Taming the SRU

SEPTEMBER 1, 2023

2015) reported a sensitivity of 98.9% 2015) reported a sensitivity of 98.9% for detecting major injuries Abnormal CXR Rapid deceleration mechanism Presence of a distracting injury Chest wall tenderness Sternal/thoracic spine/scapular tenderness There are limited decision-making rules for thoracic spine imaging Yet a study (Inaba et al.,

Sepsis 93

Sepsis Administration Documentation/Coding Fractures 93

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

She arrives in the emergency department (ED) with decreased level of consciousness and shock. There is evidence that taking those patients with ROSC and EKG showing STEMI directly for angiography +/- angioplasty is associated with positive patient-oriented outcomes.

EKG/ECG 52

EKG/ECG Academics EMS CPR 52

Don't Forget the Bubbles

NOVEMBER 15, 2023

One-liner… Understanding how to manage maintenance fluids in critically unwell children best is a basic but important way to improve outcomes. She had septic shock on presentation and was resuscitated with 60ml/kg of balanced crystalloid solution and escalating vasoactive medications. A fluid shift, if you will. Ann Intensive Care.

Resuscitation 80

Resuscitation Dehydration Administration Shock 80

ALiEM

JULY 17, 2023

Match Data The unprecedented numbers of unfilled PGY-1 EM residency training positions in the NRMP Match results shocked the specialty these last two years. In fact, the average number of applicants between 2015-2020 and 2022-2023 were relatively similar, with the latter demonstrating 122 more applicants (2,801 vs 2,923).

EMS 52

EMS Burns Emergency Department Shock 52

Don't Forget the Bubbles

JANUARY 10, 2024

Some wonder if giving blood to children with a haemoglobin <6g/dl will improve outcomes. Outcomes Primary outcome Mortality at 28 days after randomisation. The authors chose a patient-centred, primary outcome in keeping with their pragmatic design. What were the research questions? The study asked TWO questions: 1.

Blood Transfusions 78

Blood Transfusions Outcomes Research Hospitals 78

RebelEM

MAY 25, 2023

I recently gave a talk on the initial management of trauma patients with hemorrhagic shock. Clinical Take Home Point: In patients with TBI and hypovolemic shock, target a SBP or MAP ≥90mmHg, but know this is based on limited evidence. vs SBP target <90mmHg which resulted in a mortality of 33.4% NEJM 1994. [2]

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Resuscitation Fluid Resuscitation Head Injuries Shock 145

Pediatric EM Morsels

JULY 21, 2023

Motor Fingernail bed pressure with a pencil first If flexion outcome, then apply painful stimulus to neck or head (trapezius or supraorbital notch) to look for localization Spinal reflex can result in a falsely elevated score if lower extremity pain induced Verbal Orientated- Able to answer all questions. Fun fact for animal lovers!-

Head Injuries 246

Head Injuries Pediatrics Outcomes Shock 246

Don't Forget the Bubbles

DECEMBER 11, 2023

Neglect Emotional Physical A subsequent study, ‘ The Philadelphia ACE Study ’, in 2015, identified that community factors were routinely neglected from research and so added in five community domains. This is shocking, but they discovered a staggering dose-response model when they compared these results with medical histories.

Wellness 103

Wellness Research Outcomes Shock 103

EM Curious

JULY 1, 2015

ER Cast Part 1 Part 2 SMACC-stalgia SMACC CHICAGO 2015 PEARLS [PODCAST]: Missed SMACC Chicago and want to hear what all the buzz was about? Or maybe just want to reminisce on the great time you had at the conference?

EMS 52

EMS Ultrasounds EKG/ECG Fractures 52

Dr. Smith's ECG Blog

MAY 8, 2023

American Heart Journal 170(6):1255-1264; December 2015. Impella (cardiac output augmentation device) placed for cardiogenic shock Unfortunately, the patient progressed to multiorgan failure with worsening cardiac output despite being maxed on pressors and a balloon pump. Derivation in LBBB: --> Smith SW. He expired 4 days later.

EKG/ECG 52

EKG/ECG Documentation/Coding Outcomes Shock 52

Taming the SRU

MAY 3, 2023

During the admission, she completed a course of broad-spectrum antibiotics and as the underlying shock state improved, she was also weaned off all vasopressor support. For a complete discussion of cardiogenic shock and right ventricular failure, please see this other Air Care Series post on the subject.

Wellness 52

Wellness Hospitals Shock Outcomes 52

RebelEM

MARCH 30, 2023

Background: Previous observational studies published in 2015 (Geri 2015)(Vyas 2015) indicated that early cardiac catheterization in patients with out-of-hospital cardiac arrest (OHCA) might improve mortality and result in more favorable neurological outcomes. Article: How-Berlemont C, Lamhaut L, Diehl J, et al.

Hospitals 63

Hospitals Outcomes EKG/ECG Resuscitation 63

Taming the SRU

AUGUST 30, 2023

A 2015 prospective, cross-sectional study of 78 Thai patients published in the International Journal of Rheumatic Disease demonstrated a sensitivity of 59% and specificity of 84% for PCT with a cut-off of 0.5 They recommended synovial fluid analysis as essential to the diagnosis [30].

Infectious Diseases 86

Infectious Diseases Sepsis Emergency Department Point-of-Care Testing 86

Northwestern EM Blog

JANUARY 24, 2022

Written by: Elizabeth Stulpin, MD (NUEM ‘23) Edited by: Aaron Wibberly, MD (NUEM ‘22) Expert Commentary by : Joshua Zimmerman, MD (NUEM ‘17) Non-Response to Vasopressors Shock is defined as a state of cellular and tissue hypoxia resulting in end organ dysfunction. And for most forms, EM physicians are not typically shocked by shock.

Anaphylaxis 52

Anaphylaxis Shock Sepsis Resuscitation 52

RebelEM

OCTOBER 31, 2022

Used an intention-to-treat analysis for the primary outcome, resembling real-world practice instead of a per-protocol analysis. Image courtesy of Salim Rezaie first appeared on SGEM Composite outcomes Investigators used a composite for the primary outcome. Follow up on >80% of patients.

Sepsis 52

Sepsis Outcomes Research Shock 52

EB Medicine

SEPTEMBER 1, 2018

As some background, from 2006-2015 there were almost 66,000 reported snake exposures and 31 deaths from snake envenomation in the US. Nachi: Not only are they out, they actually worsen outcomes, so definitely don’t pursue any of them. In severe cases this can lead to systemic bleeding and even hemorrhagic shock.

Emergency Department 40

Emergency Department Poisoning Anaphylaxis Allergic Reactions 40

EB Medicine

MARCH 1, 2019

Consider valvular injury in any patient who appears to be in cardiogenic shock, has hypotension without obvious hemorrhage, or has pulmonary edema. In those with severe injury, you may note refractory hypotension secondary to cardiogenic shock. The latter also recommend ED thoracotomy in those with refractory shock.

Emergency Department 40

Emergency Department EKG/ECG Operations Fractures 40

RebelEM

JANUARY 29, 2024

in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47 in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47 in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47 in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47 to 4.0mg/hr typically given in EKOS therapy (See Below).

Stroke 133

Stroke Outcomes Hospitals Administration 133

Don't Forget the Bubbles

JULY 26, 2023

For anyone approaching a structured ABC would be a priority to establish whether shock was present or not. Typical features include: HR >220bpm Narrow complex regular tachycardia P waves difficult to identify In this case there is no shock present so we can proceed to the right branch of the ALSG guideline.

EKG/ECG 98

EKG/ECG Hospitals Shock Documentation/Coding 98

ACEP Now

APRIL 3, 2024

1,2 However, the European TTM1 trial in 2013 showed similar outcomes for those cooled to 33 degrees Celsius compared to 36 degrees Celsius, leading to a 2015 AHA class I recommendation of “cooling between 32 degrees Celsius-36 degrees Celsius.” degrees Celsius. 5,6 In 2021, the TTM2 trial was published. degrees Celsius for 72 hours.

Hyperthermia / Hypothermia 40

Hyperthermia / Hypothermia Resuscitation Outcomes Hospitals 40

RebelEM

JANUARY 25, 2024

What They Did: Design: Randomized, controlled, blinded-outcome trial Sites: Three emergency departments in Denmark Duration: October 9, 2019 to May 26, 2021. Outcomes: Primary Outcome: Reduction of dyspnea measured on a verbal dyspnea scale (VDS) from 0 to 10 recorded at enrollment, then at 2, 4, and 5 hours after arrival.

Ultrasounds 122

Ultrasounds Outcomes COPD Hospitals 122

PHEM Cast

SEPTEMBER 6, 2017

trauma 2004) showed that end-tidal CO2 may be of value in predicting outcome from major trauma (19). Qvigstad et al showed in again in Resuscitation in 2013, confirming inter-individual variation in effectiveness of CPR using ETCO2 as a surrogate for CO Trauma Deakin et al. (J.

CPR 52

CPR Resuscitation Wellness Operations 52

EB Medicine

JUNE 6, 2019

Nachi: And remember that hypothermic patients who are septic have worse outcomes than those who are hyperthermic and septic. Nachi: Moving on to blood pressure: frank hypotension should make you immediately think of a ruptured AAA or septic shock 2/2 an intra abd infection. In one study, a SI > 0.7 Jeff: As for the lactate.

Ultrasounds 40

Ultrasounds Radiology Radiology Sepsis 40

Mind The Bleep

JUNE 17, 2023

They may present in hypovalaemic shock On examination you may feel a sausage shaped mass in the right side of the abdomen which crosses the midline. Rosen MJ, 2015) IBD mostly presents with weight loss, crampy severe abdominal pain which may occur anywhere in the abdomen but frequently in the left lower quadrant and diarrhoea.

Shock 93

Shock Wellness Emergency Department Ultrasounds 93

Don't Forget the Bubbles

JUNE 30, 2023

Ranulf went white with the shock. The primary outcome measure was chest drain failure, i.e., retained haemothorax requiring a secondary interventional procedure. They stratified patients according to the ratio of FFP: PRBC received (1:1, 1:2, 1:3 and 1:3+) and performed logistic regression analyses for various outcomes.

Resuscitation 139

Resuscitation Operations Sepsis Pediatrics 139

EB Medicine

AUGUST 6, 2019

In the end, they reported similar rates of recurrence and bleeding outcomes for acute treatment. Jeff: Edoxaban is up next, approved by the FDA in 2015 for similar indications as the other Factor Xa inhibitors. Jeff: That is simply shocking! of patients per year. Nachi: Next we have apixaban, tradename Eliquis.

Emergency Department 40

Emergency Department Stroke Wellness Outcomes 40

PHEM Cast

APRIL 10, 2016

This was the same principle as in the Rivers trial: the standard care group is the ‘control’ group against which changes in outcome for the ‘intervention’ group are compared. Arriving by Emergency Medical Services Improves Time to Treatment Endpoints for Patients With Severe Sepsis or Septic Shock. 2015 Aug 26;:1–31. Elsevier B.V;

Sepsis 52

Sepsis Fluid Resuscitation Resuscitation Emergency Department 52

EMDocs

DECEMBER 16, 2023

Heat stroke can lead to end-organ dysfunction such as rhabdomyolysis, disseminated intravascular coagulation, cardiogenic shock, liver failure, and cerebral edema. Broad-spectrum antibiotics (A) for septic shock are not inappropriate given the hyperthermia, tachycardia, and hypotension. link] Kakoki, K., Hakariya, T., Takehara, K.,

Hyperthermia / Hypothermia 68

Hyperthermia / Hypothermia EMS Stroke Seizures 68

EB Medicine

AUGUST 1, 2018

Jeff: There are a shocking 22 million past-month users of marijuana in the US, followed by pain relievers at 3.8 Jeff: It’s also worth noting that cannabis is known to cause adverse outcomes on babies such as low birth weight and more frequent perinatal ICU placement. Acute effects of synthetic cannabinoids: update 2015.

Seizures 40

Seizures Hyperthermia / Hypothermia Administration Dehydration 40

Mind The Bleep

JUNE 17, 2023

They may present in hypovalaemic shock On examination you may feel a sausage shaped mass in the right side of the abdomen which crosses the midline. Rosen MJ, 2015) IBD mostly presents with weight loss, crampy severe abdominal pain which may occur anywhere in the abdomen but frequently in the left lower quadrant and diarrhoea.

Shock 52

Shock Wellness Emergency Department Ultrasounds 52

EB Medicine

JULY 8, 2019

Consider performing a RUSH exam (that is rapid ultrasound for shock and hypotension) to identify the cause. Nachi: Recent estimates from 2015-2016 put the prevalence of obesity of those 2 years old to 19 years old at about 19%. Jeff: Even more shockingly, some series showed a 52% repeat operation rate. First up, the kids.

Emergency Department 40

Emergency Department Sepsis Operations Dehydration 40

Pediatric Emergency Playbook

AUGUST 1, 2017

Does Functional Outcome Improve with Time Postsurgery for Hirschsprung Disease? Single-stage versus multi-stage pull-through for Hirschsprung's disease: practice trends and outcomes in infants. 2015; 18 Gilmore AW et al. 2015 Jun;50(6):923-7 Herliczek TW et al. 2015; 3(5):53-56. J Med Genet 2008; 45:1. 2008; 15-21.

Pediatrics 52

Pediatrics Ultrasounds Resuscitation Sepsis 52

EMDocs

JUNE 3, 2023

4 Patients with pelvic fractures are considered unstable when systolic blood pressure < 90mmHg and heart rate >120bpm, or in those with dyspnea, altered mental status, or skin findings of shock. link] Published June 23, 2015. Management and outcomes of open pelvic fractures: An update. Radiopaedia.org. Radiopaedia.org.

Fractures 54

Fractures Resuscitation Operations EMS 54

EMDocs

NOVEMBER 13, 2023

2 Outcomes of patients presenting with ischemic stroke who received MRI as initial imaging modality have demonstrated similar outcomes to those with initial CTA, with Kim et al. demonstrating that functional outcome at 3 months did not differ between the CTA and MRI groups (38.5% vs. 38.1%) with a good functional outcome.

Stroke 87

Stroke Radiology Radiology Emergency Department 87

Don't Forget the Bubbles

JULY 5, 2023

Furthermore, educating both patients and their families is important in order to achieve good treatment compliance and better clinical outcomes. Symptoms may be non-specific in the beginning with patients quickly developing septic shock and disseminated intravascular coagulation. Anemia ; 2015.DOI:10.1155/2015/791498.

Blood Transfusions 126

Blood Transfusions Stroke Dehydration Sepsis 126

RebelEM

MAY 15, 2024

Changing aetiology, clinical features, antimicrobial resistance, and outcomes of bloodstream infection in neutropenic cancer patients. Volume 21, Issue 6, June 2015, Pages 583-590 Perron T, Emara M, Ahmed S. Time to antibiotics and outcomes in cancer patients with febrile neutropenia. Eur J Haematol 2005; 75:1. 2014;14:162.

Infectious Diseases 96

Infectious Diseases Administration Sepsis Anaphylaxis 96

EB Medicine

JANUARY 2, 2019

With opportunities to improve outcomes for both the fetus and the mother, I’m confident that this episode will be worth your time. Nachi: For patient who have a threatened miscarriage in the first trimester, there is a 2-fold increased risk of subsequent maternal and fetal adverse outcomes.

Ultrasounds 40

Ultrasounds Radiology Radiology Infectious Diseases 40