Losing faith in evidence-based medicine: Etomidate and sepsis

MagnifyingGlass3dIn an era where evidence-based medicine is the goal, it is vitally important for practitioners to understand how to prioritize and interpret the onslaught of data coming at us.

This fact was driven home for me with a recent publication. Several weeks ago an article was published in Critical Care Medicine entitled “Etomidate is associated with mortality and adrenal insufficiency in sepsis: A meta-analysis.”

The point of this post is not to debate if etomidate should be used to intubate septic patients. Etomidate very well may kill people with sepsis. I just don’t know from the data currently available. Using this meta-analysis as an example, the goal is to point out two important areas where we could stand to sharpen our literature evaluation skills.

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Paucis Verbis: Does this adult patient need blood cultures?

Blood Cultures BottleDo you order blood cultures for all your ED patients with a fever? Obviously no. What’s your decision making process on ordering this test? There are really no findings or tests with high specificity (rules-IN bacteremia), except interestingly “shaking chills”. Notice almost all the criteria listed below approach a likelihood ratio (LR) of 1.0. Two prediction rules do exist, however, to help you virtually rule-OUT bacteremia:

  • SIRS
  • Shapiro prediction rule

The list of LRs also will be helpful to show learners in the ED that an isolated serum WBC number is useless risk-stratifier.

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2017-08-01T19:36:38-08:00

Trick of the Trade: Needlestick hotline 888-448-4911

NeedlstickGlove

You are a fourth-year medical student and super-excited to be doing your first supervised central line procedure on an actual patient. You have done so many central lines on mannequins and simulations. You feel ready. In your excitement, however, you stick yourself with the 22 gauge finder needle after you successfully get a flash-back of the patient’s venous blood.

After handing off the procedure to your senior resident, you go into a mild panic. Your patient is a known HIV patient with an unknown CD4 count and viral load. After taking off your gloves and washing your hands, you report this to the attending.

Should you start post-exposure prophylaxis medications for HIV? You remember that if post-exposure HIV medications are recommended, you should start it immediately and definitely within 2 hours of exposure.

It’s difficult to concentrate when faced with so many questions whirling in your mind.

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2019-01-28T22:38:19-08:00

Paucis Verbis: Does this DM leg ulcer have osteomyelitis?

DMfootulcerWe sometimes see diabetic patients in the ED for a worsening foot ulcer. Sometimes it’s the chief complaint. Other times, however, you just notice it on physical exam. So, be sure you examine the feet of your diabetic patients. Occasionally, you’ll be surprised by what you find.

Several questions come up with diabetic foot ulcers:

  • Is it a true diabetic foot ulcer, or is it an arterial or venous insufficiency ulcer?
  • Is there underlying osteomyelitis?
  • How can I best diagnostically work this foot ulcer up for osteomyelitis?
  • What is the Wagner grade of this ulcer? (I think it’d be Grade 2.)

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2017-08-01T23:30:55-08:00