Category: Critical Care
Keywords: amikacin, Torsades de pointes, QT prolongation (PubMed Search)
Torsades de pointes and QT prolongation Associated with Antibiotics
The authors queried the United States FDA Adverse Event Reporting System (FAERS) from 01/01/2015 to 12/31/2017 for reports of Torsade de points/QT prolongation (TdP/QT).
Reporting Odd Ratio (ROR) was calculated as the ratio of the odds of reporting TdP/QTP versus all other ADRs for a given drug, compared with these reporting odds for all other drugs present in FAERS
FAERS contained 2,042,801 reports from January 1, 2015 to December 31, 2017. There were 3,960 TdP/QTP reports from the study period (0.19%).
Macrolides ROR 14 (95% CI 11.8-17.38)
Linezolid ROR 12 (95% CI 8.5-18)
Amikacin ROR 11.8 (5.57-24.97)
Imipenem-cilastatin ROR 6.6 (3.13-13.9)
Fluoroquinolones ROR 5.68 (95% CI 4.78-6.76)
These adverse events are voluntary reports
There might be other confounded by concomitant drugs such as ondansetron, azole anti-fungals, antipsychotics.
This study confimed the previously-known antibiotics to be associated with Torsades de pointes and QT prolongation (Macrolides, Linezolid, Imipenem and Fluoroquinolones). However, this study found new association between amikacin and Torsades de pointes/QT prolongation.
Teng C, Walter EA, Gaspar DKS, Obodozie-Ofoegbu OO, Frei CR. Torsades de pointes and QT prolongation Associations with Antibiotics: A Pharmacovigilance Study of the FDA Adverse Event Reporting System. Int J Med Sci. 2019 Jun 10;16(7):1018-1022.
Keywords: opioids, toxicology (PubMed Search)
The pattern of prescription drug abuse continues to center around semisynthetic opioids like oxycodone and hydrocodone. Federal regulations have now raised hydrocodone to a schedule II drug like oxycodone. Despite efforts, the slope for natural and semisynthetic opioids remains steep. The ED measures of education, limit prescriptions for acute pain, minimize number of days/pills prescribed and utlize the prescription drug monitoring program are some basics that can assist you in better prescribing habits.
NCHS Data Brief, Number 166, September 2014
Category: Critical Care
Keywords: Right Ventricle, RV Size (PubMed Search)
Rapid Assessment of the RV on Bedside Echo
There are several causes of acute RV dysfunction resulting in a patient presenting to the ER with unstable hemodynamics. Some of these include acute cor pulmonale, acute right sided myocardial infarction and acute submassive or massive pulmonary embolism. While bedside assessment of the LV function is often performed by the ED physician, simultaneous evaluation of the RV can provide crucial information that can help guide therapeutic decisions to prevent worsening of the patient’s clinical condition. A rough guideline to determine RV size and function is below using the apical 4 chamber view.
Normal RV size : <2/3 the size of the LV
Mildly enlarged RV : >2/3 the size of the LV, but not equal in size
Moderately enlarged RV: RV size = LV size
Severely enlarged RV: RV size > LV size
Patients who are found to have RV dilation should be given fluids in a judicious fashion as the RV is not tolerant of fluid overload. Early diagnosis of the cause of acute RV failure should be sought to guide definitive therapy, but early institution of inotropic support should be considered. Frequent reassessments of biventricular function during resuscitation should be performed.
Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography Endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography, J Am Soc Echocardiogr 2010;23:685-713
Category: Critical Care
Keywords: peri-Intubation, shock index (PubMed Search)
Identifying patients at risk of hypotension during intubation is not always straight forward. The prevalence of peri-intubation hypotension in the Emergency Department has been demonstrated to be approximately 20%.1 And while certain variables increase the likelihood of peri-intubation hypotension (ex. Shock index> 0.80), no single factor predicts it accurately enough to be used at the bedside.2 In the majority of patients undergoing intubation, clinicians should be prepared for peri-intubation hypotension with either vasopressor infusions or push dose pressors.
1. Heffner AC, Swords D, Kline JA, Jones AE. The frequency and significance of postintubation hypotension during emergency airway management. J Crit Care. 2012;27(4):417.e9-13.
2. Heffner AC, Swords DS, Nussbaum ML, Kline JA, Jones AE. Predictors of the complication of postintubation hypotension during emergency airway management. J Crit Care. 2012;27(6):587-93.
Keywords: D-Dimer, Pregnancy (PubMed Search)
D-Dimer levels are known to be elevated in pregnancy. But how high is too high and can this test be used in the workup of VTE in pregnant patients?
Recent literature indicates that D-dimer levels in each of the three trimesters are approximately 39% higher: 700, 1000, and 1400 ng/dL for each trimester (normal cutoff 500 ng/dL). So, figure out what trimester your patient is in and use the corresponding D-Dimer level for that trimester.
Hernandez J, Hambleton G, Kline JA. D-dimer concentrations in normal pregnancy. Acad Emerg Med 2004;11:526-527