The Skeptics' Guide to EM

JUNE 6, 2020

Date: June 2nd, 2020 Reference: Permpikul et al. Date: June 2nd, 2020 Reference: Permpikul et al. Background: I think we have covered sepsis more often than any other topic on the SGEM. However, it has become evident that patients are often over-resuscitated with IV fluids which adversely impacts outcome.

Sepsis 52

Sepsis Shock Resuscitation Outcomes 52

PulmCCM

OCTOBER 30, 2023

Professional Medical Societies Call for Elimination of SEP-1 The Infectious Diseases Society of America (IDSA), along with societies for emergency medicine physicians and hospitalists, are again speaking up about the ongoing policy experiment known as the Centers for Medicare and Medicaid Severe Sepsis/Septic Shock Management Bundle (SEP-1).

Sepsis 52

Sepsis Shock Hospitals Outcomes 52

Don't Forget the Bubbles

NOVEMBER 27, 2023

Four-year-old Ed is being resuscitated for presumed Invasive Group A Streptococcal Sepsis from tonsilitis. In middle-to-high-income countries, after 40-60ml/kg of fluid resuscitation, the Surviving Sepsis Campaign International Guidelines recommend using vasoactive drugs. After 40ml/kg of IV 0.9% The CRT is unchanged.

Shock 143

Shock Sepsis Fluid Resuscitation Resuscitation 143

EMDocs

OCTOBER 19, 2024

Blood cultures: Blood cultures are rarely positive; however, should be obtained if suspicion for sepsis is present or if the patient is immunocompromised. [2][3] 2][3][9] Glucocorticoid were not shown to alter clinical course or patient outcomes. [2][3] Published 2020. Georgiaemsacademy.com. Published 2023. Bacterial Tracheitis.

EMS 86

EMS Pediatrics Sepsis Airway Management 86

Taming the SRU

MAY 5, 2023

Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension. 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. N Engl J Med. 2023;388(6):499-510. 2019, Bauer, Gerlach et al.

Sepsis 52

Sepsis Shock Administration Resuscitation 52

Ken Grauer, MD

FEBRUARY 28, 2023

These 2 settings are: i ) In patients with severe , often longstanding pulmonary disease ; and / or , ii ) In acutely ill patients with multi-system disease ( ie, sepsis, shock, electrolyte and/or acid-base disorders ). These cases provide insight to assessment for MAT: The January 5, 2020 post in Dr. Smith’s ECG Blog — for an example of MAT.

EKG/ECG 195

EKG/ECG Documentation/Coding Sepsis COPD 195

RebelEM

FEBRUARY 8, 2024

patients with more discrepant readings had NIBP checked more frequently) Some patients were on multiple vasopressors, but for an unclear reason the authors decided to only evaluate the dose of norepinephrine MAP discrepancy is not a patient oriented outcome (i.e. J Crit Care 2020. to 1.12; p = 0.03 to 0.99; p <0.01 to 2.47; p – 0.04

Resuscitation 126

Resuscitation Outcomes EMS Sepsis 126

The Skeptics' Guide to EM

DECEMBER 11, 2021

Back in 2019 we were talking about Vitamin C for sepsis ( SGEM#268 ). There have been at least two randomized control trials published that do not support the use of Vitamin C in sepsis. Fujii et al ( VITAMINS RCT) JAMA 2020: n=216 patients with septic shock. Not much has changed over the last two years.

Sepsis 40

Sepsis Shock Outcomes Research 40

RebelEM

AUGUST 12, 2024

What They Did: Double-blind, randomized, placebo controlled trial that ran from October 2019 through January 2024 Multinational study conducted at 22 centers in three European countries 3512 patients were enrolled and before surgery eligible patients were randomly assigned to one of the following two groups Amino Acid Group: 10% Isopuramin at a dose (..)

Outcomes 81

Outcomes Hospitals Operations Shock 81

PulmCCM

JULY 10, 2023

Continuous meropenem infusion for critically ill patients with sepsis Antibiotics have a time-dependent effect on bacteria; maintaining bacteriocidal concentrations of antibiotics should help subdue infections better than intermittent dosing. Mortality was about 30% in each group, and most patients had hospital-acquired sepsis.

Stroke 52

Stroke Sepsis Infectious Diseases Outcomes 52

PulmCCM

NOVEMBER 27, 2023

Authors wondered if chance resulted in more withdrawal-of-care decisions among the landiolol arm, making their outcomes look worse. Powered by his enthusiasm and reputation, vitamin C caught on widely as a therapy for sepsis for several years—even generating an eponymously-named “protocol.” for benefit of vitamin C.

Sepsis 52

Sepsis Shock Administration Leadership 52

Don't Forget the Bubbles

MAY 31, 2023

What outcomes did they look at? Was the outcome accurately measured to minimise bias? The inability to test for SARS-CoV-2 antibodies may have led to an underestimation of the impact of the virus on the reported outcomes. All ED visits that met the criteria for ‘new onset diabetes’ or DKA (‘decompensation’) were included.

Emergency Department 135

Emergency Department Research Documentation/Coding Outcomes 135

Don't Forget the Bubbles

JANUARY 1, 2024

During the COVID-19 pandemic (2020-2021), the incidence of IPD reached its lowest level in 20 years. 2023 Dec 12 Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Outcomes From a Randomized Clinical Trial. Two-Year Autism Risk Screening and 3-Year Developmental Outcomes in Very Preterm Infants. Eur J Pediatr.

Pediatrics 98

Pediatrics Ultrasounds Blood Transfusions Sepsis 98

ACEP Now

OCTOBER 30, 2023

One case report highlighted an unfortunate outcome from aspiration pneumonia, later found to be due to crayons rather than the expected culprits such as food, secretions, or beverages. Oftentimes, it can be an indication of pain, infection, distress, anxiety, dehydration, or the first sign of sepsis. Published September 16, 2020.

Sexual Assault 98

Sexual Assault Teamwork Outcomes Dehydration 98

Don't Forget the Bubbles

JULY 22, 2024

Randomised controlled trials addressing the benefit of steroids in preschool wheeze have compared different cohorts, used different trial designs and measured different outcomes. This is a way to overcome different trial outcomes. This paper’s primary outcome was a change in wheeze severity score (WSS). What does this mean?

Outcomes 105

Outcomes Research Pediatrics Hospitals 105

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]. Sepsis PCT may have some utility in guiding posttest probability for sepsis when the diagnosis is unclear.

Infectious Diseases 88

Infectious Diseases Sepsis Emergency Department Point-of-Care Testing 88

EMDocs

MAY 11, 2024

Cavernous sinus syndrome (B) usually presents with cranial nerve deficits, diplopia, periorbital cellulitis, and facial swelling that may progress to meningitis or sepsis. Salim Rezaie, “Thrombolysis in Acute Ischemic Stroke: Now We Have No Positive RCTs”, REBEL EM blog, July 27, 2020. 2020 Feb;19(2):115-122.

Stroke 88

Stroke EMS EKG/ECG Radiology 88

Don't Forget the Bubbles

NOVEMBER 6, 2024

Survival of Infants Born at 22 to 25 Weeks’ Gestation Receiving Care in the NICU: 2020-2022. Update to the Neonatal Early-Onset Sepsis Calculator Utilizing a Contemporary Cohort. Trends in C-Reactive Protein Use in Early-onset Sepsis Evaluations and Associated Antibiotic Use. Pediatrics. 2024 Oct 1;154(4):e2024067390.

Pediatrics 59

Pediatrics Sepsis Fractures Hospitals 59

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

NOVEMBER 3, 2022

Van Berkel 2017) In 2020 the NEAR study reported peri-intubation hypotension rates of 18.3% April 2020 ) RebelEM recently reviewed The EvK trial , which found a higher 7-day survival rate with ketamine but no difference in 28-day survival. April 2020 NEAR registry study represents 1/3rd the weight of this meta-analysis.

Outcomes 52

Outcomes Emergency Department Sepsis Operations 52

ACEP Now

MAY 9, 2024

These questionable practices led to a rash of bad outcomes. While both conditions rely on supportive care as the mainstay of treatment, plastic surgery literature suggests better outcomes with microscopic fat embolism. Aesthetic Plastic Surgery National Databank Statistics 2020–2021. Accessed March 6, 2024. Aesthet Surg J.

Emergency Department 52

Emergency Department Operations Ultrasounds Hospitals 52

The Skeptics' Guide to EM

JANUARY 25, 2020

Date: January 9th, 2020 Reference: Casey et al. Date: January 9th, 2020 Reference: Casey et al. Case: A 60-year-old male is in your emergency department with sepsis from pneumonia. Outcome: * Primary Outcome: The lowest oxygen saturation observed during the interval between induction and two minutes after tracheal intubation.

EMS 40

EMS Airway Management Administration Resuscitation 40

EM Updates

JUNE 15, 2021

Every patient admitted to the EDAT was followed to the conclusion of their hospital course; the development of this unit and patient outcomes resulting from its execution are presented here. From April 6 to May 3, 2020, 90 patients were admitted to the EDAT. The study was approved by the MMC institutional review board.

Emergency Department 52

Emergency Department Hospitals Outcomes Wellness 52

Don't Forget the Bubbles

JULY 17, 2023

Evaluating the Impact of the 2017 Dutch Neonatal Early-Onset Sepsis Guideline. Clinical Outcomes of COVID-19 in Newborns and Infants: A Multicenter Experience of 576 Cases. 2023 Jun Oral food challenge outcomes in children and adolescents in a tertiary centre: A 5-year experience. Paediatr Child Health. Van Rossem EJD, et al.

Pediatrics 98

Pediatrics Emergency Department Outcomes Fractures 98

Northwestern EM Blog

FEBRUARY 14, 2022

The primary outcome of the study was the response in MAP three hours after the start of angiotensin II infusion. It showed improvement in blood pressure which is a clinically important parameter but not a patient-oriented outcome. However, one limitation of the study was that it was underpowered to demonstrate a mortality difference.

Shock 52

Shock Resuscitation Fluid Resuscitation Sepsis 52

Don't Forget the Bubbles

JUNE 10, 2024

Despite advancements in neonatal care, NEC remains a significant concern due to its association with adverse outcomes, including prolonged hospitalisation, the need for surgical intervention, and increased mortality rates. Differential diagnoses include septic ileus, and infection causes such as sepsis, meningitis and pneumonia.

Pediatrics 40

Pediatrics Sepsis Fluid Resuscitation Outcomes 40

EMDocs

JUNE 27, 2024

2020 Feb 12;10(1):2470. Intravenous fluid therapy and hospital outcomes for vaso-occlusive episodes in children, adolescents, and young adults with sickle cell disease. Factors associated with adverse outcome among children with sickle cell disease admitted to the pediatric intensive care unit: an observational cohort.

Pediatrics 75

Pediatrics Dehydration EMS Hospitals 75

PulmCCM

FEBRUARY 28, 2022

What they did Adult patients admitted to one of 53 intensive care units in New Zealand or Australia between September 2017 and December 2020 were eligible. Death, from any cause, within 90 days of randomization was the primary outcome. The analysis was performed as an intention-to-treat. In the 24 hours prior to randomization, 55.5%

Fluid Resuscitation 40

Fluid Resuscitation Resuscitation Outcomes Sepsis 40

ACEP Now

JULY 7, 2023

Patients with sepsis get antibiotics. However, rapid initiation of treatment is actually patient-centered care that can both lead to better outcomes and limit ED boarding. 2020 Jul 3;1(5):898-907. This month, we are discussing the medical management of patients with mild to moderate agitation. Patients in DKA get insulin.

Emergency Department 52

Emergency Department Psychiatric Administration Best Practices 52

Thinking Critical Care

MAY 18, 2023

To everybody outside Glasgow glucocorticoids seemed to be the answer and Chicago surgeon William Schumer was their chief flag waver, claiming in 1976 that steroid therapy reduced the mortality of saline-treated sepsis in his service from 33% to around 10%. [5] We did not achieve a publishable consensus until 2020. 10.1016/j.jcrc.2023.154317

Shock 40

Shock Research Sepsis Resuscitation 40

Taming the SRU

NOVEMBER 13, 2024

haffner and wright The number of psychiatric emergencies across the U.S., haffner and wright The number of psychiatric emergencies across the U.S., haffner and wright The number of psychiatric emergencies across the U.S., mg/kg (of 0.1 mg/kg (of 0.1 2x maintenance rate

Psychiatric 88

Psychiatric Emergency Department Seizures Pediatrics 88

Don't Forget the Bubbles

SEPTEMBER 23, 2024

Consider sepsis and treat it accordingly. Consider CMV, EBV and BK-polyoma virus infections: Patients are often on prophylaxis for a variable length of time, with differing outcomes. Obesity: Obesity, whether before or after transplant, is linked to worse outcomes. CAKUT, catheterization requirement). Aydin, A.M., Dogan, H.S.,

Pediatrics 52

Pediatrics Fractures Dehydration Sepsis 52

EMDocs

OCTOBER 17, 2023

World Society of Emergency Surgery guidelines (2020) “What is the best way to make a diagnosis of ALCD? However, no included studies compared patient health outcomes between CT-guided care and care without the use of routine CT for suspected diverticulitis. 2020 May 7;15(1):32. 2020 Jun;63(6):728-747. N Engl J Med.

Radiology 67

Radiology Radiology Operations Best Practices 67

EMDocs

OCTOBER 23, 2023

This may also predispose a patient to sepsis, peritonitis, or bowel infarction, which need to be recognized quickly. 2020 Sep;127(10):1269-1279. Morbidity outcomes of 78,577 hysterectomies for benign reasons over 23 years. A patient may experience pelvic pressure or a bulge in the vagina if bowel evisceration occurs (1,7).

OB/GYN 66

OB/GYN Operations EMS Ultrasounds 66