias in favor of contrast and potentially masking harm.

April 26, 2021

In emergency medicine, the standard of care is to place an advanced airway for ventilatory or oxygenation failure, impending airway compromise, or inability to protect the airway. A patient with significant cognitive impairment may have depressed gag and/or cough reflexes, putting them at risk for aspiration. The evaluation of a patient’s risk for aspiration can be highly subjective. One common adage states: “If the GCS is less than 8, then intubate”, offering a seemingly simple and more objective standard to guide airway management. Using the Glasgow Coma Scale (GCS) score of 8 or below to evaluate the need for intubation is promoted by the ATLS course and the East Association for the Surgery of Trauma (EAST) practice management guidelines.[1][2] This practice is also commonly applied to patients with non-traumatic causes of obtundation. However, the evidence behind this practice is not clear, prompting many to re-examine this oft-repeated lesson.