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. 2018, Kuttab, Lykins et al. 2018, Kuttab, Lykins et al. Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension.

Sepsis 52

Sepsis Shock Administration Resuscitation 52

The Skeptics' Guide to EM

AUGUST 14, 2021

Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Date: August 12th, 2021 Reference: Daya et al.

Shock 52

Shock CPR Hyperthermia / Hypothermia EMS 52

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).

Emergency Department 94

Emergency Department Resuscitation COPD Shock 94

Taming the SRU

FEBRUARY 19, 2024

This has been the central question of many research projects with variable outcomes. A recent observational study was performed to pragmatically assess clinically meaningful differences in BP in a diverse critically ill cohort with shock. Damping Damping is essentially the shock absorbers in the pressurized system. Keville, M.

Shock 59

Shock Resuscitation Ultrasounds Research 59

The Skeptics' Guide to EM

DECEMBER 7, 2018

Date: December 6th , 2018 Reference: Perkins et al. Date: December 6th , 2018 Reference: Perkins et al. He is unsuccessfully shocked. There was also no increase in survivors with good neurological outcomes with ACLS. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. JAMA 2009, Hagihara et al.

Advances Cardiac Life Support (ACLS) 52

Advances Cardiac Life Support (ACLS) CPR Resuscitation Hospitals 52

PulmCCM

JULY 10, 2023

A 2018 meta-analysis reviewed here suggested that prolonged infusion of antipseudomonal beta-lactams reduced mortality by 30% compared with shorter infusions, and more observational data has accumulated since that time. Mortality was about 30% in each group, and most patients had hospital-acquired sepsis. access, etc., detailed here.

Stroke 52

Stroke Sepsis Infectious Diseases Outcomes 52

RebelEM

MARCH 2, 2023

Essentially there was no difference, meaning we wouldn’t expect to find a difference in outcomes Although not patient oriented, why is there no breakdown of how many patients had cardiogenic shock, congestive heart failure, echocardiographic findings, or even troponin levels. Eur Heart J 2018. Low O2 protocol: 3.1%

Outcomes 52

Outcomes EMS EKG/ECG Hospitals 52

ACEP Now

MAY 9, 2024

1,2 You’ll also find the story of Sheila Powell, a woman who suffered a pneumothorax during her 2018 Miami BBL and whose 16-year-old daughter worried that in “just a blink of the eye, I could have lost my mom.” These questionable practices led to a rash of bad outcomes.

Emergency Department 52

Emergency Department Operations Ultrasounds Hospitals 52

EMDocs

JUNE 27, 2024

2018 Aug;46(3):144-151. Epub 2018 Oct 17. Intravenous fluid therapy and hospital outcomes for vaso-occlusive episodes in children, adolescents, and young adults with sickle cell disease. Sickle Cell Disease: A Review. 2022 Jul 5;328(1):57-68. PMID: 35788790. Farooq S, Abu Omar M, Salzman GA. Hosp Pract (1995). PMID: 29648482.

Pediatrics 75

Pediatrics EMS Dehydration Hospitals 75

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. 2018 Apr;44(4):409-417. Epub 2018 Mar 27.

Resuscitation 80

Resuscitation Dehydration Administration Shock 80

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

Can J of Cardiol 2018, 34: 132-145 Here are some other cases: LVH, LBBB, RBBB, and RVH may manifest ST depression without any ischemia! An elderly man with sudden cardiogenic shock, diffuse ST depressions, and STE in aVR Literature 1. 2 cases of Aortic Stenosis: Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease?

EKG/ECG 52

EKG/ECG Shock Sepsis Emergency Department 52

EMDocs

JANUARY 16, 2024

Patients can have excellent outcomes despite prolonged resuscitation. Down time and time doing CPR is not nearly as important, and even patients with low end tidal, fixed, dilated pupils, asystole rhythm, and extended low-flow times can have favorable neurologic outcomes. Resuscitation 2018. Accessed September 30, 2023.

Hyperthermia / Hypothermia 84

Hyperthermia / Hypothermia Resuscitation CPR EMS 84

The Skeptics' Guide to EM

FEBRUARY 10, 2018

[display_podcast] Date: February 6th, 2018 Reference: Foster SJ et al. Lancet January 2018 Guest Skeptic: Dr. Tessa Davis is a Pediatrician specialising in Pediatric Emergency Medicine and currently practicing in a central London hospital. display_podcast] Date: February 6th, 2018 Reference: Foster SJ et al.

Emergency Department 40

Emergency Department Pediatrics Sepsis Hospitals 40

EMDocs

JULY 17, 2023

Measures to optimize the patient for surgical intervention and treat shock, including antibiotics and fluid resuscitation, are associated with improved outcomes in these patients. However, surgical consultation should not be delayed while waiting for imaging in a patient who is in shock, appears toxic, or has signs of peritonitis. -In

Operations 77

Operations EMS Fluid Resuscitation Resuscitation 77

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

Dr. Smith's ECG Blog

APRIL 6, 2018

We caught it though: The person manning the defibrillator was about to press shock when we remembered something very important to check in this scenario. A shock was delivered with the following change in rhythm: Likely sinus rhythm with suppressed P-wave amplitude, but could also be junctional rhythm. Learning Points: 1.

Shock 52

Shock EMS Wellness Outcomes 52

Dr. Smith's ECG Blog

MAY 8, 2023

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. Queen of Hearts Interpretation: Would 20 minutes earlier diagnosis have made a difference in his clinical outcome?

EKG/ECG 52

EKG/ECG Documentation/Coding Outcomes Shock 52

ACEP Now

JULY 7, 2023

2,3 In general, patients who develop cardiac arrest with an initial rhythm of VT or VF tend to have favorable outcomes compared to patients who develop cardiac arrest from either asystole or pulseless electrical activity. Initial guidelines defined “refractory” as VT or VF occurring despite three shocks from a cardiac defibrillator.

Resuscitation 98

Resuscitation Shock Stroke Hospitals 98

RebelEM

AUGUST 14, 2023

in both groups Mean APACHE II score was 12 in both groups Almost half of the patients had septic shock at enrollment Mean time from sepsis identification to randomization was 1.4 Secondary Outcome Results: ICU mortality: placebo 20.0% The primary outcome was patient oriented. 906 randomized to the Placebo cohort.

Sepsis 98

Sepsis Outcomes Administration EMS 98

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

NOVEMBER 20, 2023

Military practice guidelines recommend REBOA for profound shock (SBP <90mmHg) 1 and ACEP along with the American College of surgeons recommend REBOA for traumatic life-threatening hemorrhage below the diaphragm in patients with hemorrhagic shock who are unresponsive or transiently responsive to resuscitation.

Resuscitation 89

Resuscitation Outcomes Operations Hospitals 89

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

EB Medicine

SEPTEMBER 1, 2018

I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta and we’ll be taking you through the September 2018 issue of Emergency Medicine Practice - Emergency Department Management of North American Snake envenomations. Nachi: Not only are they out, they actually worsen outcomes, so definitely don’t pursue any of them.

Emergency Department 40

Emergency Department Poisoning Anaphylaxis Allergic Reactions 40

Taming the SRU

JANUARY 10, 2024

Additionally, ED boarding is a now a larger factor than in 2018. Phenobarbital has been proven to be equivalent to benzodiazepines with regard to clinical, pharmacologic and utilization outcomes. Therefore this should remain high on the differential if a patient with history of SCAD presents with similar symptoms.

EKG/ECG 91

EKG/ECG Shock Fractures Emergency Department 91

RebelEM

JUNE 26, 2023

Interventions such as early application of hemorrhage control, tranexamic acid, reduction of crystalloid fluid administration and balanced ratio blood product transfusion have improved many patients’ outcomes. However, mortality still remains high due to trauma-induced coagulopathy. Severe acute traumatic coagulopathy = PT >1.5

Administration 144

Administration Outcomes Resuscitation Radiology 144

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

RebelEM

OCTOBER 31, 2022

Amrein 2018) A small, single-center, before-and-after study utilized a sepsis cocktail consisting of IV thiamine, hydrocortisone, and vitamin C and discovered a significant decrease in mortality compared to the control group. Composite outcomes decrease the enrollment size required to power a study adequately.

Sepsis 52

Sepsis Outcomes Research Shock 52

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

EB Medicine

AUGUST 1, 2018

I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta and we’ll be taking you through the August 2018 issue of Emergency Medicine Practice. Jeff: There are a shocking 22 million past-month users of marijuana in the US, followed by pain relievers at 3.8 Jeff: So that wraps up the August 2018 episode of Emplify.

Seizures 40

Seizures Hyperthermia / Hypothermia Administration Dehydration 40

RebelEM

DECEMBER 19, 2022

This procedure involves applying another set of pads attached to a second defibrillator to a patient and shocking them in hopes of terminating the rhythm. Background Information: Double external defibrillation (DED) is an intervention often used to treat refractory ventricular fibrillation (RVF).

EMS 52

EMS CPR Shock Resuscitation 52

Taming the SRU

AUGUST 30, 2023

Significantly elevated CRP (>122mg/L) and PCT (>0.5ng/mL) levels are predictors of bad outcomes, and are useful for tracking therapy progress, but are not specific enough to rule-in infectious endocarditis [38-39]. 2018 Aug 1;10(8):a028456. Epub 2018 Oct 19. 2018 Jul 31;138(5):e78-e79. ng/mL, 0.25-0.5 2018.09.070.

Infectious Diseases 86

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

RebelEM

JANUARY 25, 2024

A 2018 systematic review and meta-analysis of 25 studies focusing on the accuracy of emergency lung ultrasound showed sensitivity of 85-95% and specificity of 75-90% for pneumonia, sensitivity of 78% and specificity of 94% for COPD/asthma, and sensitivity of 75-90% and specificity of 80-90% for acute heart failure [4].

Ultrasounds 122

Ultrasounds Outcomes COPD Hospitals 122

Dr. Smith's ECG Blog

NOVEMBER 26, 2018

The axiom of "type 1 (ACS, plaque rupture) STEMIs are not tachycardic unless they are in cardiogenic shock" is not applicable outside of sinus rhythm. Again, not an expected outcome with diltiazem). Diltiazem is not terribly effective for conversion of atrial flutter to sinus, so this should not be an expected result.

EKG/ECG 52

EKG/ECG Wellness Administration Academics 52

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. That’s where we’re at.

Sepsis 40

Sepsis Shock Fluid Resuscitation Hospitals 40

EB Medicine

AUGUST 6, 2019

In the end, they reported similar rates of recurrence and bleeding outcomes for acute treatment. Jeff: That is simply shocking! Nachi: Though you can, in theory, test for plasma DOAC concentrations, such tests are not routinely indicated as levels don’t correspond to bleeding outcomes. of patients per year.

Emergency Department 40

Emergency Department Stroke Wellness Outcomes 40

The Skeptics' Guide to EM

APRIL 28, 2018

[display_podcast] Date: April 25th, 2018 Reference: Stern A et al, Corticosteroids for pneumonia (Review). display_podcast] Date: April 25th, 2018 Reference: Stern A et al, Corticosteroids for pneumonia (Review). Outcome: * Primary Outcome: All-cause mortality at 30 days after randomization. December 2017. December 2017.

Hospitals 40

Hospitals Emergency Department Outcomes Shock 40

EMDocs

JANUARY 6, 2024

10 Dysrhythmias (more commonly ventricular), chest pain, dyspnea, acute CHF and shock are all possible. 3 Heart transplant patients with ACS have higher risks for cardiogenic shock and in-hospital mortality compared with the general population. 3 Many will experience vague, nonspecific symptoms such as weakness or fatigue.

EMS 63

EMS Infectious Diseases Shock Emergency Department 63