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

EMDocs

NOVEMBER 7, 2023

Antibiotics are recommended for those with complicated diverticulitis, as well as surgical specialist consult if necessary (e.g., Included patients had confirmed uncomplicated diverticulitis but no immunosuppression, peritonitis, sepsis. Patients with sepsis and immunocompromise were not included. perforation).  Br J Surg.

Sepsis 113

Sepsis Best Practices Hospitals Outcomes 113

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

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 113

Shock Dehydration Sepsis EKG/ECG 113

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. Pulses are well felt in all four limbs. She would be low risk by gestalt or structured scoring systems (Wells or revised Geneva), and a negative D-dimer would essentially rule out pulmonary embolism here.

EKG/ECG 110

EKG/ECG Emergency Department Burns Wellness 110

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. There is now some flow in the LMCA!

EKG/ECG 128

EKG/ECG Shock Emergency Department Ambulance Services 128

Don't Forget the Bubbles

MAY 31, 2023

The DIMPLES study by PERUKI sought to investigate the incidence of new-onset diabetes in the paediatric population across the UK and Ireland, as well as the characteristics of these ED presentations, and to determine if SARS-CoV2 infection was involved. Mintegi, S., & Country Leads (2020). Which patients were involved? Bressan, S.,

Emergency Department 135

Emergency Department Research Documentation/Coding Outcomes 135

EMDocs

MARCH 9, 2025

Well keep it short, while you keep that EM brain sharp. 2020 Jun;8(6):e19.00202-e19.00202. Other children at risk for osteomyelitis include those with sickle cell disease , sepsis , an indwelling catheter , and immunodeficiency (e.g., Pediatric osteomyelitis treatment algorithm. JBJS Reviews. Factor VIII deficiency (A) (i.e.,

Pediatrics 52

Pediatrics EMS Infectious Diseases Fractures 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 93

Operations Radiology Radiology Fluid Resuscitation 93

EMDocs

OCTOBER 19, 2024

Leukocytosis, as well as mild leukopenia, are common. 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. 2][3] Evaluation Labwork CBC: A white blood cell count is variable and nonspecific.

EMS 110

EMS Pediatrics Sepsis Airway Management 110

Taming the SRU

AUGUST 30, 2023

As the name would suggest, inflammatory markers are biological markers of, well, inflammation. 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 days (secondary endpoint) [51].

Infectious Diseases 89

Infectious Diseases Sepsis Emergency Department Point-of-Care Testing 89

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. Tachycardia may be present both from many medications or drugs, as well as withdrawal. 2020 Nov 21;41(44):4258]. In short: yes, but it depends.

Shock 105

Shock Emergency Department Pediatrics EKG/ECG 105

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. The patient was already intubated and sedated.

EKG/ECG 131

EKG/ECG Shock Hospitals Sepsis 131

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. There are of course much more complex neurohumoral, inflammatory type cytokiney thingies going on but as you can tell they are well over my head so I’ve skipped them for now.

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. If they are part of the Deaf community, ensure that they have an American Sign Language interpreter present, as well as an in-person interpreter to best communicate the emotion behind their speech. Am J Public Health.

Sexual Assault 98

Sexual Assault Teamwork Dehydration Outcomes 98

Dr. Smith's ECG Blog

OCTOBER 12, 2023

The patient was admitted with a suspicion of sepsis. The ECG could as well fit with acute myopericarditis. 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.

EKG/ECG 111

EKG/ECG Hospitals Sepsis Wellness 111

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

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 Infectious Diseases 52

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

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. The study was approved by the MMC institutional review board.

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

PulmCCM

NOVEMBER 27, 2023

Based on these findings, most intensivists will likely continue the well-established practice of not administering beta-blockers to patients with septic shock requiring vasopressors. To increase power, investigators “harmonized” (combined) the trials, which each enrolled patients during 2020-2022.

Sepsis 52

Sepsis Shock Administration Leadership 52

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. But of course you’ll only be doing this after a high quality, well interpreted echo that shows a hyperdynamic LV so that should give you a little reassurance. Chauvet, J.-L.

Sepsis 52

Sepsis Shock Wellness 52

EMDocs

JULY 29, 2023

September 9, 2020. Other bacterial causes include anaerobic oral flora, Strep viridans, E. Other bacterial causes include anaerobic oral flora, Strep viridans, E. Journal of oral and maxillofacial surgery: official journal of the American Association of Oral and Maxillofacial surgeons. 2002;60(4):446-448. doi:10.1053/joms.2002.31234

EMS 96

EMS Dehydration Ultrasounds Emergency Department 96

RebelEM

AUGUST 12, 2024

Thus further adding to the well known safety of amino acid infusions The lack of a diversified patient population in combination with having used only one type of amino acid formulary greatly limits this study’s generalizability. Comparison of the RIFLE, AKIN and KDIGO criteria to predict mortality in critically ill patients.

Outcomes 81

Outcomes Hospitals Operations Shock 81

Don't Forget the Bubbles

JANUARY 10, 2024

These were presented as hazard ratios and included fever at presentation, previous transfusion ever, haemoglobinuria, malaria, sickle cell disease on enrolment, HIV, evidence of sepsis, malnutrition, shock, hypothermia, and dehydration. Groups were well matched at baseline. Were the study groups similar at the start of the trial?

Blood Transfusions 78

Blood Transfusions Research Outcomes Hospitals 78

ACEP Now

JULY 7, 2023

Patients with sepsis get antibiotics. The article also will not address severe agitation, which is already well covered elsewhere and is the topic of an ACEP clinical policy currently in development. 2020 Jul 3;1(5):898-907. This month, we are discussing the medical management of patients with mild to moderate agitation.

Emergency Department 52

Emergency Department Psychiatric Administration Best Practices 52

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. 45% of patients were admitted to the ICU directly from operating or recovery rooms, 79% were mechanically-ventilated and 42% had sepsis. On the other hand, those randomized to 0.9%

Fluid Resuscitation 40

Fluid Resuscitation Resuscitation Outcomes Sepsis 40

Don't Forget the Bubbles

JUNE 10, 2024

Baby A, a preterm infant, appears to be faring well for the moment—requiring minimal respiratory support, on full feeds, without IV access, and generally in an okay condition. Systemic Infections : Sepsis and other systemic infections can predispose infants to NEC by compromising the gut barrier and promoting inflammation.

Pediatrics 40

Pediatrics Sepsis Fluid Resuscitation Outcomes 40

Dr. Smith's ECG Blog

JANUARY 5, 2020

Thus, both overdiagnosis and underdiagnosis of AF are well-recognized problems in computer interpreted electrocardiograms, and they adversely affect patient management with either inappropriate anticoagulation and/or antidysrhythmics or undertreatment [ 1 , 14 ]. Poon et al. sensitivity and 98.9%

EKG/ECG 52

EKG/ECG COPD Wellness Sepsis 52

Mind The Bleep

FEBRUARY 9, 2024

48 hours) to help her through the initial period of sepsis while her antibiotics take time to work. She is moderately frail with a few well-managed comorbidities, and states that she would not want to live if she was not able to do her gardening or hold her grandchildren. References and further reading Smith G, Nielsen M.

Hospitals 52

Hospitals Resuscitation Fluid Resuscitation Shock 52

Taming the SRU

SEPTEMBER 16, 2024

There are a few other factors as well that may increase risk for a transfusion reaction but are likely not readily available on patient history or are outside the physician’s control. Other factors that could be readily elicited on history include a previous abortion in women and a diagnosis of malignancy in the patient being transfused.

Blood Transfusions 90

Blood Transfusions Anaphylaxis Emergency Department Sepsis 90

EMDocs

OCTOBER 23, 2023

She had been feeling well until yesterday when she had a follow-up with her surgeon, at which time she reported that they performed an internal exam and inserted a ‘medication disk’ into her vagina. The patient is noted to be mildly tachycardic as well as febrile. 2020 Sep;127(10):1269-1279. BJOG 2008; 115:1473.

OB/GYN 93

OB/GYN Operations EMS Ultrasounds 93

Don't Forget the Bubbles

JULY 22, 2024

Using a score that’s not used in clinical practice may seem like it reduces the applicability of the findings, but ultimately, the authors have translated the studies to the well-established PRAM score. Seven provided individual participant data (1728 children between 12-71 months) for the IPD meta-analysis.

Outcomes 105

Outcomes Research Pediatrics Hospitals 105

Taming the SRU

JULY 21, 2023

In infants, this can represent a medical emergency as it can quickly lead to orbital cellulitis and sepsis. Patients will often have objective visual acuity impairment as well as a fever or leukocytosis. Corneal ulcers are most frequently caused by Pseudomonas (especially if they wear contact lens), as well as S. Dacryocystitis.

Emergency Department 88

Emergency Department EMS Burns Wellness 88

Pediatric EM Morsels

FEBRUARY 2, 2024

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 164

Infectious Diseases Pediatrics Sepsis Documentation/Coding 164

EMDocs

JUNE 27, 2024

His medical history is significant for three prior admissions for vaso-occlusive crises that have responded well to appropriate therapy, including pain control with NSAIDs and opioids, blood transfusions, antibiotics, and intravenous (IV) crystalloids. 2020 Feb 12;10(1):2470. C or 100.4 mg/kg, max 0.4 C or 100.4 mg/kg, max 0.4

Pediatrics 97

Pediatrics Dehydration EMS Hospitals 97