Sunday, October 15, 2017

Management Strategies for Acute Atrial Fibrillation in the Emergency Department - Resident Journal Review

Authors: Eli Brown, MD; Allison Regan, MD; Kaycie Corburn, MD; Jacqueline Shibata, MD
Edited by: Jay Khadpe, MD, FAAEM; Michael C. Bond, MD, FAAEM
Originally Published: Common Sense September/October 2013

Atrial fibrillation (AF) and atrial flutter (AFL) are the most commonly occurring arrhythmias in the United States. Management strategies for AF and AFL emphasize ventricular rate control, cardioversion to normal sinus rhythm and long-term interventions such as anticoagulation to reduce the risk of stroke. In patients in whom cardioversion is an option, either pharmacological or electrical cardioversion may be considered. While there is a significant amount of literature comparing the effectiveness and safety of pharmacologic versus electrical cardioversion in acute AF, studies which analyze discharge rates and hospital length of stays are becoming more frequent due to concerns over rising healthcare costs and ED overcrowding. This review focuses on treatment strategies for patients presenting to the ED with acute atrial fibrillation; in particular, rate control versus cardioversion, options for cardioversion (chemical versus electrical) and the safety of these strategies when used in the ED.

Thursday, October 12, 2017

Preserving the Humanity of Our Patients and Fostering Our Own

Image Credit: Pixabay
Author: Leana S. Wen, MD MSc
2012-2013 AAEM/RSA President
Originally Published: Common Sense March/April 2013

We EPs know that life in the ED is fast-faced, extremely busy, and ever-challenging. When things get crazy, it becomes habit to see our patients as “the chest pain in room 6” or “the lac in the hallway.” We turn people with their amazing lives and fascinating stories into chief complaints and tiles on our electronic tracking board.

It’s a practice that’s easy to justify. After all, taking a long time with one patient can delay care for all the other people who are waiting to see us. However, the patient's story and the context of his illness are important to him — and critical to the care we render.

Sunday, October 8, 2017

Development in Clinical Toxicology: Use of Intralipid Emulsion and High-Dose Insulin Therapy

Authors: Allison Regan, MD; Eli Brown, MD; Jackie Shibata, MD; Kaycie Corburn, MD
Edited by: Jay Khadpe, MD FAAEM; Michael C. Bond, MD FAAEM

There are few antidotes in clinical toxicology, especially with regards to some of the most commonly used medications including calcium channel blockers, beta-blockers, and peripheral anesthetics. Morbidity and mortality rates are high and supportive care is often ineffective. Intralipid and high-dose insulin therapy are two exciting developments in clinical toxicology. This review of the literature explores the evidence behind these new treatment options for beta-blocker and calcium channel blocker toxicity, as well as anesthetic overdoses.

Engebretsen, K, et al. High-dose insulin therapy in beta-blocker and calcium-channel-blocker poisoning. Clinical Toxicology. 2011;49,277-283.

Beta-blocker and calcium channel blockers are common medications that can result in both intentional, and unintentional, overdoses. The high morbidity and mortality associated with these overdoses is largely secondary to cardiovascular toxicity. Recent data suggests that early use of high dose insulin (HDI) may be an effective treatment strategy for beta-blocker and calcium channel blocker poisonings.

Thursday, October 5, 2017

Resident Journal Review: Mechanical Ventilation in the Emergency Department

Image Credit: Flickr
Authors: Michael Allison, MD; Kami Hu, MD; David Bostick, MD MPH; Phil Magidson MD MPH; and Michael Scott, MD
Edited by: Michael C. Bond, MD FAAEM and Jay Khadpe, MD FAAEM

Originally Published: Common Sense March/April 2014

Patients with respiratory failure are commonly encountered in the emergency department (ED), and many of these patients progress to require endotracheal intubation and mechanical ventilation. Mechanical ventilation strategies were the focus on a recent Annals of Emergency Medicine Clinical Controversy.1,2 Since its publication, there have been a number of newer studies suggesting that perhaps ventilation with low tidal volume can improve outcomes for many ED patients with respiratory failure, not just those with the acute respiratory distress syndrome (ARDS). This “Resident Journal Review” goes through the pertinent recent literature on low tidal volume ventilation.

We begin with an investigation regarding the use of low tidal volume ventilation in the ED among patients with and without ARDS. The investigators found that low tidal volumes are infrequently used in both scenarios. The impact of this becomes clearer, as the following three articles note a variety of improvements in patients ventilated with lower tidal volumes. There is a suggestion that even a 1mL/kg difference from a lung-protective strategy can worsen clinical outcomes.

Sunday, October 1, 2017

Serious Bacterial Infections in the Febrile Infant

Image Credit: Pixabay
Authors: Kaycie Corburn, MD; Jacqueline Shibata, MD; Lee Grodin, MD; Raymond Beyda, MD
Edited by: Jay Khadpe, MD FAAEM; Michael C. Bond, MD FAAEM
Originally Published: Common Sense September/October 2015

Pediatric fever, especially in infants, is often a challenging and nerve-racking presentation to evaluate in the ED. The prevalence of serious bacterial infections (SBI) in young infants range from 8-20%.[1] There is no clear cut consensus on how to work-up these patients in the ED.[2] As a result, many infants are subjected to invasive, unnecessary, and costly procedures or needlessly treated with empiric antibiotics and hospitalizations. In this edition of the Resident Journal Review, we review the literature on this topic in an effort to give more clarity on how to approach the febrile infant.