Alternatives to Labetalol- Drug currently on Shortage

Labetalol Alternatives 2

Episode 91 Occult Knee Injuries Pearls and Pitfalls

Good 5-10 minute read with lots of pearls on Knee Injuries in the ED, their assessment, exam findings, and management.

Quick Read on something I feel like comes up a lot with our cardiac arrest patients. They don’t typically need intubated, they need good CPR. Bag or put an LMA in and stop at that. While the numbers aren’t astounding, given the differences in such a large amount of patients think these make sense.

http://www.healio.com/cardiology/arrhythmia-disorders/news/online/%7B5396b1a2-0167-4a2d-885c-0e1bc527398e%7D/findings-do-not-support-early-tracheal-intubation-for-in-hospital-cardiac-arrest-in-adults

Good 5-10 minute read on myths regarding UTI and asymptomatic bacteriuria. Hope you’ll take a look as this is a common problem in many EDs, not just ours with regards to over-diagnosis and over-treatment.
http://www.medscape.com/viewarticle/865175
Ross

All,
Couple videos on what was covered today with Level 1 Infuser and Autotransfusion. They’re not bad, definitely get the overall setup at least. With the autotransfusion videos, there are a few small differences in their setup vs ours I think, but overall for your purposes is mostly the same. Hope this helps.
Ross

Level 1 Infuser
https://www.youtube.com/watch?v=9YIROsYE_Yo

Autotransfusion
https://www.youtube.com/watch?v=WmLs-43jaR4

The Great and Powerful HEART Score: Does it have a weakness?

All,
I know this came up during conference today so thought I’d send the article I think was cited. At least this is the one I found from EMRAP, below is their summary of this article. Long and short of it, complication rates are really low, when done in sterile fashion in a controlled environment.
This was done in the ICU, not in the emergency department.
Overall they didn’t say that one site was absolutely the best.

nejm-2015-central-line-site-complications

Take Home Points
No central line site is superior.
Femoral lines are fastest and most successful. Subclavian lines have a lower infection risk but higher rate of pneumothorax.

Parienti, JJ et al. Intravascular complications of central venous catheterization by insertion site. N Engl J Med. 2015 Sep 24;373(13):1220-9. PMID: 26398070

Bottom line: no line was superior. Femoral lines were the fastest to place and had the highest success rates. Subclavian lines had the lowest infection risk but had a higher rate of pneumothorax.

A patient needs central line access. Which should we choose? Which is best? There are multiple complications; infection, mechanical complications like artery puncture or pneumothorax and thrombotic complications.

The authors of this study conducted a randomized, controlled trial in 10 French ICUs. They enrolled adult patients with at least two accessible sites. Patients with all three sites accessible were randomized in a 1:1:1 fashion while those with only two sites were randomized in a 1:1 fashion. The doctors had all performed at least fifty central lines. However, they were all aware of the study and probably tried harder to reduce complications.

They looked for symptomatic clots and/or infection from the time of insertion up to 48 hours after removal. This was a large study; 3471 catheters were placed in 3027 patients. Catheters were assigned to a randomly assigned site and side; placement was successful approximately 91% of the time. 85% of subclavian lines were successfully placed, 91% of the jugular lines were placed and 95% of the femoral lines were placed. Femoral lines were most successful and subclavian lines were least likely successful.

Placement of femoral lines was also more rapid, by about a minute.

The primary outcome was a composite of infection, symptomatic clot and mechanical complications such as pneumothorax and bladder puncture. The jugular line performed the worst followed by the femoral line, then subclavian line. However, it is important to look at the individual components.
For mechanical complications, the subclavian line performed the worse. 2% had a complication versus 1.5% of jugular lines and less than 1% of femoral lines.
All lines were fairly low for symptomatic clots; 0.5% for subclavian, 1% for jugular and 1.4% for the femoral group.
In terms of infection, the subclavian group was the lowest (0.5%). The highest? Surprisingly, jugular lines had a 1.4% rate of infection versus 1.2% in the femoral line group.
Overall, there were fairly low rates of complications. These were performed in very sterile conditions in the ICU. These were not placements in crashing or coding ED patients.

Placement of central lines, including femoral lines, when done carefully under sterile conditions has a low rate of complications. This article does not identify one superior line placement.

Quick 2-3 minute read on gram negative coverage @ ULH (brought to you by my wife, the ID pharmacist). Less resistance with Tobramycin than with Levaquin.

KYOne – Bugs and Drugs – Combo Antibiogram.2016.03.22