Rank #1: COVID-19: Weingart Q & A on Airway, Vents, Tubes, Lungs, ECMO, and CPAP
ED-intensivist Scott Weingart has developed several protocols for airway management in COVID-19 patients, but each of those answers brings up more questions. In this episode: ‘happy hypoxemia’, the 4 types of COVID patients, Covid L vs H, is there a role for ECMO in severe disease, why intubation should be a last resort, the importance of patient positioning, and much more.
One of the most astounding things about treating COVID-19 patients is how well they can look with extreme hypoxia.
- Patients with saturations of 50% (and consistent ABGs) can be talking, mentating normally, and have otherwise normal vital signs. Thus, this term: “the happy hypoxemic”.
- It is not well understood why these patients are able to tolerate such low sats without having compensatory measures, such as tachycardia.
- This led to a paradigm shift in the approach to managing hypoxemia.
There are 4 types of COVID-19 patients:
- Those with mild disease -- may never enter the medical system.
- The “happy hypoxemics” -- many of these, if managed well, will be discharged without experiencing cytokine storm or needing intubation.
- The hyperacute progression patients -- these patients decompensate rapidly. Many go into cardiac arrest hours after ED arrival. Weingart believes these patients likely have the highest viral load and are the most dangerous to the healthcare workers.
- The indolent patients -- may look like the “happy hypoxemics” initially, but within 4-5 days develop cytokine storm and require intubation.
- When ventilated, there are 2 phenotypes:
- COVID L (low elastance/not stiff/normal compliance)
- This is the “happy hypoxemic” phase on the vent.
- The amount of gas in the lungs is nearly normal and there is low lung recruitability.
- Easy to ventilate.
- These patients can be damaged iatrogenically if you respond to their pulse ox with standard vent modes.
- Best managed with high FiO2 which allows you to limit the PEEP to just what you need.
- Recommended initial vent settings:
- 8 ml/kg TV, 100% FiO2
- Increase the PEEP only if the patient is desaturating on a high FiO2.
- Can turn into COVID H patients on the vent.
- COVID H (high elastance/stiff/low compliance)
- Increased permeability of the lung leads to edema, atelectasis, decreased gas volume, and decreased TV for a given inspiratory pressure.
- High degree of lung recruitability.
- Manifests similar to ARDS patients and responds nicely to typical ARDS settings.
- The ARDSNet ladder applies only to this subset of COVID patients.
- Link to ARDSNet protocol.
- COVID L (low elastance/not stiff/normal compliance)
- When ventilated, there are 2 phenotypes:
How can you tell if a patient is COVID L or COVID H?
- Observe their plateau and driving pressures when on 8 ml/kg TV.
- COVID L patients will respond like normal lungs.
- COVID H patients will respond with high plateau and driving pressures, indicating terrible compliance and classic acute lung injury.
What is the current treatment algorithm for the query COVID patient who presents with a severe asthma exacerbation?
- Use MDIs rather than nebulization to deliver bronchodilators.
- Consider terbutaline or epinephrine (0.3-0.5 mg IM).
- Many hospitals are not allowing CPAP, so more of these patients may need to be intubated if they deteriorate.
- Vent management:
- Start with 8 ml/kg TV and high FiO2.
- Follow the expired flow graph to make sure the respiratory rate is low enough to allow the patient to fully expire between breaths.
- Link to EMCrit Dominating the Ventilator Part 2 on Asthmatic Ventilation.
Which techniques can be used to minimize the aerosolization risk of intubation?
- Weingart argues that if you follow this procedure for intubation, the risk is very low.
- Important measures include:
- wearing full PPE,
- using a negative pressure room if you can,
- NOT intubating while the patient is getting chest compressions,
- attaching viral filters to occlusive face masks,
- avoiding bag-valve-mask ventilation,
- keeping the face mask on the patient until complete paralysis,
- releasing any pressure from the face mask before removal,
- using video laryngoscopy rather than DL,
- avoiding suctioning when you can, and
- consider single operator bougie intubation technique
- Link to video demonstration of Dr. Chris Holmes’ Intubation Shield which seems ergonomically superior to other aerosol containment boxes in use.
Does ECMO have a role for these patients?
- Most centers are reserving ECMO for patients who only have single organ failure.
- For patients with only pulmonary failure, this would be veno-venous (VV) ECMO.
- For those who have recovered from their lung issues but who have COVID myocarditis, they might get veno-arterial (VA) ECMO.
- Many COVID patients have multi-system organ failure and are being excluded from ECMO.
- Old age has been another common COVID ECMO exclusion.
COVID fluid management: keep them dry, but not too dry.
- Replace insensible and external losses (ie. due to vomiting or diarrhea).
- Patients who you suspect are dehydrated based on history or a flat IVC on ultrasound may benefit from 500-1000 ml of fluids.
- ED patients who you have no reason to believe are dehydrated likely need no additional fluid replacement.
- In general, it is better to run these patients dry, but monitor urine output and your ultrasound findings to make sure the patient doesn’t develop renal failure due to dehydration.
- Consider early pressors if COVID patients are hypotensive.
Non-invasive ventilation, done right, should be safe.
- Initially, people were worried about aerosolization and cautioned against it. This is because standard noninvasive used masks which vent to the environment.
- Weingart argues that the Italian helmets and his closed circuit CPAP masks have minimal dispersal and are much safer.
How is Weingart awake repositioning patients in the ED?
- He’s repositioning everyone every 60 minutes by asking them to rotate from lying on their left side, to their right side, and then sitting upright.
- Prone positioning is an option, but you need to verify it makes the patient feel better, not worse.
- Complex if a patient is on CPAP (even more so if a patient is intubated).
- Does not appear to benefit COVID H patients.
What is being done during the apneic period, prior to intubation?
- Weingart uses the CPAP set-up which allows for apneic CPAP.
- Keeps the lungs inflated with a continuous source of oxygen, providing a high FiO2 and maintains recruitment.
- Link to EMCrit’s COVID CPAP Pre-oxygenation Set-up without nasal cannula
- Link to EMCrit’s COVID-19 Intubation Pack and Preox for Intubation
- Video demonstrating that apneic CPAP inflates the lungs.
When COVID patients need supplemental oxygen, Weingart uses a stepwise progression.
- 1st tier -- normal nasal cannula @ 6 liter/minute
- 2nd tier -- Venturi mask up to 50%
- 3rd tier -- nasal cannula plus non-rebreather mask covered with a surgical mask
- 4th tier -- high flow nasal cannula
- 5th tier -- CPAP (using a machine that’s been altered to allow filtering)
- Weingart likes to keep his COVID L patients lightly sedated, arguing that spontaneous breathing is good for their lungs.
- Deep sedation is preferred by some to prevent self-extubations when patient monitoring is difficult.
- Weingart is concerned about the deep sedation/paralysis required when intubated patients share vents.
- What he finds more attractive is splitting the vents between 2-4 patients to deliver CPAP, allowing the patients to spontaneously breathe. This saves the single ICU vents for patients who need individualized settings.
- Gattinoni L. et al. COVID-19 pneumonia: different respiratory treatment for different phenotypes? (2020) Intensive Care Medicine; DOI: 10.1007/s00134-020-06033-2.
- Link to EMCrit’s COVID Airway Management Thoughts
- Link to EMCrit’s COVID CPAP Pre-oxygenation Set-up without nasal cannula
- Link to EMCrit’s COVID-19 Intubation Pack and Preox for Intubation
- Link to EMCrit Dominating the Ventilator Part 2 on Asthmatic Ventilation.
- Link to EMCrit Wee Alternatives to Vent Splitting
Apr 09 2020
Rank #2: ZDoggMD
Zubin Damania (ZDoggMD) is an internist and founder of Turntable Health, an innovative healthcare startup that was part of an urban revitalization movement in Las Vegas. During a decade-long hospitalist career at Stanford, he experienced our dysfunctional health care system firsthand leading to burnout and depression. He created videos under the pseudonym ZDoggMD as an outlet to find his voice. This launched a grassroots movement — half a billion youtube views and a passionate tribe dedicated to improving health care for everyone.
ERcast 2.0 Launches May 1
Click hereto learn more
Or hereto sign up and skip the details
In this interview we cover a wide range of topics including
- How ZDogg went from hospitalist to rapper to Medicine 3.0evanaglist
- The Mind Illuminated
- The roots of anxiety
- Mental preparation before giving a talk
- ZDogg's response to criticism, antipathy, and negative feedback from the anti-vaccine movement
- Nurse practitioners
A Smattering of Performance Improvement, Stress Management, and Wellness Episodes
- Finding the Joyin Your Job
- Performance Coach Jason Brooks
- Making Order Out of Chaos
- How to Not Freak Out
- When Consultants Give Bad Advice
- Beating Stress and the Hot Offload
- Mastering the Storm
My Favorite Zdogg Song
Apr 24 2018
Rank #3: COVID-19: Code Blue
In this episode we speak with Chris Hicks, Canadian emergency physician and trauma team leader who is a master of teaching the cognitive skills of resuscitation. Chris shares several protocols from his hospital regarding code blue and intubation in the era of COVID-19 including: the pre-brief process, communication during a code in PPE, preparing for a code (when you have time), what to do when there’s a surprise arrest and the team isn’t in PPE, how to effectively use an airway checklist, and how to find your anchor when you’re stressed.
Many of us “pregame” and have psychological skills that prepare us for whatever stressors we may encounter during a shift. Similarly, we have scripts for most of the things we do in EM. Our script for the process of resuscitating patients does not work in the COVID-19 era.
- COVID keeps us in system 2 thinking, which is time-consuming, labor intensive, and not efficient when you have to make quick decisions.
- Everything around preparation, PPE, role designation, and process is now strange.
- Since it’s an unfamiliar situation, we have to understand process and structure in a scenario with no script.
When resuscitating COVID-19 patients who are code blue, an organized structure and consistency are essential. Here are some recommendations:
- Have a team based pre-brief.
- This is a deliberate discussion before you enter the room which stresses the importance of cross-monitoring and establishes the rules.
- The team gathers around a code blue protected airway cart which contains airway equipment and PPE.
- Above the cart is a poster-sized infographic which details the pre-brief process.
- One physician is assigned the team leader.
- Roles are assigned.
- Inside the room are 2 MDs, 1 RN, and 1 RT.
- Outside the room are 2 RNs.
- 1 safety officer (MD or RN)
- Donning and doffing buddies are assigned.
- Team members check each other’s PPE.
- A safety officer observes the process and makes sure there are no lapses in the PPE protocol.
- Decisions are made in advance regarding what will be brought into the room (drugs, drips, other supplies).
- This whole process can take less than a minute.
- Communication during a code in full PPE must be deliberate, succinct, and directive.
- Use closed-loop communication techniques.
- Baby monitors can be an effective means of communicating to team members outside the resuscitation room.
What happens in the scenario where there’s an unanticipated arrest and you feel there’s no time to prepare?
- While it’s admirable and brave to want to rush into the room to care for the patient unprotected, that cannot be the case in this era.
- We must put staff safety ahead of patient care.
- Hick’s institution has developed a process for protected code blue which has 5 key messages.
- Ensure airborne PPE for all providers before initiating BLS/ACLS.
- If nobody is in PPE, then nobody responds. Consensus opinion is that if you don't have appropriate PPE, you cannot be providing high risk procedures.
- If 1 person is in PPE, they can enter the room, put a mask on the patient and start compression-only CPR while others don PPE.
- Apply a NRB mask with filter when starting CPR.
- No BVM ventilation prior to intubation.
- If BVM is necessary, it should be a two person, four handed technique.
- Prioritize intubation using a protected airway process.
- Airway is prioritized earlier in the process vs. a standard cardiac arrest.
- Endotracheal intubation is preferred over a supraglottic airway.
- Pause chest compressions during intubation.
- Ensure airborne PPE for all providers before initiating BLS/ACLS.
We are cautioned against using the BVM as it is considered highly aerosolized. Where does that happen in the circuit?
- With BVM ventilation, you run the risk of the patient’s airway secretions getting out of the BVM unless you have an interposing mechanical filter.
- Their BVMs also have a side port where a PEEP valve is meant to fit. They routinely attach a PEEP valve to prevent any passive flow of secretions from escaping.
Another cognitive offloading tool is a detailed protected airway checklist.
- The airway checklist is run by the 2nd physician, not the airway operator.
- It’s a call and response process, double checking that all necessary supplies are available and a reminder of things that will NOT be done (“We will not be inserting an airway. We will not be topicalizing medications. etc”.)
- For the intubator, it is reassuring to have somebody else supporting you to make sure the process is safe.
- See also Protected Airway Equipment Checklist
During one of Chris' first intubations, he found himself unusually stressed while he was waiting for the paralytic to take effect.
- He handled this by visualizing every step of the procedure and quietly reminding himself to be “steady”. This mental rehearsal helped center himself. He went from feeling like he might pass out to feeling ready to go.
- This situation accentuated the importance of having psychological tools when you feel afraid and stressed. And of the need to have a sense of humility when confronted with new situations. It was a nice reminder that pregaming actually works.
- Link to a pre-departure checklist for critically ill patients being transferred to the ICU,
Apr 05 2020
Rank #4: The Moral Injury of Modern Medicine with ZDoggMD
Are we calling burnout by the right name? Some would say no, we should call it 'moral injury' because what we see happening in modern medical practice can be antithetical to our core values. In this episode, ZDoggMD is our guest as we examine moral injury, as well as dealing with the EHR, stress, universal health care, meditation, and much more.
Dec 20 2019
Rank #5: How to Use the Pulse Ox Like a Boss
From Essentials of Emergency Medicine NYC 2017, Reuben Strayer explains how the pulse ox might be the most useful bit of tech in the ED.
- The pulse ox waveform is an excellent indicator of mechanical heart rate and peripheral perfusion.
- For patients breathing room air, pulse oximetry can be used to monitor for hypoventilation.
- Nail polish has minimal impact on the accuracy of pulse oximetry.
- If you are unable to get a good pulse ox waveform by adjusting or repositioning the probe, be concerned that the patient is poorly perfused.
- “The respiratory rate is the most vital of the vital signs.” Experienced doctors look at a patient who seems well, but understands that they’re not truly well, because they subconsciously notice tachypnea. Subconsciously is the only way to notice tachypnea, because respiratory rate is often not measured accurately. Since we don’t always have access to reliable respiratory rate, Strayer’s go-to vital sign is the oxygen saturation.
- “Reusable pulse oximeter probes are gross.” One study found that even when these probes are cleaned by standard procedure, ⅔ had bacteria cultured from them. Strayer recommends using single use probes in your department.
- Wilkins MC. Residual bacterial contamination on reusable pulse oximetrysensors. Respir Care. 1993 Nov;38(11):1155-60. PubMed PMID: 10145923.
- Data is conflicting about the effect of nail polish on pulse oximetry readings, but overall it is felt that the impact is minimal.
- Earlier data suggested that nail polish decreased sat readings by 2-10%, but more recent studies found minimal effect.
- If it seems that the waveform is affected by nail polish, you can remedy the situation by turning the probe 90 degrees, so it goes sideways through the finger.
- Yamamoto LG, et al. Nail polish does not significantly affect pulse oximetry measurements in mildly hypoxic subjects. Respir Care. 2008 Nov;53(11):1470-4. PubMed PMID: 18957149.
- As long as a patient is breathing room air, pulse ox can monitor ventilation and function as a hypoventilation alarm.
- Significantly hypercapnic patients saturate less than 95% when they’re breathing room air. So if you need to monitor a patient for hypoventilation, such as due to intoxication or procedural sedation, the pulse ox will do a great job of telling you if the patient is still breathing.
- If you need to give supplemental oxygen, then use capnography to monitor respirations.
- The pulse oximeter does so much more than provide oxygen saturation.
- It provides the photoplethysmogram (PPG) which is a waveform that tells you the “mechanical” heart rate. While telemetry gives the electrical heart rate, what really matters to your organs is the mechanical rate. This can be especially helpful during transvenous or transcutaneous pacing. When you have reliable tracing, the pulse ox heart rate is more reliable than the telemetry heart rate.
- The pulse ox can measure the peripheral perfusion index which is a more sensitive and earlier indicator of hypoperfusion than blood pressure. This is a numerical value which indicates the strength of the pulsations read by the pulse oximeter. It is based on the amplitude of the pulse ox waveform and expressed as a number between 1 (low) and 10 (high). The perfusion index dips before the stroke volume drops and long before the heart rate rises. Many monitors will report the perfusion index in tiny print after the word PERF.
- Lima AP, Beelen P, Bakker J. Use of a peripheral perfusion index derived from the pulse oximetry signal as a noninvasive indicator of perfusion. Crit Care Med.2002 Jun;30(6):1210-3. PubMed PMID: 12072670.
- van Genderen ME, et al. Peripheral perfusion index as an early predictor for central hypovolemia in awake healthy volunteers. Anesth Analg. 2013 Feb;116(2):351-6. PubMed PMID: 23302972.
- What if you don’t have a reliable pulse ox tracing?
- Most of the time this is because the probe is poorly positioned, the patient is moving too much, or there’s a lot of ambient light.
- If you’ve corrected for these problems and you still don’t have a good tracing, you should be concerned that the patient is poorly perfused.
- One study of 20,000 anesthesia cases showed that pulse ox failure was directly related to worsening physical status.
- Moller JT, et al. Randomized evaluation of pulse oximetry in 20,802 patients: I. Design, demography, pulse oximetry failure rate, and overall complication rate. Anesthesiology. 1993 Mar;78(3):436-44. PubMed PMID: 8457044.
- How does the pulse ox measure oxygen saturation and what is the best way to position the oximeter probe on the finger?
- One side of the pulse ox puts emits visible (red) light and infrared light. On the other side is the detector. The percent oxygen saturation is calculated based on the different way in which oxyhemoglobin absorbs visible and infrared light compared with deoxyhemoglobin.
- The pulse ox measures carboxyhemoglobin as if it were oxyhemoglobin, giving a falsely elevated pulse ox reading for a victim of carbon monoxide poisoning.
- The best spot for a peripheral pulse ox is a place with a lot of capillaries and arterioles, like the fingertips, earlobes, nose, or forehead.
- Functionally, it doesn’t seem to matter whether the emitter is on the dorsum, volar aspect, or even side of the finger. For convenience sake, most find it ergonomically superior to have the cord and emitter on the dorsum of the finger.
- Mannheimer PD. The light-tissue interaction of pulse oximetry. Anesth Analg.2007 Dec;105(6 Suppl):S10-7. Review. PubMed PMID: 18048891
- Vegfors M, Lennmarken C. Carboxyhaemoglobinaemia and pulse oximetry. Br JAnaesth. 1991 May;66(5):625-6. PubMed PMID: 2031826
Mar 11 2019
Rank #6: Acute MI in Cardiogenic Shock with Weingart and Mattu
Scott Weingart and Amal Mattu are our guests as we break down the critical decision points in a case of a patient with an acute anterior STEMI and cardiogenic shock.
Want weekly episodes, world class show notes, CME, and a super sweet app? Go to ercast.org and subscribe to the kit and caboodle.
Jul 06 2019
Rank #7: Massive GI Bleed on Anticoagulants
Rob and Tom Deloughery discuss management of actively bleeding patients who have been prescribed anticoagulation medications.
May 04 2018
Rank #8: COVID-19: Inside New York City
In this episode I speak with Dr. Reuben Strayer, emergency physician at Maimonides Medical Center in Brooklyn, NY. The news is rife with reports of New York’s escalating COVID-19 cases and there are lessons we can learn from how they are responding.
- Managing a massive surge (which is only going to get worse)
- Ventilator allocation planning
- Hot/Warm/Cold zones
- High Flow Nasal Cannula O2 for preox
- Use (or non use) of non-invasive ventilation
- Variations in COVID presentation
- COVID and cardiac arrest
- In harm’s way when PPE runs out
In one week, Strayer’s ED went from seeing 300-400 patients/day with a variety of complaints to 200-300 patients/day, HALF afflicted by COVID-19.
His department is split into 3 zones:
Acute care hot zone --
For COVID patients who need resuscitation and/or aerosol-generating procedures.
Providers wear the highest level of PPE.
Acute care warm zone --
For COVID patients who don’t need aerosolized procedures.
Lower level of PPE.
Cold zone --
Subacute area for people suspected NOT to have COVID.
Lower level of PPE. Providers wear N95 masks under a surgical mask with goggles, even if seeing ankle sprains or working at their desk.
“Wearing good but not perfect PPE is far better than wearing no PPE.”
PPE is reused, in hopes of not running out.
For the past few weeks, providers have used one N95 mask per shift. If they had been using N95s as single use devices, they would have run out long ago.
Every effort is made to minimize exposure to viral particles. This means keeping the N95 on under a surgical mask as long as they can.
Reuben’s thoughts on COVID and cardiac arrest. Is resuscitating these patients worth the risk?
If the patient codes in the ICU due to COVID pneumonia, further resuscitation should not be done since there is nothing additional to offer that patient (other than ECMO),
If an unknown, undifferentiated cardiac arrest patient comes to the ED, treat the patient as you would anyone in arrest, but use maximal PPE.
A potential modification to your arrest algorithm is to place an LMA (with a filter if you have one) rather than doing bag-valve-mask ventilation. BVM is thought to be more aerosol-generating.
How deeply should we put ourselves in harm’s way if we run out of PPE?
If you don’t have any PPE, then you shouldn’t expose yourself to heavy doses of the virus.
You can argue that it’s unethical and irresponsible to refuse to provide care to patients because you deem your PPE to be imperfect. Contrary to this, some describe the COVID+ patient as akin to a disaster zone and you only enter a zone when the scene is safe. If you enter without PPE, that is not a safe scene.
Strayer believes that we can avoid completely running out of PPE by reusing the PPE that we have. This means using one mask per shift, bringing it home in a sealed bag, potentially bleaching it and reusing it.
What should be our approach to non-invasive ventilation?
Unless you have viral filters for the inspiratory and expiratory arms of non-invasive ventilatory machines, they are hazardous to use.
Without proper viral filtration, COVID virus will essentially be spewed into the atmosphere by these machines.
If you have viral filters, non-invasive ventilation is an excellent option, especially if you have a dearth of ventilators.
High-flow nasal cannula (HFNC) has been used with great success in managing non-crashing but dyspneic, hypoxic patients.
HFNC has been helpful both to relieve severe dyspnea as well as to correct extreme hypoxia.
It is too early to say how these patients will fare in the long run. But even if many ultimately require intubation, having an option for delaying intubation if ventilators are scarce is helpful.
This can be delivered using a dedicated device with humidified HFNC capacity. The advantage is that you can titrate FiO2 and flow rate independently. Alternatively, you can use a conventional nasal cannula at the highest rate tolerable to the patient.
COVID patients present in 3 ways to the ED:
Mildly ill with a little dyspnea, fever, malaise, and no hypoxia.
These patients go home.
Moderately ill with more significant dyspnea and hypoxia.
These are first put on nasal cannula O2. Most are admitted, but some improve to the point of being able to go home in a few hours. In the ideal world, you would send them home on home O2.
If they fail nasal cannula O2, HFNC is started.
Severely ill patients clearly need to be intubated from the outset.
These patients are preoxygenated with nasal cannula and non-rebreather, unless they were already on HFNC and then they’re intubated with HFNC in place.
Now that the surge has happened with COVID in Strayer’s ED, what has surprised him about how things are playing out?
First, Strayer is confident that the surge hasn’t yet happened. He is anticipating “mountains of patients” and despite their aggressive preparation, he fears they are not going to have the capacity to care for everyone who’ll need it over the next month.
He is surprised by how little PPE we have. It is astounding how quickly hospitals are getting to the point of needing to ration PPE to providers.
He’s surprised by how few non-COVID patients have been coming to his ED. Patient volumes are dramatically down.
Who is being quarantined in New York City?
New York officially disbanded quarantine for asymptomatic patients or providers.
For providers with a positive COVID test, the policy is to stay home until you’ve been asymptomatic for 3 days and ≥7 days from the onset of illness.
How are COVID tests being used?
It’s been a roller-coaster. They went from having access to no tests, to very limited tests, to plenty.
When the testing capacity increased, they were testing lots of patients, and virtually all were coming back positive.
Now they have reverted back to having limited (if any) tests. Currently, only people who are sick are tested, and with the high prevalence of COVID in the community, the results are almost always positive and rarely helpful.
Are chloroquine or hydroxychloroquine being prescribed?
Due to dwindling supply and insufficient supporting science, at Strayer’s institution hydroxychloroquine is only given to very sick patients and with ID approval.
What is the protocol for ventilator sharing and/or rationing?
Strayer’s hospital is enacting a shared ventilator policy. The question is how much COVID patients will be harmed by sharing a ventilator with another person vs. the benefit of sharing. They are hoping that 1 ventilator can safely be used for multiple patients.
The Ventilation Allocation Protocol has several steps:
1) Assess for exclusion criteria. Excluded are patients who’ve had a cardiac arrest, those who wouldn’t normally meet ICU admission criteria based on their prognosis (ie. metastatic cancer, severe dementia), those who are DNR/DNI, and patients who the provider believes has a condition that would severely limit the prognosis despite maximal care.
2) Assign priority: blue, red, yellow, green. This is based on a quantification of short term mortality using the SOFA score. It considers a series of organ systems and uses surrogates for organ dysfunction as a way of determining short term mortality.
Blue (SOFA>11) -- Lowest priority for a ventilator due poor prognosis and being the least likely to benefit.
Mar 25 2020
Rank #9: Infected and Obstructing Nephrolithiasis
Patients with infected ureteral stones present a true medical emergency. I very well may be obvious what's going on but, often, it's not so clear. Maybe the patient has no fever but a few white cells in the urine, or maybe they look sick but have a negative UA. In this wide-ranging discussion, we interview urologist Nora Takla about her approach to infected stones, how she manages those with equivocal presentations, as well as the logistics following up non-infected stones, the significance of extravasation on CT scan, and the sometimes surprisingly complicated decision making when it comes to admitting ureteral colic patients.
Apr 13 2019
Rank #10: Aim To Be a Zero
What does emergency medicine have in common with astronautics? A lot, it turns out. Dan Mccollum and Rob break down the skills learned by International Space Station commander Chris Hadfield as explained in his autobiography An Astronaut's Guide to Life on Earth.
Become a Full Member of ERcast Here
You can be a “plus one” -- someone who actively adds value -- without behaving like an arrogant person craving significance.
Avoid trying to impress others by showing off.
We learn much through adversity, when things don’t go well.
What we say matters. Critique a behavior, not a person.
The pitfalls of thinking too highly of yourself. [1:48]
On the importance of being a “plus one” and the wisdom of not proclaiming your plus-oneness. “If you’re really a plus one, people will notice”. [2:25]
Aim to be a zero -- having neutral impact. Observe and learn. Pitch in with the grunt work. Being a zero is a good way to get to plus one.[5:10]
What Mccollum looks for in EM residency applicants: people who treat the receptionist or program administrator well. [8:02]
Focus on the simple core things which are most likely to save lives, as opposed to shooting for the stars with cutting edge treatment. [8:50]
On why the weight and power of ego impairs our ability to learn and harms patients. [11:04]
Sweat the small stuff. [13:03]
The quintessential nature of EM and how they’re similar to flight rules: solving complex problems rapidly with incomplete information. [13:51]
Why we should be using checklists, particularly when we think we don’t have time for them. [14:49]
Even when you follow all the rules, sometimes bad things happen. Perfectionism is not part of the flight rules. [15:51]
Why early success is a terrible teacher. If you’ve always been the star and never experienced failure, this can be a barrier to learning. [18:29]
Jocko Willink video, Good. When bad things happen and you get knocked down, “get up, dust off, reload, recalibrate, re-engage, and go out on the attack”. [20:15]
When in a position of leadership, be careful with your words. Don’t ridicule. The small things we do or say can have a big impact. [22:02]
Expeditionary behavior is the willingness to endure hardships for the sake of the mission. And why whining poisons the pool. [24:15]
An Astronaut's Guide to Life on Earth by Chris Hadfield
Nov 30 2019
Rank #11: Cellulitis
Recorded at Essentials of Emergency Medicine 2017, Greg Moran, MD reviews current thinking on cellulitis diagnosis and management. Greg is a professor of emergency medicine at Olive View-UCLA medical center who, in addition to emergency medicine, is fellowship trained in infectious disease and has over 100 publications in journals including: New England Journal of Medicine, British Medical journal, JAMA, Lancet, and Annals of Emergency Medicine. Greg is a thought leader in the field of emergency infectious disease and a super nice guy. In this segment, Greg covers: a common cellulitis mimic; admit vs discharge of patients with cellulitis; what bugs cause cellulitis and, taking that into account, what antibiotic should I use- double coverage, single coverage?
The great cellulitis mimic: Stasis Dermatitis
- Similar in appearance to cellulitis
- Often bilateral (where cellulitis is usually unilateral)
- Risk factors include venous stasis, lymphedema
- Fluid goes into the interstitial space -> into the dermis -> and then causes superficial redness and irritation
- Many recommendations out there, many of them consensus, opinion or based on weak data
- Compression if the patient can tolerate it
- Wet dressings if there is crusting and exudative eczema
- Topical steroids (medium to high potency) such as triamcinolone, fluocinonide, fluticasone ointments
- If you think there could be infection at play, consider a short course of oral antibiotics (also consider topical if there’s a break in the skin or part of the leg is looking particularly red and angry)
Admit or go home?
- Inpatient mortality for cellulite is low (somewhere in the low single digits percent)
- No validated decision instruments regarding admission or discharge
- 2014 study Predictors of Failure of Empiric Outpatient Antibiotic Therapy in Emergency Department Patients With Uncomplicated Cellulitis found that fever, chronic leg ulcers, edema, lymphedema, cellulitis at a wound site or recurrent in the same area were risk factors for outpatient treatment failure
- Does this mean that patients with these risk factors need mandatory admission? It doesn’t, but it gives an inkling of who might do poorly or at least fail outpatient antibiotics
- Bottom line: no clear consensus on who can be discharged but low inpatient mortality suggests we may be over-admitting
- A nice review of the admit or discharge cellulitis question can be found here
Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis. JAMA May 2017 PMID:28535235
- 500 patients with cellulitis
- Treated cephalexin alone or cephalexin plus TMP/Sulfa
- No significant difference in outcome
Comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clinical infectious diseases 2013 PMID:23457080
- 150 patients with cellulitis
- Treated cephalexin alone or cephalexin plus TMP/Sulfa
- No significant difference in outcome
Bottom line: In uncomplicated cellulitis without abscess or significant co-morbidities, current evidence suggests no advantage of adding TMP/Sulfa to cephalexin
Check out Essentials of Emergency Medicine. Well, I guess if you're against fun education and hate puppies, then disregard that recommendation. References
- Weng, Qing Yu, et al. "Costs and consequences associated with misdiagnosed lower extremity cellulitis." Jama dermatology 153.2 (2017): 141-146. PMID:27806170
- Weiss, Stefan C., et al. "A randomized controlled clinical trial assessing the effect of betamethasone valerate 0.12% foam on the short-term treatment of stasis dermatitis." Journal of drugs in dermatology: JDD 4.3 (2005): 339-345. PMID:15898290
- Talan, David A., et al. "Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection." Western Journal of Emergency Medicine 16.1 (2015): 89. PMID:25671016
- Peterson, Daniel, et al. "Predictors of failure of empiric outpatient antibiotic therapy in emergency department patients with uncomplicated cellulitis." Academic Emergency Medicine21.5 (2014): 526-531. PMID:24842503
- Khachatryan, Alexandra, et al. "Skin and Skin Structure Infections in the Emergency Department: Who Gets Admitted?." Academic Emergency Medicine 21 (2014): S50. Abstract from 2014 SAEM
- Carratala, J., et al. "Factors associated with complications and mortality in adult patients hospitalized for infectious cellulitis." European Journal of Clinical Microbiology and Infectious Diseases 22.3 (2003): 151-157. PMID:12649712
- Pallin, Daniel J., et al. "Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial." Clinical infectious diseases 56.12 (2013): 1754-1762. PMID:23457080
- Moran, Gregory J., et al. "Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis: A Randomized Clinical Trial." Jama 317.20 (2017): 2088-2096. PMID:28535235
- Original Kings of County Analysis of Admit or Discharge Cellulitis
Jan 29 2018
Rank #12: Haloperidol for Analgesia
One of the stress points when a patient taking chronic opioids presents with acute pain is that we feel we have little to offer them. Are more opioids the answer? That's often what happens, but might not be the best next step. In this episode, Reuben Strayer presents the argument in favor of haloperidol for analgesia and why more opioids can do more harm than good.
In the introduction, preview of a project we're working on for Essentials of Emergency Medicine (May 15-17).
Opioid induced hyperalgesia: compared to those not taking opioids, patients on chronic opioids may have a more unpleasant experience when exposed to painful stimuli. In other words, they are more sensitive pain. The meds used to treat pain, actually worsen pain.
A patient who uses chronic opioids will have marginal gains in analgesia with escalating doses while getting closer to potentially lethal adverse effects.
Haloperidol is an analgesic option for patients taking chronic opioids.
Reuben's strategy for using haloperidol for analgesia in chronic opioid patients: 10 mg IM haloperidol if there is no IV, 5 mg IV if they have a line. If they don't fall asleep shortly after (or have improvement of pain) he repeats the dose. If that doesn’t work, he uses analgesic dose ketamine.
For analgesic dose ketamine in these patients, Reuben uses 30 mg IV. This may cross over into the 'recreational' or 'partial dissociation' dose where the patient can have disturbing psycho-perceptual effects. He has found that the pretreatment with haloperidol leads to less distress from these psycho-perceptual effects. For more information on ketamine dosing, see Reuben's post on the Ketamine Brain Continuum.
Haloperidol and the prolonged QTc: Butyrophenones (of which haloperidol is one) are known to prolong the QTc. Should we get an EKG prior to giving haloperidol to see if the QTc is already prolonged? Reuben feels that the negative effects of butyrophenone QTc prolongation are overblown and does not routinely get an EKG prior to giving haloperidol. This includes initial and subsequent doses. Take that with a grain of salt because there are many docs who do get an EKG before the first or second dose of haloperidol, especially if there is a known QTc prolonging drug on the patient's med list (like methadone). Some hospitals even have policies that before a second dose is given, there is a hard stop for EKG and QTc check.
- Marion Lee, M., et al. "A comprehensive review of opioid-induced hyperalgesia." Pain physician 14 (2011): 145-161 Full text link. PMID: 21412369
- Hooten, W. Michael, et al. "Associations between heat pain perception and opioid dose among patients with chronic pain undergoing opioid tapering." Pain Medicine 11.11 (2010): 1587-1598 Full text link. PMID: 21029354
Droperidol for analgesia
- Richards, John R., et al. "Droperidol analgesia for opioid-tolerant patients." Journal of Emergency Medicine 41.4 (2011): 389-396. PMID: 20832967
- Amery, W. K., et al. "Peroral management of chronic pain by means of bezitramide (R 4845), a long-acting analgesic, and droperidol (R 4749), a neuroleptic. A multicentric pilot-study." Arzneimittel-Forschung 21.6 (1971): 868. PMID: 5109279
- Admiraal, P. V., H. Knape, and C. Zegveld. "EXPERIENCE WITH BEZITRAMIDE AND DROPERIDOL EN THE TREATMENT OF SEVERE CHRONIC PAIN." British journal of anaesthesia 44.11 (1972): 1191-1196. PMID: 4119073
Early studies on Haloperidol for analgesia
- Maltbie, A. A., et al. "Analgesia and haloperidol: a hypothesis." The Journal of clinical psychiatry 40.7 (1979): 323-326. PMID: 222741
- Cavenar, Jo, and A. A. Maltbie. "The analgesic properties of haloperidol." US Navy Med 67 (1976): 10.
- Cavenar, Jesse O., and Allan A. Maltebie. "Another indication for haloperidol." Psychosomatics 17.3 (1976): 128-130.
Haloperidol for pain
- Seidel, Stefan, et al. "Antipsychotics for acute and chronic pain in adults." Cochrane Database Syst Rev 4 (2008). PMID: 18843669
- Ramirez, R., et al. “Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department.” The American journal of emergency medicine (2017). PMID:28320545 Reviewed in this ERCast episode
- Salpeter, Shelley R., Jacob S. Buckley, and Eduardo Bruera. "The use of very-low-dose methadone for palliative pain control and the prevention of opioid hyperalgesia." Journal of palliative medicine 16.6 (2013): 616-622. PMID: 23556990
- Afzalimoghaddam, Mohammad, et al. "Midazolam Plus Haloperidol as Adjuvant Analgesics to Morphine in Opium Dependent Patients: A Randomized Clinical Trial." Current drug abuse reviews 9.2 (2016): 142-147. PMID: 28059034
Feb 18 2018
Rank #13: Pseudoseizures (PNES)
Walker Foland is an emergency physician practicing in Michigan and in this episode breaks down why pseudoseizures, now termed PNES (Psychogenic Nonepileptic Seizures), are a real disease.
- PNES is a conversion disorder: an unconscious manifestation of psychological trauma.
- Walker treats PNES patients with haloperidol or olanzapine with the thinking that this is psychological, not true epilepsy
- PNES is not ‘faking it’ or lying
- Patients with PNES may also have true epileptic seizures
- Diagnosing PNES, or separating it from epilepsy, may take video EEG monitoring, a neurologist, and sometimes prolonged periods of time to figure things out
How to tell the difference between an grand mal epileptic seizure vs PNES vs faking it?
- Seizures related to a specific stimulus (sound foods, body movement)
- Frequency and amplitude of concussions: same frequency through the seizure with varying amplitude.
- Maintenance of consciousness and may have some of the below
- may guard the face with passive hand drop
- resist eyelid opening
- visual fixation on a mirror
- Whit Fisher, Dr Procedurettes, squirts water in the face of patients where there is thought of PNES. If they grimace, probably not an epileptic seizure.
- Purposeful movement
- Avoids injury
- May use convulsions as a way of harming staff
- Intermittently awake and vocal during the episode
- Convulsive frequency decreases, amplitude increases as seizure progresses
- No response to pain
- Allow passive eye opening
A 2010 article from the Journal of Neurology Neurosurgery and Psychiatry broke down the evidence of what other elements can help distinguish PNES from epileptic seizures.
- Duration over 2 minutes suggests PNES, but we’ve all seen epileptic seizures last for a long time, status, and some PNES can be super short
- Happens in sleep. Evidence suggests that if the event happens in sleep, that is probably episode. PNES episodes happen when awake
- Fluctuating course such as a pause in the rhytmic movement, epileptic seizures usually don’t pause and then restart, a pause favors PNES
- Flailing. You’d think the flailing patient has PNES for sure because epilepsy doesn’t flail, but it does! Flailing is much more common in PNES, but not so much so that it’s a clear distinguishing factor
- Urinary incontinence, more common in epilepsy, but does happen in PNES.
- Post-ictal recovery period. Surely, this is the sine qua non of epilepsy. It is way way more common following generalized epileptic seizures but happens in around 15% of PNES.
- The sterterous breathing (noisy, labored) that we see after generalized tonic clonic epileptic seizures suggests epilepsy and is not a characteristic of PNES
Walker’s take home points
- PNES patients aren’t ‘faking it’
- This is a real disorder, it's just not epilepsy
Chen, David K., and W. Curt LaFrance Jr. "Diagnosis and treatment of nonepileptic seizures." CONTINUUM: Lifelong Learning in Neurology 22.1, Epilepsy (2016): 116-131. PMID:26844733
Avbersek, Andreja, and Sanjay Sisodiya. "Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures?." Journal of Neurology, Neurosurgery & Psychiatry 81.7 (2010): 719-725.Full Text PMID:20581136
Mar 21 2018
Rank #14: Internal Medicine in the Emergency Department
Internist Neda Freyha sprinkles some IM in the ED - how to interpret TSH levels and why aspirin is no longer recommended for a-fib thromboprophylaxis.
Jun 03 2018
Rank #15: Why Epi Might (and might not) Work in Cardiac Arrest
The pendulum never seems to stop swinging when it comes to the efficacy of epinephrine in cardiac arrest.
20-25 years ago, the push was to use escalating doses of epinephrine starting at 1 mg and increasing to 3 mg, then 5 mg, and continuing at 5 mg as needed. Some protocols started directly with 5 mg and continued with 5 mg thereafter. These protocols were based on early studies which suggested that higher doses of epi resulted in improved survival to hospital admission.
Subsequent analyses, 5-10 years later, showed that many of the people who got high doses of epi were dying at the same rate, or perhaps even higher rate. Also, amongst the survivors, the neurologic outcome was worse.
Over the past few years, a few studies have reported that epi, even in 1 mg doses, could be potentially harmful and not helpful.
The most recent literature seems to be coming back to a middle zone whereby there probably is some benefit to epinephrine, but only if given in a certain time period. These studies suggest that epi is most beneficial if given in the first 15-20 minutes after cardiac arrest. Continued dosing of epi beyond the 20 minute mark (post cardiac arrest) seems to produce more rapid deterioration and is not supported by the literature.
Jul 01 2018
Rank #16: Mind of an Addict
Our guest today is Joe Polish. Unlike most guests on this show, Joe is not involved in medicine- heis one of the best known marketing minds on the planet. He is the creator of the Genius Network which is the place high level entrepreneurs go to get their next big breakthrough with access to connection, contribution, and collaboration. Joe is also a best selling author and renown podcaster with I Love Marketing, genius network, Rich Cleanerand 10x Talk. But none of those things are why Joe is on the show today. Joe is also an addict, but deeper than that, he’s turning his experience with addiction into a force for change with Genius Recovery and Artists for Addicts.
In this episode
- Open Letter to Anyone Struggling with Addiction
- Joe's story of addiction and how he's dealt with it on the path to recovery
- The roots of addiction, why punishing addicts doesn't work and what we can do instead
- Sex addiction and connection
- The Craving Brain: Why addiction may not be a choice and what we need to understand about it
- How to bring more compassion and empathy to addicts and help them recover
- Gabor Mate:"Not why the addiction, but why the pain?"
- Be transformational, not transactional
Apr 30 2018
Rank #17: Evidence Based Hyperkalemia Management
Hyperkalemia is one of, if not the most, common electrolyte abnormalities we see. But much of what we do in treatment is what someone told us to do when we were young learners. In this episode we debunk hyperkalemia myths and discuss an evidence based approach to management. For more great content check out
Nov 07 2018
Rank #18: COVID-19: Fluids, Prone Position, and Your Emails
In today’s update: New York experience with fluid restriction in COVID ARDS, prone positioning for non-intubated hypoxic patients, resetting the intubation threshold, and using ABGs. Your questions for Reuben Strayer and Patrick Reinfried. For all the previous COVID podcasts plus a bunch of other super useful stuff, here is our depository of resources.
The below is not an evidence based approach, it is experience based and “here’s what we’re doing and it seems to work.” It is by no means the only way to go about this and there are certainly other shops proceeding differently with COVID-19 patients.
New York Experience
Steven Johnson, DO and Dana Gottlieb, MD surveyed their hospital's docs for lessons they’re learning. Below are some of the recommendations. A full write up can be found at the EM Pulse Blog.
Ease up on the fluids
- Don’t give fluids unless you KNOW they are hypovolemic (diarrhea, vomiting, no drinking x 1 week).
- These patients seem to be very sensitive to fluid overload. Patient’s on the floor are avoiding intubation by keeping them net negative despite tachycardia and AKI. Consider starting the patient on a low-dose pressor rather than a fluid bolus to support MAP if they are on the verge of intubation due to hypoxia.
- A suggestion for undifferentiated ED patients: if they are normotensive DO NOT give a fluid bolus. Patients that are hypotensive, carefully consider very small fluid bolus vs pressor (especially if clinically volume overloaded).
- Do not fluid resuscitate to clear lactate. The elevated lactate in a non-hypotensive patient is not from hypovolemia, this is likely from catecholamine surge from severe hypoxia and respiratory distress.
- Not that any of us normally do….but DO NOT start maintenance fluids.
It's interesting how the pendulum swings with IV fluid. Over the past few years, there has been a call to action to be more judicious with our fluid administration, especially in septic patients rather than reflexively jumping in ‘whole hog’ with 30 cc's per kilo (or even more). Much of this is going to fly in the face of policies or benchmarks so it’s something to discuss among your group to see how you want to approach it.
Adding further support to COVID ARDS fluid resuscitation, Josh Farkas has this to say in his online Critical Care Textbook. (direct quote below)
- The cause of death from COVID-19 is nearly always ARDS – which may be exacerbated by fluid administration.
- Gentle fluid administration could be considered for patients with evidence of hypoperfusion and a history suggestive of total body hypovolemia (e.g. prolonged nausea/vomiting and diarrhea). An aggressive fluid resuscitation strategy in viral pneumonia is especially misguided. The primary life-threat facing these patients is ARDS (not hypoperfusion, and certainly not hypovolemia). Perfusion can generally be easily maintained with early administration of low-dose vasopressors and a conservative fluid strategy if necessary (although most patients with viral pneumonia have adequate perfusion to begin with).
- Notably, if hyperlactatemia is being driven by dyspnea causing sympathetic activation, this will only be exacerbated by fluid (which will worsen the respiratory failure).
Oxygenation and Prone Position
Mechanical ventilation can go on a long time and intubated patients have not been doing well. Whether that’s a cause (mechanical ventilation has harmful effects), an association (if you’re sick enough to get intubated, mortality is already high), or both remains to be seen.
- These people are needing 15+ days of intubation, saving a vent for several days is meaningful. Unfortunately, every patient on the floor is developing severe hypoxia. Currently they are recommending a NRB at 15L with a NC at 10L underneath with persistent sats
Apr 02 2020
Rank #19: COVID-19: Lessons Learned and First Hand Account From Kirkland, WA.
Kirkland, Washington was the first U.S. city with reports of a large-scale COVID-19 outbreak. In this special edition of ERcast, Dr. Patrick Reinfried, an emergency physician practicing at Kirkland’s Evergreen Hospital, gives a first hand account of what happened in his community, how his hospital has responded, and lessons learned.
In this episode:
- Difficult decisions that might not have been made before the outbreak
- What factors go into deciding admission vs. discharge
- How to limit exposure to COVID patients and save PPE
- Organizing the emergency department with an area dedicated to fever and respiratory illness
- Patient flow
- Utility of BiPAP vs intubation
- Lab ordering
- Psychological impact.
Mar 21 2020
Rank #20: C Diff Treatment Changes
A few weeks ago, a post on Clay Smith’s Journal Feedabout the new IDSA C diff guidelines caught my attention (specifically, that metronidazole is no longer recommended as first line therapy). Whuut? I tweeted this and @medquestioningtweeted back, "Need to dig to see why they dropped metro in the bucket." Yes, @medquestioning, my thoughts exactly.
Mentioned in this episode
- ERcast 2.0launches May 1, 2018
- To sign up for the new site and 1 year of free CME, click here
- Essentials of Emergency Medicineis just around the corner. If you can't make it to Vegas, the digital live stream is pretty sweet.
New IDSA C Diff Guideline Treatment Recommendations
Initial Episode, Non Severe (WBC ≤ 15k, creatinine < 1.5)
- Vancomycin 125 mg PO QID for 10 days
- Fidaxomicin 200mg PO BID for 10 days
- Metronidazole 500mg TID PO for 10 days
Initial Episode, Severe (WBC >15k, creatinine >1.5)
- Vancomycin 125 mg PO QID for 10 days
- Fidaxomicin 200mg PO BID for 10 days
Initial Episode, Fulminant (Hypotension or shock, ileus, megacolon)
- Vancomycin 500 mg 4 times per day by mouth or by nasogastric tube.
- If ileus, consider adding rectal instillation of vancomycin.
- Intravenously administered metronidazole (500 mg every 8 hours) should be administered together with oral or rectal vancomycin, particularly if ileus is present
• Vancomycin 125 mg given 4 times daily for 10 days if metronidazole was used for the initial episode, OR
• Use a prolonged tapered and pulsed vancomycin regimen if a standard regimen was used for the initial episode (eg, 125 mg 4 times per day for 10–14 days, 2 times per day for a week, once per day for a week, and then every 2 or 3 days for 2–8 weeks), OR
• Fidaxomicin 200 mg given twice daily for 10 days if Vancomycin was used for the initial episode
- McDonald, L. Clifford, et al. "Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)." Clinical Infectious Diseases66.7 (2018): e1-e48. PMID:29462280
- Teasley, DavidG, et al. "Prospective randomised trial of metronidazole versus vancomycin for Clostridium-difficile-associated diarrhoea and colitis." The Lancet322.8358 (1983): 1043-1046. PMID:6138597
- Wenisch, C., et al. "Comparison of vancomycin, teicoplanin, metronidazole, and fusidic acid for the treatment of Clostridium difficile—associated diarrhea." Clinical infectious diseases22.5 (1996): 813-818. PMID:8722937
- New Evidence Favoring Vancomycin
- Zar, Fred A., et al. "A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile–associated diarrhea, stratified by disease severity." Clinical Infectious Diseases45.3 (2007): 302-307. PMID:17599306
- Johnson, Stuart, et al. "Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: results from two multinational, randomized, controlled trials." Clinical Infectious Diseases 59.3 (2014): 345-354. PMID: 24799326
CDC C. Diff Statistics
New York Times article on the association of the rise of new sweeteners and the rise of C. diff.
Apr 17 2018