Author: Don Stader, MD
- 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.
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.
Author: Rachel Beham, PharmD
- 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.
Bruce C.V. Campbell B et al (2018). Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. New England Journal of Medicine. 378:1573-1582
Author: Dylan Luyten, MD
- 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.
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.
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Author: Nick Hatch, MD
- 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.
Matsue Y et al. Time-to-Furosemide Treatment and Mortality in Patients Hospitalized With Acute Heart Failure. JACC 2017. PMID: 28641794
Author: Nick Hatch, MD
- 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.
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.
Author: Rachel Beham, PharmD
- 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).
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
Author: Gretchen Hinson, M.D.
- 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.
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
Author: Nick Hatch, M.D.
- 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.
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
Author: Aaron Lessen, M.D.
- 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.
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.
Author: Peter Bakes, M.D.
- 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.