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

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

PulmCCM

DECEMBER 11, 2023

Sepsis, infectious disease Managing septic shock with a restrictive-fluids approach (preferentially using vasopressors after a single liter crystalloid bolus) led to similar outcomes as the usual practice of bolusing large volumes of fluids first. Either approach in severe sepsis with shock seems reasonable.

Sepsis 94

Sepsis Stroke Shock Infectious Diseases 94

Pediatric EM Morsels

FEBRUARY 2, 2024

However, the destination of travel is also important as helminths have distinct geographical distribution. Hospitalization for travel-related illness are around 10% for both VFR and tourists (Leuthard 2015) Multiple studies have reported the most common travel infections in various countries.

Infectious Diseases 161

Infectious Diseases Pediatrics Sepsis Documentation/Coding 161

JournalFeed

APRIL 4, 2020

Here is the JournalFeed Podcast for the week of March 30- April 3, 2020. We cover Pediatric Surviving Sepsis; mortality risk after out-of-hospital naloxone; spontaneous pneumothorax - tube or no tube; opioids prior to pediatric sedation; and HINTS by emergency physicians and stroke risk.

Sepsis 52

Sepsis Stroke Pediatrics Hospitals 52

Don't Forget the Bubbles

AUGUST 7, 2023

Heart rate (HR) and respiratory rate (RR) are THE major vital signs used in Advanced Paediatric Life Support ( APLS) guidance , sepsis guidelines , and Paediatric Early Warning Scores (e.g., Identify the percentage of children whose heart or respiratory rate would exceed the “severe” cut-off from the UK Sepsis Trust and NICE guidelines.

Sepsis 98

Sepsis Pediatrics Urgent Care Emergency Department 98

EMDocs

NOVEMBER 7, 2023

Included patients had confirmed uncomplicated diverticulitis but no immunosuppression, peritonitis, sepsis. Patients with sepsis and immunocompromise were not included. 2020 Mar 30:S1542-3565(20)30426-2. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br  Br J Surg. 2012 Apr;99(4):532-9.

Sepsis 88

Sepsis Best Practices Hospitals Outcomes 88

The Skeptics' Guide to EM

OCTOBER 14, 2023

We have been reading online about something called sepsis that can be deadly. Does he have sepsis?” Specifically, heart rate and respiratory rates are used in early attempts to detect sepsis. His parents look at the monitor and ask you, “Is that heart rate normal for him? It seems awfully high. A prospective study.

Pediatrics 87

Pediatrics Sepsis Urgent Care Emergency Department 87

Dr. Smith's ECG Blog

OCTOBER 20, 2024

sepsis, anemia, hypoxemia, severe hypotension etc., Figure-1: Reasons for the varied ECG presentation of acute LMain occlusion — excerpted from Dr. Smith’s 8/9/2019 post ( This Table from My Comment in the January 16, 2020 post ). The patient was given aspirin and heparin.

EKG/ECG 132

EKG/ECG Shock Emergency Department Ambulance Services 132

ALiEM

FEBRUARY 9, 2024

Let’s apply the ESC 2020 0/1 hour pathway [2], with some modifications based on the 2022 ACC guidelines [1]: Figure 1. The first hs-cTn results in the intermediate range on your assay-specific cutoff for the ESC 2020 pathway or high-STEACS pathway. as seen in heart failure, arrhythmias, or sepsis). J Am Coll Cardiol.

EKG/ECG 110

EKG/ECG Emergency Department Burns Wellness 110

JournalFeed

AUGUST 1, 2020

Here is the JournalFeed Podcast for the week of July 27-31, 2020. We cover pros and cons of antibiotics for dog bites, risk of delayed antibiotics in severe infection, immediate (<1h) vs early (<3h) antibiotic outcomes, and the largest meta-analysis to date on POCUS for cellulitis vs abscess.

Sepsis 52

Sepsis Outcomes 52

JournalFeed

OCTOBER 3, 2020

28- Oct 2, 2020. It’s the JournalFeed Podcast for the week of Sept. We cover the new ACEP opioid policy statement, PE response teams during COVID-19, a SMART balanced fluid trial spin-off in septic shock, an AHA statement on drug-induced arrhythmia, and use of POCUS for shoulder dislocation.

Dislocations 52

Dislocations Sepsis Shock 52

RebelEM

FEBRUARY 8, 2024

J Crit Care 2020. to 1.12; p = 0.03 for every change in 5ug/min Lower MAP Value: aOR 0.98; 95% CI 0.98 to 0.99; p <0.01 for every change in 1mmHg Higher BMI: aOR 1.04; 95% CI 1.01 to 1.09; p = 0.01 for an increase in 1 Increased Patient Age: aOR 1.31; 95% CI 1.30 to 1.37; p <0.01 to 2.47; p – 0.04 were they in the resuscitative phase?

Resuscitation 126

Resuscitation Outcomes EMS Sepsis 126

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. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER): A Randomized Trial. Respir Crit Care Med 2019. Respir Crit Care Med 2019.

Sepsis 52

Sepsis Shock Resuscitation Outcomes 52

Don't Forget the Bubbles

MAY 31, 2023

We have a ringside view in the Children’s Emergency Department – the unique opportunity to see different types of acute presentations, whether DKA, sepsis or asthma, amongst a host of febrile children. Mintegi, S., & Country Leads (2020). Bressan, S., Buonsenso, D., Farrugia, R., Oostenbrink, R., Titomanlio, L., Nijman, R.

Emergency Department 135

Emergency Department Research Documentation/Coding Outcomes 135

Taming the SRU

AUGUST 30, 2023

Pneumonia A 2020 meta-analysis of 8 studies including 2,215 adults with confirmed community acquired pneumonia in different settings found PCT with a cutoff of 0.5 Sepsis PCT may have some utility in guiding posttest probability for sepsis when the diagnosis is unclear. 2020 Nov 20;99(47):e23315. J Med Virol.

Infectious Diseases 88

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

EMDocs

JANUARY 23, 2024

An inciting event will typically push them over the edge into BRASH syndrome: Dehydration Hypotension from sepsis or another condition GI illness Dosage increase of a chronic medication (e.g., 2020 Aug;59(2):216-223. The key is a patient who is on an AV nodal blocker and who has some sort of risk factor for renal insufficiency.

Shock 87

Shock Dehydration Sepsis EKG/ECG 87

EMDocs

JANUARY 9, 2024

McGraw Hill; 2020. Food and Waterborne Illnesses. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. Accessed August 28, 2022. link] Zafren K, Thurman R, Jones ID. Marine Dermatitis. In: Knoop KJ, Stack LB, Storrow AB, Thurman R.

Poisoning 83

Poisoning Burns Sepsis 83

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. Point-of-care ultrasound for non-vascular invasive procedures in critically ill neonates and children: current status and future perspectives. Pawlowski TW, et al.

Pediatrics 98

Pediatrics Ultrasounds Blood Transfusions Sepsis 98

Sensible Medicine

AUGUST 14, 2024

This sort of sepsis would produce many of the common autopsy findings. The CDC reports that in the US in 2020 there were 93 Sudden Unexpected Infant Deaths per 100,000 live births (Fig. million babies born in 2020, and the CDC reports there were about 1,389 SIDS deaths. Subscribe now How Many Infants Die of SIDS?

CDC 76

CDC Sepsis Research Pediatrics 76

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

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] Published 2020. ESR, CRP: Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are also nonspecific but are estimated to be elevated in 68% of patients.

EMS 87

EMS Pediatrics Sepsis Airway Management 87

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

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 89

Stroke EMS EKG/ECG Radiology 89

Dr. Smith's ECG Blog

JUNE 26, 2023

As I discuss in detail in My Comment at the bottom of the page in the May 24, 2020 post in Dr. Smith's ECG Blog — AV dissociation is not the same as AV block. Most occurrences are associated with events such as sepsis, shock, recent infarction, post-operative state, electrolyte disturbance — or "sick patient".

EKG/ECG 86

EKG/ECG Seizures Sepsis Operations 86

Dr. Smith's ECG Blog

OCTOBER 12, 2023

The patient was admitted with a suspicion of sepsis. We review ECG findings in Takotsubo Cardiomyopathy in the March 25, 2020 post of Dr. Smith's ECG Blog. What do you think? ECG#1 - day 1 The above ECG shows sinus rhythm with a narrow QRS and normal axis. There is Brugada type I STE in lead V1-V2.

EKG/ECG 110

EKG/ECG Hospitals Sepsis Wellness 110

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

Emergency Medicine Ireland

JULY 3, 2023

Type 5 is the big bucket where they put all the left over disease that cause both kidney and heart failure eg things like amyloid, or sepsis or cirrhosis. Eur J Heart Fail 22, 584–603 (2020). Type 4 is again renocardiac with the kidneys causing the heart failure but on a chronic basis. With me so far? With me so far?

Sepsis 96

Sepsis Shock Wellness Documentation/Coding 96

ACEP Now

OCTOBER 30, 2023

Oftentimes, it can be an indication of pain, infection, distress, anxiety, dehydration, or the first sign of sepsis. Published September 16, 2020. The inverse is also true; what’s normal for most may be significantly abnormal for that patient and be the first red flag. One commonly used example is tachycardia. Am J Public Health.

Sexual Assault 98

Sexual Assault Teamwork Outcomes Dehydration 98

Dr. Smith's ECG Blog

JULY 21, 2024

The stay in the cardiac intensive care unit (CICU) was further complicated by sepsis, delirium, GI bleeding, and anuric renal failure with need for renal replacement therapy. Unfortunately, he required re-intubation a few days later due to respiratory distress from severe bilateral pneumonia.

EKG/ECG 122

EKG/ECG Shock Hospitals Sepsis 122

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

More recently, another late-career scientist caught a strange fever for high-dose vitamin C, this time as a treatment for sepsis, based on his anecdotal experiences as a treating physician at a Virginia health system. Vitamin C was also tested during the Covid-19 pandemic, in two separate randomized trials (REMAP-CAP and LOVIT-COVID).

Sepsis 52

Sepsis Shock Administration Leadership 52

EMDocs

NOVEMBER 1, 2023

1 , 4 If presenting later in course or with an intra-abdominal perforation, patients are more likely to show signs of sepsis and hemodynamic instability. VBG with lactate 4 – may show low pH with elevated lactate Cardiac biomarkers – to evaluate for cardiac etiology in those presenting with chest pain or type II NSTEMI in those with sepsis.

Operations 67

Operations Radiology Radiology Fluid Resuscitation 67

EM Updates

JUNE 15, 2021

In the last week of March and first week of April 2020, hospitals across New York City were overwhelmed with critically ill COVID-19 patients, many of whom had unprecedented oxygen requirements. From April 6 to May 3, 2020, 90 patients were admitted to the EDAT. 2020;e203391. 2020 July 3. Results are presented in Table 1.

Emergency Department 52

Emergency Department Hospitals Outcomes Wellness 52

Mind The Bleep

SEPTEMBER 12, 2023

Were there any risk factors for sepsis? Increased work of breathing with grunting and tachypnoea could be due to sepsis, hypoglycaemia or acidosis due to an inborn error of metabolism. Birth History How long was the labour? Postnatal History Ask about respiratory effort since birth.

Sepsis 52

Sepsis Seizures Poisoning Wellness 52

EMDocs

OCTOBER 8, 2024

The full differential diagnosis of sinus tachycardia in isolation is extensive ranging from benign etiologies such as anxiety to severely life threatening etiologies such as sepsis. 2020 Nov 21;41(44):4258]. Discharging a patient with abnormal vital signs has been linked to unanticipated death (1-4). Ann Emerg Med. 2017;70(3):268-276.e2.

Shock 95

Shock Emergency Department Pediatrics EKG/ECG 95

Emergency Medicine Ireland

OCTOBER 16, 2023

We’ll start with sepsis. Sepsis is a state of low systemic vascular resistance leading to reduced preload and afterload in the heart. Echocardiogr Mt Kisco N Y 37 , 822–831 (2020). We’ll start with sepsis. Perhaps it’s best to start by identifying contexts where we should be on the look out for this.

Sepsis 52

Sepsis Shock Wellness 52