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

Morphine delays Clopidogrel effects!

Morphine can affect functionality of Clopidogrel. There is an article in JACC, March 2014, that showed “Morphine delays clopidogrel absorption, decreases plasma levels of clopidogrel active metabolite, and retards and diminishes its effects, which can lead to treatment failure in susceptible individuals”. This will bring a problem with patient that the pain is not controlled with Nitro and now the choice of pain meds is….


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Alpha Blocker as a treatment for Ureteral Stone!

Alpha blocker (Tamsulosin , Flomax) originally is used for medical treatment of BPH. There are growing concerns that alpha blocker can be used in treatment of ureteral stone due to same affect on bladder and prostate, relaxation of muscle fiber. The recent Cochrane database review showed that compare with Nifedipine (ca channel blocker), alpha blocker has higher stone-free rate and a shorter time to stone expulsion. They recommended this medication to adjunct pain meds for patients with ureteral stone.

Link to article

PEA Cardiac Arrest and Structured Teaching tool

Medical Principles and Practice published an article that uses a structured teaching tools to summarized 5 Hs and 5 Ts in PEA cardiac arrest, Lets start with 5 Hs(Hyper and Hypo K, Hypoxia, Hydrogen, Hypovolemia and Hypothermia) and 5 Ts( Tension PTX, Tamponade, Trauma, Toxins, Thrombosis), a very routine practice in ACLS guideline, But this method by Litmann L,  et al, seems simplified that approach to a Narrow or Wide complex and I believe this will help us when we are doing CPR to approach better. If You see a Narrow complex PEA on the monitor you should think about mechanical right ventricle issues such as Tamponade. PE, Tension PTX, mechanical hyperinflation, and Acute MI, cardiac rupture. the answer should be Ultrasound and see hyperdynamic LV. The term of pseudo PEA refers to the mechanical causes are not directly related to abnormal myocardial performance. If there is a Wide complex PEA, we should think about Sever Hyper K, Sodium channel blocker Toxicity, and Acute MI,Pump Failure, use of US will let us to know about hypokinetic vs Akinetic cardiac activity.  Based on this protocol treatment is easy in Narrow complex we will treat the cause, and based on  Wide complex we will give IV calcium chloride and Nahco3.

Medical Principles and Practices


Blood Transfusion in 2014

I had several discussions in ED regarding blood transfusion in anemic patients. My argument is that if patient does not have any acute symptoms (SOB, feeling faint, tachycardia, Cardiac ischemia, …), there is no need to emergently transfuse patients in ED. Our threshold to transfuse was 10/30 vs 9/28/ vs 8/26 long time ago and there was no definite number to stick to. In 2006, Journal of Trauma published a practice guideline: Guidelines for transfusion in the trauma patient. They recommended a threshold of Hb 7 to transfuse but non-surgeons doctors argued this with their specific patient population that they have. The argument was: trauma patients usually are young without morbidity or significant PMH, but medicine patients usually suffer from diseases and anemia can affect this threshold! When this study published in NEJM: Transfusion strategies for acute upper gastrointestinal bleeding. There was no argument that sick patient with UGIB could benefit from restrictive plan!

Now in JAMA: Health Care–Associated Infection After Red Blood Cell Transfusion A Systematic Review and Meta-analysis there is a systematic review with 18 studies that shows a restrictive plan for transfusion will help to reduce blood borne diseases. Do we still argue this?