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Chip K. -

In Jan 2011 ACEP news Mike Heller noted that the perceived efficacy of theraputic hypothermia was based on only 2 studies done in 2002 in the NEJM - one study had only 77 its, good outcome only by p=.045, so only one pt would change study to not statistically significant. In the second study of 275 patients the normothermia group had 2x the diabetes and 50% more coronary disease and the 95% confidence interval was only 1.08 - sounds to me like incredibly flimsy evidence. How we get to Amal saying NNT=6 and a class 1 recommendation is beyond me. Could we get Mike Heller to weigh in on this?

Chip K. -

the quiz includes a question on the rebleed rate in head injured patients taking coumadin - Two studies from the June 2012 AEM seemed to give very different answers - the Menditto study showed 6% but the Nashijima study showed 4/687 patients with delayed bleeds on coumadin, making it less than 1%. Both are answers on the current test, though it seems the actually number is not yet known.

MEL responds: Thanks Chip I am going to check that question and those numbers and fix it in the CME portion AND on the AUDIO series...

Ali F. -

Hi Chip,

Here is what thinks of therapeutic hypothermia. They also state that the NNT=6.

Adrian L. -

How about a complete pediatric oral pain control/medication run down?

By the way, way too many sound interjections in this puppy, especially the last section about walking up on an MBA outside your house

Dean B. -

I loved Scott Weingart's section this month. However, I think there's a mistake on the written summary at the top of page 7, regarding the dose of vasopressin.

The dose should be 0.03 u/min rather than the 0.3 u/min stated.



Robert M. H. -

What is the evidence for anti-inflamatory effect of NSAIDS beyond prostoglandin mediated pain? Is there any effect on tendinitis, for example? Cox1 vrs Cox2?

Jeanne C., M.D. -

For Scott:
Regarding bicarbonated fluid resuscitation in DKA, if they are significantly hyperglycemic, can you add the 3 amps to NS or LR versus D5W?

Ethan B. -

@ Chip K,
I think you were paraphrasing what someone else said, but the comment about the P value deserves some humble clarification. "...So only one pt would change study to not statistically significant."

It's spun to sounds like something big happened, but not really. As you know, a p-value of 0.05 means that there is only a 5% chance that the difference seen between groups was causes just by random chance (or variation). A flip of one patient outcome might change it to only 6% chance that the difference seen was caused by random variation.
5% or 6%: Not such a big difference, really, despite crossing the line of "statistical significance" that we have chosen by convention.

Much more important is was that study well designed and executed...

Rebecca S. -

Hi Mel, Michelle Lim had mentioned something about a file she had of various "PV" cards (I know you're probably snickering right now) and I was pursuing the show notes to find a link or how to access her dropbox account and was unable to find anything. Do you know how to go about this?

Rebecca Smith

Rob B., M.D. -

For Mel, re: being a "real doctor" (end of August issue).
I've run into a few people over the years that have commented on my medical specialty. One was a VA internist who had worked in the "ER" in the past. His reply to being told I was an EP was simply, "Ah, a real doctor"! Mel, what you do does make a difference.

Ann L. -

For Rebecca S. - you can find all the PV cards here in either dropbox or googledoc form (printable via PDF).

Bryan D.O. -

For Jeanne: Adding the Bicarb to NS or LR often creates a very hypertonic solution as the Amp of Bicarb in most code carts is sodium bicarbonate. Each Amp has 50mEq of Sodium so if you added 3 Amps Sodium Bicarb to 1L NS you would change the Sodium content of NS which is 154mEq to 304 mEq. You could do 1.5 Amps Sodium Bicarb in 1/2 NS. So that would be 77mEq of Sodium from the 1/2NS + 75 mEq of Sodium in the 1.5 Amps Sodium Bicarbonate to give a total solution content of 152 mEq Sodium. Hope this helps.

Clark W. -

Love the sounds bites and interjections. The day I stop laughing while listening is the day that this turns into another one of those dronning...

Also makes it safer; much less likely to wrap my car around a tree drifting off.

Not to squabble over email but keep it coming.

Sara L. -

I know this was YEARS ago, but the lecture with Dr. Bryan Hayes has always stuck in my head...So...I just tried to order Ceftriaxone 250mg IV for treatment of PID in a patient with an IV. Pharmacology felt this was not safe for the patient. Here's the reasoning:
A pubmed search was virtually fruitless with no studies to support IV push Ceftriaxone.
Micromedex suggests to infuse over 30 minutes; concentrations between 10 mg/mL and 40 mg/mL are preferred, but lower concentrations may be used [19]. Reference: [19] Product Information: ceftriaxone sodium IV IM injection powder for solution, ceftriaxone sodium IV IM injection powder for solution. Sandoz Inc (per DailyMed), Princeton, NJ, 2010.
I guess the problem is that there could be variability in how the RN reconstitues it and it may not be the appropriate concentration (hypertonic concentrations can cause irritation and vessel necrosis).
Lastly, the CDC STD guidelines only mention IM, never IV.
My ED Pharmacist was okay with infusing IVPB over about 1/2 hour. But that defeats the whole purpose of ease. Patient ended up getting an IM injection.
Does Dr. Hayes have any references to support this recommendation?
Sara, PA-C

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Episode 143 Full episode audio for MD edition 232:42 min - 110 MB - M4AAgosto 2013 EM:RAP EspaƱol 90:08 min - 62 MB - MP3EM:RAP 2013 August MP3 272 MB - ZIPAugust 2013 Written Summary 792 KB - PDFEM:RAP August 2013 Board Review Questions 641 KB - PDFEM:RAP August 2013 Board Review Questions: Answer Sheet 651 KB - PDF