Snake Envenomation (Podcast)


Hello friends,

This week, we are going to discuss a problem which is a major public health issue especially in and around SE Asia. It affects thousands of people but treatment protocols are not in place. This podcast will give you information which you need at the bedside when you come across these critically ill victims.

This information presented here comes from the national snakebite protocol (India) and WHO guidelines for snake bites in SE Asia. Checkout the show notes and listen to the podcast.





Pediatric Syncope (DFO ~ Done Fell Out)

Welcome back to the show Dr. Buck Kyle!  Dr. Kyle is a attending pediatric cardiologist at Texas Children’s Hospital and on  this episode we will discuss what causes all those little kids to pass out before they come to your ER and then look so fantastic.  Are they all OK to go home?  Is there anyone in there that’s truly sick and if so how do we identify that subset?  Sit back, hold on tight, and try not to DFO (done fell out) because it’s going to be fast, fun, and may leave you a little mareado….

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Epinephrine in Out-of-Hospital Cardiac Arrest

Journal Club Podcast #19: January 2015

This month I sat down with EMS physician Dr. Bridgette Svancarek and talk all about epinephrine, and whether it really does any good...

 

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Articles:

Article 1: Reardon PM, Magee K. Epinephrine in out-of-hospital cardiac arrest: A critical review. World J Emerg Med. 2013;4(2):85-91. Answer Key.

Article 2: Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation. 2011 Sep;82(9):1138-43. Answer Key.

Article 3: Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L. Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial. JAMA. 2009 Nov 25;302(20):2222-9. Answer Key.

Article 4: Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA. 2012 Mar 21;307(11):1161-8. Answer Key.

Vignette:

You are doing an EMS ride-along during your EMS elective and get a call for a 70-year old male in cardiac arrest. The paramedic hits the lights and sirens and you're on scene in five minutes. The fire department has already arrived and CPR is in progress. They tell you that the patient was watching TV with his wife when he collapsed about 15 minutes prior to their arrival. He did not receive any bystander CPR and was pulseless and apneic on their arrival.

You and the EMS team take over CPR and bag the patient while hooking up the monitor. He is found to be in asystole and the paramedic grabs an amp of epinephrine. You place a supraglottic airway, he gets the epinephrine, and you load him up while continuing good, uninterrupted chest compressions. He gets two more rounds of epi en route and gets a pulse back.

On arrival to the ED he has a pulse, is mildly hypotensive, but has no spontaneous breaths and his pupils are fixed and dilated. You know that giving epinephrine in cardiac arrest is the standard of care, but wonder what effect it really has: does it improve ROSC, and if so does it actually improve neurologic function down the road. You wonder if there is really any evidence to support its use at all. You head to the computer and start searching...

PICO Question:

Population: Adult patients with atraumatic out-of-hospital cardiac arrest

Intervention: Intravenous epinephrine administration

Comparison: Standard CPR without epinephrine administration

Outcome: Return of spontaneous circulation, survival to hospital admission, survival to hospital discharge, survival with a good neurologic outcome

Search Strategy:

A PubMed search was performed using the search terms “(out of hospital cardiac arrest) AND (epinephrine OR adrenaline).” The search was limited to humans, resulting in 207 citations (http://tinyurl.com/lsgy63r). These were searched and two randomized controlled trials, one observational trial, and a systematic review were chosen for inclusion.

Bottom Line:

Epinephrine is currently recommended in the management of out-of-hospital cardiac arrest (OHCA) by both the American Heart Association and the European Resuscitation Council despite a paucity of clear evidence that it improves patient-centered outcomes. This lack of evidence has led some clinicians to question the use of epinephrine in cardiac arrest. The primary proposed benefit of epinephrine has been an increase in coronary perfusion pressure, which has been demonstrated in animal studies. While no placebo-controlled human studies have confirmed these findings, high-dose epinephrine has been shown to increase coronary perfusion to an even greater extent than low-dose epinephrine. However, this dose-response relationship does not necessarily confirm the benefits of epinephrine. While high-dose epinephrine has been shown to improve rates of return of spontaneous circulation (ROSC), it does not improve the more clinically relevant outcome of survival to hospital discharge (Gueugniaud 1998, Vandycke 2000). This may be in part due to reduced microcirculatory cerebral blood flow caused by epinephrine, resulting in worse neurologic outcomes among survivors.

There have been several observational studies evaluating the use of epinephrine in OHCA with varying results (Herlitz 1995, Holmberg 2002, Ohshige 2005, Wang 2005, Ong 2007, Yanagawa 2010). The largest of these studies (Hagihara 2012) prospectively evaluated outcomes in over 400,000 patients in Japan. The authors found that while epinephrine use was associated with a significant increase in ROSC (adjusted odds ratio [AOR] 2.01, 95% CI 1.83-2.21), it was also associated with significant decreases in survival at one month (AOR 0.71, 95% CI 0.62-0.81) and survival with good neurologic function, as defined by a cerebral performance category (CPC) score of 1 or 2 (AOR 0.41, 95% CI 0.33-0.52).

There has been, to date, one randomized controlled trial comparing the use of epinephrine with placebo in the management of OHCA (Jacobs 2011). While this study demonstrated improvements in survival to hospital discharge with the use of epinephrine, this result did not achieve statistical significance (OR 2.2, 95% CI 0.7-6.3). The study was afflicted, unfortunately, by a small sample size and was underpowered to detect a potentially clinically significant improvement in outcomes. While the investigators initially planned to perform a large study involving five ambulance services throughout Australia and New Zealand, all but one service withdrew from the study due to ethical concerns.

There has been an additional randomized controlled study evaluating the effectiveness of intravenous drug administration during cardiac arrest (Olasveengen 2009), of which epinephrine is arguably the most important component. This study also demonstrated higher rates of ROSC among patients with IV access initiated by EMS (OR 1.99, 95% CI 1.48-2.67). However, there was no statistically significant improvement in survival to discharge (OR 1.16, 95% CI 0.74-1.82) or survival with a CPC score of 1 or 2 (OR 1.24, 95% CI 0.77-1.98). There was a large degree of crossover in this study, and the authors chose to perform an “as treated” analysis of the data based on epinephrine administration (Olasveengen 2012). This analysis demonstrated a significant decrease in both survival to discharge (OR 0.5, 95% CI 0.3-0.8) and survival with a CPC score of 1 or 2 (OR 0.4, 955 CI 0.2-0.7) when epinephrine was administered. These results must be viewed cautiously, as the reasons for crossover between the groups likely disrupted the prognostic balance afforded by randomization, leading to a poorer baseline prognosis among patients receiving epinephrine. Note that among 418 patients randomized to receive an IV, 42 did not have IV access initiated because they had ROSC; only 12 patients in this group did not have IV access initiated due to futility. Among 433 patients randomized to have no IV access initiated, 27 received IV access only after having ROSC and then rearresting.

The existing data is clearly limited, and the authors of a systematic review on the subject understandably conclude that “although the results…exhibit the paucity of high quality published research supporting the use of epinephrine in OHCA, there is insufficient evidence to support changing current guidelines” (p. 90). Fortunately, a trial has recently begun in the United Kingdom (PARAMEDIC 2: the Adrenaline Trial), which plans to enroll 8000 patients randomized to either epinephrine or placebo. This trial will hopefully further elucidate the efficacy or harm associated with epinephrine and provide statistically significant outcomes data to solidify or change our current practice.

Healthcare Update Satellite — 02-03-2015

Thanks for the patience in putting up with my lack of regular posting. Life has been challenging lately. Still working on it.

When government pays for your care, government may try to force its values on you. Learning-disabled mother of six children in England deemed at “grave” risk if she has any more children. Now the government wants to forcibly remove her from her home and sterilize her. A lawyer representing the woman stated that sterilization was “therapeutic.”

This process will come to medicine sooner than you think. Just watch. Uber drivers now get to rate their passengers after a ride. When passengers get lower scores, some drivers no longer want to deal with them and they have to wait longer for a ride. “1 star for passengers does not do them any harm. Sensible drivers won’t pick them up, but so what?” One expert interviewed for the article stated that “It’s inevitable that these review systems are coming. What I’m worried about is whether they’re accurate enough. Otherwise, we’re going to get a disinformation economy.” The disinformation economy is already happening with doctors via Press Ganey and its ilk. Wait until it happens with patients and they can’t find a physician willing to care for them. Then watch it happen to hospital administrators as the ratings follow them around after they destroy the morale at one hospital and try to bring their destructive ways to another facility.

What’s the sex position most likely to cause a man to have a penile fracture? Cowgirl, baby. Cowgirls are twice as likely to cause penis fractures than the boring missionary position.

Think you’re doing yourself a favor by purchasing those herbal supplements at health food stores? About 80% of the time you’ll be wrong. When the NY Attorney General investigated supplements such as ginkgo biloba from retailers GNC, Target, Walgreens, and Wal-Mart, only 5 of 24 contained the actual ingredients by DNA testing. The others contained either unrecognizable DNA or DNA from a different plant. Even more worrisome was that 5 of 24 impostors contained either wheat or beans, putting people with allergies to those products at risk.

Because we don’t have enough clipboards walking around hospital hallways … Studer Group being acquired by Huron Consulting Group in $325 million deal to create a consulting operation with more than 1500 employees.

Fascinating article on a topic that isn’t really discussed. What should people do when they hear voices? Some experts recommend talking back to them. Reading the stories about people suffering from this problem really opened my eyes. It’s one thing to have a patient tell you they’re hearing voices. It’s another thing to read about patients who go into detail about what the voices are saying and how the voices affect every aspect of their lives.

Woman develops toxic shock syndrome, develops liver and kidney failure, falls into a coma and deteriorates to point that family planned to meet with doctors to take her off of ventilator. Four hours before the family had their meeting, the patient woke up. Kidney and liver function improved. Now she’s eating and undergoing rehab. I’m happy for the patient and her family, but I’m worried about the precedent that the story sets. Will families of all terminally ill patients in comas now expect the same to happen to their family members?

Back in December, Dr. Wes Fisher did an investigation into the ABIM Foundation, Choosing Wisely, and the ABIM Foundation’s $2.3 million condiminium with regard to Maintenance of Certification requriements. He ripped the ABIM Foundation for waste, hypocrisy, and corruption.
Today, the ABIM Foundation admits “we got it wrong” and announced fundamental changes to its MOC Program.
The power of the well-written word should never be underestimated.
Great job, Wes!

Swarms of nanobots being used in clinical trials to target 12 types of cancer cells and to repair spinal cords.
I used to laugh at people who worried about government controlling our thoughts by injecting nanobots into our systems. Now I’m stocking up on tin foil to make hats for all my family.

Latest proposed budget includes a $50 million cut to program to help vaccinate un-insured and underinsured patients. However, the budget increases funding by $128 million to provide vaccines free of charge to children under 19 years old.
Of course the free children’s vaccinations will come to a screeching halt when people finally listen to ophthalmologist and Senator Rand Paul who reportedly has personal knowledge of children getting “profound mental disorders” after receiving vaccines.

Great quote from Glenn Reynolds at Instapundit: “ObamaCare — the policy that’s so popular, it never takes effect until after the next election!

Endobronchial Obstruction: The Impact of Interventional Pulmonology on Morbidity & Mortality

 The Case:  64 yo M veteran smoker w PMH severe COPD on 4L O2 by NC, pAfib on AC, admitted in December for progressive dyspnea over weeks, found to have a bronchus intermedius obstruction due to extrinsic compression from a NSCLC mass near the right hilum.   Portable CXR on admission        …

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