May 17, 2021

Background: A patient presents to the emergency department (ED) for medical treatment. After comprehensive evaluation and management, the patients condition improves and you prepare to discharge the patient home. The nurse notifies you the blood pressure (BP) is 185/105 and asks if you are comfortable discharging the patient in light of the abnormal vital signs. 

This clinical scenario happens regularly in the ED. Our training in emergency medicine has always been: We do not treat asymptomatic hypertension in the ED.” In fact, ACEPs 2013 Clinical Policy statement recommends referring patients with asymptomatic hypertension for outpatient follow-up and NOT starting antihypertensive therapy in the ED. However, this tends to be a controversial topic with various clinical opinions and practices. Ask ten emergency medicine physicians: What BP value would make you uncomfortable when discharging a patient? You may get ten different answers.

Patient safety is paramount. Furthermore, individual physicians have varying levels of risk tolerance and aversion which contribute to treatment decisions. This paper attempts to address concerns in patients with elevated blood pressure readings in the ED.

May 13, 2021

Background Information: Over one year into the pandemic many therapies to treat COVID-19 have targeted innumerable aspects of the virus. Most recently, the use of corticosteroids to treat the virus’ excessive inflammatory effects has become the front and center of therapy in patients requiring oxygen therapy.1 The RECOVERY trial showed a mortality benefit when using Dexamethasone in severe cases where oxygen therapy or mechanical ventilation was required.2 Interestingly, compared to other corticosteroids, high doses of Methylprednisolone are actually the preferred agent for anti-inflammation in pulmonary diseases as it achieves a more direct effect on cell membrane associated proteins.3 The authors of the following paper sought to investigate the effectiveness of methylprednisolone compared to Dexamethasone in hypoxemic ICU patients with COVID-19.

May 10, 2021

Background: Occlusion myocardial infarction (OMI) is defined as acute coronary occlusion or near occlusion with insufficient collateral circulation leading to downstream myocardial infarction. Currently, we use STEMI ECG criteria to identify acute coronary OMI in the clinical setting. The diagnosis of STEMI is based on millimeter criteria on the ECG (see below) and essentially acts as a surrogate marker for the presence of an OMI. Under the current STEMI vs NSTEMI paradigm, almost 1/3rd of NSTEMI patients have unrecognized acute total occlusion (OMI) discovered on delayed angiograms. The delay in diagnosis results in increased short and long-term mortality compared to NSTEMI patients without OMI (We have reviewed these trials before on REBEL EM). As ECG interpretation has improved it has become clear that there are other early ECG indicators of OMI that do not meet STEMI criteria (i.e. hyperacute T-waves) that would benefit from early percutaneous coronary intervention [2].  Additionally, there are other features such as hemodynamic instability and persistent symptoms, as well as adjunct modalities, like echocardiography, that can add useful information and increase the likelihood of OMI. Ultimately, the OMI paradigm emphasizes underlying pathology over surrogate test results (i.e. STEMI).

May 6, 2021

Background: Hyponatremia is one of the most common electrolyte abnormalities seen in clinical practice. Under-correction could lead to cerebral edema, whereas overcorrection could result in osmotic demyelination syndrome (ODS).  The current recommendation is to use hypertonic saline in small, fixed, intermittent boluses. This approach avoids rapid partial correction of serum sodium, limits risk of overcorrection, and doesn’t require complex calculations. Slow continuous infusions on the other hand, require complex calculations to adjust hypertonic saline infusions to a rate of correction over time based on the rate of serum sodium correction.  Despite these facts, there are limited high-quality trials that have demonstrated if slow continuous infusion (SCI) therapy is as good as or as safe as rapid intermittent bolus (RIB) therapy.