It's one of those things that gets hammered into the head of nearly every EM resident by their attendings during their training. That little nugget of information related to rapid sequence intubation (RSI) that is woven into the curriculum and gets passed on from class to class of EM residents who will go on to advocate it when they become EM attending physicians. We cannot help it...it just IS. Yet, when we stare at it [...]
If anyone remembers studying for their SAT’s back in the day, complete this sequence:If SUX sucks, and ROC rocks, then Sugammedex _________.In a word, “unavailable.” Sugammadex is a selective muscle relaxant-binding agent. As a result of its chemical structure, modified cyclodextrin compound with a hydrophilic outer surface and a lipophilic central cavity, sugammadex encapsulates both rocuronium and vecuronium. This encapsulation creates a concentration gradient by which rocuronium or vecuronium leaves the neuromuscular junction for the [...]
An elderly female patient rolls into the emergency department as a trauma. The story from the paramedics is that she had a witnessed fall, and she was initially alert and answering questions appropriately. However, en route to the hospital, her mental status became altered and she began to go "in and out." She became combative and because the paramedics feared that her airway would become unprotected, the decision was made to intubate the patient. Her [...]
The empiric use of two antimicrobial agents with similar spectrum of coverage (aka double coverage) is often fancied for a few reasons:Synergy, either clinical or pharmacokinetic, between two antimicrobial agents.Differing resistance patters to increase likelihood of adequate coverage of the suspected organism.Prevention of the development of resistance. Often, the second agent to be considered is either a fluoroquinolone (cipro/levo/moxi) or an aminoglycoside (amikacin/gentamicin/tobramycin). There is little, if any, data to steer towards one class or [...]
In the past couple of months, we have had a number of patients present to our ED with acute overdose secondary to the ingestion of valproic acid (VPA). When reading further about toxicity secondary to VPA, I was surprised to find that on an annual basis, there are approximately 8,000 reported cases of VPA toxicity in the United States. There are a number of concerns with VPA toxicity that one should be mindful of: The [...]
In a departure from previous guideline recommendations for sedation, the new Pain, Agitation, and Delirium guidelines in CCM have moved away from benzodiazepines as first line sedatives. Taking over are propofol or dexmedetomidine who now occupy the first line sedative of choice position. While many of us in the ED are familiar with propofol and have amassed an understanding of its practical use, dexmedetomidine is equally unfamiliar. Dexmedetomidine is a central alpha-2 agonist, similar to clonidine, [...]
A number of retrospective studies have demonstrated conflicting data regarding the association of morbidity and mortality secondary to intracerebral hemorrhage (ICH) in patients being treated with antiplatelet agents.1-4 In addition, an association between the severity of ICH as well as the conversion of a minor head trauma to an ICH secondary to the prehospital use of antiplatelet agents has yet to be determined. I was intrigued by this and evaluated a number of institutional protocols [...]
In the recently published guidelines for management of pain, agitation, and delirium (PAD) in adult ICU patients, several key changes to the way PAD is approached were discussed. Over the next few posts, I will go into depth into each one and tie in how we, in the ED, can help provide optimal PAD - another step towards the theory of "upstairs care, downstairs."But first, I wanted to point out the first three authors credited [...]
Let's say you have a male patient who presents to the emergency department with an abscess in the right axilla. The patient appears to be a relatively healthy gentleman with no significant past medical history (other than the heartburn that develops when he socially drinks on the weekends every now and then). He has not been hospitalized for any previous infection or recent surgery within the past year, and he denies the use of IV [...]
Let's say you have a male patient who presents to the emergency department with an abscess in the right axilla. The patient appears to be a relatively healthy gentleman with no significant past medical history (other than the heartburn that develops when he socially drinks on the weekends every now and then). He has not been hospitalized for any previous infection or recent surgery within the past year, and he denies the use of IV [...]