April 16, 2020

Background Information: Nausea and vomiting during pregnancy most commonly occurs during the first trimester. If left untreated, the development of hyperemesis gravidarum can lead to further complications characterized by dehydration and electrolyte abnormalities.1 Ondansetron, a 5-HT3 receptor antagonist has quickly become the most frequently prescribed drug in the United States for nausea and vomiting during pregnancy.2 With the creation of an oral dissolving tablet in 2006, Ondansetron’s popularity as an antiemetic continues to rise. In fact, a study from 2014 shows that nearly a quarter of all pregnant women in the United States are using it.3 There is uncertainty in the literature as to the association between Ondansetron and birth defects. While some studies report there is no increased risk in congenital abnormalities among women who took this antiemetic early in pregnancy, other evidence suggests it may be associated with cleft palate and cardiac malformations.2 The authors of this study sought to investigate the association between exposure to Ondansetron during the first trimester of pregnancy and risk of congenital malformations in newborns using a national cohort of publicly insured pregnant women.

February 20, 2019

Take Home Points:

  1. Hypothermia is neuroprotective and patients can survive prolonged periods of cardiac arrest. Termination of resuscitative efforts in cardiac arrest should not considered until the patient is >32°C or has a K > 12 mEq/L
  2. Active internal rewarming is the keystone of treatment for unstable hypothermic patients. Utilize available resources including ECMO to effectively warm your patient
  3. Consider alternate causes for hypothermia, especially in patients who fail to respond to warming

January 21, 2019

Background Information: In 2017, more than two-thirds of the 70,000 drug overdose deaths in the United States involved an opioid.1 Many emergency departments are affected as opioid overdoses increased 30% from July 2016 through September 2017 in 52 areas in 45 states.2 With the half-life of naloxone being between 60-90 minutes the appropriate disposition and observation time of these patients following naloxone reversal continues to be debated in the literature.3,4, A study on heroin overdose patients treated and released by pre-hospital providers showed no deaths in the one-year period studied.5 While this only applies to isolated heroin use, other studies have shown no increased incidence of death within 48 hours of patients treated with naloxone for non-fentanyl opioid overdoses.6,7 Many of these studies, however, suffer from poor follow up which is unsurprising given the difficulty in tracking patients with opiate use disorders. It is important to note that the increased presence of synthetic and long-acting opioids further complicates this topic. A systematic review of a clinical prediction rule known as the St. Paul’s Early Discharge Rule, concluded that ambulatory patients with normal vital signs, and a Glasgow Coma Scale (GCS) of 15 only needed 1 hour of observation prior to discharge.8,9 The authors of this study sought to validate this single center derived rule and its six criteria.

January 10, 2019

Background: The mainstay of treatment for alcohol withdrawal syndrome is a symptom-triggered approach using benzodiazepines. Phenobarbital, however, is an interesting agent in this scenario for several reasons. It is famous for  it is long duration of action. IV Phenobarbital has an onset of action of over 15 – 20 minutes, a duration of action of 10 – 12 hours and a half-life of 53 – 118 hours in adults [5]. But phenobarbital has several other characteristics that make it attractive in the treatment of alcohol withdrawal. Importantly, it works on the GABA receptor differently than benzodiazepines. First, it increases the duration (not frequency) the chloride channel is open. Also, chronic alcohol abuse can alter the GABA receptor making it less sensitive to benzodiazepines not barbiturates. And finally, at very high doses, phenobarbital can open the chloride channel independent of the presence of GABA. The authors of this paper sought to compare a phenobarbital-adjunct versus benzodiazepine-only approach for the management of alcohol withdrawal syndrome in the ED.

May 17, 2018

Definition: Salicylate toxicity is characterized by a constellation of symptoms caused by acute or chronic overdose of salicylate containing compounds. The most common salicylate is aspirin, but the group also includes topical forms of salicylates, methyl salicylate (Oil of Wintergreen), and bismuth subsalicylate (such as in Pepto-Bismol).

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