Single Dose Antibiotic before ED Discharge!

This is a very routine practice in ED, “I’ll be more comfortable to give one dose of Abx and then send him/her home” I did not know where this quote came from. I searched Pubmed and found this article: Antibiotic use in the emergency department. IV: Single-dose therapy and parenteral-loading dose therapy. J Emerg Medicine in 1996!!! This is the only review on this topic without any supporting good data. Am J of EM published a new study regarding one dose abx use in ED before discharging patient. This study shows one dose of abx use in ED prior to discharge was associated with higher rates of antibiotic associated diarrhea and also c-diff diarrhea! in this study 18% of pts had antibiotic associated diarrhe and 1% c-diff, now its time to think what is benefit of one dose abx IV vs risk of diarrhea to practice this kind of medicine!

Am J Emerg Med. 2014,  Factors influencing the development of antibiotic associated diarrhea in ED patients discharged home: risk of administering IV antibiotics.



Epinephrine in OHCA!

We discussed 2 studies in our class specific session on impact of EPi on out of hospital cardiac arrest. J Am Coll Cardiol published another study  this month and challenged again use of Epi in OHCA. 1,556 patients from 2000 to 2012, using EPi with different doses, and the conclusion is  pre-hospital use of epinephrine was consistently associated with a lower chance of survival.

(French) JACC: Is Epinephrine During Cardiac Arrest Associated With Worse Outcomes in Resuscitated Patients?

(Japan) JAMA: Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. 

(Australian) Resuscitation:  Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial



Thershold for Blood Transfusion

In my series of EBM, I was talking on our grand rounds regarding restrictive vs liberal strategies for blood transfusion! I have already posted the evidence for it. But NEJM published a study in septic shock patient that will really change practice: This is a multi-center, parallel-group trial, they randomly assigned 998 patients in the ICU who had septic shock and they did transfusion when the hemoglobin level was 7 g per deciliter or less (lower threshold) versus when the level was 9 g per deciliter or less (higher threshold) during the ICU stay. The primary outcome measure was death by 90 days after randomization. As other study showed their conclusion is” patients with septic shock who underwent transfusion at a hemoglobin threshold of 7 g per deciliter, as compared with those who underwent transfusion at a hemoglobin threshold of 9 g per deciliter, received fewer transfusions and had similar mortality at 90 days, use of life support, and number of days alive and out of the hospital; the numbers of patients with ischemic events and severe adverse reactions to blood in the ICU were also similar in the two intervention groups.”


Link to article

Cavity Lesion

Very nice mnemonic for Cavity lesion DDx in cxray: Cavity, C: Cancer or Mets, A: autoimmune; granulomas from, V: vascular (both bland and septic pulmonary embolus), I: infection(TB, fungall), T: trama (pneumatocoeles), Y: youth (congenital pulmonary airways malformation) Reference


Angioedema to Treat or Not to Treat

We are very familiar with the term of Angioedema. Mostly comes from ACE-In but has a large ddx from NSAIDS to hereditary to idiopathic. There is an article in Academic EM that is discussing the treatment options for Angioedema. They categorize Angioedema to  histaminergic-mediated vs Bradykini-meiated. In ED usually we do not know the underline disease of patient . we may find with history that patient has hereditary angioedema(HAE), but we can not diagnose the pathology in an acute setting specifically with a patient with airway concern. I recommend you to read this article in AEM.

Link to Abstract