Rogue Medic

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Rogue Medic
182 posts

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  • April 12, 2012
  • 11:45 PM
  • 1,121 views

Most Common Cause of Death in Anaphylaxis is Failure to Give Epinephrine

by Rogue Medic in Rogue Medic

The most common cause of death in anaphylaxis is failure to give epinephrine.

That is according to Dr. Corey Slovis, presenting at the 2012 Gathering of Eagles Conference.[1]

This is shocking news. Where do we have any evidence of that?... Read more »

  • April 5, 2012
  • 10:30 PM
  • 1,440 views

Naloxone in cardiac arrest with suspected opioid overdoses

by Rogue Medic in Rogue Medic

Can naloxone improve survival from cardiac arrest?

This is an interesting study that looks at some old charts to try to figure out if naloxone made any difference when it was given to cardiac arrest patients suspected of having an opioid overdose. Here is the interesting part of their hypothesis –... Read more »

Saybolt, M., Alter, S., Dos Santos, F., Calello, D., Rynn, K., Nelson, D., & Merlin, M. (2010) Naloxone in cardiac arrest with suspected opioid overdoses. Resuscitation, 81(1), 42-46. DOI: 10.1016/j.resuscitation.2009.09.016  

  • April 4, 2012
  • 03:40 PM
  • 1,119 views

Should We Start Using a Glucose-Insulin-Potassium Cocktail

by Rogue Medic in Rogue Medic

Those unfamiliar with research have been making the usual exaggerated claims that come from wishful thinking and not considering the possible harm from rushing to adopt a treatment based on weak evidence.

Should we rush to make this a standard treatment, that will become a Standard Of Care through inertia and tradition?... Read more »

  • March 23, 2012
  • 09:00 AM
  • 964 views

Dr. Ken Grauer on Killing Patients Just to Get a Temporary Pulse With Epinephrine – Part II

by Rogue Medic in Rogue Medic

Dr. Ken Grauer wrote a couple of extended comments in response to "Killing Patients Just to Get a Temporary Pulse With Epinephrine."

Dr. Grauer has provided some commentary on this on his web site – KG-EKG Press.

"ISSUE #10: Should We Still Use Epinephrine for Cardiac Arrest?"

So, how bad was epinephrine in this study?... Read more »

Hagihara, A., Hasegawa, M., Abe, T., Nagata, T., Wakata, Y., & Miyazaki, S. (2012) Prehospital Epinephrine Use and Survival Among Patients With Out-of-Hospital Cardiac Arrest. JAMA: The Journal of the American Medical Association, 307(11), 1161-1168. DOI: 10.1001/jama.2012.294  

Callaway, C. (2012) Questioning the Use of Epinephrine to Treat Cardiac Arrest. JAMA: The Journal of the American Medical Association, 307(11), 1198-1200. DOI: 10.1001/jama.2012.313  

  • March 17, 2012
  • 01:30 PM
  • 932 views

Two Experiments Confirm the Importance of the Scientific Method

by Rogue Medic in Rogue Medic

I could try to make this suspenseful, but it is not a surprise. Attempts to confirm the experiment did not confirm faster than light neutrinos.

The other experiment is even less surprising. There was a paper that claimed that psychic powers are real and that there is proof. Several attempts have been made to reproduce the results. The psychics predicted success, but those predictions were not correct and nobody should be surprised.... Read more »

  • March 15, 2012
  • 05:45 PM
  • 1,090 views

Does RSI Protect Against Aspiration of Stomach Contents

by Rogue Medic in Rogue Medic

One of the reasons we use RSI (Rapid Sequence Induction/Intubation) is to protect the airway from aspiration of stomach contents, blood, debris, and other things that might make their way into the lungs and make the patient’s already very bad day, very much worse.

Does RSI protect against aspiration?

We are presented with a patient who appears to need airway management.... Read more »

  • March 14, 2012
  • 09:00 AM
  • 1,228 views

Intramuscular Midazolam for Seizures – Part VI

by Rogue Medic in Rogue Medic

Which seizure patients should be treated with benzodiazepines?

Most patients stop seizing without any treatment and benzodiazepines can cause respiratory depression, so we need to be careful.

You can’t be too careful!

Right?... Read more »

Silbergleit, R., Durkalski, V., Lowenstein, D., Conwit, R., Pancioli, A., Palesch, Y., & Barsan, W. (2012) Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus. New England Journal of Medicine, 366(7), 591-600. DOI: 10.1056/NEJMoa1107494  

  • March 13, 2012
  • 01:15 PM
  • 1,064 views

Intramuscular Midazolam for Seizures – Part V

by Rogue Medic in Rogue Medic

How should this large double-blind, randomized, noninferiority trial comparing IM (IntraMuscular) midazolam (Versed) with IV (IntraVenous) lorazepam (Ativan) affect the way we treat patients with seizures?

21.3% of patients had their seizures stop before they could be given IV lorazepam, while none of the IM midazolam patients had seizures stop before being given medication.

Does that provide a bias toward improved outcomes with IM midazolam?... Read more »

Silbergleit, R., Durkalski, V., Lowenstein, D., Conwit, R., Pancioli, A., Palesch, Y., & Barsan, W. (2012) Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus. New England Journal of Medicine, 366(7), 591-600. DOI: 10.1056/NEJMoa1107494  

Alldredge BK, Gelb AM, Isaacs SM, Corry MD, Allen F, Ulrich S, Gottwald MD, O'Neil N, Neuhaus JM, Segal MR.... (2001) A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus. The New England journal of medicine, 345(9), 631-7. PMID: 11547716  

  • March 9, 2012
  • 09:00 AM
  • 1,129 views

Intramuscular Midazolam for Seizures – Part IV

by Rogue Medic in Rogue Medic

If an IV is already in place, on average the IV lorazepam should stop the seizure about 1.6 minutes after the lorazepam is pushed into the IV line.

The IM midazolam should stop the seizure about 3.3 minutes after the midazolam is injected into the muscle, on average.

If an IV is already in place, IV lorazepam should be significantly faster.

An IV is usually not already in place when EMS shows up. so what should we do?... Read more »

Silbergleit, R., Durkalski, V., Lowenstein, D., Conwit, R., Pancioli, A., Palesch, Y., & Barsan, W. (2012) Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus. New England Journal of Medicine, 366(7), 591-600. DOI: 10.1056/NEJMoa1107494  

  • March 7, 2012
  • 09:00 AM
  • 976 views

Nontraumatic out-of-hospital hypotension predicts inhospital mortality

by Rogue Medic in Rogue Medic

An interesting examination of something that we take for granted. Does any instance of hypotension increase the risk of death for patients with life-threatening or potentially life-threatening conditions? Hypotension is categorized as SBP (Systolic Blood Pressure) less than 100 mm Hg, rather than SBP less than 90.

They assessed patients with respiratory distress, syncope, chest pain, dizziness, altered mental status, anxiety, thirst, weakness, fatigue, or the sensation of impending doom.... Read more »

Jones, A., Stiell, I., Nesbitt, L., Spaite, D., Hasan, N., Watts, B., & Kline, J. (2004) Nontraumatic out-of-hospital hypotension predicts inhospital mortality☆. Annals of Emergency Medicine, 43(1), 106-113. DOI: 10.1016/j.annemergmed.2003.08.008  

  • February 27, 2012
  • 12:59 AM
  • 1,018 views

Trauma Criteria – preventative medicine – Part I

by Rogue Medic in Rogue Medic

There are a lot of interesting things about this study, but Table 3 shows that there is some ability to improve the accuracy of triage criteria by combining criteria. This should be a no brainer, but here are some data to support this. 2.8% 4.7% 8.0% = 50%. That is a tremendous improvement over the 15.5% that they add up to individually.... Read more »

Sasser SM, Hunt RC, Sullivent EE, Wald MM, Mitchko J, Jurkovich GJ, Henry MC, Salomone JP, Wang SC, Galli RL.... (2009) Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control, 58(RR-1), 1-35. PMID: 19165138  

  • February 22, 2012
  • 09:00 AM
  • 1,315 views

Mass sociogenic illness initially reported as carbon monoxide poisoning

by Rogue Medic in Rogue Medic

Here is a report of a mass delusion that seems to have been compounded by the use of the Masimo RAD-57 non-invasive CO monitor. CO (Carbon monOxide) is a significant cause of poisoning in the US, but not relevant in this case. The RAD-57 incorrectly identified CO poisoning in half a dozen people who do not appear to have had any exposure to CO.... Read more »

Nordt, S., Minns, A., Carstairs, S., Kreshak, A., Campbell, C., Tomaszweski, C., Hayden, S., Clark, R., Joshua, A., & Ly, B. (2012) Mass Sociogenic Illness Initially Reported as Carbon Monoxide Poisoning. The Journal of Emergency Medicine, 42(2), 159-161. DOI: 10.1016/j.jemermed.2011.01.028  

  • February 21, 2012
  • 07:10 PM
  • 1,190 views

Accuracy of Noninvasive Multiwave Pulse Oximetry Compared With Carboxyhemoglobin From Blood Gas Analysis in Unselected Emergency Department Patients

by Rogue Medic in Rogue Medic

The Masimo RAD-57 non-invasive CO monitor is promoted as an accurate way to identify patients at risk of life-threatening complications of CO poisoning. CO (Carbon monOxide) is a significant cause of poisoning in the US, with hundreds of fatalities each year.

Masimo claims that their RAD-57 is able to accurately measure blood levels of CO without any complicated lab equipment. If it works, the RAD-57 might save some lives. Unfortunately, the research that has not been funded by Masimo does no........ Read more »

  • February 20, 2012
  • 09:50 AM
  • 1,360 views

Intramuscular Midazolam for Seizures – Part III

by Rogue Medic in Rogue Medic

This presents an interesting conundrum. Doses of benzodiazepines (midazolam, lorazepam, diazepam, . . .) are often limited, due to a fear of causing respiratory complications. When treating seizures, higher doses of benzodiazepines may protect patients from respiratory complications.... Read more »

Silbergleit, R., Durkalski, V., Lowenstein, D., Conwit, R., Pancioli, A., Palesch, Y., & Barsan, W. (2012) Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus. New England Journal of Medicine, 366(7), 591-600. DOI: 10.1056/NEJMoa1107494  

Alldredge BK, Gelb AM, Isaacs SM, Corry MD, Allen F, Ulrich S, Gottwald MD, O'Neil N, Neuhaus JM, Segal MR.... (2001) A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus. The New England journal of medicine, 345(9), 631-7. PMID: 11547716  

  • February 19, 2012
  • 07:30 AM
  • 1,265 views

Intramuscular Midazolam for Seizures – Part II

by Rogue Medic in Rogue Medic

While there have been studies comparing IM (IntraMuscular) midazolam (Versed) with IV (IntraVenous) anti-epileptic medications, this is a large study that compares IM midazolam with the best IV anti-epileptic medication in a double-blind, randomized, noninferiority trial.

For the study, there were two different doses for the auto-injector (the same as an EpiPen). The doses were not small.

Midazolam for seizures is an off-label use both when given IM and when given IV.[2]

The lorazepa........ Read more »

Silbergleit, R., Durkalski, V., Lowenstein, D., Conwit, R., Pancioli, A., Palesch, Y., & Barsan, W. (2012) Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus. New England Journal of Medicine, 366(7), 591-600. DOI: 10.1056/NEJMoa1107494  

  • February 2, 2012
  • 07:30 AM
  • 1,065 views

This is the Way to Bad Medicine - II

by Rogue Medic in Rogue Medic

Their categorization of only 3 (out of 32) serious adverse events as "Probably related to treatment" and none as "Definitely related to treatment" suggests that they are not being objective. How do they explain this in the discussion? They don’t. Maybe they aren’t referring to the serious adverse events, but are referring to deaths. I don’t know and since they do not explain, I can only speculate.... Read more »

  • January 24, 2012
  • 05:30 PM
  • 1,028 views

This is the Way to Bad Medicine

by Rogue Medic in Rogue Medic

Dr. Radecki at EM Literature of Note has a nice analysis of a study that promises to try to change medicine for the worse. Of course, that is not the intent of the study’s authors, but they have too much confidence in their results. The study is only looking at patients with minor head injury and minor symptoms, but taking warfarin (Coumadin).... Read more »

  • January 4, 2012
  • 03:20 PM
  • 1,227 views

Nifekalant versus lidocaine for in-hospital shock-resistant ventricular fibrillation or tachycardia

by Rogue Medic in Rogue Medic

Why compare nikefelant with lidocaine? Why not compare nikefelant with amiodarone? Why not compare nikefelant with an antiarrhythmic that is more effective than amiodarone – procainamide, sotalol, or ajmaline?

Lidocaine is probably used because the IRB (Institutional Review Board) would consider it unethical to have a placebo group. Lidocaine is the placebo, but with less safety than the placebo.... Read more »

  • December 27, 2011
  • 07:30 AM
  • 1,297 views

Charging the Defibrillator While Continuing Chest Compressions – Part II

by Rogue Medic in Rogue Medic

ACLS (Advanced Cardiac Life Support) recommends charging the defibrillator during compressions. This is no less of a recommendation than giving epinephrine. How many people ignore ACLS guidelines for compressions during charging, but claim that it is evil to disobey anything ACLS recommends on epinephrine, amiodarone, or ventilations? ... Read more »

Edelson, D., Robertson-Dick, B., Yuen, T., Eilevstjønn, J., Walsh, D., Bareis, C., Vanden Hoek, T., & Abella, B. (2010) Safety and efficacy of defibrillator charging during ongoing chest compressions: A multi-center study. Resuscitation, 81(11), 1521-1526. DOI: 10.1016/j.resuscitation.2010.07.014  

  • December 15, 2011
  • 07:30 AM
  • 2,780 views

Intraosseous Versus Intravenous Vascular Access During Out-of- Hospital Cardiac Arrest – A Randomized Controlled Trial

by Rogue Medic in Rogue Medic

For treatment of medical cardiac arrest patients, which is better – IO (IntraOsseous) or IV (IntraVenous) access for medication administration?

Since no medications have ever been demonstrated to improve survival from cardiac arrest (only chest compressions and defibrillation have), the most important consideration will be what method results in the least interruption of compressions and the least interference with defibrillation.... Read more »

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