Steroids in pharyngitis: Do they make a difference?

If you have a few moments to spare today I’d recommend you do one or both of the following:

Read the following post from the excellent FOAM blog R.E.B.E.L. EM.

It is an excellent review of a recent systematic review of corticosteroids for pharyngitis. The study includes children, and at both 24 and 48 hours patients had improved pain relief when compared with placebo.

Check out the actual article and decide for yourself whether or not a single dose of steroids in pharyngitis makes a difference that is important for your patients.

Sadeghirad B et al. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials BMJ 2017; 358 :j3887. PMID: 28931508

Naloxone — a how to

Have you ever tried to figure out what the appropriate starting dose of naloxone is? When you dig in the literature it’s pretty clear that its a lot of hand waving and muddy water — but let me give you an approach and some of the literate that is out there

Apneic patient: 1-2mg naloxone

Altered with respiratory depression: 0.1 mg and repeat with increasing doses* every 2 minutes with close monitoring for response

Goal: sleepy, but with adequate respirations

Duration of action: 30-45 minutes (most patients need repeat dosing or a drip)

How to make a drip?

  1. Calculate the dose the patient required for response, for example 1mg.
  2. Then reduce to 2/3 (0.6 mg) because you would like to keep them breathing but sleepy and not alert and agitated
  3. Give that amount (2/3 of response dose or in our example 0.6) over 1 hour
Mechanism of Action: Pure opioid antagonist that competes and displaces opioids at opioid receptor sites

*A recent article on initial naloxone doses / titration 

included one-hundred opioid-dependent patients with signs/symptoms of methadone overdose. Patients were split in to 2 groups. Group 1 received naloxone with the dose 0.1 mg given every two to three minutes while group 2 received naloxone with the initial dose of 0.04 mg increasing to 0.4, 2, and 10 mg every two to three minutes to reverse respiratory depression. The time to reversal of the overdose signs/symptoms was significantly less in group 2 (P<0.001). Frequency of withdrawal syndrome and recurrence of respiratory depression were not significantly different between the two groups.

So, the jury is still out, but I hope this gives you a sense of the options out there and clarifies some of the nebulous answer provided by UTD.

References: 

Berlot G et al. Naloxone in cardiorespiratory arrest. Anaesthesia. 1985;40(8):819.

https://www-uptodate-com.eresources.mssm.edu/contents/naloxone-drug-information?search=naloxone&source=search_result&selectedTitle=1~149&usage_type=default&display_rank=1

https://www-uptodate-com.eresources.mssm.edu/contents/acute-opioid-intoxication-in-adults?search=opioid%20overdose&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H13

Goldfrank L, et al. A dosing nomogram for continuous infusion intravenous naloxone. Ann Emerg Med. 1986 May;15(5):566-70.

Khosravi N, et al. Comparison of Two Naloxone Regimens in Opioid-dependent Methadone overdosed Patients: A Clinical Trial Study. Current Clinical Pharmacology. Vol 12 :4 . 2017.

The Lowly Blood Pressure Cuff: Is It Accurate?

Yesterday, I described how the typical automated oscillometric blood pressure cuff works. We rely on this workhorse piece of equipment for nearly all pressure determinations outside of the intensive care unit. So the obvious question is, “is it accurate?”

Interestingly, there are not very many good papers that have ever looked at this! However, this simple question was addressed by a group at Harvard back in 2013. This study utilized an extensive ICU database from 7 ICUs at the Beth Israel Deaconess Medical Center. Seven years of data were analyzed, including minute by minute blood pressure readings in patients with both automated cuffs and indwelling arterial lines. Arterial line pressures were considered to be the “gold standard.”

Here are the factoids:

  • Over 27,000 pairs of simultaneously recorded cuff and arterial line measurements from 852 patients were analyzed
  • The cuff underestimated art line SBP for pressures at or above 95 torr
  • The cuff overestimated SBO for pressures below 95 torr (!)
  • Patients in profound shock (SBP < 60) had a cuff reading 10 torr higher
  • Mean arterial pressure was reasonably accurate in hypotensive patients

sbp-cuff-v-aline

Bottom line: The good, old-fashioned automated blood pressure cuff is fine for patients with normal pressures or better. In fact, it tends to understimate the SBP the higher it is, which is fine. However, it overestimates the SBP in hypotensive patients. This can be dangerous! 

You may look at that SBP of 90 and say to yourself, “that’s not too bad.” But really it might be 80. Would that change your mind? Don’t get suckered into thinking that this mainstay of medical care is perfect! And consider peeking at the mean arterial pressure from time to time. That may give you a more accurate picture of where the patient really is from a pressure standpoint.

Related posts:

Reference: Methods of blood pressure measurement in the ICU. Crit Care Med Journal, 41(1): 34-40, 2013.

Source: http://thetraumapro.com/2018/05/25/the-lowly-blood-pressure-cuff-is-it-accurate-2/