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

EMDocs

NOVEMBER 13, 2024

Older age, recurrent episodes of SBP, hepatorenal syndrome, hepatic encephalopathy, acute kidney injury (AKI), concurrent GI bleeding, and higher MELD scores are predictors of worse outcomes. Management: Patients can rapidly progress to septic shock and multiorgan failure. 2023 Aug;70:84-89. coli (50-90% of cases).

Hyperthermia / Hypothermia 105

Hyperthermia / Hypothermia Ultrasounds Shock Hospitals 105

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

RebelEM

MAY 25, 2023

I recently gave a talk on the initial management of trauma patients with hemorrhagic shock. Clinical Take Home Point: In patients with TBI and hypovolemic shock, target a SBP or MAP ≥90mmHg, but know this is based on limited evidence. vs SBP target <90mmHg which resulted in a mortality of 33.4% NEJM 1994. [2]

Resuscitation 145

Resuscitation Fluid Resuscitation Head Injuries Shock 145

Taming the SRU

MARCH 30, 2023

Diastolic shock index and clinical outcomes in patients with septic shock. O: There was an association between increased diastolic shock index score and mortality at 90 days and performed similarly to more advanced measures of morbidity and mortality in septic shock including lactate levels and SOFA scores.

Shock 52

Shock Outcomes Sepsis Resuscitation 52

RebelEM

NOVEMBER 6, 2023

Background Information: Vasoplegic shock is defined as hypotension with normal or increased cardiac output and can commonly occur in post-cardiac surgery patients having received cardiopulmonary bypass. Hydroxocobalamin Versus Methylene Blue for the Treatment of Vasoplegic Shock Associated With Cardiopulmonary Bypass. 2023 Jul 19.

Shock 71

Shock Administration Academics Hospitals 71

Don't Forget the Bubbles

MARCH 31, 2025

This was a secondary analysis of the Management and Outcome of Fever in Children in Europe (MOFICHE) study. The primary outcome measure was SBI, and 1854 children included were diagnosed with an SBI. 2023 Nov;7(1):e002094. doi: 10.1136/bmjpo-2023-002094. 41% of patients with septic shock had MODS. Whats it about?

Sepsis 59

Sepsis Fluid Resuscitation Shock Resuscitation 59

RebelEM

FEBRUARY 15, 2024

not a patient oriented outcome) Single country study which may limit generalizability Excluded pregnancy where risk of emesis is increased due to gravid uterus Alcohol was the implicated in the overwhelming majority of patients. Paper: Freund Y et al. References: Freund Y et al.

Poisoning 141

Poisoning Airway Management Seizures Shock 141

EMDocs

JANUARY 13, 2024

Spoon Feed High-dose nitroglycerin improves outcomes in patients with sympathetic crashing acute pulmonary edema (SCAPE) without significant side effects when compared to low-dose nitroglycerin. 2023 Nov 28:emermed-2023-213285. doi: 10.1136/emermed-2023-213285. 2023 Nov 28:emermed-2023-213285. Emerg Med J.

Stroke 86

Stroke Shock Pediatrics Resuscitation 86

RebelEM

MAY 18, 2023

Background: IV fluids are part of the standard resuscitation bundle in septic shock, however it is unclear if they provide a significant benefit. The goal of the trial was to see if early vasopressors improved shock control by 6 hours. This resulted in better shock control by 6hrs (76.1% Liberal: 14.9% Liberal: 14.9%

Sepsis 104

Sepsis Shock Resuscitation Outcomes 104

RebelEM

NOVEMBER 30, 2023

Current SSC guidelines recommend fluid resuscitation with at least 30mL/kg IV crystalloid in patients with sepsis induced hypoperfusion or septic shock within the first three hours of resuscitation, regardless of comorbidities. Outcomes: Primary Outcome: In-hospital mortality. Am J Emerg Med. 2023;73:34-39. 2.89, p = 0.01.

Sepsis 121

Sepsis Fluid Resuscitation Resuscitation Administration 121

RebelEM

SEPTEMBER 28, 2023

The STREAM-1 trial found that for [2] patients with STEMI presenting within 3 hours of symptom onset and unable to attain PCI within 1 hour of first medical contact, a pharmaco-invasive strategy resulted in similar rates of death, shock, heart failure, or reinfarction compared to primary PCI. Primary PCI: 95.7% Primary PCI: 95.7%

EKG/ECG 138

EKG/ECG Allergic Reactions Shock Stroke 138

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 145

Administration Outcomes Resuscitation Radiology 145

The Skeptics' Guide to EM

FEBRUARY 11, 2023

Date: February 7, 2023 Reference: Cheskes et al. Date: February 7, 2023 Reference: Cheskes et al. Intervention: * Vector Change Defibrillation: Pads are placed in an anterior-posterior pad placement after standard anterior-anterior configuration following the third shock with standard defibrillation.

Shock 57

Shock CPR Hyperthermia / Hypothermia Hospitals 57

The Trauma Pro

SEPTEMBER 12, 2023

This work comes from the Shock Trauma Center in Baltimore and is a follow on to a paper published in the New England Journal of Medicine earlier this year. AAST 2023 Plenary Paper 3. N Engl J Med 2023; 388:203-213. The paper demonstrates that aspirin is not inferior to LMWH when used for VTE prophylaxis of patients.

Fractures 113

Fractures Head Injuries Research Outcomes 113

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 ). MAT almost always occurs in one of 2 common predisposing settings. Additional material on MAT.

EKG/ECG 195

EKG/ECG Documentation/Coding Sepsis COPD 195

ALiEM

OCTOBER 30, 2024

We did not use clonidine, despite its known alpha agonist utility in opioid withdrawal, due to the undifferentiated nature of our patients receiving the pathways, not wanting to give an antihypertensive agent to patients who sometimes are experiencing shock and other critical illness. 2023 Jan 1;53(1):140-2. 2022; 06/26/2023.

Emergency Department 64

Emergency Department Operations Psychiatric Hospitals 64

Taming the SRU

SEPTEMBER 21, 2023

2023) doi:10.1016/j.annemergmed.2023.05.014. Exclusion criteria were pre-intubation hypotension, use of topical anesthesia, or missing data including primary outcome, patient weight, etomidate / ketamine dose. Primary outcome was post-intubation hypotension, defined as SBP < 100mg Hg within the first 15 minutes post-intubation.

Outcomes 93

Outcomes Emergency Department Shock 93

RebelEM

JANUARY 29, 2024

Clin Exp Emerg Med 2023. REBEL Cast Ep123: Reduced-Dose Systemic Peripheral Alteplase in Massive PE? Click here for Direct Download of the Podcast Paper: Aykan AC et al. Reduced-Dose Systemic Fibrinolysis in Massive Pulmonary Embolism: A Pilot Study. in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47 in the paper but 2.7%

Stroke 136

Stroke Outcomes Hospitals Administration 136

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

ACEP Now

OCTOBER 10, 2023

Both INTERACT-2 and ATACH-2 showed no statistical difference in their primary outcome between intensively lowering the BP and a less-intensive strategy. Background There have been a couple of large and influential trials published on BP management after an intracranial hemorrhage (ICH). Reference Ma LM, Hu X, Song L, et.

Outcomes 52

Outcomes Stroke Emergency Department Hospitals 52

Stop and Think

JANUARY 10, 2024

Let’s do two topics on the RCT that I covered in my Top Ten Stories of 2023 piece. They found no significant improvement in the primary endpoint of survival with a favorable neurologic outcome. Cardiogenic shock simply means that the heart is not pumping enough blood to support organ function, such as brain and kidneys.

CPR 44

CPR Shock Outcomes Resuscitation 44

RebelEM

OCTOBER 5, 2023

Secondary Outcome By day 90, mortality was 9.3% Strengths: The investigators framed a research question centered on patient outcomes, ensuring the study’s relevance and practicality. Control: Normal Saline via continuous infusion according to the same regimen used in the hydrocortisone group. in the placebo group (p = 0.006).

Research 94

Research Outcomes Administration Shock 94

AENJ: Current Issue

MAY 8, 2024

The article titled “Using Artificial Intelligence to Predict Adverse Outcomes in Emergency Department Patients With Hyperglycemic Crises in Real Time,” authored by C.

Emergency Department 40

Emergency Department Outcomes Sepsis Research 40

PulmCCM

JUNE 5, 2023

Corticosteroids for community-acquired pneumonia have been studied with inconclusive results, and expert guidelines currently advise against their use except in patients with refractory septic shock. Patients with septic shock or influenza were excluded. standards of care. In the U.S., Patients with secondary pneumothoraces (e.g.,

Advances Cardiac Life Support (ACLS) 96

Advances Cardiac Life Support (ACLS) Documentation/Coding CPR Shock 96

RebelEM

JANUARY 25, 2024

What They Did: Design: Randomized, controlled, blinded-outcome trial Sites: Three emergency departments in Denmark Duration: October 9, 2019 to May 26, 2021. Outcomes: Primary Outcome: Reduction of dyspnea measured on a verbal dyspnea scale (VDS) from 0 to 10 recorded at enrollment, then at 2, 4, and 5 hours after arrival.

Ultrasounds 129

Ultrasounds Outcomes COPD Hospitals 129

Mind The Bleep

OCTOBER 29, 2024

Sodium Chloride or Hartmanns if indicated, monitoring for signs of shock. Proper stabilization and detailed communication with the burns centre are essential for optimal patient outcomes. Updated 2023 Jul 17]. Updated 2023 Jul 17]. Establish IV access and begin fluid resuscitation with 250ml boluses of 0.9% PMID: 7077702.

Burns 52

Burns Fluid Resuscitation PPE Resuscitation 52

PulmCCM

JANUARY 29, 2024

AHA Updates its Cardiac Arrest Guidelines In December 2023, the American Heart Association published a “focused update” to its landmark guidelines for the management of cardiac arrest. three shocks with 2 minutes CPR in between) have been performed. PulmCCM is not affiliated with the American Heart Association.

Seizures 115

Seizures CPR Documentation/Coding Hyperthermia / Hypothermia 115

RebelEM

AUGUST 14, 2023

2023;e230780. 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. JAMA Intern Med.

Sepsis 98

Sepsis Outcomes Administration EMS 98

ALiEM

JULY 17, 2023

sought to identify program factors associated with unfilled post-graduate year 1 (PGY-1) emergency medicine (EM) positions in the 2023 Match [1]. as well as an analysis of the 2023 Match by Pupazan and Cook in Emergency Medicine News [3,4]. A staggering 131 (47%) EM residency programs had unfilled PGY-1 positions among in 2023 [7].

EMS 52

EMS Burns Emergency Department Shock 52

Don't Forget the Bubbles

OCTOBER 7, 2024

Was the patient thrown from the source (suggestive of DC shock and may result in further blunt force trauma)? Children, especially toddlers, may insert objects into outlets, leading to shocks or burns. Electrical devices used near water sources can cause severe shocks. Was the voltage high or low (as below)?

Burns 80

Burns Fluid Resuscitation Shock Resuscitation 80

ACEP Now

SEPTEMBER 3, 2024

These stakeholders are similarly shielded in court when adverse patient outcomes, such as negligent deaths, occur under their management or when the bought-out companies are challenged for anticompetitive business practices overseen by the PE firm. Published July 10, 2023. They leave the area deprived of access.” Cai C, Song Z.

Hospitals 113

Hospitals Radiology Radiology Emergency Department 113

Taming the SRU

JUNE 3, 2024

CESAR Trial Published in 2009 Found that even those who didn’t get ECMO, but were transported to a tertiary care center had better outcomes No matter where you go, critical care transport will be part of your life as a sending physician, receiving physician, or both. Get a blood gas when possible to help guide your ventilation.

Shock 91

Shock Seizures Airway Management Stroke 91

EMDocs

SEPTEMBER 7, 2024

Clinical features include abdominal or flank pain; ecchymosis to the flank, periumbilical region, proximal thighs, or scrotum; and hemorrhagic shock early in the disease course. Spontaneous retroperitoneal hematoma: etiology, characteristics, management, and outcome. angioembolization). J Emerg Med. 2012 Aug;43(2):e157-61. 2011.06.006.

EMS 97

EMS Fluid Resuscitation Resuscitation Radiology 97

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. link] Published February 12, 2023. Ann Emerg Med.

Hyperthermia / Hypothermia 109

Hyperthermia / Hypothermia Resuscitation CPR EMS 109

Don't Forget the Bubbles

FEBRUARY 5, 2025

There is significant evidence in adults and developing in the paediatric population that TXA results in better outcomes if given early in patients with mild to moderate traumatic brain injury (TBI) and does not cause harm. Question 2 At what threshold of blood loss do children begin to show signs of haemorrhagic shock?

Fluid Resuscitation 59

Fluid Resuscitation Domestic Violence Head Injuries Sexual Assault 59

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. 2023;e2320850.

Resuscitation 91

Resuscitation Operations Outcomes Hospitals 91