REBEL Cast

Neutropenic fever poses serious risks, especially for chemotherapy patients. The podcast discusses its causes, emphasizing that the body's own flora can be the biggest threat. Quick administration of broad-spectrum antibiotics is crucial in reducing mortality. Additionally, management strategies such as initial resuscitation and collaboration with infection specialists are highlighted. The shift in infection prevalence from gram-negative to gram-positive is another important point, making vigilant monitoring essential.

Background: The holy grail of outcomes in OHCA is survival with good neurologic outcome.  The only interventions proven to increase this outcome are high quality CPR and defibrillation in shockable rhythms.  Ventilation is also an important component of resuscitation in OHCA.  Excess minute ventilation can adversely affect hemodynamics due to increased intrathoracic pressure (i.e. decreased venous return). Additionally, low CO2 levels from hyperventilation can lead to cerebral vasoconstriction which could lead to worsened secondary brain injury.       Most organizations recommend adults to be ventilated with tidal volumes of 500 to 600mL/breath during ongoing CPR.  Large adult BVMs can have maximum tidal volumes of ≈1500mL and deliver about 750mL per one handed ventilation.  Simulation studies have shown that health care professionals often provide minute ventilation well above these recommended ranges.       One of the recommendations from many experts to mitigate the perceived risk of large adult BVMs is using smaller adult BVMs.  This change would result in decreasing the maximum volume from 1500 to 1000mL and an expected delivered tidal volume from 750 to 450mL/breath  (much more inline with recommended ranges). However, evidence that this approach makes is difference is lacking. REBEL Cast 126: Should We Not Be Recommending Small Adult BVMs in OHCA? Click here for Direct Download of the Podcast Paper: Snyder BD et al. Association of Small Adult Ventilation Bags with Return of Spontaneous Circulation in Out of Hospital Cardiac Arrest. Resuscitation 2023. PMID: 37805062 Clinical Question: Is large adult BVM or small adult BVM associated with more ROSC in adult patients treated with advanced airway placement for nontraumatic OHCA? What They Did: Retrospective, observational cohort analysis of prospectively obtained data from a single urban EMS system Evaluating adults treated with advanced airway placement for nontraumatic OHCA Jan 2015 to Dec 2021 Changed from large adult BVMs to small adult BVMs in summer of 2017 (3 month crossover period was allowed and excluded from analysis) Used a Mercury medical CPR-2 small ventilation bag Compared rates of ROSC, ventilation rate, and mean end tidal carbon dioxide (ETCO2) by minute before and after small adult BVM implementation Outcomes: Primary: ROSC at the end of EMS care (i.e. Arrival to ED or terminated efforts in the field) Secondary: Ventilation rate Mean end-tidal CO2 (ETCO2) during CPR Inclusion: Adult patients with nontraumatic OHCA Treated with an advanced airway (i.e. Endotracheal intubation or iGel) Exclusion: Age <18 years Received basic life support only Termination of resuscitation due to advanced directives ALS interventions prior to EMS arrival Insufficient capnography data Cricothyrotomy Advanced airway placed while patient had spontaneous circulation Airway was managed with BVM only Did not receive CPR while under EMS ALS care Results: 1994 Patients included in analysis 1331 (67%) treated with small adult BVM 663 (33%) treated with large adult BVM 21% had an initial shockable rhythm ROSC Small Adult BVM: 33% Large Adult BVM: 40% uOR 0.74; 95% CI 0.61 to 0.90; P = 0.003 After adjustment for age, sex, witnessed arrest, bystander CPR, and initial rhythm this finding remained statistically significant (aOR 0.74; 95% CI 0.61 to 0.91) Ventilation rates did not differ between cohorts (≈12BPM) ETCO2 Small Adult BVM: 36.9 +/- 19.2mmHg Large Adult BVM: 33.2 +/- 17.2mmHg P <0.01 Strengths: Written records are compared to cardiac monitor files and audio recordings to adjudicate differences before integrating information into the registry Intubations confirmed with ETCO2 Took into account the COVID-19 pandemic time period Also took into account the potential for trends over time by visualizing the incidence of ROSC by month over a seven year period and found no significant change in the slope before and after the implementation of the small adult BVM Limitations: Only included patients that were intubated with an endotracheal tube or iGel (these results may not apply in patients without these devices) There were some confounding baseline differences (explained more in discussion) Unclear what other interventions were performed in terms of ACLS medications or what the specific causes of the cardiac arrest were from This was a before and after study not allowing for a control group. Before and after studies can introduce numerous biases particularly if other pieces of care changed between the two time periods. (Can also go in the discussion) The actual tidal volume delivered was not measured in this trial and therefore the delivered minute ventilation is unknown As this is a retrospective study, we can only show association, BUT NOT causation of the size of the adult BVM affecting ROSC outcomes Discussion: There are some key BASELINE DIFFERENCES that could account for the results of this trial (i.e. confounders): More patients in the small adult BVM cohort received bystander CPR (64% vs 59%). This would favor more ROSC in the small adult BVM cohort Unwitnessed arrest was slightly greater in the large adult BVM cohort (58% vs 53%)…This would favor more ROSC in the small adult BVM cohort Fewer patients in the small adult BVM cohort arrested in public (22% vs 27%…Unclear how this would impact ROSC The interval from 911 call to start of CPR (10 vs 9min) and advanced airway placement (20 vs 18min) were longer in the small adult BVM cohort…Not sure 1 to 2min of difference would result in more ROSC in the large adult BVM cohort Adherence to guideline recommended ventilation rates of 10 BPM was more common in the small adult BVM cohort (28.4% vs 31.2%)…This would favor more ROSC in the small adult BVM cohort It would appear most things at baseline favored the small adult BVM cohort (Although the authors did account for most of these in adjusted analyses) The end of this trial took place during the COVID-19 PANDEMIC: Anyone who took care of cardiac arrest patients during the COVID-19 pandemic knows that there were significant delays in care According to the authors any cases of OHCA that occurred after the start of the pandemic (Feb 2020) were censored from the analysis and the results were evaluated again When looking at cases of OHCA that occurred prior to Feb 2020 the small adult BVM cohort had a similarly lower odds of ROSC (OR 0.75; 95% CI 0.60 to 0.93; p = 0.008) as the entire time period this intervention was implemented This remained the case even after adjusting for initial rhythm, age, sex, witnessed arrest and bystander CPR (aOR 0.76; 95% CI 0.61 to 0.95; p = 0.018) While I would imagine during a code most people are bagging faster than 10BPM, in this study 6 to 18 BPM were delivered in 82.5% of the measured ventilations. Is this a result of Hawthorne effect or the implementation of a metronome to guide chest compression and ventilation rates (implemented June of 2015) or simply a well trained EMS system? This addition would seem to favor the small adult BVM group This EMS organization appears to be very high functioning with lots of training and education which may not be the standard at other agencies. The fact that the medics are providing a good RR and good TV throughout a 7-year period would suggest this and in doing so a simple change from a large adult BVM to a small adult BVM may have resulted in the association of lower ROSC whereas an agency that does not get as much training or high functioning may actually still be causing harm with the large adult BVM Finally, there was a higher ETCO2 in the small adult BVM cohort compared to the large adult BVM cohort. As ventilatory rate was essentially similar between groups, this most likely means a smaller tidal volume was delivered with each breath.  This smaller tidal volume could have lead to physiologic changes that are potentially harmful: Hypoventilation Increased dead space fraction Alveolar decruitment Atelectasis causing shunt physiology Author Conclusion: “Use of small adult bag during OHCA was associated with lower odds of ROSC at the end of EMS care.  The effects on acid base status, hemodynamics, and delivered minute ventilation remain unclear and warrant additional study.” Clinical Take Home Point: This is a really messy trial, with lots of methodological and confounding issues that make it difficult to interpret.  It does show that when experts recommend an intervention it is important to study it.  Until better evidence shows us differently it is probably best to stick with a large adult BVM but use one hand for bagging and maintain a rate of 10BPM. References: Snyder BD et al. Association of Small Adult Ventilation Bags with Return of Spontaneous Circulation in Out of Hospital Cardiac Arrest. Resuscitation 2023. PMID: 37805062 Post Peer Reviewed By: Anand Swaminathan, MD (Twitter/X: @EMSwami) The post REBEL Cast Ep126: Should We Not Be Recommending Small Adult BVMs in OHCA? appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points Acute rhinosinusitis is a clinical diagnosis The vast majority of acute rhinosinusitis cases are viral in nature and do not require antibiotics Consider the use of antibiotics in select groups with severe disease or worsening symptoms after initial improvement. REBEL Core Cast 121.0 – Acute Sinusitis Click here for Direct Download of the Podcast. Definition: Acute rhinosinusitis (ARS) – Symptoms for less than four weeks Subacute rhinosinusitis – Symptoms for 4 to 12 weeks Chronic rhinosinusitis – Symptoms persisting greater than 12 weeks Recurrent acute rhinosinusitis – Four or more episodes of ARS per year, with interim symptom resolution Epidemiology: (Anon 2004) 20 million cases of sinusitis annually in the US, costing $3.5 billion/year Source of 1 in 5 antibiotic prescriptions for adults Presentation: Sinusitis is most commonly diagnosed by clinical symptoms Common symptoms Purulent nasal discharge Nasal congestion Facial pain or pressure, especially over a sinus or unilaterally Anosmia Hyposmia Fever Cough Fatigue Maxillary pain Ear pressure or fullness. Classification of Sinusitis: ●Acute viral rhinosinusitis (AVRS) ARS with viral etiology (i.e. rhinovirus, influenza, and parainfluenza) Most common form of ARS ●Uncomplicated acute bacterial rhinosinusitis (ABRS) ARS with a bacterial etiology without clinical evidence of extension outside the paranasal sinuses and nasal cavity Bacterial superinfection: 0.5-2% of all ARS ●Complicated acute bacterial rhinosinusitis ARS with bacterial etiology with clinical evidence of extension outside the paranasal sinuses and nasal cavity Sinusitis: Viral vs. Bacterial: Color change in sputum does not determine whether infection is viral or bacterial Viral infections Tend to begin resolution by 7-10 days Rarely have associated fevers If fever present, usually only in the first 48 hours. Guidelines for diagnosing ABRS are Presence of URI/cold symptoms that Don’t improve after 10 days Worsen after 5-7 days of improvement Severe symptoms including high fever, purulent discharge or facial pain for 3-4 days The Data Behind Antibiotic Use Clinically diagnosed acute sinusitis Multiple studies show the same cure rate at 7 days, but improved cure rate at 7-14 days for those who use antibiotics (Lemiengre 2012, Berg 1986, Gwaltney 1996) Overall Treatment Effect NNT = 18 Overall Harm NNH = 8 (mostly GI side effects) Radiographically-diagnosed acute sinusitis (Ahovuo-Saloranta 2008) Endpoint: clinical cure at 7-15 days NNT = 15 NNH = 8 IDSA Recommendations for Antibiotic Treatment (Chow 2012) Patients that should be treated Persistent symptoms w/o improvement (> 10 days) Severe symptoms (> 3-4 days) Worsening (“double-sickening”) (> 3-4 days) Antimicrobials 1st Line Amoxicillin 875 mg PO BID X 5-7 days Doxycycline 100 mg PO BID X 5-7 days 2nd Line Amoxicillin/Calvulanate 875/125 mg PO BID X 5-7 days Levofloxacin 500 mg PO Q24 X 5 days Bottom Line: Given the risk for adverse events associated with antibiotic use, the growing specter of resistance and the lack of significant differences in outcomes with antibiotic use, it is better to avoid antibiotics in most patients with ARS. Antibiotics should be considered in those with severe disease and in immunocompromised patients Take Home Points Acute rhinosinusitis is a clinical diagnosis The vast majority of acute rhinosinusitis cases are viral in nature and do not require antibiotics Consider the use of antibiotics in select groups with severe disease or worsening symptoms after initial improvement. References Anon JB et al. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2004; 130(Suppl 1): 1-45. PMID: 14726904 Lemiengre MB et al. Antibiotics for Clinically Diagnosed Acute Rhinosinusitis in Adults. Cochrane Database Syst Rev 2012. PMID: 23076918 Berg O et al. Occurence of asymptomatic sinusitis in common cold and other acute ENT-infections. Rhinology 1986; 24(3): 223-5. PMID: 3775189 Gwaltney JM. Acute community-aquired sinusitis. Clin Infect Dis 1996; 23(6): 1209-23. PMID: 8953061 Ahovuo-Saloranta A et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev 2008. PMID: 18425861 Chow AW et al. IDSA Clinical practice guideline for acute bacterial rhino sinusitis in children and adults. Clin Infect Dis 2012; 54(8): e72-e112. PMID: 22438350 Read More The NNT.com: Antibiotics for Clinically Diagnosed Acute Sinusitis in Adults The NNT.com: Antibiotics for Radiologically-Diagnosed Acute Maxillary Sinusitis Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie) The post REBEL Core Cast 121.0 – Acute Sinusitis appeared first on REBEL EM - Emergency Medicine Blog.

Podcast Direct Download: Link Release Date: April 16th, 2024 Show Notes The Visible Voices Podcast Dr. Glaucomflecken: Power of Ultrasound with Emergency Medicine Dr. Resa Lewiss Adaira I Landry MD Resa E Lewiss MD is a Professor of Emergency Medicine at the University of Alabama at Birmingham. A TEDMED speaker and TimesUp Healthcare founder, she’s an internationally renowned point-of-care ultrasound educator and champion for diverse, equitable, and inclusive workplaces. She attended college at Brown, medical school at Penn, Emergency Medicine residency at Harvard, and fellowship at Mount Sinai St. Luke’s Roosevelt.  She led point-of-care ultrasound sections at St. Luke’s Roosevelt, the University of Colorado, and Thomas Jefferson. A physician healthcare design consultant for Perkins&Will, her design focus has been ultrasound hardware and workflows. She’s helped to redesign the built environment of a Harvard ICU and an infectious diseases unit in Malawi. As host and founder of the Visible Voices Podcast, she’s interviewed dozens of subject matter experts in healthcare, equity, and current trends. Her writings are published in the popular press and scientific journals, such as Harvard Business Review, Slate, Nature, and Fast Company. Her new book, MicroSkills : Small Actions, Big Impact is forthcoming from HarperCollins in 2024. Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie) The post REBEL EM Book Club – MicroSkills appeared first on REBEL EM - Emergency Medicine Blog.

Dr. Dara Kass, an emergency medicine physician and former Regional Director for the U.S. Department of Health and Human Services, is joined by Dr. Monica Saxena, an assistant professor at Stanford and advocate for reproductive justice. They delve into how the Emergency Medical Treatment and Labor Act (EMTALA) shapes access to reproductive health services. The discussion highlights the legal challenges post-Dobbs v. Jackson, the tension between state laws and federal protections, and the critical need for greater awareness of patient rights and physician advocacy.

Background: The mainstay of treatment for symptomatic pulmonary embolism  (PE) is anticoagulation (AC).  Patients with higher-risk PE may require advanced interventions such as thrombolytic therapy, surgical thrombectomy, or even extracorporeal membrane oxygenation (ECMO). Because of its short half-life and availability of a reversal agent, unfractionated heparin (UFH) is commonly used when percutaneous or surgical interventions are being considered. The standard weight based dosing of UFH is 80U/kg bolus followed by an infusion started at 18U/kg/hr, titrated to a target activated partial thromboplastin time (aPTT) of 1.5 to 2.5x the control range or an anti-Xa level of 0.3 to 0.7u/mL. The efficacy of UFH in reaching and maintaining appropriate anticoagulation is poorly understood. REBEL Cast 125: 1st 48 Hours of PE Management – How Good is Unfractionated Heparin? Click here for Direct Download of the Podcast Paper: Prucnal CK et al. Analysis of Partial Thromboplastin Times in Patients With Pulmonary Embolism During the First 48 Hours of Anticoagulation With Unfractionated Heparin. Acad Emerg Med 2020. PMID: 31625654 Clinical Question: How effective is UFH in obtaining appropriate anticoagulation during the first 48 hours of administration to patients with acute PE? What They Did: Retrospective analysis of a PE response team (PERT) data base Single, large, urban academic teaching hospital (Massachusetts General Hospital) October 2012 to April 2017 2 Standard Dosing Regimens Evaluated Bolus + Drip (Low Risk of Bleeding): 80U/kg + Continuous titrated infusion starting at 18U/kg/hr Drip Only (Higher Risk of Bleeding): Continuous titrated infusion starting at 18U/hr Subsequent aPTT (seconds) and Rate Changes <40: +3U/kg/hr 40 – 49.9: +2U/kg/hr 50 – 49.9 +1U/kg/hr 60 to 80: No change 1 to 100: -2U/kg/hr >100: Hold for 60minutes then -3U/kg/hr Outcomes: Proportion of patients with a therapeutic aPTT value during each 6 hour time period A therapeutic aPTT was defined as a value of 60 to 80seconds A therapeutic Anti-Xa level was defined as a value of 0.3 to 0.7u/mL Inclusion: Adult patients Acute PE PERT team consulted Received anticoagulation with UFH according to guideline standard dosing Exclusion: Patients treated with nonstandard dosing regimens Results: 505 patients met inclusion criteria PE Severity Saddle: 17.4% Rt Heart Strain on CT: 46.9% Hemodynamic Collapse: 7.9% Massive PE: 28.3% Right Heart Strain on Echo: 21.4% Elevated Troponin Level: 55.3% Interventions Received: Systemic thrombolysis: 4.0% Catheter-Based Intervention: 5.9% Surgical Thrombectomy: 2.0% ECMO: 1.4% IVC Filter: 5.0% 30d Outcome: Mortality: 5.7% Re-Thrombosis: 3.9% Bleeding: 3.0% Therapeutic aPTT in patients receiving bolus and infusion of UFH At 6hrs: 13.9% (10.2 to 18.5%) At 12hrs: 19% (14.2 to 25.0%) At 24hrs: 26.3% (25.3 to 33.1%) At 36hrs: 28.3% (22.0 to 35.4%) At 48hrs: 28.4% (20.8 to 37.5%) Therapeutic aPTT in patients receiving infusion only of UFH At 6hrs: 14.5% (9.5 to 21.5%) At 12hrs: 23.3% (15.2 to 32.3%) At 24hrs: 41.4% (31.6 to 51.9%) At 36hrs: 37.0% (26.8 to 48.5%) At 48hrs: 42.1% (30.2 to 55.0%) No patients had all therapeutic aPTT values Strengths: Asks a clinically important question Study was stratified for patients being treated with bolus plus titrated infusion or titrated infusion only Used UFH standard dosing strategies used by most physicians Performed a sensitivity analysis that excluded all patients treated with systemic or catheter-directed thrombolysis, surgical embolectomy, or ECMO Limitations: Initiation of AC was defined as the order start time for UFH in the electronic medical record. There could have been delays in actually starting the UFH No real details on chart extraction methodology (i.e. how they handled incomplete or conflicting data) Only one abstractor where there is no assessment of the abstractors performance or comparison to another abstractor Unclear why one strategy was chosen over another Selection bias: Only patients consulted by PERT For patients with more than one aPTT value in a given 6 hour time period, the first therapeutic value was selected for analysis. If there was no therapeutic value, the first aPTT value reported was used Single center study meaning local factors may limit generalizability to other institutions Time outside therapeutic aPTT is not all equal. An aPTT that is slightly above or below the reference range would be considered outside the range (i.e. values close to the therapeutic cutoff were considered equivalent to those far from the cut-off range) This study does not determine whether time spent in the therapeutic range affects morbidity and mortality (Very low mortality rate = 6%) Discussion: Only a minority of patients in whom the PERT team was consulted treated with UFH using standard dosing had a therapeutic aPTT during the first 48 hours of anticoagulation with the majority of patients being subtherapeutic The proportion of patients in therapeutic range was lowest at 6 hours (14%) and highest at 42 hours (35%) Approximately 40% of patients failed to reach the therapeutic range in the first 48 hours of AC It wasn’t until 36 hours after the initiation of UFH that >50% of patients had at least one therapeutic aPTT There were no patients who had all aPTT values within the therapeutic range during the first 48hours of UFH therapy Something to Think About: Thrombus burden can be substantial and heparin resistance may be present, so standard dosing may be inadequate in these patients My Opinion: LMWHs offer several advantages over unfractionated heparin including a longer half-life, increased bioavailability, and a more predictable dose response. In addition, LMWHs are dosed by weight, administered subcutaneously, and usually do not require dose adjustments or laboratory monitoring. Whereas unfractionated heparin is largely hepatically cleared, LMWHs are renally cleared In 2017 [2], there was a Cochrane review that compared LMWH to UFH for the initial treatment of VTE. This included 29 RCTs with over 10,000 patients. The authors concluded that with moderate quality of evidence fixed dose LMWH reduced the incidence of recurrent thrombotic complications and occurrence of major hemorrhage during initial treatment with no difference in overall mortality compared to UFH The 2019 European Society of Cardiology [3] also states: “LMWH and fondaparinux are preferred over UFH for initial anticoagulation in PE, as they carry a lower risk of inducing major bleeding and heparin-induced thrombocytopenia. Neither LMWH nor fondaparinux need routine monitoring of anti-Xa levels. Use of UFH is nowadays largely restricted to patients with overt hemodynamic instability or imminent hemodynamic decompensation in whom primary reperfusion treatment will be necessary.  UFH is also recommended for patients with serious renal impairment [creatinine clearance ≤30mL/min] or severe obesity.  If LMWH is prescribed in patients with CrCl 15 – 30mL/min, an adapted dosing scheme should be used.” Author Conclusion: “The majority of patients with acute PE spend most of their first 48 hours outside of the therapeutic range of AC when treated with guideline standard dosing of UFH.  Over half of the patients fail to achieve any therapeutic PTT level within 24 hours of UFH initiation, and no patient had all therapeutic aPTTs.  Future research should focus on identifying factors associated with achieving therapeutic AC with UFH.” Clinical Take Home Point: In this single center study of PERT team consulted PE patients standard dosing of UFH left most patients with a subtherapeutic aPTT level in the first 48 hours of treatment.  Either we need to question the dosing regimen we use for UFH or we should consider switching to LMWH in the initial treatment of PE patients. References: Prucnal CK et al. Analysis of Partial Thromboplastin Times in Patients With Pulmonary Embolism During the First 48 Hours of Anticoagulation With Unfractionated Heparin. Acad Emerg Med 2020. PMID: 31625654 Robertson L et al. Fixed Dose Subcutaneous Low Molecular Weight Heparins Versus Adjusted Dose Unfractionated Heparin for the Initial Treatment of Venous Thromboembolism. Cochrane Database Syst Rev 2017. PMID: 28182249 Post Peer Reviewed By: Anand Swaminathan, MD (Twitter/X: @EMSwami) The post REBEL Cast Ep125: 1st 48 Hours of PE Management – How Good Is Unfractionated Heparin? appeared first on REBEL EM - Emergency Medicine Blog.

Background: Nitrates can help improve symptoms and ischemia in the setting of acute myocardial infarction. Current teaching holds that nitrates should be avoided in patients with potential right ventricular myocardial infarction (RVMI), due to the risk of decreasing preload and precipitating hypotension. This belief is based on a single 1989 study of 40 patients with RVMI and endorsed by both the AHA and ESC guidelines [2]. In that 1989 study, of the 40 patients with RV infarction 20 had a decrease in blood pressure of ≥30mmHg and associated symptoms after the administration of nitrates (SL, Oral, Transdermal, or IV) and 20 did not. The conclusion of this paper was that inferior AMI with RV involvement has a strong association with hypotensive response to nitrates. The major issue is the study is limited by the fact that we are given no information on dosage and multiple routes of administration making clinical application difficult. Better data is needed to guide management. REBEL Cast 124: Nitrates in Right Sided MIs? Click here for Direct Download of the Podcast Paper: Wilkinson-Stokes M et al. Adverse Events From Nitrate Administration During Right Ventricular Myocardial Infarction: A Systematic Review and Meta-Analysis. Emerg Med J 2023. PMID: 36180168 Clinical Question: Is giving nitrates to patients with right ventricular myocardial infarction (RVMI) associated with increased adverse events compared with nitrate administration to patients with myocardial infarctions in other regions of the heart? What They Did:  A systematic review and meta-analysis Exposure of interest: administration of nitrates, via any route and dose Outcomes: Primary: All forms of adverse events reported in the included studies (Hypotension, Bradycardia, AMS, Syncope, Cardiac Arrest) Inclusion: Patients diagnosed with AMI with a subset of the sample with RV myocardial infarction Experimental and analytical observational study designs Studies only published in English Exclusion: Patients with coronary vasospasm Results: 5 studies included in the analysis Only 2 observational studies using SL NTG 400mcg were used for the meta-analysis Adverse Events (Hypotension, Bradycardia, AMS, Syncope, Cardiac Arrest) RVMI: 18/105 (17.1%) Other MIs: 83/945 (8.8%) RR 1.31 (95% CI 0.81 to 2.12) No patients had cardiac arrest or death Strengths: Asks a clinically important question Searched 6 different databases for relevant papers All included studies underwent quality assessment using standard appraisal tools If data was missing corresponding authors were contacted for the missing information Limitations: None of the included studies were RCTs All studies samples were of combined inferior and RVMI making it difficult to determine the safety of nitrates during isolated RVMI One of the included studies was only an abstract Studies defined hypotension in different ways which could alter frequency of adverse events Discussion: Overall this review provides low certainty evidence that there is no statistically significant difference in the rate of adverse events when nitrates are administered to RVMI compared with other cardiac region MIs. Hypotension is the primary adverse event reported.  Nitrates have a serum half-life of 1 to 4 minutes and therefore hypotension is likely to be transient in nature Transient hypotension is not really clinically meaningful, especially since it can be treated with cessation of nitrates and fluid challenges Author Conclusion: “This review suggests that the AHA and ESC contraindications are not supported by evidence. Key limitations include all studies having concomitant inferior and RVMI, not evaluating beneficial effects and very low certainty of evidence. As adverse events are transient and easily managed, nitrates are a reasonable treatment modality to consider during RVMI on current evidence.” Clinical Take Home Point: From a clinical perspective, the potential benefit of analgesia and reduced sympathetic stimulation in the setting of RVMI seems to outweigh the potential of transient hypotension with the use of nitrates.  Although better studies are needed, this systematic review and meta-analysis argues against a contraindication against nitrates in the setting of RVMI and maybe one of precaution. References: Wilkinson-Stokes M et al. Adverse Events From Nitrate Administration During Right Ventricular Myocardial Infarction: A Systematic Review and Meta-Analysis. Emerg Med J 2023. PMID: 36180168 Ferguson JJ et al. Significance of Nitroglycerin-Induced Hypotension with Inferior Wall Acute Myocardial Infarction. Am J Cardiol 1989. PMID: 2502902 Neumar RW et al. Part 1. Executive Summary: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015. PMID: 26472989 Ibanez B et al. 2017 ESC Guidelines for the Management of Acute Myocardial Infarction in Patients Presenting with ST-Segment Elevation. Eur Heart J 2018. PMID: 28886621 For More Thoughts on This Topic Checkout: REBEL EM: The Death of MONA in ACS – Part III – Nitroglycerin Post Peer Reviewed By: Anand Swaminathan, MD (Twitter/X: @EMSwami) The post REBEL Cast Ep124: Nitrates in Right Sided MIs? appeared first on REBEL EM - Emergency Medicine Blog.

REBEL Core Cast 119.0 – Sleep Hygiene Click here for Direct Download of the Podcast Employ sleep strategies: Anchor sleep: a period of sleep that overlaps each day regardless of your night shift schedule to provide a guidepost for your body clock. Ideally would overlap with when you would normally be asleep if you were not on night shift.  Split sleep: sleep 3-4 hours immediately after shift then another 3-4 hours immediately before shift Melatonin timing/dosing: Most sleep specialists recommend 1-3 mg 30 minutes before desired onset of sleep Align timing to bolster your circadian rhythm, not fight it Caffeine:  Limit intake 4-8 hours before bed and no more than 400 mg a day  Diet:  Choose healthy foods and snacks and consume them in patterns that align with your normal day-night cycle (i.e. eat dinner before your night shift and eat breakfast afterwards)  Residency/hospital leadership should consider having healthy low-cost/free food options available for residency and staff, particularly on night shifts Don’t drive sleepy:  Practice recognizing signs of sleep deprivation (yawning, drifting lanes, falling asleep at signout or at red lights) and do not drive home if present Residency/hospital leadership should provide a comfortable place for residents/faculty to sleep and/or provide rideshare options to safely get home when signs of sleep deprivation are recognized References Sleep strategies: Minors DS, Waterhouse JM. Does ‘anchor sleep’ entrain circadian rhythms? Evidence from constant routine studies. J Physiol. 1983 Dec;345:451-67. doi: 10.1113/jphysiol.1983.sp014988. PMID: 6663508; PMCID: PMC1193807. Crowley SJ, Lee C, Tseng CY, Fogg LF, Eastman CI. Complete or partial circadian re-entrainment improves performance, alertness, and mood during night-shift work. Sleep. 2004 Sep 15;27(6):1077-87. doi: 10.1093/sleep/27.6.1077. PMID: 15532201. Melatonin Farahmand S, et al. Comparison of exogenous melatonin versus placebo on sleep efficiency in emergency medicine residents working night shifts: A randomized trial. World J Emerg Med. 2018;9(4):282-287. doi: 10.5847/wjem.j.1920-8642.2018.04.008. PMID: 30181797; PMCID: PMC6117540. Morgenthaler TI et al; Standards of Practice Committee of the American Academy of Sleep Medicine. Practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders. An American Academy of Sleep Medicine report. Sleep. 2007 Nov;30(11):1445-59. doi: 10.1093/sleep/30.11.1445. Erratum in: Sleep. 2008 Jul 1;31(7):table of contents. PMID: 18041479; PMCID: PMC2082098. Caffeine Walsh JK, Muehlbach MJ, Schweitzer PK. Hypnotics and caffeine as countermeasures for shift work related sleepiness and sleep disturbance. J Sleep Res. 2009;4;80-83. Nehlig A. Interindividual Differences in Caffeine Metabolism and Factors Driving Caffeine Consumption. Pharmacol Rev. 2018;70(2):384-411. doi:10.1124/pr.117.014407 U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. Available at DietaryGuidelines.gov. Stephanie Centofanti, Siobhan Banks, Scott Coussens, Darren Gray, Emily Munro, Johnathon Nielsen & Jillian Dorrian (2020) A pilot study investigating the impact of a caffeine-nap on alertness during a simulated night shift, Chronobiology International, 37:9-10, 1469-1473, DOI: 10.1080/07420528.2020.1804922. Diet Lowden A, Holmbäck U, Åkerstedt T, Forslund J, Lennernäs M, Forslund A [2004]. Performance and sleepiness during a 24 h wake in constant conditions are affected by diet. Biol Psychol 65(3):251–263. Anderson C, Horne JA [2006]. A high sugar content, low caffeine drink does not alleviate sleepiness but may worsen it. Hum Psychopharmacol 21(5):299–303. Driving Sleepy Barger LK, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med. 2005;352(2):125-34. Green W, Gao X, Li K, et al. The Association of Sleep Hygiene and Drowsiness with Adverse Driving Events in Emergency Medicine Residents. West J Emerg Med. 2020;21(6):219-224. Published 2020 Oct 27. doi:10.5811/westjem.2020.8.47357 Steele MT, Ma OJ, Watson WA, Thomas HA Jr, Muelleman RL. The occupational risk of motor vehicle collisions for emergency medicine residents. Acad Emerg Med. 1999 Oct;6(10):1050-3. doi: 10.1111/j.1553-2712.1999.tb01191.x. PMID: 10530665. Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie) The post REBEL Core Cast 119.0 – Sleep Hygiene appeared first on REBEL EM - Emergency Medicine Blog.

REBEL Core Cast 118.0 – IM vs PO NSAIDs Click here for Direct Download of the Podcast Bottom Line Up Top: There is no difference in analgesic efficacy between oral and intramuscular NSAIDs. Clinical Scenario: A 34-year-old woman presents to the ED with back pain. After your history and physical, you conclude that the patient’s pain is muscular in origin and likely secondary to heavy lifting while moving apartments. You contemplate analgesic options and decide that a NSAID makes sense.  Should you give her PO ibuprofen or IM ketorolac? What Your Gut Says: Give the ketorolac IM. IM ketorolac will provide better pain relief and the patient will be happier with her care since she got an ‘injection’ and, after all, she did come all the way to the hospital. What The Evidence Says: Unlike with many areas of medicine, there is ample evidence to answer this question and most of that evidence has been around for a couple of decades. Reviewing every study would be tedious and, fortunately, we’ve got a great review article on the topic. One important thing to understand is that the different NSAIDs have widely accepted equianalgesic doses; at the right dose, all NSAIDs (whether it be naproxen, ibuprofen, ketorolac or diclofenac) give equivalent pain relief (Irizarry 2021). This allows us to look at studies with the different NSAIDs and compare them to each other. A 2007 review of the literature concluded that there was no difference in analgesia between IM ketorolac and PO ibuprofen (Arora 2007). The study included a number of high-quality research studies: Study Format Comparison Findings Notes Wright 1994 Retrospective analysis of prospectively collected data. PO Ibuprofen 800 mg vs IM ketorolac 60 mg No difference in analgesic effect. Ibuprofen superior secondary to cost, ease of administration + lack of pain w/ administration. Turturo 1995 Double-blind RCT PO Ibuprofen 800 mg vs IM ketorolac 60 mg No difference in analgesic effect. Similar onset of action in mild-moderate pain. Neighbor 1998 Double-blind RCT PO Ibuprofen 800 mg vs IM ketorolac 60 mg No difference in analgesic effect. Mixter 1998 Double-blind RCT PO Ibuprofen 800 mg vs IM ketorolac 60 mg No difference in analgesic effect. Surgical Patients Quereshi 2019 Double-blind RCT IM diclofenac 75 mg vs PO diclofenac 100 mg Small difference favoring IM in terms of speed to pain relief Authors conclude PO superior due to time to prepare injection The data looks fairly clear in terms of analgesic efficacy but, don’t some patients simply prefer to receive a shot? While this dogmatic claim is often made, the data doesn’t appear to support it. Schwartz and colleagues performed an ingenious trial (Schwartz 2000) Enrolled 64 ED patients with acute pain. Treatment arms: Oral group: Orange drink (800 mg ibuprofen) + placebo “ibuprofen” pill Injection group: Orange drink (800 mg ibuprofen) + placebo “ketorolac” injection Essentially, all patients got the same analgesic medication (the orange drink) thinking it was just some juice and an inert study placebo (pill or injection). No significant difference in analgesia between the two groups. Bottom Line: Just give the NSAID by mouth. IM NSAIDs may provide slightly faster time to analgesia but, IM dosing comes with the cost of injection, pain , a longer time to prepare the dose and more intensive nursing resources to administer the medication. As long as the patient’s gut works, oral NSAIDs provide similar analgesic effects to IM dosing and should be the preferred route of administration. Bonus Pearls: IM injection of ketorolac causes significant pain. If the patient can’t take PO, be kind and pop in an IV. The ceiling pain relief dose for ketorolac is 15 mg IV (Motov 2017). Read More REBEL EM: The Ketorolac Analgesic Ceiling References Irizarry E et al. A randomized controlled trial of ibuprofen versus ketorolac versus diclofenac for acute, nonradicular low back pain. Acad Emerg Med 2021; 28(11): 1228-35. PMID: 34133820 Arora S et al. Myth: Parenteral ketorolac provides more effective analgesia than oral ibuprofen. Can J Emerg Med 2007; 9(1): 30-2. PMID: 17391598 Wright JM et al.. NSAID use and efficacy in the emergency department: single doses of oral ibuprofen versus intramuscular ketorolac. Ann Pharmacother 1994;28:309-12. PMID: 8193414 Turturro MA et a. Intramuscular ketorolac versus oral ibuprofen in acute musculoskeletal pain. Ann Emerg Med 1995;26:117-20. PMID: 7618770 Neighbor ML et al. Intramuscular ketorolac vs oral ibuprofen in emergency department patietns with acute pain. Acad Emerg Med; 1998; 5(2): 118-122 .PMID: 9492131 Mixter CG et al. Preemptive pain control in patients having laparoscopic hernia repair: a comparison of ketorolac and ibuprofen. Arch Surg 1998;133:432-7. PMID: 9565125 Qureshi I et al. Intramuscular versus oral diclofenac for acute pain in adults with acute musculoskeletal injuries presenting to the ED setting: a prospective, double-blind, double dummy, randomised controlled trial. 2019; 36: 401-6. PMID: 31217178 Schwartz NA et al. Patient’s perceptions of route of nonsteroidal anti-inflammatory drug administration and its effect on analgesia. Acad Emerg Med 2000; 7: 857-61. PMID: 10958124 Motov S et al. Comparison of intravenous ketorolac at three single-dose regimens for treating acute pain in the emergency department: a randomized controlled trial. Ann Emerg Med 2017; 70(2): 177-84. PMID: 27993418 Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie) The post REBEL Core Cast 118.0 – IM vs PO NSAIDs appeared first on REBEL EM - Emergency Medicine Blog.

Infections during pregnancy can lead to severe complications and are a major cause of maternal mortality. The discussion dives into common infections, particularly urinary tract infections, and highlights their treatment protocols. Timely intervention is crucial to safeguard both maternal and neonatal health. Listeners will learn about the importance of diagnostic tests, broad-spectrum antibiotics, and the necessity of careful monitoring and teamwork among healthcare professionals to ensure effective management.