A digest of Dr. Herbert’s monthly audio CME series
edited by Chris Feier, MD


1. Should I use Etomidate in my septic patient?

Dr. Al Sacchetti weighs in on the issue of etomidate in sepsis and reviews his recent debate with Dr. Ron Walls in the July issue of annals of emergency medicine. Here’s a highlight. A single dose of etomidate will eliminate the adrenal gland’s response to ACTH by inhibition of 11-ß-hydroxylase leading to a depressed cortisol response. Brinker (Intensive Care Med 2008;34:163–168) studied 60 children with meningococcal sepsis in which etomidate or another drug was used for intubation. He found that the mortality with etomidate in this septic population was 30% versus 12% if another medication was used. As emergency physicians we feel very comfortable with etomidate because we know that it provides ideal intubating conditions, but there are alternatives. Ketamine provides both hemodynamic stability and may actually blunt the sepsis cascade, thus having beneficial effects in the septic patient. Dr. Sacchetti uses a timed intubation technique in which he starts with high dose Rocuronium 1mg/kg IV followed by Ketamine 1-1.5mg/kg IV about 15 seconds later. This technique provides ideal intubating conditions and may have beneficial effects in sepsis.
Source: Al Sacchetti MD

2. Can I place a foley in urethral injuries?

We were taught by our surgery colleagues and ATLS guidelines that if there are any signs of possible urethral injury (high riding prostrate, meatal blood, perineal ecchymosis, scrotal hematoma, pelvic fracture) that a foley should not be placed. The origins of these claims stems from an article entitled “A Personal View of the Immediate Management of Pelvic fractures and Urethral Injuries” that appeared in the 1977 edition of Urologic Clinics of North America.  This is the personal opinion of the author and no references are sited. But what is the evidence behind these claims? Shlamovitz, G et al. (J Trauma. 2007 Feb;62 (2):330-5) reviewed trauma patients at UCLA from 1998-2005 and found 46 patients with either a urethral injury, bladder injury, or both. Of these, a blind insertion of a foley catheter was attempted in 37 patients. They did not find evidence that a blind attempt to insert a urethral catheter worsened the initial urinary injury. Also, they found that gross hematuria in the urethral catheter was the most sensitive sign for the presence of a urethral or urinary bladder injury and often the only sign of such an injury. The authors argue that larger studies will still be needed to determine the safety of blind urethral catheterization in patients that are suspected to suffer from a lower urological trauma.
Source: Gil Shlamovitz, MD

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