Ketamine for Acute Geriatric Pain in the ED

Subdissociative-dose ketamine (SDK) provides effective analgesia with lower rates of unwanted side effects when administered as a slow IV infusion. However, safety and efficacy studies have excluded geriatric patients until now, when Dr. Sergey Motov and colleagues strike again. SDK offers a much-needed pain management strategy for moderate to severe pain in this population who are often not ideal candidates for opioid analgesia.

Continue reading “Ketamine for Acute Geriatric Pain in the ED”

Nitrofurantoin vs. Fosfomycin for Uncomplicated UTI

Background

Nitrofurantoin and fosfomycin are both recommended by the IDSA guidelines as first-line options in the treatment of uncomplicated cystitis due to their low resistance rates and minimal collateral damage. However, deciding which to choose is often based on convenience or habit, rather than supported by literature. This study was performed to compare sustained clinical resolution and microbiologic response between these two agents in middle-aged women with uncomplicated lower urinary tract infections.

Continue reading “Nitrofurantoin vs. Fosfomycin for Uncomplicated UTI”

Ondansetron and QTc Prolongation: Clinical Significance in the ED

Background

Just like many other medications, ondansetron can prolong the QTc interval on an electrocardiogram. In fact, the FDA released a Drug Safety Communication in 2012 recommending against IV doses > 16 mg to help limit the risk. A prospective, observational study in 40 cardiac patients (heart failure or ACS) found that ondansetron 4 mg IV prolonged the QTc interval by 19 msec for up to 2 hours after the dose (Hafermann, Drug Healthc Patient Safety 2011). A retrospective cohort study of 210 ondansetron doses in pediatric ICU patients found that the QTC  interval increased to 460-500 msec in 29% and to more than 500 msec in 11% (Trivedi, Pediatr Crit Care Med 2016). Underlying electrolyte abnormalities and organ dysfunction seemed to add the most risk.

But, what about in ED patients? What is the extent of QTC prolongation and is it clinically significant? Two groups have now published on this patient population. Here’s what they found.

Continue reading “Ondansetron and QTc Prolongation: Clinical Significance in the ED”

Topical TXA for Epistaxis in Patients on Antiplatelet Agents

Epistaxis is a common emergency department (ED) presentation, particularly in patients on antiplatelet and anticoagulation agents. Traditional remedies for bleeding include local vasoconstrictors, silver nitrate, and anterior nasal packing (ANP), each with variable efficacy. In recent years tranexamic acid (TXA) applied topically has gained popularity due to its efficacy, minimal systemic absorption lending to a low side-effect profile, and ease of use for the patient and provider (Zahed, Am J Emerg Med 2013; Ker, Cochrane Database Syst Rev 2013). In this recently published study, Zahed et al narrowed their focus to explore clinical efficacy of topical TXA in patients on antiplatelet agents (aspirin, clopidogrel, or both).

Continue reading “Topical TXA for Epistaxis in Patients on Antiplatelet Agents”