Ketamine as a First-Line Treatment for Severe Agitation 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).
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Are Vasopressors Useful for Toxin-Induced Cardiogenic Shock?

Toxin-induced cardiogenic shock is a life-threatening condition characterized by severe hypotension and ineffective tissue perfusion. Many drugs can lead to cardiogenic shock in overdose, for example beta blockers or calcium channel blockers. Given the poor prognosis of these cases AND theoretically-sound reasoning, vasoactive agents make sense as a therapeutic option. A detailed, comprehensive review, just published online in Clinical Toxicology, asks the question “Are vasopressors useful in toxin-induced cardiogenic shock?”
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IV Nitroglycerin Bolus for Acute Pulmonary Edema

Nitroglycerin (NTG) is an important preload reducer in acute pulmonary edema, and even modestly reduces afterload with high doses. For pulmonary edema in the ED, NTG is often administered as a sublingual tablet and/or IV infusion. Starting the infusion at ≥ 80 mcg/min produces rapid effects in many patients, and can be titrated higher as needed. Combined with noninvasive positive pressure ventilation (and sometimes IV enalapril), patients often turn around quickly, from the precipice of intubation to comfortably lying in bed. But what about high-dose IV bolus NTG?
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The Ceiling Effect of IV Ketorolac

For acute pain in the ED, parenteral ketorolac is generally administered as 30 mg IV or 60 mg IM. Dr. Chris Bond (@socbmobem) has written about the ‘ceiling effect’ of NSAIDS. The question is: are we using too much ketorolac without getting additional pain benefit?

Hot-off-the-press is a new randomized, double-blind trial from Dr. Sergey Motov’s group (@painfreeED) that addresses this exact question.
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Preventing Interruptions During IV NAC Therapy

Background

The FDA-approved dosing for IV acetylcysteine (NAC) for acetaminophen overdose is complicated: a 1-hour loading dose, followed by a 4-hour maintenance infusion at a different rate, followed by a second maintenance infusion for 16 hours at yet a different rate. Back during my clinical toxicology fellowship, we published a study that found there was an interruption in antidotal therapy > 1 hour in 18.6% of cases (and medication errors in 33% of cases overall). [1]
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Esmolol for Refractory VFib

Up until two years ago, beta blocker use for refractory ventricular fibrillation (VFib) had only been studied in animal models with sporadic human case reports. Two studies in humans have now been published and may provide some guidance in managing this difficult-to-treat condition.
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Blood Pressure Management in ICH: ATACH-2 Trial with a Focus on the Meds

Does intensive blood pressure control improve outcomes and reduce hematoma expansion in acute intracerebral hemorrhage (ICH)? The INTERACT-2 trial previously compared intensive vs. conservative blood pressure control in ICH patients and found no difference in death or disability between the two groups. Enter the ATACH-2 trial, published in the New England Journal of Medicine September 15, 2016. Dr. Ryan Radecki provides his review of the article on his EM Lit of Note site.

The purpose of this post is to evaluate the antihypertensive regimens used. Were they appropriate and are they applicable to practice everywhere?
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