LET’S START WITH THE FACTS
Bleeding in general is bad. Bleeding while on anticoagulants is VERY bad. Dr. Rahul Patwari reviews the pathophysiology of coagulation, the various reversal agents, and treatment approaches we can use. In this five-part series where all videos are less than 10 minutes, Rahul goes from the basic physiology of coagulation all the way to the complex reasoning and approaches to reversing anticoagulants. These are worth a quick look and review.
You’re a recent graduate picking up an extra shift in a small ED somewhere north of here. At 3 AM an obese 47 year-old woman presents with shortness of breath and difficulty speaking after eating a Snickers bar an hour earlier. She admits to history of hypertension, peanut allergy, and a prior intubation for a similar presentation. She is becoming more obtunded in the resuscitation room as you are collecting your history. A glance at the monitor shows:
Acute uncomplicated cystitis is becoming more difficult to treat in the setting of increasing antimicrobial resistance. In the 2010 IDSA Guideline, as summarized in a PV Card on Cystitis and Pyelonephritis in Women, nitrofurantoin is now listed as the first-line choice, surpassing ciprofloxacin and sulfamethoxazole/trimethoprim from the previous iteration.
Propofol for the treatment of migraines in the ED might be on the horizon. This will possibly be a new practice in emergency medicine, although it has been known for some time. Propofol, when given at procedural sedation doses, seems to miraculously terminate migraines refractory to usual treatment. Patients awake with minimal to no headache and may be discharged from the ED much quicker than traditional treatment with possibly less side effects. The proposed mechanism of action is described in below papers, but in short, propofol seems to “reboot” the brain and terminate the migraine.
This Paucis Verbis (PV) card is an updated version of the PV card on Contraindications to Thrombolytics for CVA from September 10, 2010, based on the Stroke 2013 AHA/ASA new guidelines that were just published.1 Some changes include…
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
The CaseA 56 y/o man presents to the ED via ambulance. He was sent from clinic for ‘new onset afib.’ His pulse ranges between 130 and 175 bpm, while his blood pressure is holding steady at 106/58 mm Hg. He has a past medical history significant for hypertension and hypercholesterolemia. His only medications are hydrochlorothiazide and atorvastatin. The decision is made to administer an IV medication to ‘rate control’ the patient with a goal heart rate < 100 bpm.
Calcium channel blockers, such as diltiazem and verapamil, can both cause hypotension. In the case above, the patient has borderline hypotension.
What is the evidence behind giving IV calcium as a pre-treatment to prevent hypotension from calcium channel blockers?