RebelEM

OCTOBER 30, 2023

The optimal approach to fibrinogen administration in massive hemorrhage protocols is unknown. Most major hemorrhage protocols give a balanced transfusion of PRBCs, FFP, and platelets in ratios approaching concentrations found in whole blood. Fibrinogen products may also be needed to stabilize clots and stem bleeding. Paper: Davenport R et al.

Administration 125

Administration Blood Transfusions Outcomes Hospitals 125

RebelEM

NOVEMBER 30, 2023

For those with sepsis, the administration of intravenous fluids (IVF) at the volumes recommended in the Surviving Sepsis Campaign (SSC) requires careful consideration of an individual’s chronic medical conditions and subsequent sensitivity to IVF. Studies without a clear timeframe for fluid administration. 2.89, p = 0.01.

Sepsis 118

Sepsis Fluid Resuscitation Resuscitation Administration 118

RebelEM

MAY 25, 2023

vs 3U) but no difference in mortality (Study not powered for this outcome) Clinical Take Home Point: The use of vasopressors is controversial and requires a nuanced approach SUMMARY OF MINIMIZING IATROGENIC INJURY RESTORE PERFUSION VOLUME REPLACEMENT Blood Products >>> Crystalloids Holcomb JB et al. NEJM 1994. [2]

Resuscitation 145

Resuscitation Fluid Resuscitation Head Injuries Shock 145

PulmCCM

JANUARY 15, 2025

Draft Guidance for Industry and Food and Drug Administration Staff. Clinical Outcomes Associated With Overestimation of Oxygen Saturation by Pulse Oximetry in Patients Hospitalized With COVID-19. January 2025. Draft Guidance Document Wong et al. Fingertip oxygen sensors can fail on dark skin — now a physician is suing.

Academics 81

Academics Documentation/Coding Administration Research 81

RebelEM

MAY 29, 2023

Judicious fluid resuscitation is indicated in patients with signs of hypo perfusion but is often inadequate necessitating the administration of vasoactive medications. At the most severe end, this includes endothelial dysfunction leading to increased vascular permeability, abnormal nitric oxide metabolism, and vasodilation (i.e. 95% CI 15.4

Shock 145

Shock Fluid Resuscitation Sepsis Resuscitation 145

EMDocs

JANUARY 11, 2025

A) Administration of IV morphine for pain control B) Admission to general surgery for IV antibiotics C) Discharge home on lactulose D) Emergent surgical consultation for exploratory laparotomy E) Manual disimpaction Correct answer: E Although uncommon, stercoral colitis is a potentially life-threatening complication of chronic constipation.

EMS 94

EMS Sepsis Shock Fluid Resuscitation 94

PulmCCM

JANUARY 6, 2025

With financial penalties coming for noncompliance with the new rule, hospital administrators rapidly deployed the alerts to fire on all eligible inpatients. A cluster randomized trial using all-cause mortality as an outcome was always needed to determine whether EMR alerts improve outcomes for suspected severe infection.

Sepsis 45

Sepsis Documentation/Coding Hospitals Outcomes 45

RebelEM

JANUARY 29, 2024

PMID: 37188358 Clinical Question: What is the efficacy and safety of low-dose (25mg) prolonged administration (over 6hrs) of alteplase in patients with massive PE? Reduced-Dose Systemic Fibrinolysis in Massive Pulmonary Embolism: A Pilot Study. Clin Exp Emerg Med 2023. in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47

Stroke 133

Stroke Outcomes Hospitals Administration 133

RebelEM

JUNE 19, 2023

PMID: 37314244 Clinical Question: In advanced trauma systems, does prehospital administration of TXA increase the rate of survival with a favorable neurologic outcome in patients at risk for trauma-induced coagulopathy? Primary Results Patients enrolled from 15 emergency medical services at 21 hospitals across 3 countries over 7 years.

Blood Transfusions 105

Blood Transfusions Outcomes Administration Hyperthermia / Hypothermia 105

RebelEM

JULY 3, 2023

What They Did: Researchers conducted a multicenter, retrospective cohort study in three community hospitals and two freestanding emergency departments. Secondary outcome All secondary outcomes were found to be similar (Not statistically significant) between groups (See table above). received CaCl 89.3%

Administration 91

Administration Outcomes Documentation/Coding Emergency Department 91

RebelEM

JUNE 8, 2023

Assessed clinical practice, outcome, length of stay, safety, and efficacy of both phenylephrine and epinephrine peripherally administered through a push dose. In other words these were pre-made syringes and not mixed at the bedside.

Administration 98

Administration Emergency Department Outcomes Documentation/Coding 98

RebelEM

SEPTEMBER 29, 2022

Outcomes: Primary: Progression to moderately severe or severe acute pancreatitis (according to the Revised Atlanta Classification). Secondary outcomes were pre-specified which helps in terms of minimizing bias (i.e. non-statistically significant difference in the primary outcome. to 9.8L) Moderate: 5.5L (Range 4.0

Administration 52

Administration Fluid Resuscitation Resuscitation Outcomes 52

Sensible Medicine

AUGUST 21, 2023

Administrative data sets are often collected for the purpose of billing, or costing, or administrative organization, and thus are extremely vulnerable to up coding or intentional or accidental omissions. ” For example, mortality is a patient outcome—provided it can be reliably ascertained.

Administration 98

Administration Outcomes Research COPD 98

The Skeptics' Guide to EM

OCTOBER 5, 2019

Guest Skeptic: Clay Odell is a Paramedic/RN for New London Hospital EMS in New Hampshire, USA which provides 9-1-1 coverage and Mobile Integrated Healthcare […] The post SGEM#269: Pre-Hospital Nitroglycerin for Acute Stroke Patients? Hypertension is common in acute stroke and is a predictor of poor outcome [ 1 ].

Stroke 52

Stroke Hospitals EMS Administration 52

EM Literature of Note

APRIL 11, 2024

The most notable feature of this trial is the simple, negative topline result – rollout of this intervention had no reliably measurable effect on patient-oriented outcomes relating to disease progression or acute clinical deterioration. “Pragmatic Trial of Hospitalization Rate in Chronic Kidney Disease” [link] Tweet

Outcomes 92

Outcomes Administration Hospitals Wellness 92

Don't Forget the Bubbles

JANUARY 31, 2024

As a Trauma Unit within the Thames Valley Trauma Network, Wexham Park Hospital hosts trainees from across the spectrum of acute specialties. Two really important patient groups were excluded – those who were admitted to hospital and families who were not fluent in English. the pre-hospital setting. Why does it matter?

Hospitals 72

Hospitals Ultrasounds Emergency Department Pediatrics 72

EMDocs

DECEMBER 6, 2024

In 1997, the Food and Drug Administration (FDA) mandated unit-dose packaging for all iron-containing products with more than 30 milligrams of elemental iron. 7 Workup other than serum iron concentration at 4 hours after ingestion not shown to accurately predict clinical outcomes or severity of toxicity. Antiemetics as needed.

Poisoning 94

Poisoning Fluid Resuscitation Seizures Resuscitation 94

RebelEM

AUGUST 22, 2024

Administration of intravenous tissue plasminogen activator (IV tPA) within 4.5 hours of symptom onset appears to be the most promising approach for improving visual outcomes, supported by multiple studies and meta-analyses. Administration of intravenous tissue plasminogen activator (IV tPA) within 4.5 1 week after treatment.

Stroke 85

Stroke Administration Outcomes Documentation/Coding 85

RebelEM

AUGUST 14, 2023

4 XBJ received approval from the China Food and Drug Administration in 2004, 2 although the FDA of the United States has not approved it. Secondary Outcome Results: ICU mortality: placebo 20.0% vs. Secondary Outcome Results: ICU mortality: placebo 20.0% 001) Hospital mortality: Placebo 22.8% vs. XBJ 14.2%

Sepsis 97

Sepsis Outcomes Administration EMS 97

RebelEM

SEPTEMBER 7, 2023

ClinicalTrials.gov: NCT02631759 Clinical Question : In adult patients aged 18 years or older presenting within 24 hours of a spontaneous ICH, does the administration of levetiracetam, compared to placebo, reduce the occurrence of clinical seizures? The primary outcome was patient-oriented. Lancet Neurology 2022; 21:781-91.

Seizures 123

Seizures Stroke Outcomes Research 123

Don't Forget the Bubbles

NOVEMBER 29, 2023

Even though sedation after endotracheal intubation (ETI) reduces the risk of self-extubation, uncontrolled pain, and awakening awareness, several small single-centre studies demonstrate low rates of sedative drug administration after ETI in the emergency department (ED). This is referred to as CPR I nduced C onsciousness ( CPRIC ).

Airway Management 135

Airway Management Emergency Department Resuscitation Psychiatric 135

RebelEM

APRIL 29, 2024

Many clinicians don’t consider IO placement while others consider it a last resort or only a pre-hospital procedure. In cardiac arrest, a delay in IV access subsequently results in a delay in epinephrine administration. Impact of intraosseous versus intravenous resuscitation during in-hospital cardiac arrest: A retrospective study.

Resuscitation 105

Resuscitation Administration Emergency Department Ultrasounds 105

Critical Care Now

AUGUST 18, 2024

The primary outcome showed a 28-day mortality of 6.2% Secondary outcomes included reduced mortality at 90 days, lower rates of intubation and vasopressor use, and fewer serious adverse events in the hydrocortisone group. A total of 800 patients were enrolled, with 401 receiving hydrocortisone and 399 receiving a placebo.

Outcomes 93

Outcomes Sepsis Administration EMS 93

RebelEM

JULY 17, 2023

Background: Standard rapid sequence intubation (RSI) in the emergency department involves administration of an induction agent and a neuroblocking agent in quick succession. RSI inherently carries with it risks of complications such as post-intubation hypotension and cardiac arrest in the most extreme cases. Range 5 to 9) Etomidate: 7.0

Outcomes 93

Outcomes Emergency Department Administration Resuscitation 93

EMDocs

JUNE 8, 2023

and 9 hours after onset of symptoms, with non-infarcted brain tissue, does the administration of alteplase improve functional outcome at 90 days? and 9 hours of symptom onset; stroke symptoms that started during sleep were assumed to have started halfway between the actual last known well and the time of wake-up. to 53.54, p=0.053).

Stroke 95

Stroke Administration Documentation/Coding Outcomes 95

EMDocs

SEPTEMBER 30, 2024

Primary outcome: Prescription of ICS on ED discharge from the index visit Secondary outcomes: ICS prescription rates in high-risk subgroups Rates of outpatient follow-up within 30 days of an ED visit for asthma Variation in ICS prescription rates among attending ED physicians. The primary outcome was hospital admission rates.

Outcomes 101

Outcomes Academics Documentation/Coding Emergency Department 101

Pediatric EM Morsels

MAY 24, 2024

IAI Rule – The Validation A multicenter prospective validation was planned at hospitals distinct from those where the initial derivation was performed. Cohort of 12,000 children with blunt IAI were prospectively enrolled to determine the number of subjects requiring acute intervention . This concerned clinicians.

Pediatrics 164

Pediatrics Blood Transfusions EMS Fractures 164

RebelEM

FEBRUARY 29, 2024

1, 2 Its occurrence often portends worse outcomes in intubated patients, whose projected hospital course was already tenuous. SECONDARY OUTCOMES At day 28 , ceftriaxone group had (vs placebo): Lower VAP risk (20% vs 36%); hazard ratio 0.62 4, 8 Paper: Dahyot-Fizelier, C.,

CDC 111

CDC Radiology Radiology Head Injuries 111

EMDocs

NOVEMBER 7, 2023

No difference in their primary outcome of complications and need for emergency surgery (1.9% The recurrence rate and length of hospital stay were the same. Hospital stay was significantly shorter in the observation group (2 versus 3 days; P = 0·006). 623 patients included. versus 2.6%), ongoing diverticulitis (7·.3

Sepsis 108

Sepsis Best Practices Hospitals Outcomes 108

RebelEM

OCTOBER 2, 2023

Mild to moderate DKA represents a subgroup of patients that often require admission to the ICU due to hospital policies not allowing insulin infusions outside of this clinical setting. No statistical differences in safety between groups Operational Impact Median ED LOS (PRIMARY OUTCOME): SQuID: 8.9hrs (6.5 tests/hr (0.8 Traditional: 1.0

Operations 97

Operations Academics Outcomes Fluid Resuscitation 97

EMDocs

JUNE 12, 2024

HypoCa is common in trauma patients and is associated with poor outcomes. Two randomized controlled trials by Moore et al found that prehospital plasma administration in trauma patients is associated with hypoCa (53% vs 36%). Prehospital Ca administration reduces risk of hypoCa on arrival (70% vs. 28%). Anesth Analg.

Hyperthermia / Hypothermia 104

Hyperthermia / Hypothermia Resuscitation Administration Blood Transfusions 104

EMDocs

MAY 25, 2023

mg/kg or 10 mg Seizures must persist for at least 5 minutes after administration of the prespecified benzodiazepines. In light of these data, I will give levetiracetam due to its less severe side effects and ease of administration. mg/kg or 10 mg Intravenous lorazepam 0.1 mg/kg or 4 mg Intravenous midazolam 0.2

Seizures 81

Seizures Administration Anaphylaxis Outcomes 81

The Skeptics' Guide to EM

FEBRUARY 25, 2023

2022 Date: February 15, 2023 Guest Skeptic: Dr. Carlie Myers is Pediatric Critical Care Attending at Cincinnati Children’s Hospital Medical Center. Case: A 6-month-old boy presents to […] The post SGEM#394: Say Bye Bye Bicarb for Pediatric In-Hospital Cardiac Arrest first appeared on The Skeptics Guide to Emergency Medicine.

Pediatrics 52

Pediatrics Hospitals CPR Resuscitation 52

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

ACEP Now

SEPTEMBER 3, 2024

Hahnemann University Hospital in Philadelphia closed in 2019, a year and a half after it was acquired along with St. Christopher’s Hospital for Children by private equity (PE) firm Paladin Healthcare Capital for 170 million dollars. Christopher’s was able to find a buyer prior to bankruptcy but Hahnemann could not.

Hospitals 113

Hospitals Radiology Radiology Emergency Department 113

The Skeptics' Guide to EM

OCTOBER 19, 2024

Guest Skeptic: Dr. Brendan Freeman is an emergency medicine physician, assistant professor of emergency medicine, and medical education fellow at Staten Island University Hospital. Ketamine’s administration is flexible, with several routes available including IV, intranasal (IN), and more recently, nebulized forms. Annals of EM 2024.

Emergency Department 94

Emergency Department EMS Research Administration 94

ACEP Now

NOVEMBER 8, 2024

Historically, the endotracheal tube (ETT) has been considered the definitive airway of choice in both the prehospital and in-hospital setting. 1 Prehospital endotracheal intubation and EGAs are typically placed without paralytics and are reserved for unconscious, apneic, and out-of-hospital cardiac arrest patients. DOT HS 813 151).

Airway Management 40

Airway Management EMS Hospitals Administration 40