Idarucizumab: Plenty of optimism, not enough science

A critique of the current science supporting idarucizumab

Optimism is essential. Few things are as powerful as hope for the future. When facing an onslaught of critically ill patients, optimism allows emergency physicians to persist. Optimism, however, can cloud also cloud our judgement; allow us to focus only on the good, not the bad. As physicians, we cannot afford optimism blindness. We need to be objective. We need to be scientists.

This month I was distressed to hear overly-optimistic, unscientific statements about idarucizumab on two of my favourite emergency medicine education programs: EM:RAP and EM Cases. I have incredible respect for these sources. EM:RAP has been irreplaceable in my emergency medicine education. On EM Cases, the statements were made by Dr. Walter Himmel, who is one of the smartest individuals I have ever had the opportunity to meet. But in this instance, I think that they were both wrong.

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Evidence Based Medicine is Easy

A simplified guide to approaching the medical literature

Evidence based medicine is easy.

I know that evidence based medicine scares people. That stats seem complicated. Papers are often full of obtuse language. People are constantly debating small details at journal clubs, which can leave many physicians feeling inadequate.

But I can assure you, evidence based medicine is easy. If I can do it, anyone can. The only difficult part is getting into the habit of actually picking up a paper and starting to read.

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Emergency Airway Management Part 4: Cricothyroidotomy (surgical front of neck access)

An approach to managing the emergency department patient in a can’t intubate can’t oxygenate scenario

Case

A 55 year old man was found unconscious in the bathroom by his family. After appropriate resuscitation and pre-oxygenation, you determine that there are no major predictors of difficulty, and so proceed with RSI. On 2 attempts at laryngoscopy, both direct and video, you cannot visualize the cords. The LMA won’t sit properly, and now his oxygen saturation is 70% despite your best attempt at bag valve mask ventilation…

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Emergency Airway Management Part 3: Intubation – the procedure

An approach to intubation in the emergency department

Case

A 55 year old man was found unconscious in the bathroom by his family. He has a GCS of 7. His vital signs on arrival are a heart rate of 130, a blood pressure of 90/55, a respiratory rate of 28, and an oxygen saturation of 89% on room air. After using basic airway maneuvers to temporarily stabilize his airway, you were able to take the time to appropriately resuscitate and pre-oxygenate him. His vital signs are now a heart rate of 105, a blood pressure of 122/77, a respiratory rate of 16, and an oxygen saturation of 100% with a non-rebreather set at flush rate and nasal prongs at 15 L/min. However, he remains unconscious and you think it is now time to proceed with intubation…

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Sucrose: Analgesic or placebo?

Does sucrose really relieve pain in infants?

It is time for a (potentially unpopular) rant. Over the last few months, the topic of using sucrose for pain control in neonates has come up a number of times. It has been called the standard of care. It has been stated that it is unethical to run any more trials with a non-treatment arm, because we know that sucrose works.

I have a problem with that.

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Does contrast cause kidney injury? The evidence

A look at the evidence around post contrast acute kidney injury (or “contrast induced nephropathy”)

It’s time for another Emergency Medicine Cases Journal Jam, and we chose to tackle the concept of “contrast induced nephropathy” this time around. For this review, we focused on the risk of acute kidney injury following intravenous contrast for CT scans, because that is what we are really concerned about in the emergency department. For a variety of reasons, including higher contrast loads, higher risk patients, and procedure induced micro-emboli, the risk of kidney injury is significantly higher when using intra-arterial contrast for procedures such as cardiac catheterization. What follows are the notes I made in preparation for the podcast.

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Article of the month (November 2017)

There are a lot of recurrent themes in this month’s edition (which has clearly shifted from being a monthly to a bimonthly publication). Podcast over on BroomeDocs.

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