Taming the SRU

MAY 5, 2023

doi:10.1056/NEJMoa2212663 BACKGROUND Sepsis, including severe sepsis and septic shock, is a frequently encountered condition in the emergency department and carries a high mortality rate. Each subsequent one-hour delay in antimicrobial administration increases mortality by 35% in patients with septic shock (Im, Kang et al.

Sepsis 52

Sepsis Shock Administration Resuscitation 52

EB Medicine

OCTOBER 1, 2018

This month, we’ll be talking Updates and Controversies in the Early Management of Sepsis and Septic Shock. Jeff : So as well all know Sepsis is bread and butter emergency medicine, but, what is sepsis? Jeff : So get this -- one study showed that out-of-hospital shock index and respiratory rate were highly predictive of ICU admission.

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Sepsis Shock Fluid Resuscitation Hospitals 40

PHEM Cast

JULY 14, 2016

Crane T, Cooke MW, Wellings R, Wayte S, Higgins J. Journal of Emergencies, Trauma, and Shock. 2014 Feb 11;7(4):251–5. 2014 Mar 15;31(6):531–40. 2014 Jul 3;14(1):1–5. 2014 Mar 15;31(6):531–40. Elsevier Ltd; 2015 Apr 1;46(4):528–35. Smyth M, Cooke MW. Emergency Medicine Journal. 2013 May 13;30(6):516–6.

Fractures 52

Fractures Hospitals Shock Research 52

ACEP Now

JUNE 14, 2024

And the Board approved a new clinical policy, “Critical Issues in the Management of Adult Patients Presenting to the ED with Seizures,” rescinding the 2014 clinical policy with same title. There were some ACEP business decisions at the April Board meeting, as well. 17-23, 2025 in Orlando, Florida.

Sexual Assault 52

Sexual Assault Seizures Documentation/Coding EMS 52

EMDocs

NOVEMBER 1, 2023

ECG – May show tachycardia or rate related ST depressions Laboratory evaluation: CBC w/ differential – may reveal leukocytosis with left shift CMP, Lipase – can reveal alternative intra-abdominal diagnoses as well as show findings of end-organ hypoperfusion (elevated serum creatinine, transaminitis, etc.) McGraw-Hill Education; 2014.

Operations 67

Operations Radiology Radiology Fluid Resuscitation 67

Advanced Emergency Nursing from AENJ

JANUARY 26, 2015

All went well. 2014) Emergency Care Institute, New South Wales. 2014) Tiny Tip: PRE -eclampsia. Journal of Emergencies, Trauma and Shock, 3(1), 39. 2014) Medscape.com Sullivan, MG (2007) Time Is Critical for Success in Perimortem C-Section ACEP News. 2014) Trauma in the Obstetric Patient: A Bedside Tool.

OB/GYN 40

OB/GYN Ultrasounds Emergency Department Resuscitation 40

Greater Sydney Area HEMS

APRIL 26, 2023

Both the stuff of legend and go by multiple names including harness hang syndrome and orthostatic intolerance, as well as bigfoot and the abominable snowman, respectively. See I told you this sounded a lot like crush injury… Let me put it another way: ST is a state of shock that can be rapidly induced by passive hanging. That’s it?

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia Shock Research Operations 52

Pediatric Emergency Playbook

APRIL 1, 2016

Brain natriuretic peptide (BNP) In adults, we typically think of a BNP Luckily, we have data in children with congenital heart disease as well. This has been studied in children as well, and an elevated lactate in children – typically above 4 – was a predictor of prolonged ICU course and mortality in septic patients.

Pediatrics 52

Pediatrics Sepsis Shock Outcomes 52

Pediatric Emergency Playbook

JANUARY 1, 2016

Be aware that later stages of malrotation may present as shock – they present in hypovolemic shock due to third-spacing from necrotic bowel and/or septic shock from translocation or perforation. Consider surgical causes of forceful vomiting, especially if the child does not look anything other than well. J Emerg Med.

Head Injuries 40

Head Injuries Pediatrics Shock Sepsis 40

Don't Forget the Bubbles

JUNE 30, 2023

Ranulf went white with the shock. You will be running the show today, and you want to use your preparation time well. A recent review was conducted on Trauma Quality Improvement Program data between 2014 and 2016. 2014 Sep;45(9):1287-95. The trauma call goes out. So, what are your key priorities?

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Resuscitation Operations Sepsis Pediatrics 139

EMDocs

APRIL 22, 2024

However, as shock resolved and hemodynamic stability improved, RV strain and underfilling of the LV remained apparent 30 minutes after ROSC (Vid 4). If RV pressure is extreme, it can exceed LV pressure causing paradoxical septal wall motion toward the LV as well. 2014 May;145(5):950-957. RV pressures > LV pressures.

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Ultrasounds Advances Cardiac Life Support (ACLS) EKG/ECG Resuscitation 82

PEMBlog

JANUARY 17, 2024

Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:e10. You can also see petechiae and hemorrhage, as well as superficial bulla, vesicles, or even echemosis. Full blown sepsis and toxic shock syndrome.

Infectious Diseases 59

Infectious Diseases Sepsis Wellness Pediatrics 59

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Authors' commentary: Cardiogenic shock in the setting of severe aortic stenosis. This patient’s severe aortic stenosis (AS) and associated severe cardiogenic shock likely created the ECG pattern, resulting in a very difficult challenge for our inpatient team. Fundamentally, cardiogenic shock is an issue of decreased cardiac output.

EKG/ECG 40

EKG/ECG Shock Fluid Resuscitation Documentation/Coding 40

Advanced Emergency Nursing from AENJ

FEBRUARY 29, 2016

Perhaps, not insignificantly, they were accustomed to receiving systematized government-supplied medical and trauma care, with "shock rooms" receiving an influx of victims, as contrasted to those later who opposed "socialized medicine." Erratum in Mouth-to-Airway [adjunct] 4/22/2014. Committee on Shock.

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Emergency Nursing EMS Resuscitation Military 40

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

An elderly man with sudden cardiogenic shock, diffuse ST depressions, and STE in aVR Literature 1. Methods STEMI activations between January 2014 and April 2018 at the University of Arizona Medical Center were identified. 2 cases of Aortic Stenosis: Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? Knotts et al.

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EKG/ECG Shock Sepsis Emergency Department 52

ACEP Now

AUGUST 8, 2023

Methodologic standards for interpreting clinical decision rules in emergency medicine: 2014 update. Ann Emerg Med 2014; 64: 286-291 Phillips B. How to avoid missing an aortic dissection. ACEP NOW 2023; 42 (6): 14. Green SM, Schriger DL, Yealy DM. Clinical decision rules: how to build them. Arch Dis Child Educ Pract Ed 2010; 95: 83-87.

Shock 52

Shock Hospitals Wellness 52

Dr. Smith's ECG Blog

DECEMBER 14, 2016

There are tall R-waves in V2, which could be a sign of old or well developed posterior MI However, the ECG shows no evidence of acute MI whatsoever. The patient had no hypertension, no tachycardia, a normal hemoglobin, no drug use, no hypotension/shock, no murmur of aortic stenosis. This is from the 2014 ACC/AHA guidelines.

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EKG/ECG Shock Hospitals Wellness 52

Pediatric Emergency Playbook

AUGUST 1, 2017

J Pediatr Surg 2014; 49:1619. 2014; 8(5):533-541. 2014; 15(4):859-871. J Pediatr Surg 2005; 40:197. Sulkowski JP, Cooper JN, Congeni A, et al. Single-stage versus multi-stage pull-through for Hirschsprung's disease: practice trends and outcomes in infants. Pyloric Stenosis Aspelund G, Langer JC. Semin Pedaitr Surg. Applegate KE.

Pediatrics 52

Pediatrics Ultrasounds Resuscitation Sepsis 52

RebelEM

JANUARY 25, 2023

Emery Med J 2014; 31(3): 248-9. Late findings Fever Abdominal distension (+) LR: 5.64 – 16.8 (-) LR: 0.34 – 0.43 Absent bowel sounds Peritoneal signs (i.e. rebound and guarding) Diagnostics Laboratory Tests Commonly ordered lab tests (i.e. 3.6 – 55.6) (-) LR: 0.13 (0.08 – 0.20) ED US (+) LR: 9.5 (2.1 0.27 – 0.83

Operations 52

Operations Sepsis Resuscitation Ultrasounds 52

EMDocs

JUNE 27, 2024

His medical history is significant for three prior admissions for vaso-occlusive crises that have responded well to appropriate therapy, including pain control with NSAIDs and opioids, blood transfusions, antibiotics, and intravenous (IV) crystalloids. 2014 Feb;69(2):144-51. C or 100.4 mg/kg, max 0.4 Epub 2013 Aug 7.

Pediatrics 76

Pediatrics Dehydration EMS Hospitals 76

Pediatric Emergency Playbook

JUNE 1, 2017

This child is at risk for expected complications, as well as overdiagnosis and iatrogenia. These children depend on their preload to run blood passively into the pulmonary circuit; afterload reduction is also important to compensate for a poor left ejection fraction, as well as to avoid the development of pulmonary hypertension.

Pediatrics 52

Pediatrics EKG/ECG Wellness Seizures 52

Advanced Emergency Nursing from AENJ

MAY 3, 2014

Although told several times, the story of the development by Henning Ruben of the prototypical modern manual resuscitator, the self-refilling bag with unidirectional non-rebreathing valves which now dominate the world of resuscitation, is still not well-known. Committee on Shock. What were its recent antecedents? National Academies.

Resuscitation 40

Resuscitation Military Operations Emergency Nursing 40

Pediatric Emergency Playbook

FEBRUARY 1, 2016

Protocols work well for adults, but trauma in children requires that we exercise our clinical muscles just a bit more. They used REBOA for refractory hemorrhagic shock due to either blunt or penetrating injury. 2014 Apr;133(4):e1104-16. Traumatized children need your full attention. Brenner et al. Pediatrics. J Pediatr Surg.

Resuscitation 40

Resuscitation Pediatrics Fractures Emergency Department 40

Pediatric Emergency Playbook

JANUARY 1, 2017

Tachycardia, tachypnea, and a change in behavior can be indicators not only to the presence of pain, but possibly to its etiology as well. For children greater than one year who are preverbal, a well performing scale is the FLACC score: Face, Legs, Activity, Cry, Consolability ( Table 3 ).

Pediatrics 40

Pediatrics Soft Tissue Injuries Burns Emergency Department 40

Don't Forget the Bubbles

JULY 5, 2023

SCD, therefore, is not only a mechanical disease but there are also many other cellular and plasma factors as well as endothelial interaction that generate chronic inflammation. Symptoms may be non-specific in the beginning with patients quickly developing septic shock and disseminated intravascular coagulation. 2014; 349–356.

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Blood Transfusions Stroke Dehydration Sepsis 126

Pediatric Emergency Playbook

MARCH 1, 2016

On arrival, he was in compensated shock, with tachycardia. Adults tolerate hypotension relatively well, and is sufficient until we send them to the OR or interventional radiology suite. 2014 Apr;63(4):460-2. 2014 Aug;49(8):1295-9. He decompensates and needs blood. In children, this is simply not the case. Acad Emerg Med.

Resuscitation 40

Resuscitation Pediatrics Hyperthermia / Hypothermia Operations 40

Taming the SRU

AUGUST 30, 2023

As the name would suggest, inflammatory markers are biological markers of, well, inflammation. Epub 2014 Dec 3. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Epub 2014 Oct 27. Paosong S, Narongroeknawin P, Pakchotanon R, Asavatanabodee P, Chaiamnuay S. Int J Rheum Dis.

Infectious Diseases 87

Infectious Diseases Sepsis Emergency Department Point-of-Care Testing 87

EB Medicine

JULY 8, 2019

Jeff: Well that’s kind worrisome. Jeff: A 2014 study even showed an up to 80% reduction in the likelihood of developing DM2 postoperatively at the 7-year mark. Which again reiterates why this is such an important topic for us as EM clinicians to be well-versed in. While it was < 15% in 1990, by 2016 it reached 40%.

Emergency Department 40

Emergency Department Sepsis Operations Dehydration 40

PEMBlog

JUNE 5, 2024

2014 May;133(5):e1179-88. Infants can get a cervical spine injury during breech delivery or, unfortunately, during non accidental trauma as well. You should also consider the possibility of quote unquote spinal shock. than it is spinal shock. Cervical spine injury patterns in children. Pediatrics. doi: 10.1542/peds.2013-3505.

Fractures 52

Fractures Pediatrics Radiology Radiology 52

Don't Forget the Bubbles

JANUARY 10, 2024

3,950 children were recruited between September 2014 to May 2017. These were presented as hazard ratios and included fever at presentation, previous transfusion ever, haemoglobinuria, malaria, sickle cell disease on enrolment, HIV, evidence of sepsis, malnutrition, shock, hypothermia, and dehydration. Do you believe the results?

Blood Transfusions 78

Blood Transfusions Outcomes Research Hospitals 78

EMDocs

FEBRUARY 12, 2024

ABG and VBG Correlation The correlation between venous and arterial blood gases is well-documented for standard differences (Table 1), and the data obtained from the VBG can be acted on as if it were an ABG (1, 3-6). While ABGs and VBGs usually correlate well, there are a few situations where this correlation is disturbed.

Emergency Department 94

Emergency Department Resuscitation COPD Shock 94

Mind The Bleep

JUNE 17, 2023

Examine for capillary refill, peripheral pulses, are they warm and well perfused? The child will be well in between episodes of pain. Brott NR, 2023) The child will look otherwise well and the abdomen will be soft with only mild tenderness to palpation in the lower abdomen with no guarding. Are there crepitations?

Shock 93

Shock Wellness Emergency Department Ultrasounds 93

RebelEM

MAY 15, 2024

The loss of these cells leads to immunosuppression as well as decreased responsiveness of the immune system as a whole Patients with neutropenia will not only get very sick very quickly, but also will have blunted immune response and may not localize signs of infection well Fever or malaise may be their only presenting symptoms.

Infectious Diseases 93

Infectious Diseases Administration Sepsis Anaphylaxis 93

Sensible Medicine

APRIL 29, 2024

You can assess how well (or poorly) a practicing cardiologist did analyzing a paper in the Journal of Clinical Epidemiology. This came as a shock to me. Then they applied the specification curve analysis to one specific database—the NHANES (National Health and Nutrition Examination Survey) from 2007 to 2014.

Stroke 126

Stroke Documentation/Coding Shock Research 126

RebelEM

FEBRUARY 7, 2024

Philadelphia, PA: Elsevier Saunders; 2014:2331-2350. Philadelphia, PA: Elsevier Saunders; 2014: 2282-2299. Triple antibiotic coverage is recommended. Gorgas, D. “Infections related to pregnancy.” ” Emerg Med Clin North Am 26 (2): 345-366, viii. PMID: 18406978 Houry, D and B. Acute Complications of Pregnancy.

Sepsis 93

Sepsis Shock Hospitals Ultrasounds 93

EMDocs

DECEMBER 18, 2023

Septic shock is high on the differential diagnosis for this patient’s presentation. Introduction Sepsis and septic shock are life-threatening conditions characterized by severe systemic inflammation and organ dysfunction due to a dysregulated host response to infection. What are the most up-to-date guidelines for managing this patient?

Sepsis 65

Sepsis Fluid Resuscitation Resuscitation Shock 65

Mind The Bleep

JUNE 17, 2023

Examine for capillary refill, peripheral pulses, are they warm and well perfused? The child will be well in between episodes of pain. Brott NR, 2023) The child will look otherwise well and the abdomen will be soft with only mild tenderness to palpation in the lower abdomen with no guarding. Are there crepitations?

Shock 52

Shock Wellness Emergency Department Ultrasounds 52