小兒發燒：ACT好還是NSAIDs好？

Feverish debate
When you see a young child with a fever, what do you recommend that parents do? Give paracetamol alone, paracetamol and ibuprofen, or ibuprofen alone? This report of a high quality study of 156 children concludes that we should recommend ibuprofen alone.

• Dual therapy (ibuprofen plus paracetamol) reduced fever better than paracetamol alone in the first 24 hours
• But dual therapy was no better than ibuprofen alone in the first 24 hours
• Ibuprofen alone was best at making the child feel better in the first 48 hours

However, a comment says that reduction of fever is of no value if the child does not feel better. Fever helps the body combat infection; antipyretics may prolong the duration of infection, without providing any reduction in fever seizures. So, "we should use ibuprofen if an antipyretic is needed (which is seldom) and not routinely combine paracetamol with ibuprofen."

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Source: Evidence-Bases Medicine 2009;14:174

院外ACLS不須IV給藥？

Do IV Meds Matter in Out-of-Hospital Cardiac Arrest?
Use of IV drugs did not affect long-term neurological outcome or survival.

Intravenous access and drug administration have long been central elements of advanced cardiac life support (ACLS) protocols despite the absence of evidence that they improve outcomes. In a randomized, controlled, nonblinded trial, 851 consecutive adult patients with out-of-hospital, nontraumatic cardiac arrest in Oslo, Norway from 2003 to 2008 were randomized to receive ACLS with IV access and drug administration (epinephrine, atropine, and amiodarone were used) or ACLS with no IV access.

In the group that received ACLS with no IV access, IV access was established within 5 minutes after return of spontaneous circulation (ROSC). In both groups, patients with ventricular fibrillation received cardiopulmonary resuscitation for 3 minutes before the first shock and between unsuccessful series of shocks. Endotracheal intubation was standard, and postresuscitation therapeutic hypothermia was instituted regardless of initial rhythm or course of arrest. Quality of CPR was determined by transthoracic impedance signals from defibrillators. The primary outcome was survival to discharge.

The rate of hospital admission for patients with ROSC was significantly higher in the group with IV access than in the group without IV access (32% vs. 21%). However, no significant differences were found between the IV-access and no-IV-access groups in rates of survival to discharge (10% and 9%), survival with favorable neurological outcome (10% and 8%), and survival at 1 year (10% and 8%). CPR was performed according to guidelines, and its quality was similar in both groups.

Comment:
This first effort to evaluate the effect of IV access and drug administration on outcomes in patients with out-of-hospital cardiac arrest, after more than 4 decades of use, yields provocative results: These long-standing interventions were not associated with improvement in long-term survival or neurological outcome. The results are in concert with those from studies in which epinephrine, atropine, and amiodarone improved short-term but not long-term outcomes compared with placebo. In addition, IV access had no negative effect on the quality of CPR. This trial begs for research targeted at novel pharmacologic therapies and should prompt the rethinking of ACLS guidelines.

—
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine December 18, 2009
Citation(s): Olasveengen TM et al. Intravenous drug administration during out-of-hospital cardiac arrest: A randomized trial. JAMA 2009 Nov 25; 302:2222.

Emergency obstetric care

Decision-making algorithm in emergency obstetric care.

C-section, cesarean section;

FHTs, fetal heart tones;

US, ultrasonography.

Transtubular potassium gradient (TTKG)

Indications：Hyperkalemia

Precautions：

• Results altered by Hyperkalemia Management.
• Obtain lab sample prior to intervention if possible.
• Do not delay treatment in emergent Hyperkalemia.

Labs：

• Serum Potassium and Serum Osmolality.
• Spot urine for Urine Potassium and Urine Osmolality.

Formula of Transtubular Potassium Gradient (TTPG)：

• TTPG = (Urine K+ x Serum Osm)/(Serum K+ x Urine Osm)
  ... where K+ is potassium and Osm is Osmolality.

Interpretation of Fractional Excretion of Potassium：

• TTPG <6-8%:>
• TTPG). TTPG >6-8: Extrarenal cause of Hyperkalemia (May also be increased in Chronic Renal Failure).

【新藥】Dabigatran有可能取代warfarin？！

Oral Alternative to Warfarin for Venous Thromboembolism?
Dabigatran was safe and effective and had advantages over warfarin.

Dabigatran is a direct oral thrombin inhibitor that, unlike warfarin, can be given in a fixed dose and requires no laboratory monitoring. In a recently published study, dabigatran compared favorably with warfarin in patients with atrial fibrillation (JW Cardiol Sep 1 2009).
In this new industry-sponsored double-blind trial, more than 2500 patients with acute venous thromboembolism (69% with deep venous thrombosis [DVT] only, 21% with pulmonary embolism only, and 10% with both) were randomized to receive either warfarin or dabigatran after initial heparin therapy. At 6 months, significant differences were found between the dabigatran and warfarin groups in incidence of recurrent venous thromboembolism (2.4% and 2.1%) or major bleeding (1.6% and 1.9%). A combined endpoint of major bleeding plus clinically relevant nonmajor bleeding occurred less often with dabigatran (5.6% vs. 8.8%). One side effect, dyspepsia, occurred more commonly with dabigatran than with warfarin (3.1% vs. 0.7%).

Comment:
Dabigatran, which is not yet FDA approved, appears to be comparable to warfarin in both efficacy and safety in patients with venous thromboembolism. Its advantage, compared with warfarin, is that it requires neither laboratory monitoring nor dose adjustments. A previous direct oral thrombin inhibitor, ximelagatran, was effective but failed to gain FDA approval because of hepatotoxicity; in contrast, no hepatotoxicity has occurred in studies of dabigatran. Note that both dabigatran and an oral direct inhibitor of factor Xa (rivaroxaban) already have been approved for use in Canada and some European countries for DVT prophylaxis following total hip or knee arthroplasty but not yet for atrial fibrillation or DVT treatment.

—
Allan S. Brett, MD
Published in Journal Watch General Medicine December 8, 2009
Citation(s): Schulman S et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med 2009 Dec 10; 361:2342.