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1.
J Pharm Pract ; : 8971900211048623, 2021 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-34601987

RESUMO

Purpose: The effect of the use of antihypertensive agents in patients prior to the development of shock is unclear. The purpose of this study was to determine the impact of antihypertensive agents on vasopressor dose and duration in shock. Materials and Methods: This retrospective, single-center study included patients with shock who received at least one vasopressor for at least 24 hours after shock onset from January 1 to June 30, 2017. Patients taking an antihypertensive agent(s) were compared to those who were not. The primary outcome was the number of vasopressor-free hours at 72 hours. Secondary outcomes included maximum and cumulative vasopressor doses, intensive care unit length of stay, and 30-day mortality. Results: One hundred and sixty-eight patients were included and 99 (59%) were on antihypertensives. Distributive shock was the most common type of shock (75.5%) and more patients taking antihypertensives had hypertension, coronary artery disease, and dyslipidemia at baseline. There was no difference in the number of vasopressor-free hours at 72 hours between patients taking an antihypertensive medication(s) and the control group (2 hours vs 1 hour; P = .11). No difference was found between any of the secondary outcomes. Conclusion: Patients taking antihypertensive agents prior to shock onset did not require increased vasopressor doses or duration.

3.
Artigo em Inglês | MEDLINE | ID: mdl-34232286

RESUMO

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

4.
Am J Emerg Med ; 2021 Jul 21.
Artigo em Inglês | MEDLINE | ID: mdl-34312038

RESUMO

Acute bilateral hearing loss is an uncommon presentation in the Emergency Department (ED), with a variety of potential causes. It is important to consider neurologic vascular etiologies as a cause for acute sensorineural hearing loss. We report a case of acute hemorrhagic stroke presenting as acute bilateral hearing loss. A 60-year-old male with a history of atrial fibrillation presented to the ED with the acute onset of bilateral hearing loss with otherwise intact neurologic testing. He was found to have an acute left temporal hemorrhagic stroke, and magnetic resonance imaging demonstrated multifocal ischemia including an acute right temporal ischemic stroke. In the ED setting, cerebrovascular pathology is an important consideration in the patient presenting with acute hearing loss in the absence of an alternative diagnosis. Missing such a diagnosis can lead to significant morbidity and mortality.

5.
Am J Emerg Med ; 49: 326-330, 2021 Jun 26.
Artigo em Inglês | MEDLINE | ID: mdl-34224954

RESUMO

INTRODUCTION: Four-factor prothrombin complex concentrate (4PCC) is the preferred reversal agent for warfarin reversal, although the ideal dose is unknown. Fixed-dose 4PCC offers simplified dosing compared to standard-dosing algorithms with potentially lower risks of thromboembolic complications given lower doses are typically utilized. METHODS: Retrospective, observational, multicentered, pre- post- study of patients who received 4PCC for warfarin reversal among four hospitals within the same regional health system. Standard-dose patients received variable doses ranging from 25 to 50 units/kg based on total body weight and initial INR and fixed-dose patients received 2000 units. The primary outcome was achievement of a target INR ≤ 1.4 on the first post-4PCC INR result. RESULTS: After exclusions, 48 and 42 patients were analyzed in the standard-dose and fixed-dose groups, respectively. There was no difference in the ability to achieve a target INR of ≤1.4 (82.6% vs 81.5%, p = 0.14). Both groups received the same median dose of 2000 units, although fixed-dose patients actually received a higher weight-based dose than standard-dose patients (27 units/kg vs 24.5 units/kg). CONCLUSION: A fixed-dose 4PCC regimen of 2000 units among patients with ICH was as effective as standard-dose 4PCC for INR reversal among patients with ICH. However, fixed-doses of 2000 units at times exceeded standard 4PCC doses which may be contradictory to the goals of fixed-dose 4PCC for warfarin reversal.

6.
Am J Emerg Med ; 50: 93-96, 2021 Jul 22.
Artigo em Inglês | MEDLINE | ID: mdl-34329955

RESUMO

BACKGROUND: Treatment of acute ischemic stroke (AIS) with intravenous alteplase within 4.5 h of symptom onset is associated with neurologic improvement. High baseline blood pressure (BP) and BP variability during the first 24 h of AIS is associated with increased early adverse events and death. The purpose of this study is to characterize the incidence of poor neurologic outcome in patients treated with alteplase for AIS who received antihypertensive medications prior to and within the first 24 h following alteplase administration compared with patients who did not. METHODS: This was a multicenter, retrospective cohort of patients >18 years diagnosed with AIS from January 1, 2011 through December 31, 2015 who received one or more antihypertensive medication in the first 24 h of AIS in patients receiving alteplase compared to controls. The primary endpoint was poor neurologic outcome at 90 days, according to modified Rankin Scale ≥3. Univariate analysis was conducted using Chi-square, Fisher's exact test, or Mann-Whitney U test. Multivariable logistic regression was conducted to determine independent predictors of poor outcome. RESULTS: Of the 587 patients evaluated, 351 (59.7%) were included, of which 127 (36.2%) received antihypertensive(s). More patients in the antihypertensive treatment group had a history of hypertension (88.2% vs. 69.6%, p < 0.01), diabetes (37% vs. 25.5%, p = 0.03) and chronic kidney disease (19.7% vs. 8.5%, p < 0.01). Intravenous push labetalol was most commonly administered (81.2%), followed by nicardipine (44.1%), and hydralazine (22%). More patients in the antihypertensive treatment group experienced poor neurologic outcome at 90 days (53.5% vs. 38.8%, p < 0.01), however, this finding was not observed after multivariable logistic regression. CONCLUSION: Antihypertensive treatment in the first 24 h of AIS was associated with poor neurologic outcomes at 90 days. However, after controlling for other clinical factors in a multivariable logistic regression, this association was no longer observed.

7.
Am J Emerg Med ; 2021 Jun 18.
Artigo em Inglês | MEDLINE | ID: mdl-34217564

RESUMO

Transverse myelitis (TM) is an inflammatory disorder of the spinal cord characterized by acute onset sensory loss and motor weakness below the level of the lesion. The etiology of the disease is varied, and diagnosis of TM in the Emergency Department (ED) can be difficult owing to the low incidence of the disease, and frequently insidious onset. We report a case of a 59-year-old female who presented to the ED from home with left upper quadrant abdominal pain and flank pain of sudden onset. While in the ED, she experienced left lower extremity weakness and sensory changes that slowly progressed bilaterally, and ultimately was diagnosed with transverse myelitis. Transverse myelitis rarely diagnosed in the ED setting, but it is an important clinical consideration when evaluating ED patients presenting with both pain and progressive neurologic symptoms.

8.
Am J Emerg Med ; 49: 200-205, 2021 Jun 14.
Artigo em Inglês | MEDLINE | ID: mdl-34139435

RESUMO

The year 2020 was not easy for Emergency Medicine (EM) clinicians with the burden of tackling a pandemic. A large focus, rightfully so, was placed on the evolving diagnosis and management of patients with COVID-19 and, as such, the ability of clinicians to remain up to date on key EM pharmacotherapy literature may have been compromised. This article reviews the most important EM pharmacotherapy publications indexed in 2020. A modified Delphi approach was utilized for selected journals to identify the most impactful EM pharmacotherapy studies. A total of fifteen articles, eleven trials and four meta-analyses, were identified. This review provides a summary of each study, along with a commentary on the impact to the EM literature and EM clinician.

9.
Ann Pharmacother ; : 10600280211021925, 2021 Jun 02.
Artigo em Inglês | MEDLINE | ID: mdl-34075807

RESUMO

BACKGROUND: Patients with COVID-19 acute respiratory distress syndrome (ARDS) have been shown to have high sedation requirements. OBJECTIVE: The purpose of this study was to compare sedative use between patients with COVID-19 ARDS and non-COVID-19 ARDS. METHODS: This was a retrospective study of patients with COVID-19 ARDS compared with historical controls of non-COVID-19 ARDS who were admitted to 2 hospitals from March 1, 2020, to April 30, 2020, and April 1, 2018, to December 31, 2019, respectively. The primary outcome was median cumulative dose of propofol (µg/kg) at 24 hours after intubation. RESULTS: There were 92 patients with COVID-19 ARDS and 37 patients with non-COVID-19 ARDS included. Within the first 24 hours of intubation, patients with COVID-19 ARDS required higher total median doses of propofol: 51 045 µg/kg (interquartile range, 26 150-62 365 µg/kg) versus 33 350 µg/kg (9632-51 455 µg/kg; P = 0.004). COVID-19 patients were more likely receive intravenous lorazepam (37% vs 14%; P = 0.02) and higher cumulative median doses of midazolam by days 5 (14 vs 4 mg; P = 0.04) and 7 of intubation (89 vs 4 mg; P = 0.03) to achieve the same median Richmond Analgesia-Sedation Scale scores. COVID-19 ARDS patients required more ventilator days (10 vs 6 days; P = 0.02). There was no difference in 30-day mortality. CONCLUSION AND RELEVANCE: Patients with COVID-19 ARDS required higher doses of propofol and benzodiazepines than patients with non-COVID-19 ARDS to achieve the same median levels of sedation.

10.
West J Emerg Med ; 22(2): 163-169, 2021 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-33856296

RESUMO

INTRODUCTION: Factor Xa (fXa) inhibitor reversal for life-threatening bleeding is controversial due to a lack of high-quality evidence. The purpose of this study was to determine the hemostatic efficacy of four-factor prothrombin complex concentrate (4F-PCC) for the reversal of fXa inhibitors compared to warfarin for life-threatening bleeding. METHODS: This was a multicenter, retrospective cohort study at two academic medical centers between January 1, 2014-December 31, 2019, which included patients who presented to the emergency department with a life-threatening bleed necessitating anticoagulation reversal with 4F-PCC. The primary endpoint was achievement of hemostatic efficacy after 4F-PCC administration. RESULTS: Of the 525 patients who had an order for 4F-PCC during the study period, 148 patients met the criteria for inclusion (n = 48 fXa inhibitor group; n = 100 warfarin group). Apixaban (52.1%) and rivaroxaban (45.8%) were the most commonly used fXa inhibitors. Effective hemostasis was similar between groups (79.2% fXa inhibitor group vs 85% warfarin group, p = 0.38). This was consistent across all types of bleeding. Thrombotic events were rare in both groups (2% vs 3%). CONCLUSION: This multicenter, retrospective cohort study demonstrated that using 4F-PCC for treatment of life-threatening bleeding produced effective hemostasis in patients on fXa inhibitors and warfarin.


Assuntos
Anticoagulantes/efeitos adversos , Fatores de Coagulação Sanguínea/efeitos adversos , Inibidores do Fator Xa/efeitos adversos , Hemorragia/induzido quimicamente , Pirazóis/efeitos adversos , Piridonas/efeitos adversos , Tromboembolia/induzido quimicamente , Varfarina/efeitos adversos , Idoso , Fatores de Coagulação Sanguínea/administração & dosagem , Feminino , Hemorragia/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tromboembolia/epidemiologia , Resultado do Tratamento
11.
Pharmacotherapy ; 41(2): 191-197, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33421200

RESUMO

BACKGROUND: Dexmedetomidine is a centrally acting α-2 receptor agonist used to maintain light analgosedation in mechanically ventilated adults. This study was conducted to determine factors predictive of successful maintenance of light sedation (Richmond Agitation-Sedation Scale (RASS) 0 to -2) for ≥60% of the first 48 h of mechanical ventilation with dexmedetomidine. METHODS: This was a single-center, retrospective, cohort study of critically ill adult patients receiving dexmedetomidine and admitted to an intensive care unit (ICU) between January 1, 2013, and August 31, 2019. A multivariable logistic regression analysis was performed in patients receiving dexmedetomidine for sedation to assess patient and clinical characteristics associated with a positive clinical response to dexmedetomidine. RESULTS: Of 1065 patients reviewed for study inclusion, 158 patients were included. Sixty-two percent of patients initiated on dexmedetomidine to maintain light sedation were able to remain within this sedation target ≥60% of the time during the first 48 hours of therapy. Patients maintained within the target RASS score ≥60% of the time had a higher percentage of ventilator-free days at 14 days (p = 0.044). The odds of having a mean time within goal RASS score ≥60% in the first 48 hours of mechanical ventilation after intubation were decreased by 9% for every point increase in sequential organ failure assessment score (odds ratio: 0.91, 95% confidence interval: 0.82-0.99). CONCLUSION: Patients were less likely to maintain light sedation with dexmedetomidine as their degree of critical illness increased. The duration of time maintained within goal sedation after dexmedetomidine initiation and the impact on patient outcomes remain a research priority.

12.
Am J Emerg Med ; 41: 265.e5-265.e8, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33010991

RESUMO

Intracranial hemorrhage (ICH) is a known complication in patients with ventricular assist devices (VAD). We present a case of a 42-year-old male with a VAD and on warfarin who presented to the emergency department with ICH necessitating anticoagulant reversal. An attenuated dose of 15 units/kg of 4-factor prothrombin complex-concentrates (4F-PCC) was given and the patient's coagulation profile was subsequently assessed using rotational thromboelastometry (ROTEM®) to determine appropriateness of reversal. ROTEM® analysis showed adequate reversal at the time of assessment and the patient ultimately returned home without further functional deficits, highlighting the role of ROTEM® to guide anticoagulation reversal in the VAD patient population.


Assuntos
Anticoagulantes , Fatores de Coagulação Sanguínea/uso terapêutico , Coração Auxiliar/efeitos adversos , Hemorragias Intracranianas/tratamento farmacológico , Hemorragias Intracranianas/etiologia , Tromboelastografia , Varfarina/antagonistas & inibidores , Adulto , Humanos , Masculino
13.
Acad Emerg Med ; 28(6): 647-654, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33354815

RESUMO

OBJECTIVE: This study aimed to determine if 0.15 mg/kg intravenous (IV) subdissociative ketamine is noninferior to 0.3 mg/kg in emergency department (ED) patients with acute pain. METHODS: This randomized, prospective, double-blinded, noninferiority trial included patients' age 18 to 59 years presenting to the ED with acute moderate to severe pain. Subjects were randomized to IV subdissociative ketamine, 0.15 mg/kg ("low" dose) or 0.30 mg/kg ("high" dose), over 15 minutes. The primary endpoint was the 11-point numeric rating scale (NRS) pain score between groups at 30 minutes. Secondary endpoints included NRS pain scores at 15 and 60 minutes; change in NRS at 15, 30, and 60 minutes; rescue analgesia; and adverse effects. The noninferiority limit, δ0 , was set to 1.3. RESULTS: Forty-nine patients were included in each group. After the differences in the baseline NRS score were adjusted for, the mean NRS score at 30 minutes was 4.7 (95% confidence interval [CI] = 3.8 to 5.5) in the low-dose group and 5.0 (95% CI = 4.2 to 5.8) in the high-dose group (mean difference = 0.4, 95% CI = -0.8 to 1.5), indicating that the low-dose subdissociative ketamine was noninferior to the high dose (lower limit of 95% CI = -0.8 to ≥1.3 = -δ0 ). Adverse effects were similar at 30 minutes. At 15 minutes, the high-dose group experienced greater change in NRS; however, more adverse effects occurred. CONCLUSION: Our data did not detect a large difference in analgesia or adverse effect profile between 0.15 mg/kg IV ketamine and 0.30 mg/kg in the short-term treatment of acute pain in the ED.


Assuntos
Dor Aguda , Analgesia , Ketamina , Dor Aguda/tratamento farmacológico , Adolescente , Adulto , Analgésicos Opioides , Método Duplo-Cego , Serviço Hospitalar de Emergência , Humanos , Ketamina/efeitos adversos , Pessoa de Meia-Idade , Medição da Dor , Estudos Prospectivos , Resultado do Tratamento , Adulto Jovem
14.
J Pharm Pract ; : 897190020979610, 2020 Dec 11.
Artigo em Inglês | MEDLINE | ID: mdl-33302788

RESUMO

INTRODUCTION: Etomidate is commonly used for induction of anesthesia for rapid sequence intubation (RSI). It has little impact on hemodynamic status, making it a widely used agent. Due to the inhibition of cortisol production, etomidate causes adrenal suppression. The purpose of this study is to determine whether there is a correlation with etomidate use and the incidence of secondary infections. METHODS: This was a retrospective cohort of hospitalized patients who received either etomidate or control (ketamine, propofol, or no agent) for RSI. The primary endpoint was the incidence of secondary infections. Secondary outcomes included number of mechanical ventilator-free days within 28 days, 30-day mortality, length of hospital stay, and length of intensive care unit stay. RESULTS: A total of 434 patients were reviewed, of which 129 (29.7%) met the study criteria (n = 94 etomidate; n = 35 control). The incidence of secondary infection was numerically higher in the etomidate group compared with the control group, though this was not statistically significant (38.7% vs. 28.6%, p = 0.447). Also, though the secondary outcomes showed no statistically significant difference between the groups, the patients in the control group had a longer hospital stay (14.0 vs. 18.1, p = 0.20) and a longer ICU stay (11.0 vs. 14.1, p = 030). Furthermore, the etomidate group had a non-statistically significant higher incidence of bacteremia (8 vs. 0, p = 0.17). CONCLUSION: The use of etomidate was not associated with increased incidence of secondary infection. To fully understand the effects of etomidate use and its subsequent adrenal suppression, larger studies are needed.

16.
J Stroke Cerebrovasc Dis ; 29(12): 105351, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33045624

RESUMO

INTRODUCTION: Small, dense low-density lipoprotein (sdLDL) is strongly associated with symptomatic carotid artery stenosis, but is not routinely evaluated in ischemic stroke patients. A method using the logarithmic transformation of the ratio of the plasma concentration of triglycerides (TGY) to HDL-cholesterol (HDL-C)[(Log[TGY/HDL-C])] has been described as a surrogate marker for sdLDL termed the atherogenic index of plasma (AIP). OBJECTIVE: To determine if the AIP is independently associated with symptomatic carotid artery stenosis. METHODS: We conducted a single center case-controlled study using a sample of ischemic stroke patients and compared risk factors of patients with and without symptomatic carotid artery stenosis. A multivariate logistic regression model was used to determine if the AIP divided into four quartiles was independently associated with symptomatic carotid artery stenosis. This model was compared to three other lipid models. Associations between non-lipid variables and the AIP were also identified. RESULTS: 31 cases of ischemic stroke due to symptomatic carotid artery stenosis and 236 controls of ischemic stroke not due to carotid artery stenosis were identified. Of the four lipid models assessed, only the model including the AIP (model 4) was found to be significantly associated with symptomatic carotid artery stenosis. The odd's ratio (OR) for quartile 3 was 3.82 (95% CI 1.03-14.17) and the OR for quartile 4 was 4.13 (95% CI 1.09-15.54) using quartile 1 as a reference. Metabolic syndrome was the only variable associated with the AIP (OR 5.06 95% CI 2.6-9.7). CONCLUSION: At our single center, the AIP was the only lipid parameter independently associated with symptomatic carotid artery stenosis; and metabolic syndrome was independently associated with the AIP. The AIP may serve as a useful surrogate of sdLDL in patients with symptomatic carotid artery stenosis.


Assuntos
Estenose das Carótidas/etiologia , HDL-Colesterol/sangue , Dislipidemias/sangue , Síndrome Metabólica/sangue , Triglicerídeos/sangue , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Estenose das Carótidas/sangue , Estenose das Carótidas/diagnóstico por imagem , Dislipidemias/complicações , Dislipidemias/diagnóstico , Feminino , Humanos , Masculino , Síndrome Metabólica/complicações , Síndrome Metabólica/diagnóstico , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco
19.
Crit Care Explor ; 2(6): e0132, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32695997

RESUMO

Objectives: This survey sought to characterize the national prescribing patterns and barriers to the use of thrombolytic agents in the treatment of pulmonary embolism, with a specific focus on treatment during actual or imminent cardiac arrest. Design: A 19-question international, cross-sectional survey on thrombolytic use in pulmonary embolism was developed, validated, and administered. A multivariable logistic regression was conducted to determine factors predictive of utilization of thrombolytics in the setting of cardiac arrest secondary to pulmonary embolism. Setting: International survey study. Subjects: Physicians, pharmacists, nurses, and other healthcare professionals who were members of the Society of Critical Care Medicine. Interventions: None. Measurements and Main Results: Thrombolytic users were compared with nonusers. Respondents (n = 272) predominately were physicians (62.1%) or pharmacists (30.5%) practicing in an academic medical center (54.8%) or community teaching setting (24.6%). Thrombolytic users (n = 177; 66.8%) were compared with nonusers (n = 88; 33.2%) Thrombolytic users were more likely to work in pulmonary/critical care (80.2% thrombolytic use vs 59.8%; p < 0.01) and emergency medicine (6.8% vs 3.5%; p < 0.01). Users were more likely to have an institutional guideline or policy in place pertaining to the use of thrombolytics in cardiac arrest (27.8% vs 13.6%; p < 0.01) or have a pulmonary embolism response team (38.6% vs 19.3%; p < 0.01). Lack of evidence supporting use and the risk of adverse outcomes were barriers to thrombolytic use. Working in a pulmonary/critical care environment (odds ratio, 2.36; 95% CI, 1.24-4.52) and comfort level (odds ratio, 2.77; 95% CI, 1.7-4.53) were predictive of thrombolytic use in the multivariable analysis. Conclusions: Most survey respondents used thrombolytics in the setting of cardiac arrest secondary to known or suspected pulmonary embolism. This survey study adds important data to the literature surrounding thrombolytics for pulmonary embolism as it describes thrombolytic user characteristic, barriers to use, and common prescribing practices internationally.

20.
Am J Emerg Med ; 38(9): 1984.e1-1984.e3, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32505475

RESUMO

INTRODUCTION: Systemic reactions from local tetracaine use are often an anomaly - not only is tetracaine short-acting and quickly metabolized by the pseudocholinesterase system leading to very limited systemic uptake, but most adverse reactions are usually associated with dental or spinal anesthesia. Furthermore, reactions to local anesthetics manifest in standard allergy-type reactions. When local anesthetics lead to nervous or cardiac system abnormalities, it is termed a local anesthetic systemic toxicity - an event with an incidence currently estimated to be 0.03%. CASE PRESENTATION: We present a case of a 56-year-old female who experienced a systemic reaction to tetracaine 1% while undergoing a fine needle biopsy of a thyroid nodule. The patient had previous allergic reactions to lidocaine. Upon conclusion of the procedure, the patient began convulsing and became rigid and non-verbal. She was able to move all extremities, had no respiratory distress, no swelling, hives, or redness, and was swallowing without difficulty. After about 5 min, the patient began to improve and experienced reversal of all previous symptoms. Her physical exam and labs were otherwise normal, she returned to her baseline functioning, and was discharged without any medical interventions. DISCUSSION: This case illustrates a case of LAST in a patient with previous Lidocaine allergy without any other obvious risk factors. There have been no cases of cross-reaction between lidocaine and tetracaine so it explores the possibility of patients having cross reaction to those two different kinds of local anesthetic.


Assuntos
Anestésicos Locais/toxicidade , Convulsões/induzido quimicamente , Tetracaína/toxicidade , Anestesia Local/efeitos adversos , Anestesia Local/métodos , Biópsia por Agulha/efeitos adversos , Feminino , Humanos , Pessoa de Meia-Idade , Nódulo da Glândula Tireoide/patologia
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