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.

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RebelEM

SEPTEMBER 26, 2022

A meta-analysis of fifteen RCTs comparing blood product transfusion rates of cardiothoracic and surgery patients found significantly lower transfusion rates of FFP in TEG/ROTEM guided group compared to traditional tests, with no difference in survival rates (Fahrendorff 2017). Published 2017 Apr 13. Article: Kumar M et al.

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Resuscitation Blood Transfusions Outcomes Hospitals 52

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.

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Northwestern EM Blog

FEBRUARY 14, 2022

The ATHOS-3 trial in 2017 explored the efficacy of angiotensin II as a vasopressor for severe vasodilatory shock. Severe shock is defined as persistent hypotension requiring vasopressors to maintain a mean arterial pressure of 65mmHg and serum lactate <2 despite adequate volume resuscitation.

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EMDocs

OCTOBER 9, 2023

1 Though hydrocortisone is often included in ‘crash carts,’ the most recent consensus on cardiopulmonary resuscitation (CPR) has a weak recommendation against the use of corticosteroids during CPR. 6 However, due to the vasoconstrictive effects, hydrocortisone may be useful in refractory shock. Published 2017 Mar 28.

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Basic Life Support CPR Fractures Emergency Department 81

PHEM Cast

APRIL 16, 2018

It might be better to consider traumatic cardiac arrest as a completely different disease eg LOST: Low Output State due to Trauma The 2015 European Resuscitation Council and UK Resuscitation Council Algorithms for Traumatic Cardiac Arrest: To read the whole ERC guideline on special circumstances cardiac arrest including trauma, click here.

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Critical Care Now

APRIL 7, 2022

Notable is the patient’s feeling that their “heart stopped” or the sensation of an “electric shock”. The large benefit with using diltiazem is that there is no association with the “electric shock” or “heart stop” feeling that is synonymous with adenosine. Published 2017 Oct 12. Resuscitation. What is the Alternative?

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RebelEM

JUNE 26, 2023

Clinical Take Home Point: In adult patients with trauma at risk of massive transfusion, receiving standard trauma resuscitation management, the addition of 4F-PCC did not result in a decrease in blood product consumption over 24 hours compared to placebo. Lancet Haematol 2017. Severe acute traumatic coagulopathy = PT >1.5

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Don't Forget the Bubbles

MAY 10, 2023

A shocked friend is being ushered out of the way. Resuscitation is a team sport. Role stickers or role aprons with names on them are simple measures to highlight resuscitation roles. A study in Denmark in 2021 explored barriers to effective resuscitation in over 900 in-hospital resuscitations across six hospitals in Denmark.

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Emergency Department Resuscitation Documentation/Coding Teamwork 91

Don't Forget the Bubbles

NOVEMBER 18, 2024

Before considering fluid resuscitation or inotropes, it is essential to correct the infant’s body temperature. Check electrolytes and consider the diagnosis, especially if the infant shows signs of shock or has a family history suggestive of CAH. Hypothermia: Newborns, particularly preterm infants, are prone to hypothermia.

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Sepsis Shock Hyperthermia / Hypothermia Administration 59

The Skeptics' Guide to EM

NOVEMBER 18, 2017

[display_podcast] Date: November 11th, 2017 Reference: Sundén-Cullberg et al. Fever in the Emergency Department Predicts Survival of Patients With Severe Sepsis and Septic Shock Admitted to the ICU. Critical Care Medicine 2017. display_podcast] Date: November 11th, 2017 Reference: Sundén-Cullberg et al.

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EB Medicine

OCTOBER 1, 2018

This month, we’ll be talking Updates and Controversies in the Early Management of Sepsis and Septic Shock. And sepsis-3 redefined septic shock as “hypotension not responsive to fluid resuscitation” with the added requirement of vasopressors to maintain a MAP greater than or equal to 65 and with a lactate > 2.

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Sepsis Shock Fluid Resuscitation Hospitals 40

Don't Forget the Bubbles

JUNE 30, 2023

Ranulf went white with the shock. In addition, a flimsy cannula is easily dislodged during ongoing resuscitation and easily clots off. This was a randomised controlled multisite study comparing resuscitation of trauma patients requiring massive transfusion using either 1:1::1 or 1:1:2 ratios of platelets to plasma to red blood cells.

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The Skeptics' Guide to EM

DECEMBER 7, 2018

You are the first provider on scene with Emergency Medical Services (EMS) and start high-quality Cardiopulmonary Resuscitation (CPR). He is unsuccessfully shocked. published in Resuscitation 2011. A cardiac defibrillator is hooked up and the patient is in ventricular fibrillation. JAMA 2009, Hagihara et al.

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Advances Cardiac Life Support (ACLS) CPR Resuscitation Hospitals 52

EMDocs

JUNE 3, 2023

For a broader overview of pelvic trauma, please review Dr. Lupez’s 2017 article here: [link]. 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. Figure 5: Pelvic binding with a sheet.

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ACEP Now

MARCH 14, 2024

Electrical injuries—excluding lightning injuries—account for roughly 10,000 nonfatal shock incidents a year and 500 deaths a year. Treatment for burns should focus on fluid resuscitation as appropriate based on your institution’s burn protocol per Brooke, Parkland, Rule of 10s etc. Click to enlarge.) McGraw Hill; 2016. Am J Emerg Med.

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Burns Fluid Resuscitation EKG/ECG EMS 52

EMDocs

JULY 17, 2023

However, routine labs, including a complete blood count and metabolic panel, can guide resuscitative efforts preoperatively and may identify clinically relevant abnormalities associated with obstruction, including electrolyte changes, renal injury from hypoperfusion, or anemia secondary to underlying malignancy. Cancers (Basel ). 2018;13:36.

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Operations EMS Fluid Resuscitation Resuscitation 77

RebelEM

MARCH 30, 2023

Clinical Question : In patients who suffer an OHCA without ST-segment elevation on the post-resuscitation ECG, will early coronary angiogram (CAG) vs. delayed CAG improve outcomes? Secondary Outcomes: Shock, ventricular tachycardia, and/or fibrillation within 48 hours after hospital admission. Published online June 08, 2022.

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Hospitals Outcomes EKG/ECG Resuscitation 83

EMDocs

JUNE 27, 2024

2017 Dec 1;30(4):191-201. -smoke, high ozone levels, smog) Asthma/reactive airway disease (RAD) Diagnostic criteria 7,8 Respiratory symptoms +/- fever (at least 38.0 C or 100.4 2 mcg/kg, max 100 mcg) while obtaining IV access 20 IV/IM ketorolac (1 mg/kg, max 15 mg) Morphine (05-0.1 mg/kg, max 4 mg per dose q20-30min) or hydromorphone (0.01-0.02

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Pediatrics Dehydration EMS Hospitals 75

Downeast Emergency Medicine

APRIL 26, 2021

The primary outcome was 30-day mortality with secondary outcomes looking at 24 hour in-hospital mortality, blood resuscitation at 6 and 24 hours, incidence of multiorgan failure, ARDS, nosocomial infection, early seizures, PE/DVT, crystalloid resuscitation after 24 hours, and the incidence of coagulopathy. MI or stroke).

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Head Injuries Administration Outcomes Seizures 52

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). During this resuscitation two different ultrasound machines were used to capture images due to a malfunction with the first machine after initial images were captured. doi: 10.7759/cureus.28481.

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Ultrasounds Advances Cardiac Life Support (ACLS) EKG/ECG Resuscitation 81

Taming the SRU

OCTOBER 1, 2023

doi:10.1155/2017/6014967 Light RW. Unsuspected tension pneumothorax as a hidden cause of unsuccessful resuscitation. J Emerg Trauma Shock. Resuscitation. Published 2017 Sep 7. References Onuki T, Ueda S, Yamaoka M, et al. Can Respir J. 2017;2017:6014967. Pleural diseases. 1992;38(5):266-331. Ann Emerg Med.

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Fractures COPD Hospitals Emergency Department 95

Advanced Emergency Nursing from AENJ

FEBRUARY 19, 2017

How great must be her shock. I recall a shift in emotional content for myself while attempting resuscitation of a one-month old infant (who appeared more dead than stated); the care-giver thinking that it "had only been 10 minutes." Tears welled up while doing so as I thought of my own toddlers.

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EMDocs

FEBRUARY 12, 2024

First, there can be a poor correlation between venous and arterial gases in states of shock, hemodynamic instability, or extremes of acid-base disturbances, due to poor cardiac output/circulatory failure impairing venous and arterial flow, with associated poor gas exchange as well as hypercapnia and acidemia at the tissue level (8).

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EMDocs

OCTOBER 5, 2024

4 The incidence of ESBL-E identified in bacterial cultures in the United States increased by 53% from 2012 to 2017. Management 9-12 Patients such receive standard resuscitation care including: Antipyretics such as Tylenol (650-1000 mg PO), Ibuprofen (600 mg PO), or Toradol (15mg IV). IV fluid resuscitation as needed.

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EMS Infectious Diseases Sepsis Hospitals 74

Dr. Smith's ECG Blog

NOVEMBER 28, 2022

Given her tachycardia and episodes of syncope, the patient was judged to be in compensated obstructive shock with very high risk of imminent decompensation. 2017 Nov;35(4):525-537. J Am Soc Echocardiogr. 2013 Sep;26(9):965-1012.e15. doi: 10.1016/j.echo.2013.06.023. 2013.06.023. PMID: 23998693. Appleton C, Gillam L, Koulogiannis K.

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EKG/ECG Ultrasounds Documentation/Coding COPD 52

EB Medicine

SEPTEMBER 1, 2018

Both are at the University of Florida Jacksonville, and they reviewed a total of 120 articles from 2006-2017, in addition to reviews from both Cochrane and Dare. If EMS has placed bandages, leave them in place until antivenom and resuscitative equipment is ready. It’s an easy number to remember. 1-800-222-1222.

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EB Medicine

JUNE 6, 2019

CT is good but you really should learn ultrasound, and lastly, sick patients need prompt consultation and resuscitation, not rapid trips to radiology. 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

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Ultrasounds Radiology Radiology Sepsis 40

EMDocs

JANUARY 4, 2024

Cardiogenic shock and hypotension can occur (systolic heart failure with reduced ejection fraction.) 10,12 Refractory shock or malignant arrhythmias occur in < 5% of patients. Eds (2017). Comparison of Resuscitative Protocols for Bupropion Overdose Using Lipid Emulsion in a Swine Model. Clin Toxicol (Phila).

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Seizures EKG/ECG Poisoning Shock 66

EB Medicine

AUGUST 6, 2019

Nachi: Next we have Betrixaban, the latest Factor Xa inhibitor to be approved, back in 2017. Jeff: That is simply shocking! Jeff: For all agents, regardless of the DOAC, the initial resuscitation follows the standard principles of hemorrhage control and trauma resuscitation. Let’s also talk lab studies.

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Emergency Department Stroke Wellness Outcomes 40

RebelEM

MAY 15, 2024

Epub 2017 Nov 22. 2017 Jun;69(6):755-764. Give appropriate fluids, vasopressors, and antibiotics. Default to using whichever score your oncologist is more comfortable with. Support Care Cancer. 2018 May;26(5):1465-1470. doi: 10.1007/s00520-017-3985-0. Clarke, R. Warnick, J., Stretton, K., Littlewood, T. British Journal of Haematology.

Infectious Diseases 105

Infectious Diseases Administration Sepsis Anaphylaxis 105

EMDocs

DECEMBER 16, 2023

Evaporative cooling is the preferred method to actively reduce body temperature in the emergency department , as it can be performed with ongoing resuscitation efforts. Ice water immersion and iced peritoneal lavage are additional methods used to lower temperature but are more invasive or can prevent additional resuscitative efforts.

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Hyperthermia / Hypothermia EMS Stroke Seizures 68

EB Medicine

JULY 8, 2019

Nachi: Taken all together, the rising rates of obesity and the rising success and availability of bariatric procedures has led to an increased number of bariatric procedures, with 228,000 performed in the US in 2017. In 2017, these were performed 60%, 18%, and 3% of the time. Finally, there is the roux-en-y gastric bypass.

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Emergency Department Sepsis Operations Dehydration 40

EMDocs

MARCH 11, 2024

The clinical picture of this patient was consistent with hypovolemic shock secondary to acute cholera infection. Rehydration therapy for patients with cholera should include volume resuscitation and electrolyte repletion. Cholera vaccines: WHO position paper – August 2017. Published online August 25, 2017. 2020;10:582554.

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Dehydration CDC Rapid Diagnostic Testing Fluid Resuscitation 89

Pediatric Emergency Playbook

JUNE 1, 2017

Hemodynamically labile children should be resuscitated and a stat transesophageal echocardiogram obtained. The infant in shock after a ‘cold’: myocarditis Beware of the poor feeding, tachycardic, ill appearing infant who “has a cold” because everyone else around him has a ‘cold’. 2017; 15:47-50. 2009; 8:67-69. Güvenç O et al.

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Pediatrics EKG/ECG Wellness Seizures 52

Pediatric Emergency Playbook

JANUARY 1, 2017

Unexplained tachycardia may be the early signs of shock. Below is a reprint (with permission) of a soon-to-be released chapter, Horeczko T. Acute Pain in Children". In Management of Pain and Procedural Sedation in Acute Care. Strayer R, Motov S, Nelson L (eds).

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Pediatrics Soft Tissue Injuries Burns Emergency Department 40

EB Medicine

JANUARY 2, 2019

Nachi: This month’s issue was authored by Dr. Ryan Pedigo, you may remember him from the June 2017 episode on dental emergencies, though he is perhaps better known as the director of undergraduate medical education at Harbor-UCLA Medical center. This result was for the most part re-confirmed in a 2017 cochrane review.

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Ultrasounds Radiology Radiology Infectious Diseases 40