February 11, 2019

Background: Syncope, defined as a transient loss of consciousness with a complete recovery, is a common ED presentation. There are numerous causes of syncope ranging from the relatively benign (eg vasovagal syncope) to the potentially life-threatening (eg dysrhythmia, ectopic pregnancy, aortic dissection). Among the life-threatening diagnoses is pulmonary embolism (PE). PE is a common cause of sudden, unexpected, non-traumatic death and, syncope in the setting of PE portends poor 30-day outcomes (Roncon 2018). What is not well known is how often ED presentations of syncope are the result of PE. A study in 2016 demonstrated a 17.3% rate of PE in first time syncope presenting to the ED but, had numerous significant biases and limitations (Prandoni 2016). Ultimately, this study is unlikely to reflect the reality of ED syncope cases and lacks external validity. Incorporating the PESIT trial data into clinical assessment would lead to a profound increase in PE evaluation without adding significant benefit. Additional clinical data demonstrating the true prevalence of PE in syncope patients is needed to confirm these suspicions.

January 23, 2019

Take Home Points
  1. Single dose oral dexamethasone is an excellent choice for asthma exacerbations. It takes away the compliance issue for patients who have trouble getting medications or filling medications once they leave the ED.
  2. Antibiotics aren’t always indicated in COPD exacerbations, but are used much more frequently than in asthma exacerbations because the structural changes in the patient’s lung lead to increased bacterial colonization. In general, if the patient has increased cough or sputum production, they probably would benefit from a course of antibiotics
  3. In general, azithro alone is no longer a good choice as solo covereage for community acquired pneumonia.  Adding either amoxicillin or cefdinir to you amoxicillin should get you good coverage of both strep pneumo and atypicals.

December 3, 2018

Background: Use of tranexamic acid (TXA), an antifibronlytic medication,  has certainly become popular for numerous indications (i.e. trauma, uterine bleeding, epistaxis).  Patients with hemoptysis, frequently come through EDs, and as an ED healthcare provider, I am unable to provide the definitive therapies of bronchial artery embolization and bronchoscopy for these patients at many of the institutions in which I work.  And, of course, it’s not like I can just put my finger on the bleeder. There is no real effective medical therapy for hemoptysis, other than antibiotics for infection.  I often find myself helpless with these patients as all I can do is transfer them to larger institutions where definitive therapies can be done.  Well hold on…It turns out inhaled TXA may be an option to reduce bleeding in patients with hemoptysis.  Thus far the evidence for this has  only been from small case series.  There have been no prospective studies evaluating nebulized TXAs effectiveness as an inhaled treatment for hemoptysis.  I have certainly used this treatment for post-tonsillectomy bleeding and have at times used it for hemoptysis, with great success, but it would be nice to see some evidence to support this practice.

September 3, 2018

EM Journal Update: Safety of Using Wells’ Clinical Model With D-Dimer To Manage Patients In The ED With Suspected Pulmonary Embolism

Background: In the US, pulmonary embolism (PE) kills 100,000 people each year and over 360,000 new cases of PE are diagnosed each year (Horlander 2003). Currently, the gold standard for diagnosing PE is the computed tomographic pulmonary angiography (CTPA). Patients with PE present with varying symptoms, from anxiety and tachycardia, to shortness of breath and syncope. Thus, it is difficult to exclude this life-threatening diagnosis and thus far there is no validated method to exclude PE. Prior work from this group derived and validated Wells’ criteria for calculating clinical probability of PE, and using it to determine which patients should get serial ultrasonography, venography, or angiography after an equivocal ventilation perfusion (VQ) scan (Wells 1998). Now, this group examines how the D-dimer assay, together with Wells’ clinical model can help manage PE patients.

August 27, 2018

Choosing Your Initial Settings: I hope you now see what physiologies to consider when setting up the ventilator and your goals for each. If your patient doesn't fit into one of these three categories, then I set up my ventilator as if I was managing a patient who has refractory hypoxemia to maintain a lung protective strategy even if they don't think they have very significant lung disease. Maintaining a lung protective strategy with low tidal volume ventilation has been shown to decrease ventilator induced lung injury and minimize harm, even in patients without refractory hypoxemia and ARDS (1-2).