Rogue Medic

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Rogue Medic
182 posts

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  • April 17, 2013
  • 05:30 PM

Is Nitroglycerin Bad for Severe Sepsis?

by Rogue Medic in Rogue Medic

Yesterday at "The Paramedic's Edge," this was the topic of discussion of a possible use of NTG (NiTroGlycerin – GTN GlycerylTriNitrate in Commonwealth countries).

NTG is a vasodilator and sepsis is a vasodialtion problem. There are other problems with sepsis, but vasodilation may be the primary problem.... Read more »

SPRONK, P., INCE, C., GARDIEN, M., MATHURA, K., & ZANDSTRA, D. (2003) Nitroglycerin for septic shock. The Lancet, 361(9360), 880-880. DOI: 10.1016/S0140-6736(03)12692-X  

Spronk, P., Ince, C., Gardien, M., Mathura, K., Straaten, H., & Zandstra, D. (2002) Nitroglycerin in septic shock after intravascular volume resuscitation. The Lancet, 360(9343), 1395-1396. DOI: 10.1016/S0140-6736(02)11393-6  

  • March 26, 2013
  • 11:30 AM

Does the Goal of a Pulse Lead to Bad Resuscitation Decisions

by Rogue Medic in Rogue Medic

The paper does address some interesting aspects of resuscitation.

ROSC (Return Of Spontaneous Circulation) is the goal for many people.

ROSC is a red herring.

Those of us who think ROSC is important do not seem to understand how much long-term damage we can do in our attempts to get ROSC, or to get ROSC quickly.

This study helps to point out some of the inconsistencies with our ROSC fetish.... Read more »

Koscik, C., Pinawin, A., McGovern, H., Allen, D., Media, D., Ferguson, T., Hopkins, W., Sawyer, K., Boura, J., & Swor, R. (2013) Rapid Epinephrine Administration Improves Early Outcomes in Out-of-Hospital Cardiac Arrest. Resuscitation. DOI: 10.1016/j.resuscitation.2013.03.023  

  • March 22, 2013
  • 11:00 AM

Equipoise and Ethics and IRBs, Oh My!

by Rogue Medic in Rogue Medic

In the comments to what I wrote yesterday about seizures and a study comparing lorazepam (Ativan), diazepam (Valium), and placebo,[1] Brooks Walsh had the following comment –

"Although I’ve read the study before, I am only wondering now how the IRB for Alldredge 2001 thought there was 'equipoise' between placebo and benzos."... Read more »

Alldredge BK, Gelb AM, Isaacs SM, Corry MD, Allen F, Ulrich S, Gottwald MD, O’Neil N, Neuhaus JM, Segal MR, Lowenstein DH. (2001) A Comparison of Lorazepam, Diazepam, and Placebo for the Treatment of Out-of-Hospital Status Epilepticus. New England Journal of Medicine, 345(25), 1860-1860. DOI: 10.1056/NEJM200112203452521  

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

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. DOI: 10.1001/jama.2012.294  

  • March 14, 2013
  • 10:30 PM

Should We Use Immobilization For Penetrating Injuries To The Neck - Comments at Paramedic's Edge

by Rogue Medic in Rogue Medic

Are you required to backboard a patient who was shot in the neck no matter how the patient is presenting? [1]

That is the entire question that was asked at The Paramedic’s Edge.

There are really several questions being asked.... Read more »

  • March 10, 2013
  • 11:00 PM

Japanese man dies after 25 hospitals reject him

by Rogue Medic in Rogue Medic

In January, in Japan, 25 hospitals refused to permit an ambulance to transport a man who was pronounced dead when he finally arrived at a hospital.

Were the patients already in the ED (Emergency Department) less stable than this patient?

Was this patient going to be the straw that breaks the camel’s back and result in the deaths of other patients already in the ED?

What kind of evidence do we have to justify diversion?
... Read more »

Khaleghi, M., Loh, A., Vroman, D., Chan, T., & Vilke, G. (2007) The Effects of Minimizing Ambulance Diversion Hours on Emergency Departments. The Journal of Emergency Medicine, 33(2), 155-159. DOI: 10.1016/j.jemermed.2007.02.014  

Burke, L., Joyce, N., Baker, W., Biddinger, P., Dyer, K., Friedman, F., Imperato, J., King, A., Maciejko, T., Pearlmutter, M.... (2013) The Effect of an Ambulance Diversion Ban on Emergency Department Length of Stay and Ambulance Turnaround Time. Annals of Emergency Medicine, 61(3), 303-3110. DOI: 10.1016/j.annemergmed.2012.09.009  

  • March 5, 2013
  • 05:30 PM

Bougies and ALS Airways

by Rogue Medic in Rogue Medic

The last paper we were working on for the EMS Research Podcast was this paper on the use of a bougie in the intubation of a simulated patient with spinal immobilization.

Is BAI (Bougie-Assisted Intubation) an improvement over traditional intubation (ETI or EndoTracheal Intubation)?... Read more »

  • February 28, 2013
  • 12:55 AM

Does Intubation Prevent Aspiration of Stomach Contents?

by Rogue Medic in Rogue Medic

This is a study that looked at the rate of aspiration among patients intubated in the PH (PreHospital or EMS) setting and compared them to patients intubated in the ED = (Emergency Department) setting.

There is one huge difference between these settings – EMS was not authorized to use any form of chemically assisted intubation or RSI (Rapid Sequence Induction/Intubation). At the time of this study, the only drugs available to snow the patient would have been morphine, midazolam (Versed)........ Read more »

Ufberg, J., Bushra, J., Karras, D., Satz, W., & Kueppers, F. (2005) Aspiration of gastric contents: association with prehospital intubation. The American Journal of Emergency Medicine, 23(3), 379-382. DOI: 10.1016/j.ajem.2005.02.005  

  • February 10, 2013
  • 12:00 PM

Advanced Airway vs. BVM During CPR – Which is Worse?

by Rogue Medic in Rogue Medic

The authors wanted to find out what method is (worst) best for ventilating patients during out-of-hospital treatment of cardiac arrest.
Endotracheal tube?
Supraglottic airway (laryngeal mask airway, laryngeal tube, and esophageal-tracheal twin-lumen airway device)?
BVM (Bag Valve Mask)?
This assumes that ventilations provide some sort of benefit to the patient. There is no evidence to support this myth.... Read more »

  • February 3, 2013
  • 10:00 PM

Is the Difference in Penetrating Trauma Mortality Truly Significant? Part I

by Rogue Medic in Rogue Medic

MV observed the following the lack of distinction in scene time for penetrating trauma mortality, which I did not give the proper attention in "EMS Time and Survival from Blunt and Penetrating Trauma." I will try to correct my mistake here.... Read more »

  • January 31, 2013
  • 11:00 PM

EMS Time and Survival from Blunt and Penetrating Trauma

by Rogue Medic in Rogue Medic

People will tell you that they just know the we need to load and go. Some even claim that the mythological Golden Hour is real. Maybe there will be an episode of Ancient Aliens about R Adams Cowley identifying the meaning of trauma and writing it on a cocktail napkin in a bar.
... Read more »

  • December 27, 2012
  • 10:00 PM

If the patient is asleep, does that mean that the pain is gone?

by Rogue Medic in Rogue Medic

Is it appropriate to stop giving pain medicine just because the patient is asleep?

My little burned patient was probably not expressing relief from pain with her periods of unresponsiveness – especially since she had not received anything for her severe pain. Each time that she woke up screaming, that was also a clue. the medical command doctor’s orders were to give no pain medicine.[1]

Is propofol effective at putting patients to sleep without relieving their pain?

Sleep do........ Read more »

Paqueron X, Lumbroso A, Mergoni P, Aubrun F, Langeron O, Coriat P, & Riou B. (2002) Is morphine-induced sedation synonymous with analgesia during intravenous morphine titration?. British journal of anaesthesia, 89(5), 697-701. PMID: 12393765  

  • December 19, 2012
  • 05:15 PM

More evidence that antibiotics are over-prescribed - How should that change?

by Rogue Medic in Rogue Medic

Today Lancet Infectious Diseases posted an early release of an article that shows that the antibiotic amoxicillin still does not work on viruses.

Many doctors still routinely prescribe antibiotics for viral infections.

Bias, perhaps the biggest confounder in medical research, is controlled for very well.

What does the study show?... Read more »

  • December 14, 2012
  • 12:45 AM

How do we measure the QT segment when there are prominent U waves?

by Rogue Medic in Rogue Medic

This ECG has large T waves, U waves, and P waves, but where does one end and the other begin?

When measuring the QT segment, where do we measure the end of the QT segment and why?... Read more »

Omar, H. (2012) Amiodarone-induced T-U fusion. The American Journal of Emergency Medicine, 30(9), 20810-208100. DOI: 10.1016/j.ajem.2011.10.024  

  • November 29, 2012
  • 09:30 PM

Is Digoxin a Killer?

by Rogue Medic in Rogue Medic

Digoxin (Lanoxin) is an antiarrhythmic drug, which means that it is also a proarrhythmic drug. Any drug that affects the heart’s conduction system can produced changes that are bad, good, or a combination of the two. Digoxin has been associated with a higher death rate, but is that because it is prescribed to sicker patients?... Read more »

Whitbeck, M., Charnigo, R., Khairy, P., Ziada, K., Bailey, A., Zegarra, M., Shah, J., Morales, G., Macaulay, T., Sorrell, V.... (2012) Increased mortality among patients taking digoxin-analysis from the AFFIRM study. European Heart Journal. DOI: 10.1093/eurheartj/ehs348  

  • November 15, 2012
  • 05:30 PM

Extreme Spinal Injury With Preservation of Neurologic Function

by Rogue Medic in Rogue Medic

How bad can spinal injuries be without causing paralysis?

The spine is supposed to be continuous.

The spine should not zig, zig, or take any other detours.

The red line over the spine should be drawn as a roughly straight line, with slight curvature, which can be extreme with kyphosis, scoliosis, or other diseases affecting the spine.... Read more »

  • November 14, 2012
  • 09:00 PM

Is a clot-busting drug safe for 6 hours after stroke symptom onset – or only for an hour and a half? – Part II

by Rogue Medic in Rogue Medic

It has been a couple of months since I wrote Part I and I have not been that motivated to write this part, but Dr. Jerome R Hoffman and Dr. Richelle J Cooper have been busy with the topic. Their paper appears in the current Emergency Medicine Australasia.

"Just before the release of the results of the third inter-national stroke trial (IST-3),1 the largest trial of thrombolysis in acute ischaemic stroke (AIS), the journal Stroke published a remarkable pre-emptive strike – a comm........ Read more »

  • October 30, 2012
  • 01:00 AM

Fluid Replacement in the vomiting child - IV, IO, or NG?

by Rogue Medic in Rogue Medic

Annals of Emergency Medicine has some Systematic Review Snapshots that are free and useful for getting a quick look at the evidence on various topics. In the current issue, there is a review of the evidence on fluid replacement for the child unable to take fluids orally, or unable to keep those fluids down.

Which is the best route to give fluids?



... Read more »

  • October 25, 2012
  • 06:30 PM

Uneventful prolonged misdiagnosis of esophageal intubation

by Rogue Medic in Rogue Medic

The ability of the patient to remain alive, and even stable, in spite of medical mismanagement, does not mean that the endotracheal tube has been placed endotracheally.

We have an infinite capacity for self-deception. This case is just one example of what is probably the most common mistake in medicine.
... Read more »

  • October 17, 2012
  • 05:00 PM

Nitroglycerin for Treatment of Acute, Hypertensive Heart Failure – Bolus, Drip or Both?

by Rogue Medic in Rogue Medic

If standard doses of nitrate – NTG, ISDN, or ISMN improve outcomes for CHF/ADHF patients, and larger IV doses are more effective than standard doses,[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] what method(s) of drug delivery works best?

High dose IV drip?

High dose IV bolus?

A high dose IV bolus combined with a high dose IV drip?... Read more »

Kwiatkowski, G.M.; Saely, S.; Purakal, J.; Mahajan, A.; Levy, P.D. (2012) Nitroglycerin for Treatment of Acute, Hypertensive Heart Failure - Bolus, Drip or Both?. Annals of Emergency Medicine, 60(4), 59-59. info:/

  • October 11, 2012
  • 08:15 PM

Is Epinephrine a Rat Poison AND a Human Poison?

by Rogue Medic in Rogue Medic

Dr. Minh LeCong has been a proponent of epinephrine in cardiac arrest, but he is now realizing that the evidence in favor of epinephrine is weak, old, and limited to animal studies. In humans, the evidence for epinephrine is based on an unreasonable infatuation with the temporary production of a pulse.
... Read more »

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