The ACLS-recommended dosing strategy of 6 mg, 12 mg, and 12 mg for adenosine may not be appropriate in every situation. There are a few instances when lower or higher dosing should be considered.
Caveat: All recommendations are data-based, but many factors affect successful conversion of paroxysmal supraventricular tachycardia (PSVT) including proper line placement and administration technique.
I am in the process of creating a PV card on metacarpal fractures, divided into anatomical areas (base, shaft, neck, head), and am realizing that the EM and orthopedic literature don’t quite agree. Actually they are quite vague on whether reductions should occur in the ED vs orthopedics clinic in the next few days.
Subclavian central lines are commonly touted as the central line site least prone to infection and thrombosis. The problem is that they are traditionally performed without ultrasound guidance. They are done blindly because of the transducer’s difficulty in getting a good view with the clavicle in the way.
You decide to use ultrasonography to help you establish peripheral IV access for and obtain blood cultures from your patient. How can you ensure that you get a sterile sampling to avoid blood culture contamination? Do you need to open a full central-line ultrasound probe cover?
In 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.
Do you send some of your low-risk patients with pulmonary embolism home?
This is a controversial issue which warrants a look at risk stratification tools. The primary one used is the validated Pulmonary Embolism Severity Index (PESI) score. In Lancet 2011, the authors looked at whether PESI class I and II (low risk) patients could be managed safely as outpatients. It turns out in their study, regardless of whether their PESI class I and II patients were treated as outpatients and inpatients, all fared equally well from a complications standpoint (recurrent clot, bleeding from anticoagulation).
I like the validated PESI scoring system to risk-stratify patients as low vs high risk for complications. I, however, do caution people to look closely at the exclusion criteria for this study before applying this to all ED patients.
The exclusion filter was so strict that they likely have captured a very narrow and unrealistic scope of patients to be widely applicable. It makes sense from a research standpoint to have these criteria to achieve internal validity but the question is external validity. Two exclusion criteria that struck me as awfully strict were: (1) needing parenteral opioids or (2) active alcohol or drug abuse.
For me, this study alone seems not have enough external validity to decide about the decision to treat PE patients as inpatient vs outpatient. Although I think that ultimately some can be managed as outpatients, I’d like to see more studies.
See other ALiEM (PV) Cards.
1. Rapid acting systemic and coronary artery vasodilator with minimal effects on cardiac conductivity or inotropy. Well studied in pregnancy. Caution in patients with left ventricular failure, liver cirrhosis
Answer: Nicardipine
2. Predominantly dilates the venous system. Useful in patients with cardiac ischemia, pulmonary edema, or congestive heart failure. Caution in patients with right ventricular failure
Answer: Nitroglycerin
3. Drug of choice in eclampsia, pre-eclampsia, and aortic dissection. Contraindicated in patients with congestive heart failure and heart block
Answer: Labetalol
4. Decreases peripheral vascular resistance and increases collateral coronary blood flow in an uncontrolled and unpredictable manner and may result in serious complications. Drug of choice during pregnancy
Answer: Nifedipine
5. Direct arterial vasodilator that increases cardiac output and heart rate (Reflex response). Patient may develop lupus like syndrome. Not to be used as first line in the ED
Answer: Hydralyzine
6. Arterial vasodilator that delays atrioventricular conduction and has a negative inotropic effect
Answer: Verapamil
7. Rapid onset of effect after oral administration (30 mins) with little change in cardiac output or reflex tachycardia. Adverse effect may include cough, angioedema. Toxic during first trimester.
Answer: Captopril
8. Only for patients with subarachnoid hemorrhage. Not to be given IV only PO or NG tube
Answer: Nimodipine
9. The only parenteral angiotensin-converting enzyme inhibitor. May cause azotemia in older patients after MI
Answer: Enalapril
10. Oral or transdermal decreases peripheral vascular resistance. May cause sedation and bradycardia
Answer: Clonidine
11. Used in patients who are volume overloaded but not in patients who are hypertensive and volume depleted
Answer: Diuretics
12. Drug of choice for pheochromocytoma, MAOI crisis, and cocaine overdose
Answer: Phentolamine
Reference:
1. Richard S. Irwin, James M. Rippe. Manual of Intensive Care Medicine; 4th ed
2. Marx: Rosen’s Emergency Medicine, 7th ed (Chapter 82- Hypertension: Richard O. Gray)