Epinephrine in out of hospital cardiac arrest: a review of all the evidence

A summary of the evidence for (or against) epinephrine (adrenaline) in out of hospital cardiac arrest

The most recent episode of Emergency Medicine Cases Journal Jam takes a look at the evidence for epinephrine in cardiac arrest. (I suppose as I prepare for my move to New Zealand, I should probably get used to using the term adrenaline, but for now I will stick with the Canadian “epinephrine”.) These are the written notes to accompany that podcast.

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Femoral nerve block for hip fractures: the evidence

A deep dive into the evidence for providing femoral nerve blocks for patients with hip fractures

The most recent topic that Rory Spiegel, Anton Helman and I covered for the Emergency Medicine Cases Journal Jam is femoral nerve blocks for hip fractures. This is my summary of the evidence. Continue reading “Femoral nerve block for hip fractures: the evidence”

What’s the word on Word catheters?

A brief review of the evidence in the management of Bartholin’s abscesses

One of the very first medical myths I encountered was the packing of abscesses. It is pretty clear that packing provides no benefit in small abscesses, but significantly increases pain for our patients. (Barnes 1988; O’Malley 2009; Kessler 2012) Knowing that, I have always been confused about the management of Bartholin’s abscesses. Although exquisitely painful, these are relatively small abscesses in an area of the body with excellent vascularity and healing. It makes sense to manage them exactly like any small abscess, but I have always been taught that these abscesses absolutely required packing – and not just any packing, but the special (and sometimes hard to find) Word catheter. Was this evidence-based teaching, or just another medical myth handed down from generation to generation? Let’s look at some evidence. Continue reading “What’s the word on Word catheters?”

Peripheral vasopressors: the myth and the evidence

The evidence for using vasopressors through a peripheral IV

You are working in a small, rural hospital staffed by one physician and one nurse. There are multiple sick patients, all of whom require your attention, but the sickest is probably the 62 year old female with pneumonia and a blood pressure of 75/40 despite 3 liters of normal saline. This is septic shock, and you need to start a vasopressor, but the hospital protocol is that norepinephrine should only be given through a central line. You just haven’t had time to get one started, and wonder if it wouldn’t be better to get the patient started on the vasopressor using their peripheral IV.

The myth: It is an absolute contraindication to administer vasopressors through a peripheral intravenous line.

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NPO for sedation? Don’t swallow the myth

A brief review of the evidence for fasting in sedation

When was your last meal? Yes, I know that your leg is currently bent at about a 90 degree angle, but I must know, when did you last eat? You had some chips an hour ago? Well I’m very sorry, but you are just going to have to wait. Next time, remember that you need an empty stomach if you are going to have an emergency… Continue reading “NPO for sedation? Don’t swallow the myth”

Most medical practices are not parachutes

I was invited on EMCrit to discuss my position on idarucizumab and I fear I didn’t do a great job explaining myself. I don’t want to spend more time discussing the specifics of idarucizumab, but I think the larger problem of declaring that a therapy works without study, or declaring that it would be unethical to study a therapy because we “know it works” despite a lack of randomized control trials, is worth pursuing. Continue reading “Most medical practices are not parachutes”

Magical thinking in modern medicine: IV antibiotics for cellulitis

A summary of the evidence comparing IV to oral antibiotics for cellulitis

“I’ve been on these oral antibiotics for 36 hours and my cellulitis isn’t improving. My doctor sent me in because I NEED IV antibiotics.”

“This patient has pretty mild cellulitis, but he does have a fever, so I think we should go with IV antibiotics.”

“That is a pretty big cellulitis. There is no way it is going to improve with just oral antibiotics.”

Among physicians and patients alike, it is generally accepted that IV antibiotics are better than oral. They are stronger. They will work faster. They will save the day when oral antibiotics have failed. But do the bacteria floating around in the soft tissues of your leg really care (or even know) whether the antibiotics entered your system through a vein or via the stomach?

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