The American journal of emergency medicine
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The outcomes of large-volume IVF administration to septic shock patients with comorbid congestive heart failure (CHF) and/or end-stage renal disease (ESRD) are uncertain and widely debated in the existing literature. Despite this uncertainty, CMS continues to recommend that 30 ml/kg of an intravenous crystalloid solution be administered to patients in septic shock starting within 3 h of presentation. We performed a systematic review and meta-analysis to assess the relationship between adherence to this guideline and outcomes among patients whose underlying comorbidities present a risk of fluid overload. ⋯ Among septic shock patients with CHF and/or ESRD, administration of greater than or equal to 30 ml/kg IVF was associated with a non-significant increase in odds of mortality. All other outcomes measured were found to be non-significant, although there was a trend toward better outcomes among patients in the restricted-volume compared to the standard-volume IVF groups. Since this meta-analysis only included five observational studies, more studies are needed to guide an optimal volume and rate of fluid administration in this patient population.
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Meta Analysis
Effectiveness and safety of tranexamic acid in pediatric trauma: A systematic review and meta-analysis.
Trauma is the leading cause of childhood death in the United States. Our goal was to determine the effectiveness of tranexamic acid (TXA) in improving survival in pediatric trauma. ⋯ The utility of TXA in children with trauma is unclear. Guidelines supporting TXA use in pediatric trauma may not be based on the available evidence of its use in this context. Rigorous trials measuring survival and other meaningful outcomes and exploring optimal TXA dosing are urgently needed. Study Registration (PROSPERO): CRD42020157683.
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Randomized Controlled Trial
Intravenous ibuprofen versus sodium valproate in acute migraine attacks in the emergency department: A randomized clinical trial.
Sodium valproate and ibuprofen are drugs with known efficacy in the treatment of headache associated with acute migraine attacks. In this study, our aim was to compare the efficacy of these two drugs in the treatment of acute migraine attacks when administered as a single intravenous (IV) dose in the emergency department. ⋯ Ninety-nine patients (49 patients in the sodium valproate group and 50 in the ibuprofen group) completed the trial, and their data were included in the statistical analysis. The mean decrease in the post-treatment delta NRS values was statistically significantly higher in the sodium valproate group than in the ibuprofen group. The mean differences were 1.69 [confidence interval (CI): 1.02-2.37, p<0.001], the mean difference between N0 and N2 was 3.61 (CI: 2.96-4.26, p < 0.001), the mean difference between N0 and N3 was 4.11 (CI: 3.54-4.67, p < 0.001), and the mean difference between N0 and N4 was 3.92 (CI: 3.67-4.46, p < 0.001). The number of patients who achieved the primary endpoint of pain relief was significantly higher in the sodium valproate group than in the ibuprofen group (p < 0.001). According to the Kaplan-Meier analysis showing the rates of reaching the targeted endpoint, there was a significant difference in the efficacy of the two-treatment group (χ2 = 79.98, CI: 80.35-99.65; p = 0.000).
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An increasing number of pediatric patients with inherited metabolic disorders are reaching adulthood. In addition, many patients are diagnosed for the first time in adult life due to improved awareness of these disorders and the availability of advanced diagnostic technology. Knowledge of these inherited metabolic disorders in adults is crucial for the emergency physician to promptly recognize their acute illness and appropriately manage them in the emergency department. ⋯ Acute metabolic decompensation is a life-threatening condition. The emergency physician is usually the first provider to evaluate these patients when they present to the emergency department. Early recognition of their illness and prompt management of these cases improve patient outcomes.
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Caffeine poisoning is relatively rare, and a near-fatal caffeine overdose is highly uncommon. We present an 18-year-old male who attempted suicide with 295 mg/kg pure caffeine powder (lethal oral dose: 150-200 mg/kg) and was successfully rescued. ⋯ Then, hemodialysis ultimately eliminated serum caffeine and completely alleviated caffeine-related central nervous system toxicity. We discuss the clinical symptoms, management and toxicodynamics based on the concentration of caffeine and its metabolites in serum and urine.