Suppose you have a patient in whom you highly suspect a pulmonary embolism (PE) that devolves into PEA arrest while awaiting a CT angiogram. Or, what about a patient with an ECG showing clear STEMI that loses pulses?
There was recently a great study published in the American Journal of Cardiology (2012) by Sharifi et al1, questioning whether we should be considering tPA in patients other than those patients with massive pulmonary embolism (PE)? You know the big “Saddle Embolus” we all fear? Well it turns out this is only about 5% of all PEs.
Should we be considering tPA in patients with sub-massive PEs?
Sometimes a question is posed on Twitter that generates a great discussion from colleagues ’round the globe. Such was the case for dexmedetomidine. Although benzodiazepines remain the standard of treatment for ethanol withdrawal, particularly seizures and delirium tremens, what’s all the hype about dexmedetomidine?
What is your approach to the poisoned patient? Listen to these 4 videos by Dr. Rahul Patwari to build your foundation of knowledge in toxicology.
You are managing an otherwise healthy patient with cellulitis but no abscess to poke. You decide this patient needs antibiotics but is stable enough to go home.
“Give em’ a dose of vanc before they go,” right?
The story of vancomycin all started when a missionary from Boreno sent a sample of dirt to a friend at Eli Lilly. The compound isolated had activity against most gram positive organisms. In fact, it got its name from the word ‘vanquish.’ Vancomycin was FDA-approved in 1958. [1]
Vancomycin is still a powerful tool against gram positive organisms, but there are some important learning points for using it properly in the critically ill ED patient.
There has been a lot of discussion on the ideal intravenous fluids (IVF) for resuscitation in the Emergency Department and ICU. This was highlighted by the landmark study in JAMA on ICU patients who received chloride-rich versus chloride-restricted IVFs. This got me to thinking, what exactly comprises the common IVFs that we order? We so often take for granted what’s in 1 liter of normal saline. As it turns out, normal saline is not really “normal”. Dr. Scott Weingart has a great podcast on “chloride poisoning” using IVFs.
This PV card helps remind me what’s in each liter bag of fluids we order (composition of intravenous fluids). At the bottom half of the card is a brief summary of the JAMA findings.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
After the posting of this PV card, there was intense discussion about why the D5W osmolarity was 252 mOsm/L instead of 272 mOsm/L, which is found on various medical calculators. See the discussion by Dr. Joel Topf.
@kidney_boy @M_Lin @BrianJL @PharmERToxGuy
Great story.
It's not what we know/don't know, it's what we don't know that we don't know.— David Y.T. Chen (@dytcmd) January 4, 2013
Has this JAMA study changed your approach to ED intravenous fluid management?
It sure has for me. After 2 liters of normal saline, I consider switching patients to a more chloride-restrictive fluid (we have Plasma-Lyte in our ED). Examples include patients with DKA, AKA, sepsis, and severe dehydration.