The Skeptics' Guide to EM

MARCH 10, 2018

Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the Director of Simulation Education at Markham Stouffville Hospital in Ontario. Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the Director of Simulation Education at Markham Stouffville Hospital in Ontario. AEM March 2018. AEM March 2018.

Blood Transfusions 40

Blood Transfusions Emergency Department Shock Hospitals 40

Taming the SRU

AUGUST 4, 2024

Can present in a delayed fashion, does not always occur immediately after pacemaker placement Delayed presentations present with signs and symptoms of cardiac tamponade in two-thirds of cases Abdominal Aortic Aneurysm Repair is usually indicated when aortic diameter is >5.5

Dislocations 86

Dislocations Emergency Department Documentation/Coding Burns 86

Dr. Smith's ECG Blog

SEPTEMBER 9, 2020

The ECG that is shown in Figure-1 was obtained from an elderly patient, who was admitted to the hospital for a fall. As presented at the beginning of this post — the elderly patient in today’s case was admitted to the hospital following a fall. The patient was found to be severely anemic — but was not hemodynamically unstable.

EKG/ECG 52

EKG/ECG Blood Transfusions Operations Hospitals 52

Taming the SRU

SEPTEMBER 16, 2024

In the era of modern medicine, blood transfusions are commonplace, especially in the emergency department. Transfusion reactions are a spectrum of adverse events that can occur with the transfusion of whole blood or any of its components. One of the major risk factors is receiving a blood transfusion in the past.

Blood Transfusions 91

Blood Transfusions Anaphylaxis Emergency Department Sepsis 91

Pediatric EM Morsels

NOVEMBER 3, 2023

This allowed US hospitals to stock the drug to ensure quick treatment of suspected severe cases, rather than having to ship it from the CDC under the prior expanded-access protocol (Thomas 2023). Higher Rates of Misdiagnosis in Pediatric Patients versus Adults Hospitalized with Imported Malaria. June 28, 2023. J Travel Med.

Seizures 281

Seizures Pediatrics CDC Infectious Diseases 281

EMDocs

MAY 15, 2024

Consider risk factors for multi-drug resistant microbes: Recent IV antibiotics Hospitalization within 90 days. COVID-19 and ACS COVID increases the risk of hospitalization, pneumonia, pain, and ACS in SCD patients. Empiric antibiotics All patients with ACS should receive antibiotics. 25% have an infection as the trigger for ACS.

Blood Transfusions 103

Blood Transfusions Fluid Resuscitation Dehydration Ultrasounds 103

EMDocs

MAY 28, 2024

Consider risk factors for multi-drug resistant microbes: Recent IV antibiotics Hospitalization within 90 days. Blood transfusion Reduces the overall proportion of HbS. COVID-19 and ACS COVID increases the risk of hospitalization, pneumonia, pain, and ACS in SCD patients. 25% have an infection as the trigger for ACS.

Blood Transfusions 97

Blood Transfusions Fluid Resuscitation Dehydration Ultrasounds 97

PulmCCM

JANUARY 8, 2024

Smaller blood-collection tubes to reduce red blood cell transfusion (STRATUS trial) Cumulatively, daily labs on hospitalized patients deplete substantial volumes of blood, almost all of which is wasted. They have a less-powerful vacuum that removes about half as much blood per tube.

Blood Transfusions 96

Blood Transfusions Hospitals Outcomes Operations 96

The Trauma Pro

SEPTEMBER 18, 2023

The door-to-prophylaxis time was defined as the time from hospital arrival to the first dose of medication. Severe injury and blood transfusion are already known to be associated with a higher likelihood of VTE. The authors concluded that the door-to-prophylaxis time was significantly associated with increased incidence of VTE.

Blood Transfusions 113

Blood Transfusions Resuscitation Hospitals Wellness 113

EMDocs

DECEMBER 6, 2024

Blood transfusion for clinically significant blood loss. 5 Consider exchange transfusion in addition to deferoxamine for serum iron concentrations greater than 1000 g/dL, or those who clinically deteriorate despite supportive care and chelation. 10 Maximum daily dose of 6-8g total of defuroxamine. Manoguerra, A.

Poisoning 97

Poisoning Fluid Resuscitation Seizures Resuscitation 97

ALiEM

MAY 29, 2023

Because he presumably had uremia-induced thrombasthenia (weak platelets), he received blood transfusions and IV TXA. We thus removed the anterior packing and instead inserted a Foley catheter into the posterior nasal space and inflated the balloon. Unfortunately, the bleeding still continued. Posterior Epistaxis Nasal Packing.

Blood Transfusions 98

Blood Transfusions Emergency Department Shock Hospitals 98

PulmCCM

APRIL 10, 2025

Almeida et al Crit Care Med 2025 ) They did have more major bleeding (10% vs 1%), often requiring blood transfusions. Only about one-quarter of 5,300 patients with septic shock received corticosteroids at 26 ICUs at nine UPMC hospitals between 2018 and 2020. Most hospital microbiology labs do not reliably detect C.

CDC 40

CDC Stroke Sepsis Radiology 40

RebelEM

MAY 25, 2023

Lancet 2010 [10] >20,000 adult trauma patients with SBP <90mmHg Patients randomized to TXA 1g over 10 min + 1g IV over 8hrs vs Placebo given within 8hrs of injury In-hospital mortality by 28d reduced (14.5% Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality. NEJM 1994. [2] NEJM 1994.

Resuscitation 145

Resuscitation Fluid Resuscitation Head Injuries Shock 145

Don't Forget the Bubbles

JANUARY 10, 2024

Let’s take the humble blood transfusion – used in emergency departments across the globe and playing a key role in critical care. Severe anaemia is a common and life-threatening cause of hospital admission in children in sub-Saharan Africa. 8% die in hospital, with a further 12% dying in the six months following discharge.

Blood Transfusions 78

Blood Transfusions Research Outcomes Hospitals 78

Sensible Medicine

NOVEMBER 27, 2023

But, in general, blood transfusion strategies have been studied in many other clinical situations. A Cochrane review of trials of more than 21K patients have shown that restrictive strategies have led to a 50% decreased use of blood without differences in morbidity or mortality. And this is a negative result!

Blood Transfusions 114

Blood Transfusions Outcomes Hospitals 114

RebelEM

OCTOBER 30, 2023

This would normally make me worry about dilution of results and biasing the results to the null hypothesis, but in the per protocol analysis (170 patients excluded from the full cohort, due to no longer requiring blood transfusion, dying within 90 minutes of arrival or being randomized in error) didn’t seem to affect this result either.

Administration 127

Administration Blood Transfusions Outcomes Hospitals 127

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

EMDocs

JUNE 22, 2024

Authors: Kyle Smiley, MD (EM Resident Physician, San Antonio, TX) and Brit Long, MD (@long_brit, EM Attending Physician) // Reviewed by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital); Sophia Görgens, MD (EM Physician, Northwell, NY); Cassandra Mackey, MD (Assistant Professor of Emergency Medicine, UMass Chan (..)

EMS 111

EMS Resuscitation Seizures Blood Transfusions 111

The Skeptics' Guide to EM

DECEMBER 17, 2022

Massive Blood Transfusion Following Older Adult Trauma: the Effect of Blood Ratios on Mortality. AEM December 2022 Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine at Lancashire Teaching Hospitals. Massive Blood Transfusion Following Older Adult Trauma: the Effect of Blood Ratios on Mortality.

Blood Transfusions 52

Blood Transfusions Fractures EMS Emergency Department 52

The Trauma Pro

MAY 10, 2024

It also standardizes comparisons between hospitals that use STAT. They reviewed 2.5 years of their registry data (Level I center). Once again, let’s look at over- and undertriage experience in the paper: Undertriage: 9.1% undertriage (Cribari) reduced to 3.3% This may be helpful for future triage-related research. What Does It All Mean?

Blood Transfusions 113

Blood Transfusions Radiology Radiology Documentation/Coding 113

RebelEM

JUNE 19, 2023

Primary Results Patients enrolled from 15 emergency medical services at 21 hospitals across 3 countries over 7 years. The study is relatively small (CRASH2 enrolled > 20,000 patients); just 1300 patients from 21 hospitals over 7 years. Resides in a facility for older persons. 1310 patients were recruited and randomized.

Blood Transfusions 105

Blood Transfusions Outcomes Administration Hyperthermia / Hypothermia 105

Ziqitza HealthCare Ltd

JULY 23, 2023

It provides sufficient oxygen, blood transfusions and other medication that helps the patient to be in a stabilized condition till reaching the hospital. The Current Scenario Despite having state-of-the-art life support systems and devices, a considerable number of deaths occur during the transfer of patients to hospitals.

Ambulance Services 52

Ambulance Services Basic Life Support Blood Transfusions Patient Safety 52

PHEM Cast

FEBRUARY 23, 2017

.: Prehospital transfusion of plasma and red blood cells in trauma patients. Weaver AE, Eshelby S, Norton J, Lockey DJ: The introduction of on-scene blood transfusion in a civilian physician-led pre-hospital trauma service. Prehosp Emerg Care 19(1):1–9, 2015. Scand J Trauma Resusc Emerg Med 21(Suppl1):S27, 2013.

Blood Transfusions 52

Blood Transfusions Head Injuries Resuscitation Radiology 52

RebelEM

SEPTEMBER 26, 2022

There was no statistically significant difference in failure to control bleeding by day 5 or failure to prevent rebleeding after day 5, total hospital length of stay in the first admission, total ICU and hospital length of stay up to 42 days, or 5 and 42-day mortality rates between the two groups. Furthermore, 14.3% Ann Intern Med.

Resuscitation 52

Resuscitation Blood Transfusions Outcomes Hospitals 52

Emergency Medicine Journal

MAY 23, 2023

Methods A single-centre retrospective study was performed including patients with suspected UGIB visiting the ED of Saint-Antoine hospital (Paris, France) from January 2016 to December 2018. Need for intervention was defined as the need for blood transfusion, endoscopic haemostasis or rebleeding within 7 days.

Emergency Department 40

Emergency Department Blood Transfusions Hospitals Wellness 40

EMDocs

JUNE 12, 2024

Concentration-Dependent Effect of Hypocalcaemia on Mortality of Patients with Critical Bleeding Requiring Massive Transfusion: A Cohort Study. Citrate metabolism in blood transfusions and its relationship due to metabolic alkalosis and respiratory acidosis. Transfusion-Related Hypocalcemia After Trauma. 2011;39(1):46-54.

Hyperthermia / Hypothermia 106

Hyperthermia / Hypothermia Resuscitation Administration Blood Transfusions 106

PulmCCM

MAY 8, 2023

Among 1150 patients considered high risk for aspiration at 15 French hospitals, those randomized to receive remifentanil had a higher rate of severe complications of intubation (aspiration, hypoxemia, hypotension, arrhythmia, cardiac arrest, or anaphylaxis), compared to those receiving neuromuscular blockade. This feels like a bad sign.

Stroke 52

Stroke Blood Transfusions Hospice Anaphylaxis 52

Taming the SRU

APRIL 3, 2023

Cardiac Arrest in Pregnancy 1 in 30,000 pregnancies 800 maternal deaths globally Rates have nearly doubled between 1989 and 2009 Survival to hospital discharge after maternal in-hospital cardiac arrest 58.9% Do not transport to an alternative location.

Blood Transfusions 40

Blood Transfusions Fluid Resuscitation Resuscitation Stroke 40

Downeast Emergency Medicine

APRIL 26, 2021

Four level-1 US trauma centers participated in the study where the inclusion criteria were trauma patients who were within 2 hours of their injury and were transported to the trauma center from either the field or another hospital. The primary outcome was head injury-related death in-hospital within 28 days of injury.

Head Injuries 52

Head Injuries Administration Outcomes Seizures 52

EB Medicine

OCTOBER 1, 2018

For those listening, my hospital probably looks a little bit like yours. Roughly half of in-hospital mortality is associated with septic in some fashion. clearly this is an important topic if it warrants it’s own chair at a major hospital in NYC. At our hospital in southern Manhattan, patients tend to breathe around 16.

Sepsis 40

Sepsis Shock Fluid Resuscitation Hospitals 40

Taming the SRU

OCTOBER 25, 2023

Goals of treatment: Control hemorrhage, reduce risk of early-rebleeding (within 5 days), prevent bleed-related complications (infection, hepatic encephalopathy, AKI) (12) Standard of care includes: Vasoactive drugs + prophylactic antibiotics + endoscopic techniques Vasoactive drugs: IV octreotide 50ug bolus + 25 or 50 ug/h infusion Other options include (..)

Blood Transfusions 99

Blood Transfusions Stroke Hospitals Anaphylaxis 99

EMDocs

MARCH 6, 2024

Post-hoc analysis of patients with LGIB compared a liberal transfusion threshold of 9 g/dL (8 g/dL in those with acute coronary syndrome) with restrictive strategy and found no difference in in-hospital mortality. 2023 ACG guidelines recommend against transfusing platelets to reverse an antiplatelet agent. 2017;2(5):354–60.

Blood Transfusions 105

Blood Transfusions Outcomes Resuscitation Radiology 105

EMDocs

JULY 3, 2023

Blood Transfus. Outcomes of CSF spectrophotometry in cases of suspected subarachnoid haemorrhage with negative CT: two years retrospective review in a Birmingham hospital. Br Risk Factors for In-Hospital Seizures and New-Onset Epilepsy in Coil Embolization of Aneurysmal Subarachnoid Hemorrhage. World Neurosurg. 2018

Seizures 98

Seizures Stroke Outcomes EMS 98

RebelEM

FEBRUARY 22, 2024

in liberal) received a blood transfusion (2.3 Liberal versus restrictive transfusion thresholds for patients with symptomatic coronary artery disease. Third universal definition of myocardial infarction. Circulation. 2012;126(16):2020-2035. years Female sex 44.3 Baseline hemoglobin 8.6 g/dl Prior myocardial infarction 33.7

Blood Transfusions 58

Blood Transfusions Outcomes Wellness Research 58

EMDocs

JUNE 3, 2023

Her Glasgow Coma Scale (GCS) is 14 (3E-5V-6M), and she arrives in a cervical collar placed pre-hospital. Demographic epidemiology of unstable pelvic fracture in the United States from 2000 to 2009: trends and in-hospital mortality. Her airway is intact, and she has equal bilateral breath sounds. J Clin Orthop Trauma. doi:10.1097/TA.0b013e3182ab0cde

Fractures 63

Fractures Resuscitation Operations EMS 63

RebelEM

DECEMBER 23, 2024

saline affect hospital-free days by day 30? PMID: 39250114 Clinical Question: In adult patients admitted for a vaso-occlusive episode, does early fluid resuscitation with Lactated Ringer solution compared to 0.9%

Fluid Resuscitation 128

Fluid Resuscitation Resuscitation Documentation/Coding Outcomes 128

Emergency Medicine Journal

MARCH 25, 2025

Background Hypofibrinogenaemia on ED arrival and in the prehospital setting has been associated with both increased mortality and increased blood transfusions. receiving prehospital blood transfusions. The cohort was predominately male (82.9%) with a median age of 35 years (IQR 26–51). to 0.61).

Blood Transfusions 52

Blood Transfusions Administration Operations Hospitals 52