Dexmedetomidine in the ED

Is a viable alternative sedative/hypnotic agent for procedural sedation in the ED? Mark Estrellado MD, PGY3 Given the regularity of noninvasive and minimally invasive procedures that emergency physicians must perform on a daily basis, proficiency in the art of procedural sedation remains an indispensable component of their already broad repertoire of skills. And while every discussion on the topic of procedural sedation most often begins with the description of the "ideal sedative" as an inexpensive agent that is easily administered, has a rapid and predictable onset and dissipation of effect without prolonged accumulation despite repeated dosing, and is free of adverse side effects and drug interactions, no such agent exists. Instead, the ED physician's current armamentarium consists of a handful of agents--namely benzodiazepines, opioids, propofol, ketamine, and etomidate--each of which…
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Cancel the Cath Lab Activation; Its only an NSTEMI

Cardiology, CCU Rotation, EBM, residents
By Andrew Barbera, PGY3 Who Needs a Cath?   63 year old male with history of HTN, OA s/p R hip replacement, PTSD was BIBEMS after syncopal event. Pt states that evening he felt acute general weakness when he was on the subway. The weakness worsened when he got off the subway and was walking in the street. He then developed acute severe SOB and he stopped and rested himself on the trunk of a car. Pt then lost consciousness and awoke in the ambulance. Pt stated upon awakening he was alert and oriented. Pt denied CP, palpitations, diaphoresis or dizziness before passing out or during initial ED evaluation. Pt also denied any recent exercise intolerance, recent chest pain, orthopnea or additional symptoms. Pt reported normal stress test done 6…
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Why Not Dobutamine?

Cardiology, CCU Rotation, EBM, Why We Do What We Do
Why Not Dobutamine? PGY3 Neil McCormack   A patient rolls into the emergency room. You don’t need this. You’ve got a lot of other patients. This patient however is in shock. They are hypotensive and with a decreased mental status. You need to give them something and the attending asks what vasopressors you would like. “Why not dobutamine” the intern asks. With a sigh and a heavy eye roll you turn away. But… Why not dobutamine?                 Dobutamine is a synthetic catecholamine used primarily for cardiac stress testing outside of the hypotensive patient (8). This is due to the positive inotropic effects it plays on the heart. Dobutamine acts via a 3:1 selective agonist effect on β1 and β2 receptors respectively. This causes…
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Dilt v. Metoprolol in Afib/RVR

Cardiology, EBM, Journal Club, Why We Do What We Do
by Najm Haque, PGY2   Atrial fibrillation with rapid ventricular response is a common emergency room problem. Patient with stable blood pressure who present in Afib with RVR need medications to control their heart rate (unstable patients require more cardioversion). Traditionally, these patients receive beta blockers or calcium channel blockers in IV form for rate control. The most common medications used in the US are metoprolol and diltiazem, but it is unclear which is superior. Fromm et al Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department This study was published in the Journal of Emergency Medicine in April 2015 and compared how fast rate control was achieved in diltiazem vs metoprolol. This was a prospective, double-blind study which compared…
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