June 28, 2021

58 y/o female with colorectal cancer recently started on continuous 5-FU chemotherapy presents to the ED with chest pain, shortness of breath, and diaphoresis.  The symptoms wax and wane with no specific exacerbating factors.  She has no other past medical history, had a port placed recently for her chemotherapy and not a smoker.  Initial vital signs are shown below… BP: 146/64 HR: 113 RR: 15 Temp: 98.1 O2 Sat on RA: 100%

June 24, 2021

Background: Antibodies targeted at the SARS-CoV2 spike protein are an essential part of the body’s immune response to COVID19 infection. Infection with SARS-CoV2 stimulates the immune system to produce a polyclonal spike protein antibody response in the host. Vaccines have similar results and recent studies show that the antibody response is even more robust than with natural infection. These antibodies bind to numerous locations on the SARS-CoV2 spike protein limiting the virus’s ability to enter and infect host cells. 

One of the many massive challenges of the COVID19 pandemic has been the lack of targeted therapeutics. Extensive efforts have been invested into research with only glimmers of benefit for most drugs. The exception to this has been dexamethasone which was shown in the RECOVERY trial to have remarkable impacts on death in patients requiring O2 (NNT = 29) and in those requiring invasive ventilation (NNT = 8.5).  The RECOVERY Group has continued to perform excellent research but most of the investigated therapeutics including azithromycin, convalescent plasma, aspirin and colchicine have all fallen flat.

Monoclonal antibody infusions have gained national attention as a potential therapeutic in COVID patients and have been touted by medical experts. The goal of these drugs is to give patients antibodies prior to their body mounting a response in an effort to prevent progression of disease. We have previously reviewed the EUA drug bamlanivimab (LY-CoV555) - a monoclonal antibody. In that review, we note the absence of any difference in patient centered outcome as well as serious methodological flaws. We have also reviewed REGN-COV2 (casirivimab/imdevimab) noting the lack of any evidence of benefit as well as the suspect methodology. In January, in a post for Brief 19, I concluded that “there is no convincing data that monotherapy or a cocktail of antibodies improves meaningful outcomes in patients with COVID19.” However, the RECOVERY group has submitted a new study that was released as a preprint on June 16th, 2021.

June 21, 2021

Background: Acute basilary artery occlusion has a high morbidity and mortality.  Treatment strategies for acute basilar artery occlusion are rather sparse.  Endovascular research over the last 5 years (REBEL EM Post) adds little to the conversation of these strokes as very few patients with basilar artery strokes were included. The Basilar Artery International Cooperation Study (BASICS) was a prospective observational registry in which ≈600 patients were divided into three groups: antithrombic treatment only (antiplatelet drugs or systemic anticoagulation), primary intravenous thrombolysis (including subsequent intra-arterial thrombolysis), or intra-arterial therapy (which compromised thrombolysis, mechanical thrombectomy, stenting, or a combination of these approaches) [2].  The majority of patients (68%) received intra-arterial therapy, but the study showed no statistically significant superiority for any treatment strategy.  In a subgroup analysis of the BASICS registry, patients with the most severe neurologic deficits (NIHSS >19) showed a trend toward lower risk of a poor neurologic outcome with endovascular therapy. Clearly, additional data is needed to elucidate the role of endovascular treatment in basilar artery strokes.

June 17, 2021

Background: The evidence supporting the use of a 10-day course of high-dose amoxicillin to treat community-acquired pneumonia (CAP) in pediatric patients is weak. In addition, medicine is trending towards shorter courses of antibiotics when clinically appropriate. REBEL EM covered a similar paper that compared a 3-day course of antibiotics to 8 days in hospitalized adults with CAP [Link is here]. Antimicrobial resistance is a global health crisis, and antibiotic stewardship is paramount. This paper attempts to tackle a significant public health concern in an area with minimal evidence; the duration of antibiotics in pediatric CAP.

June 16, 2021

Take Home Points
  • Neck movement (both extension and flexion) has the ability to cause cord damage.
  • Using hyperangulated blade in video laryngoscopy improves chances for glottic visualization in patients with a c-collar in place.
  • Ultimately, hypoxemia kills – Intubate the patient with what you have available, as there has not been shown to be a definitively superior technique.