NSAIDS increase risk of Heart Attacks

A cohort of 446 763 individuals including 61 460 with acute myocardial infarction was acquired. Taking any dose of NSAIDs for one week, one month or more than a month was associated with an increased risk of myocardial infarction. With use for one to seven days, the probability of increased myocardial infarction risk (posterior probability of odds ratio >1.0) was 92% for celecoxib, 97% for ibuprofen, and 99% for diclofenac, naproxen, and rofecoxib. The corresponding odds ratios (95% credible intervals) were 1.24 (0.91 to 1.82) for celecoxib, 1.48 (1.00 to 2.26) for ibuprofen, 1.50 (1.06 to 2.04) for diclofenac, 1.53 (1.07 to 2.33) for naproxen, and 1.58 (1.07 to 2.17) for rofecoxib. Greater risk of myocardial infarction was documented for the higher dose of NSAIDs. With use for longer than one month, risks did not appear to exceed those associated with shorter durations.

 

Local Anaesthesia Toxicity (LAST)

  • The key in managing LAST is prevention. Know your dose, know your maximum dose, always aspirate prior to injection and ask patient about symptoms
  • Lidocaine toxicity cardiovascular complications are typically preceded by neurological signs/symptoms. If these develop, stop administration, place patient on monitor and ready your antidote
  • Bupivacaine toxicity can be sudden and catastrophic. If you are using the drug, undershoot your max dose and know where your antidote is
  • Intralipid has been shown to be effective in LAST. Administer the drug anytime there are signs of hemodynamic compromise

 

Rapid Sequence Intubation Medications

Induction Agents

Medication Weight-Based Dosing Time to Onset of Action Adverse Effects/

Contraindications

Etomidate 0.3 mg/kg <1 minute May cause clinically insignificant adrenal suppression.
Ketamine 1-2 mg/kg 1-3 minutes May increase blood pressure. May cause hypersalivation.
Propofol 2 mg/kg <1 minute May cause hypotension. Cardiac depressant. Contraindicated in egg/soybean allergy
Midazolam 0.3 mg/kg 1-5 minutes May cause hypotension

Paralytics

Medication Weight-Based Dosing Time to Onset of Action Adverse Effects/

Contraindications

Succinylcholine 1.5 – 2.0 mg/kg 45-60 seconds Bradycardia. Malignant hyperthermia. Hyperkalemia.
Rocuronium 1.2 mg/kg 45-60 seconds
Vecuronium 0.1 mg/kg 2-4 minutes Questionable RSI utility when rocuronium available

Post-Intubation Sedation

Medication Weight-Based Dosing Notes
Midazolam 0.04-0.2 mg/kg/hr Short duration, but with long-term use has long half-life. Often used with fentanyl
Propofol 5-80 mcg/kg/min Propofol Infusion Syndrome with long term use: monitor TG, amylase/lipase
Dexmedetomidine 0.2-0.7 mcg/kg/hr
Ketamine 0.5-1 mg/kg/hr May decrease bronchospasm
Fentanyl 1-2 mcg/kg bolus25-250 mcg/hr

 

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Cut, Drain & Give some Antibiotics

Antibiotics after I&D lead to significantly better outcomes with significantly fewer antibiotic-treated participants having clinical failure requiring a new antibiotic or another drainage procedure. New abscesses may develop in 10.1 percent of the antibiotic group compared to 19.1 percent of the placebo group.

 

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Does adrenaline need a central line?

iv-adrenalineIt has been dogmatically believed that prolonged infusion of any vasopressor mandates placement of a central line.  However, available evidence doesn’t support this. Diluted solutions of epinephrine and norephrine are safe for infusion via a well funcioning 18-20G IV proximal to the wrist.

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