QI Series: Pitfalls in Diagnosing Hyperkalemia

A 55 year old male was brought to the Emergency Department (ED) by paramedics complaining of weakness and chest discomfort. His past medical history was notable for coronary artery disease with bypass grafting, diabetes mellitus, and end stage renal disease. He reported being non-compliant with his last 2 scheduled hemodialysis sessions. Paramedics noted pallor and recorded a blood pressure of 80/palpated and a heart rate of 44. Upon arrival to the ED, a 12 lead ECG was obtained.

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By Steven Polevoi, MD|2016-11-11T19:17:44-08:00Dec 16, 2013|ECG, Endocrine-Metabolic|

Insulin Pumps: Understanding them and their complications

While the rate of diabetes climbs, the number of patients who are using insulin pumps grows apace. Pumps appeal to physicians because they mimic normal insulin physiology with a consistent basal rate and appropriate bolus doses for meals. This leads to tighter glucose control and smaller variations. For patients, the pumps can be liberating, requiring far fewer injections than a typical multi-dose regimen. Regardless of why your patient has an insulin pump, it helps to know about how they work… for when they don’t.

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By Josh Joseph, MD|2016-12-23T19:56:28-08:00Dec 11, 2013|Endocrine-Metabolic|

Mechanical CPR and the LINC trial

The first time I saw the Thumper performing CPR on a patient I thought “well, that makes sense.” Since then we have seen other devices, most notably the Zoll AutoPulse and the Physio-Control LUCAS. It was disappointing to many in 2005 when the AutoPulse trial was halted early due to harm. ¹ Although four-hour survival was similar between groups, the hospital discharge survival rate in the manual CPR group was 9.9% compared to 5.8% in the mechanical CPR group. Many hypotheses were proposed to explain the results, which included Hawthorne effect, prolonged device deployment time, and enrollment bias. Last month, the results of the LUCAS in Cardiac Arrest (LINC) trial were published in JAMA, breathing new life into the mechanical vs manual CPR debate. ²

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By Sean Kivlehan, MD MPH|2016-11-11T19:17:51-08:00Dec 10, 2013|Critical Care/ Resus, EMS, Expert Peer Reviewed (Clinical)|

Prehospital: Does QUICKER hypothermia equal BETTER hypothermia?

The short answer to this question is NO. Since the landmark post-arrest, therapeutic hypothermia studies published in 2002, ^1,2 extensive efforts have been made to ensure our post-arrest patients are cooled… and cooled fast. It only seemed logical to extend this revolutionary treatment into the field and have paramedics begin the cooling in the field. New EMS protocols were developed around the country to incorporate hypothermia into cardiac arrest management and well received by paramedics and EMTs. But a recent JAMA publication calls this now into question. ³

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By Sean Kivlehan, MD MPH|2016-12-23T19:38:30-08:00Dec 5, 2013|Critical Care/ Resus, EMS|

Bicarbonate: Completely Useless?

Intravenous sodium bicarbonate seems like a wonderful drug. It fixes acidosis, pushes potassium into cells, alkalinizes urine, and even helps with smelly feet. However, this literature review of four conditions casts some doubt into the seemingly cure-all that is bicarbonate.

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By Andrew Grock, MD|2016-11-11T19:17:46-08:00Dec 4, 2013|Endocrine-Metabolic, Expert Peer Reviewed (Clinical), Pulmonary, Renal|

Modified Sgarbossa Criteria: Ready for Primetime?

The recognition of ST-segment elevation myocardial infarction (STEMI) in the presence of left bundle-branch block (LBBB) remains difficult and frustrating to both emergency medicine physicians and cardiologists. According to the 2004 STEMI guidelines, emergent reperfusion therapy was recommended to patients with suspected ischemia and new LBBB however, the new 2013 STEMI guidelines made a drastic change by removing this recommendation. Several papers have recently been published discussing a modified Sgarbossa’s criteria and a new algorithm to help decrease false cath lab activation and/or fibrinolytic therapy, but are they ready for primetime? (more…)

By Salim Rezaie, MD|2016-11-11T19:17:42-08:00Dec 3, 2013|Cardiovascular, ECG|

Subsegmental Pulmonary Embolisms (SSPE) are Important

Multi-detector computed tomographic pulmonary angiography (CTPA) allows for better visualization of peripheral pulmonary arteries allowing for diagnosis of small peripheral emboli limited to the subsegmental pulmonary arteries. Interestingly as these SSPE’s get diagnosed more and more, two questions come to mind: