Epinephrine Dosing for Anaphylaxis in Patients on Beta-Blockers

I love when complex medication questions come across my desk from folks like Drs. Amal Mattu, Rob Orman, Mike Winters, and Haney Mallemat (just to name a few). This week I received one from Dr. Scott Weingart that someone had sent to him. This paramedic was reviewing his anaphylaxis protocol with some new medics and providers. They asked a challenging question regarding a “pearl” they learned in which half-dose epinephrine should be administered in anaphylactic patients on beta-blockers. Patients on beta-blockers do have an increased risk for anaphylaxis, so there is a chance you’ll see a case just like this at some point.

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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2016-11-16T09:38:02-08:00Oct 29, 2013|Tox & Medications|

CPR: Hands-on or Hands-off Defibrillation?

Pauses in chest compressions are known to be detrimental to survival in cardiac arrest, so much so that the 2010 American Heart Association (AHA) emphasize high-quality compressions while minimizing interruptions. There have been some studies that now advocate for continuous chest compressions during a defibrillation shock. There have been substantial changes to external defibrillation technology including:

Biphasic shocks with real-time impedance monitoring to reduce peak voltages
Paddles being replaced by adhesive pre-gelled electrodes
Enhancement in ECG filtering permitting rhythm monitoring during chest compressions.

So the mantra of “hard and fast” may be true when it comes to CPR, but the real question now becomes, should we be continuing CPR during defibrillation?

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By Salim Rezaie, MD|2019-09-10T13:35:23-07:00Oct 28, 2013|Cardiovascular, Critical Care/ Resus, Expert Peer Reviewed (Clinical)|

Mechanical vs Manual CPR Chest Compressions

When talking about Out of Hospital Cardiac Arrest (OHCA) there are really only three things that make a true difference on outcomes (i.e. survival and neurologic function):

High quality, non-interrupted CPR
Early defibrillation
Therapeutic hypothermia

The quality of CPR is often under appreciated and performed incorrectly (too slow and/or not hard enough). With mechanical CPR, chest compressions are delivered uninterrupted and at a predefined depth and rate. In my own practice I have seen these devices being used more and more, but my questions is do these devices impact outcomes?

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By Salim Rezaie, MD|2019-09-10T13:35:31-07:00Oct 23, 2013|Cardiovascular, Critical Care/ Resus|

P-Video: Rule of 15 in anion gap metabolic acidosis

You have a patient with an anion gap of 30 and bicarbonate of 10 mEq/L. You also determine on VBG that the patient’s pCO2 is 25 mmHg. What trick of the trade can you use to quickly determine whether this low pCO2 is an appropriate compensation of the primary metabolic acidosis? Dr. Jeremy Faust and Dr. Corey Slovis explains the quick “Rule of 15”.

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By Michelle Lin, MD|2019-01-28T21:53:37-08:00Oct 22, 2013|Endocrine-Metabolic, Tricks of the Trade|

P-Video: Sources for pediatric and adult fevers

Dr. Jeremy Faust is back with another P-video, which stands for Paucis Videos (paucis means “few” or “brief” in Latin) much like the Paucis Verbis cards. These P-videos are short video-based educational pearls for the practicing physician with a focus on Emergency Medicine and Critical Care. Here Jeremy shares two mnemonics, LUCAS and FEBRILE, to help you remember the common causes for fevers in pediatric and adult patients, respectively.

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By Michelle Lin, MD|2019-01-28T21:53:48-08:00Oct 17, 2013|Infectious Disease, P-videos, Pediatrics|

Treating Ischemic Stroke with tPA in the ED: Time is Brain

Ischemic stroke is an emergent and devastating neurologic disorder, and is a leading cause of both death and disability in the United States. With each minute of brain ischemia, two million neurons are irreversibly damaged. Total ischemic time is linked to functional outcome, and therefore, the role of the Emergency Department is paramount in the management of these patients. Fibrinolytic therapy has become a mainstay of therapy for acute stroke, but guidelines for the use of tPA are dynamic, and often even controversial. When you identify someone with symptoms of stroke, what is your approach to determining if a patient should receive tPA?

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By Todd A. Seigel, MD|2016-11-11T19:04:15-08:00Oct 10, 2013|Critical Care/ Resus, Expert Peer Reviewed (Clinical), Neurology|

Acute Pulmonary Embolism: Size does matter and ECG can give us clues

Acute pulmonary embolism (PE) is a common condition that can be both severe and difficult to diagnose. Half of all acute PE cases are diagnosed in the emergency department, and acute PE follows acute coronary syndrome as the second most common cause of sudden unexpected death in outpatients. Also, right ventricular dysfunction is a consequence of massive/submassive acute pulmonary embolism and correlates with a poor prognosis and high mortality rate. Although an ECG lacks both sensitivity and specificity for acute PE, there are some clues that can help in determining the size of an acute PE.

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By Salim Rezaie, MD|2019-09-10T13:35:37-07:00Oct 8, 2013|Cardiovascular, ECG, Pulmonary|