Podcast # 372: The Latest on Epinephrine in Cardiac Arrest

Author:  Don Stader, MD

Educational Pearls:

  • 8014 patients with out-of-hospital cardiac arrest randomized to epinephrine vs placebo
  • 30-day survival was not dramatically better between groups (3.2%in the epinephrine group and 2.4% in the placebo group)
  • Functional neurological outcome was nearly identical at 2.2% and 1.9% of patients
  • Adds to literature that epinephrine provides little important benefit in cardiac arrest – focus on chest compressions and early defibrillation

 

Editor’s note: NNT for epinephrine to prevent one death in this study was 115 – compared to bystander CPR (NNT 15) and defibrillation (NNT 5) from prior studies.

 

References

Perkins GD et. al. . A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest.    N Engl J Med. 2018 Aug 23;379(8):711-721. doi: 10.1056/NEJMoa1806842. Epub 2018 Jul 18.

Kitamura T, Kiyohara K, Sakai T, et al. Public-access defibrillation and out-of-hospital cardiac arrest in Japan. N Engl J Med 2016;375:1649-1659.

Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2015;372:2307-2315.

Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA. 2012 Mar 21;307(11):1161-8. doi: 10.1001/jama.2012.294. PubMed PMID: 22436956.

Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. JAMA Intern Med. 2015 Feb;175(2):196-204. doi: 10.1001/jamainternmed.2014.5420.

Podcast # 341: Tenecteplase vs. Alteplase

Author: Rachel Beham, PharmD

Educational Pearls:

  • Tenecteplase is more specific for fibrin and has a longer half-life than alteplase.
  • In setting of ischemic stroke, tenecteplase before thrombectomy was associated with a statistically higher incidence of reperfusion and better functional outcome than alteplase.

 

References

Bruce C.V. Campbell B et al (2018). Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. New England Journal of Medicine. 378:1573-1582

Podcast # 336: Hypokalemia

Author: Dylan Luyten, MD

Educational Pearls:

  • Most important questions to answer with low potassium are 1. What are their symptoms? 2. Can they take potassium by mouth?
  • Oral repletion is faster, cheaper, and more effective than IV repletion.
  • Give IV potassium when patients have K < 2.5 mmol/L or present with arrhythmias and/or characteristic EKG changes (flattened T waves).
  • Most patients who are hypokalemic are hypomagnesemic and require magnesium supplementation.  Checking a level is unnecessary.

References

Ashurst J, Sergent SR, Wagner BJ, Kim J. Evidence-based management of potassium disorders in the emergency department. Emerg Med Pract. 2016 Nov 22;18(Suppl Points & Pearls):S1-S2

 

Whang R, Flink EB, Dyckner T, et al. Magnesium depletion as a cause of refractory potassium repletion. Arch Intern Med 1985; 145:1686.

Check out this episode!

Podcast #332: Door To Furosemide Time

Author: Nick Hatch, MD

Educational Pearls:

  • Recent study argues that CHF patients receiving furosemide within 60 minutes of arrival had a lower in-hospital mortality than those receiving it after (2.3% vs. 6.0%, p=0.002).
  • A flaw in the study is that there were significant baseline differences between groups.

References:

Matsue Y et al. Time-to-Furosemide Treatment and Mortality in Patients Hospitalized With Acute Heart Failure. JACC 2017. PMID: 28641794

Podcast # 331: Oral Rehydration Therapy (ORT)

Author: Nick Hatch, MD

Educational Pearls:

  • The sodium-glucose cotransporter in the gut is essential for rehydration.
  • Oral rehydration therapies require an equimolar concentration of glucose and sodium to be effective.
  • ORT has saved millions of lives globally.
  • Consider using ORT in patients with dehydration. Especially useful in resource limited settings.

References:

Victora CG, Bryce J, Fontaine O, Monasch R. Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Organ. 2000; 78:1246.

Santillanes G, Rose E. Evaluation and Management of Dehydration in Children. Emerg Med Clin North Am. 2018. 36(2):259-273. doi: 10.1016/j.emc.2017.12.004.

Podcast #324: Superwarfarin

Author: Rachel Beham, PharmD

Educational Pearls:

  • Some synthetic cannabinoids have been contaminated with Brodifacoum. Brodifacoum is a Vitamin K antagonist and can present with a severe coagulopathy.
  • Brodifacoum is commonly known as “superwarfarin” and has a very long half life of 120+ days.
  • Check PT/INR in patients with a bleeding diathesis in setting of synthetic cannabinoid use.
  • Treatment is activated charcoal and large doses of Vitamin K (10mg Q6H for months).

References:

Lipton R.A.; Klass E.M. (1984). “Human ingestion of a ‘superwarfarin’ rodenticide resulting in a prolonged anticoagulant effect”. JAMA. 252: 3004?3005.

La Rosa F; Clarke S; Lefkowitz J. B. (1997). “Brodifacoum intoxication with marijuana smoking”. Archives of Pathology & Laboratory Medicine. 121: 67?69

Podcast #310: Bicarb in DKA

Author: Gretchen Hinson, M.D.

Educational Pearls:

  • Controversial topic.
  • Pathophysiology – acidosis leads to an extracellular potassium shift. Patients in DKA will be intracellularly potassium deplete, but will have a falsely normal/elevated serum potassium.
  • 3 risk of giving bicarb in DKA – alkalosis will drive potassium intracellularly but can overshoot (hypokalemia) and  increase risk of arrhythmias; bicarb slows clearance of ketones and will transiently increase their precursors; bicarb can cause elevated CSF acidosis.
  • 3 instances when appropriate to give bicarb in DKA: DKA in arrest; hyperkalemic in DKA with arrhythmia; fluid and vasopressor refractory hypotension.

References:

Bratton, S. L., & Krane, E. J. (1992). Diabetic Ketoacidosis: Pathophysiology, Management and Complications. Journal of Intensive Care Medicine, 7(4), 199-211. doi:10.1177/088506669200700407

Chua, H., Schneider, A., & Bellomo, R. (2011). Bicarbonate in diabetic ketoacidosis – a systematic review. Annals of Intensive Care, 1(1), 23. doi:10.1186/2110-5820-1-23

Podcast #306: Tramadol Drama

Author: Nick Hatch, M.D.

Educational Pearls

  • Tramadol acts at multiple receptors and is a partial agonist at the mu opioid receptor, but also blocks reuptake of serotonin and norepinephrine throughout the body among others.

 

  • One major side effect to be aware of is that it lowers the seizure threshold.
  • Useful in setting of pain control in patients with contraindications to NSAIDs who are poor opioid candidates.
  • Use with caution as it potential for abuse.

 

References

Hennies HH, Friderichs E, Schneider J (July 1988). “Receptor binding, analgesic and antitussive potency of tramadol and other selected opioids”. Arzneimittel-Forschung. 38 (7): 877?80.

“Tramadol Hydrochloride”. The American Society of Health-System Pharmacists. Retrieved Dec 1, 2014.

“Withdrawal syndrome and dependence: tramadol too”. Prescrire Int. 12 (65): 99?100. 2003

Podcast #305: Stuffers vs. Packers : Drug-Packet Ingestion

Author: Aaron Lessen, M.D.

Educational Pearls

  • A “stuffer” is a term for someone who hastily and conceals a bag of drugs orally/rectally/vaginally in an unplanned situation. A “packer” is someone who is planning to smuggle drugs, and does so in a similar manner.

 

  • “Stuffers”are more likely to have the drug container open up in their system, while packers tend to have more reliable containment, but typically have larger quantities on-board.
  • Be on look out for symptoms associated with the drug’s exposure (drug dependent) as well as mechanical symptoms (perforation; obstruction).
  • If suspicious, order CT as X-rays underestimate severity.
  • Management: treat symptoms of intoxication appropriately, observe if packets are intact, consider surgery/endoscopy if necessary.

 

References

Dueñas-Laita A, Nogué S, Burillo-Putze G (2004). “Body packing”. New England Journal of Medicine. 350 (12): 1260?1

Hergan K, Kofler K, Oser W (2004). “Drug smuggling by body packing: what radiologists should know about it”. Eur Radiology. 14 (4): 736?42.

Traub SJ, Hoffman RS, Nelson LS (2003). “Body packing?the internal concealment of illicit drugs”. New England Journal of Medicine. 349 (26): 2519?26.

Podcast #300: Probiotics

Author: Peter Bakes, M.D.

Educational Pearls

  • Probiotics are living bacteria that are taken as an oral supplement.
  • Most of the data to support their use is in the prevention of antibiotic-related diarrhea and the reduction of the symptoms of ulcerative colitis (UC).
  • Some studies have some a reduction of the incidence of antibiotic-related diarrhea in children of up to 12% with the use of probiotics.
  • There may be a reduction of up to 60% in the incidence of antibiotic-related C. diff infection in adults with probiotic use
  • Studies have shown a 10% or more reduction in the duration and severity of the symptoms of UC with probiotic use.
  • Proposed mechanisms of probiotics include a decrease in gut permeability and a decrease in pathogenic gut bacteria due to resource competition.

References: http://www.cochrane.org/CD006095/IBD_use-probiotics-prevent-clostridium-difficile-diarrhea-associated-antibiotic-use