April 8, 2019

Screen-Shot-2019-03-19-at-5.32.30-AM.pngBackground: Multiple guidelines recommend tramadol or NSAIDs as 1stline treatment for patients with osteoarthritis (OA).  Tramadol is viewed as a weak opioid because it binds to the mu receptor at a significantly lower affinity than morphine.It also inhibits the reuptake of serotonin and norepinephrine.  Tramadol is converted in the liver via CYP2D6 which can cause some issues.  The big issue is that CYP2D6 activity varies among patients and this is important because you don’t know how much opiate the patient is actually receiving (i.e. the same dose of tramadol will have widely different effects from patient to patient).  Not only is tramadol potentially not giving pain relief, but patients often return to the ED for common side effects of tramadol including nausea/vomiting, dizziness, constipation, etc. Because of it’s multiple mechanisms of action, potential drug-drug interactions, and lowering of the seizure threshold, the safety of tramadol has been brought to question.

April 4, 2019

Background: Computed tomography (CT) scans using IV contrast agents are one of the most common imaging modalities used in the emergency department (ED). The reason for this is no secret. CT scans with IV contrast offer a large amount of information on patients when limited information is available, they are diagnostic of many conditions with good performance characteristics, and they are often requested by consultants.   Many patients get suboptimal studies without IV contrast due to fear of contrast induced nephropathy (CIN). However, more recent studies suggest that with the use of iso- and low-osmolar contrast agents (almost universally used today) this concern is unwarranted.  Most studies on this topic have focused on unselected populations, and not focused on patient groups at higher risk for AKI, including those with sepsis.

April 3, 2019

Take Home Points on Non-Inferiority Studies

  • Non-inferiority studies should be done when a new treatment (or diagnostic modality) requires less resources (cost or time), is easier for the patient or has a lower side-effect profile.
  • Non-inferiority study design largely negates the protections against bias added by blinding and randomization.
  • Non-inferiority studies can be used to manipulate clinicians when a superiority study would be more appropriate.

April 1, 2019

Background: No matter which side of the debate you sit on in regard to systemic thrombolysis in acute ischemic stroke (AIS), there is one truth: systems have undergone major changes to ensure tPA is offered to patients in the ≤4.5-hour window.  The debate surrounding tPA in AIS lies in the equipoise surrounding benefits while there are very real harms.  Advocates of tPA in AIS hang on to two trials that have never been replicated (i.e. NINDS and ECASS-III), and both have major methodological issues. Skeptics of tPA in AIS appropriately argue that there are 11 other randomized clinical trials which have shown almost no benefit, but come at the cost of early increased early mortality and symptomatic intracranial hemorrhage (sICH) (Nice breakdown of individual trials of thrombolysis in stroke can be found at First10EM).  Now there is a push to extend the window of tPA out to 9 hours in AIS with newer imaging modalities such as MRI diffusion-weighted studies in patients with unknown onset of symptoms. The push for this stems from the fact that patients with a visible ischemic lesion on diffusion-weighted imaging, combined with the absence of a clearly visible hyperintense signal in the same region on fluid-attenuated inversion recovery (FLAIR) is predictive of symptom onset within 4.5 hours before imaging.

March 29, 2019

On the last day of the last SMACC conference, Dr. Ken Milne (The SGEM) and I had a cage match debating four critical care controversies. It was all done in good fun with both of us taking our opportunities to poke a little fun at each other. While we took a pro vs con approach to the presentation, our positions are much closer than the debate demonstrates. Although the literature is far from perfect, development of critical appraisal skills and application of evidence-based medicine to the literature is what we should be using to inform our care but not dictate our care. It is equally as important to incorporate clinical judgment and ask our patients what their values and preferences are before making decisions about care.