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Podcast 754: Balanced Fluids vs. Normal Saline, The Battle Continues

Emergency Medical Minute

Release Date: 02/08/2022

Episode 908: Sympathomimetic Drugs show art Episode 908: Sympathomimetic Drugs

Emergency Medical Minute

Contributor: Taylor Lynch MD Educational Pearls: Overview: Sympathomimetic drugs mimic the fight or flight response, affecting monoamines such as dopamine, norepinephrine, and epinephrine Limited therapeutic use, often abused. Types: Amphetamines: Methamphetamine, Adderall, Ritalin, Vyvanse MDMA (Ecstasy) Cocaine (Both hydrochloride salt & free based crack cocaine) Theophylline (Asthma treatment) Ephedrine (For low blood pressure) BZP, Oxymetazoline (Afrin), Pseudoephedrine (Sudafed) MAO Inhibitors (treatment-resistant depression) Mechanisms: Act on adrenergic and dopaminergic...

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Episode 907: Wide-Complex Tachycardia show art Episode 907: Wide-Complex Tachycardia

Emergency Medical Minute

Contributor: Travis Barlock MD Educational Pearls: Wide-complex tachycardia is defined as a heart rate > 100 BPM with a QRS width > 120 milliseconds Wide-complex tachycardia of supraventricular origin is known as SVT with aberrancy Aberrancy is due to bundle branch blocks Mostly benign Treated with adenosine or diltiazem Wide-complex tachycardia of ventricular origin is also known as VTach Originates from ventricular myocytes, which are poor inherent pacemakers Dangerous rhythm that can lead to death Treated with amiodarone or lidocaine 80% of wide-complex...

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Episode 906: Case Study of Hypernatremia show art Episode 906: Case Study of Hypernatremia

Emergency Medical Minute

Contributor: Aaron Lessen MD Educational Pearls: The case: A gentleman came in from a nursing home with symptoms concerning for sepsis. He was hypotensive, hypoxic, febrile, and mentally altered. His past medical history included previous strokes which had left him with deficits for which he required a feeding tube. Initial workup included some point of care labs which revealed a sodium of 165 mEq/L (normal range 135-145) Hypernatremia What causes it? Dehydration, from insufficient fluid intake. This might happen in individuals who cannot drink water independently, such as...

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Episode 905: Oseltamivir (Tamiflu) for Influenza show art Episode 905: Oseltamivir (Tamiflu) for Influenza

Emergency Medical Minute

Contributor: Aaron Lessem MD Educational Pearls:  Oseltamivir (Tamiflu) is an antiviral medication used commonly to treat influenza Trials show that the medication reduces the duration of illness by less than 1 day (~16 hours in one systematic review) Benefit only occurs if taken within 48 hours of symptom onset Must be taken for 5 days A 2024 meta-analysis reviewed 15 randomized-controlled trials for the risk of hospitalization No reduction in hospitalizations with oseltamivir in patients over the age of 12 No difference in high-risk patients over the age of 65 or those...

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Episode 904: Cardiovascular Risks of Epinephrine show art Episode 904: Cardiovascular Risks of Epinephrine

Emergency Medical Minute

Contributor: Aaron Lessen MD Educational Pearls: Epinephrine is essential in the treatment of anaphylaxis, but is epinephrine dangerous from a cardiovascular perspective? A 2024 study in the Journal of the American College of Emergency Physicians Open sought to answer this question. Methods: Retrospective observational study at a Tennessee quaternary care academic ED that analyzed ED visits from 2017 to 2021 involving anaphylaxis treated with IM epinephrine. The primary outcome was cardiotoxicity Results: Out of 338 patients, 16 (4.7%) experienced cardiotoxicity. Events included...

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Episode 903: Treating Precipitated Opioid Withdrawal show art Episode 903: Treating Precipitated Opioid Withdrawal

Emergency Medical Minute

Contributor: Aaron Lessen MD Educational Pearls: Opioid overdoses that are reversed with naloxone (Narcan), a mu-opioid antagonist, can precipitate acute withdrawal in some patients Treatment of opioid use disorder with buprenorphine can also precipitate withdrawal Opioid withdrawal symptoms include nausea, vomiting, diarrhea, and agitation Buprenorphine works as a partial agonist at mu-opioid receptors, which may alleviate withdrawal symptoms The preferred dose of buprenorphine is 16 mg Treatment of buprenorphine-induced opioid withdrawal is additional buprenorphine Adjunctive...

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Episode 902: Liver Failure and Cirrhosis show art Episode 902: Liver Failure and Cirrhosis

Emergency Medical Minute

Contributor: Travis Barlock MD Educational Pearls: How do you differentiate between compensated and decompensated cirrhosis? Use the acronym VIBE to look for signs of being decompensated. V-Volume Cirrhosis can cause volume overload through a variety of mechanisms such as by increasing pressure in the portal vein system and the decreased production of albumin. Look for pulmonary edema (dyspnea, orthopnea, wheezing/crackles, coughing up frothy pink sputum, etc.) or a tense abdomen. I-Infection The ascitic fluid can become infected with bacteria, a complication called Spontaneous...

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Episode 901: Underdosing in Status Epilepticus show art Episode 901: Underdosing in Status Epilepticus

Emergency Medical Minute

Contributor: Aaron Lessen MD Educational Pearls: Lorazepam (Ativan) is dosed at 0.1 mg/kg up to a maximum of 4 mg in status epilepticus Some ED protocols only give 2 mg initially The maximum recommended dose of levetiracetam (Keppra) is 60 mg/kg or 4.5 g In one retrospective study, only 50% of patients received the correct dose of lorazepam For levetiracetam, it was only 35% of patients Underdosing leads to complications Higher rates of intubations More likely to progress to refractory status epilepticus References 1. Cetnarowski A, Cunningham B, Mullen C, Fowler M....

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Episode 900: Ketamine Dosing show art Episode 900: Ketamine Dosing

Emergency Medical Minute

Contributor: Travis Barlock MD Educational Pearls: Ketamine is an NMDA receptor antagonist with a wide variety of uses in the emergency department. To dose ketamine remember the numbers 0.3, 1, and 3. Pain dose For acute pain relief administer 0.3 mg/kg of ketamine IV over 10-20 minutes (max of 30 mg). Note: There is evidence that a lower dose of 0.1-0.15 mg/kg can be just as effective. Dissociative dose To use ketamine as an induction agent for intubation or for procedural sedation administer 1 mg/kg IV over 1-2 minutes. IM for acute agitation If a patient is out of control and a...

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Episode 899: Thrombolytic Contraindications show art Episode 899: Thrombolytic Contraindications

Emergency Medical Minute

Contributor: Travis Barlock MD Educational Pearls: Thrombolytic therapy (tPA or TNK) is often used in the ED for strokes Use of anticoagulants with INR > 1.7 or  PT >15 Warfarin will reliably increase the INR Current use of Direct thrombin inhibitor or Factor Xa inhibitor  aPTT/PT/INR are insufficient to assess the degree of anticoagulant effect of Factor Xa inhibitors like apixaban (Eliquis) and rivaroxaban (Xarelto)  Intracranial or intraspinal surgery in the last 3 months Intracranial neoplasms or arteriovenous malformations also increase the risk of...

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More Episodes

Contributor: Aaron Lessen, MD

Educational Pearls:

  • Normal saline is thought to interfere with renal function and cause an acidosis and balanced fluids (like lactated ringers) are a better option
  • The SALT-ED trial and SMART trial showed a small benefit with renal injury and need for dialysis using balanced fluid in critically ill patients
  • Recent multicenter RCT in Brazil evaluated balanced fluids versus normal saline and looked at 90-day mortality
  • Found no difference in 90-day mortality or secondary outcomes like renal function
  • PLUS trial is currently being done in Australia and New Zealand to further evaluate fluid choice
  • Larger trials don’t show a major difference at this point, keep an eye out for future trials

References

Semler MW, Wanderer JP, Ehrenfeld JM, et al. Balanced Crystalloids versus Saline in the Intensive Care Unit. The SALT Randomized Trial. Am J Respir Crit Care Med. 2017;195(10):1362-1372. doi:10.1164/rccm.201607-1345OC

 

Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):829-839. doi:10.1056/NEJMoa1711584

Zampieri FG, Machado FR, Biondi RS, et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial [published online ahead of print, 2021 Aug 10]. JAMA. 2021;326(9):1-12. doi:10.1001/jama.2021.11684

https://clinicaltrials.gov/ct2/show/NCT02721654

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

 

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