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).
Activated charcoal is a funny intervention. There is plenty of data, with various drugs, demonstrating decreased absorption after its administration (much of it in healthy volunteers). However, there is a lack of quality evidence demonstrating benefit in clinically meaningful outcomes, such as mortality. In fact, the most recent Position Paper on Single-Dose Activated Charcoal (from 2005) suggests charcoal “should not be administered routinely in the management of poisoned patients.” This may be an oversimplification and I think Drs. Lotte Hoegberg and Anne-Bolette Gude astutely address this point in Goldfrank’s Toxicologic Emergencies:
“These opinions are unfortunately biased by the fact that most ‘routinely’ poisoned patients have low-risk exposures and do well with minimal intervention. Despite little scientific basis or support from clinical trials, less severely poisoned patients might benefit from activated charcoal in terms of reduced need for life support, monitoring, and antidotes.” (Isbister 2011)
And, there is data demonstrating a lower risk of seizures (venlafaxine, Kumar 2011), QT prolongation (citalopram, Friberg 2006), and delirium (promethazine, Page 2009) after charcoal administration. [Thanks, Dr. Martin Caravati, via Twitter!]
Conventional teaching is that the most benefit will be gained if charcoal is administered within the first hour after an overdose. This is important because we know that if charcoal is not administered in the prehospital setting, patients arriving to the Emergency Department are unlikely to receive it within that time frame.
The purpose of this brief post is to draw your attention to two recent articles that may change our thinking in when/how to use charcoal.
In the U.S., intravenous acetaminophen (IV APAP) has made its way into some emergency departments as part of a multi-modal pain management approach, in part due to a perception of more rapid and effective pain control compared to the oral/rectal routes. In an effort to reduce opioid use, IV APAP seemingly has the potential to increase the number of non-opioid options such as ketorolac, lidocaine, and ketamine. Indeed, in some post-surgery literature, IV APAP has demonstrated a reduction in opioid use. The utility of IV APAP (compared to PO/PR) in the ED is unclear as there is a paucity of head-to-head efficacy studies comparing IV vs PO therapy… until now.
What is the risk of bleeding after an acute (or acute-on-chronic) overdose of the newer oral antiplatelet and anticoagulant agents? A new study in the Annals of Emergency Medicine set out to answer this question.
Continue reading “Risk of Bleeding After Antiplatelet or Oral Anticoagulant Overdose”
When it comes to Angiotensin Converting Enzyme Inhibitor (ACE-I) induced angioedema, we don’t have a lot of therapeutic options. Traditionally, patients receive the standard allergic reaction medications including corticosteroids, histamine receptor blockers, and sometimes epinephrine. But, for true ACE-I induced angioedema, these therapies do not target the underlying cause and probably treat the clinician more than the patient. In severe cases with airway involvement, we long for a treatment that can reverse impending intubation (or worse).
Enter icatibant, a bradykinin B2 receptor antagonist, that theoretically does target the pathologic process.
Back in 2013, Dr. Pallin’s group in Boston published a study comparing clinical cure rates in uncomplicated cellulitis patients receiving cephalexin or cephalexin plus sulfamethoxazole-trimethoprim (SMX-TMP). I covered this study in a UMEM pearl, with the end result suggesting there was no difference in cure rate between the two treatment arms. Even in communities with high prevalence of MRSA, uncomplicated cellulitis cases without pus or abscess generally seem to be strep species. This was confirmed in the 2014 IDSA guidelines on SSTI in which they recommended streptococcal-only coverage for uncomplicated cases. A new study in JAMA reexamines this treatment strategy.
Most studies evaluating early antibiotic administration in sepsis patients focus on timing of the first dose. We highlight many of these studies in our recent review article on Appropriate Antibiotic Therapy in Emergency Medicine Clinics of North America. But, what about the second dose? A new study in Critical Care Medicine asks that question. Specifically, what is the frequency and magnitude of delays in second dose in patients admitted from the Emergency Department AND what are the risk factors for these delays?
Salicylate-poisoned patients can be incredibly complex and severely ill. Secondary to the significant acid-base abnormalities that can accompany salicylate poisoning, hemodialysis (HD) is sometimes required to facilitate removal and correct acid-base status. In addition, if intubation is needed, hyperventilation on the vent is crucial to match the patient’s minute ventilation prior to insertion of the endotracheal tube.
A new study from the Illinois Poison Center evaluated the relationship between salicylate level, intubation, HD, and mortality.
Back in 2015, Dr. Sergey Motov’s (@painfreeED) group published a study demonstrating the efficacy of low-dose ketamine compared to morphine for analgesia in the ED. Here’s my quick analysis of that study as a UMEM pearl. The question, though, is how best to administer the 0.3 mg/kg IV ketamine dose while minimizing the risk of adverse effects.
Fortunately, Dr. Motov’s group has just published a follow-up study addressing that exact question.
Continue reading “How to Administer Low-Dose IV Ketamine for Pain in the ED”
Ketamine is steadily gaining traction as a treatment option for excited delirium and/or severe agitation in both the prehospital and ED settings. We published a summary of the available data back in 2015 on Academic Life in EM. Last year in 2016, two prospective studies added important information to our understanding of the role of ketamine; one in the prehospital setting by Dr. Jon Cole’s group out of Minnesota and one in the ED from Dr. Geoffrey Isbister’s group in Australia. I was invited to write a commentary along with the Cole study, also published in 2016.
Hot off the press in 2017 is another prospective study, this time from Dr. Jeff Riddell’s group in California (@Jeff__Riddell).
Continue reading “Ketamine as a First-Line Treatment for Severe Agitation in the ED”