PE and Pregnancy

Having a pregnant patient with suspected PE, you know what I’m talking about. It is usually a disaster, mom is worry about fetus, dad is worry about mom, you are worry about both! how much is the risk of PE in pregnancy?

Meng etal, reviewed 27 articles related to this topic in a meta-analysis. They found 1.1‰ (1.0-1.3‰) for deep vein thrombosis (DVT) and 0.3‰ (0.2-0.4‰) for pulmonary embolism (PE). Risk of VTE after postpartum was significantly higher.

 

link to article

Appendicitis OR versus IV antibiotics!

There are a lot confusion/controversy regarding appendicitis treatment :ABx vs surgery:

The NOTA Study (Non Operative Treatment for Acute Appendicitis) in Ann surg, 2014 showed that antibiotics for suspected acute appendicitis are safe and effective and may avoid unnecessary appendectomy.

Long-Term Outcomes of Patients with Nonsurgically Managed Uncomplicated Appendicitis in J Am Coll Surg, 2014 with same result.

But there is a JAMA article published today regarding this topic:  Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis, There were 273 patients in the surgical group and 257 in the antibiotic group. Patients randomized to antibiotic therapy received IV ertapenem (1 g/d) for 3 days followed by 7 days of oral levofloxacin (500 mg once daily) and metronidazole (500 mg 3 times per day). Patients randomized to the surgical treatment group were assigned to undergo standard open appendectomy.
The result showed that 27 % of patients treated with antibiotics instead of surgery have a recurrence within 1 year. Their conclusion is among patients with CT-proven, uncomplicated appendicitis, antibiotic treatment did not meet the pre-specified criterion for non-inferiority compared with appendectomy.

Probably this will come to our practice in near future (next 5-10 years) we will give options to patient to have abx vs surgery.

To Stress or Not to Stress!

Troponin 1 set, 2 sets, 3 sets, Stress test, Echo, Observation vs Admission. LOW risk chest pain, when will be a safe practice. JAMA internal medicine in March found patients that they do not have

MI in ED  are at very low risk of experiencing an MI during short- and longer-term follow-up. Interestingly, this study did not show that initial testing strategy can affect outcome!

Link to article

Amiodarone with Dose of 300 mg!!!

I was reading an article regarding Managing Afib in Annals of EM. They are recommending Amiodarone 300 mg IV over an hour and then 10-50 mg/hour for 24 hour.

I thought something wrong with this, but I checked their reference and it is correct. So, don’t be surprise of dose of 300 mg in alive patient!

Amiodarone is a very invasive IV medication and I believe we have to use other options before we get to this dose!

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary