Don't Forget the Bubbles

NOVEMBER 27, 2023

Four-year-old Ed is being resuscitated for presumed Invasive Group A Streptococcal Sepsis from tonsilitis. The amount of blood that comes from the heart with each contraction is the stroke volume (SV). The stroke volume is the difference between how full it is at the start and how full it is after a contraction.

Shock 143

Shock Sepsis Fluid Resuscitation Resuscitation 143

EMDocs

SEPTEMBER 6, 2023

Learning points: Consider differential – sepsis, thyroid storm, thalamic stroke, exertional and classic heat stroke, serotonin syndrome, neuroleptic malignant syndrome, sympathomimetic toxicity, and anticholinergics. Removed from cooling at 102 and admitted to ICU. Must consider differential in complex cases.

Anaphylaxis 71

Anaphylaxis Shock Sepsis Stroke 71

PulmCCM

NOVEMBER 11, 2021

To focus matters, the hemodynamic variable under consideration is the stroke volume [SV]; in other words, how does a push of phenylephrine affect SV? ’ Diminished stroke volume? evaluated phenylephrine in 7 critically-ill patients with ‘hyperdynamic’ sepsis [defined as sepsis with CO above 6.0

Stroke 40

Stroke Sepsis Administration Wellness 40

ACEP Now

SEPTEMBER 6, 2024

You may have mastered all the latest changes affecting management of sepsis, STEMI, and opiate-use disorder, but there’s no stopping the relentless revisions to our approach to neurologic emergencies. This comes out of INTERACT-4, a trial testing the efficacy of blood pressure reduction in undifferentiated acute stroke syndromes.

Research 64

Research Stroke Outcomes Sepsis 64

Don't Forget the Bubbles

NOVEMBER 18, 2024

Neonatal hypotension can result from inadequate cardiac output, low systemic vascular resistance, or a combination of both, which are influenced by: Cardiac Output: Neonates, particularly preterm ones, may have compromised cardiac output due to myocardial immaturity, leading to reduced stroke volume and heart rate.

Sepsis 59

Sepsis Shock Hyperthermia / Hypothermia Administration 59

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

Taming the SRU

APRIL 17, 2024

The surviving sepsis guidelines weakly recommend invasive arterial blood pressure monitoring (IABP) over noninvasive blood pressure monitoring (NIBP) with a blood pressure cuff supported by low quality evidence.(1) Surviving sepsis campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med.

Sepsis 93

Sepsis Research Academics Stroke 93

PulmCCM

APRIL 8, 2024

Read in Journal of Palliative Medicine New-onset atrial fibrillation provoked by sepsis: anticoagulate or not? Your elderly patient with sepsis develops new-onset atrial fibrillation that spontaneously converts to normal sinus rhythm. If so, maybe we should allow more patients to experience it.

Sepsis 40

Sepsis Stroke Hospitals Wellness 40

Don't Forget the Bubbles

JULY 5, 2023

The Kilifi algorithm includes five clinical situations that are common sickle cell presentations – clinical jaundice, severe anaemia, bone and joint infections, and stroke. Vaccination: PCV13 (pneumococcal vaccination), meningococcal vaccines, and Hib conjugated vaccines are important to prevent life-threatening sepsis.

Blood Transfusions 126

Blood Transfusions Stroke Dehydration Sepsis 126

EM Literature of Note

OCTOBER 20, 2022

Don’t forget the Annals of Emergency Medicine Podcast , a lighthearted feel-good romantic comedy with Rory Spiegel, available for free on your choice of streaming platforms: Apple Podcasts Google Podcasts Soundcloud Bimonthly #FOAMed in ACEPNow : Updates from the 2022 International Stroke Conference A skeptical look at new tools for diagnosing (..)

Stroke 40

Stroke Sepsis Pediatrics Resuscitation 40

Taming the SRU

SEPTEMBER 1, 2023

to divert the plane). for detecting major injuries Abnormal CXR Rapid deceleration mechanism Presence of a distracting injury Chest wall tenderness Sternal/thoracic spine/scapular tenderness There are limited decision-making rules for thoracic spine imaging Yet a study (Inaba et al., 2015) reported a sensitivity of 98.9%

Sepsis 95

Sepsis Documentation/Coding Administration Fractures 95

ACEP Now

MARCH 6, 2024

What’s New in Stroke Care? The simplicity of tenecteplase administration makes its use likely the preferred agent for treating acute ischemic stroke. the “ARAMIS” trial throws up another red flag for patients suffering mild stroke. the “ARAMIS” trial throws up another red flag for patients suffering mild stroke.

Research 52

Research Airway Management Stroke Outcomes 52

RebelEM

JANUARY 29, 2024

in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47 in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47 to 4.0mg/hr typically given in EKOS therapy (See Below).

Stroke 137

Stroke Outcomes Hospitals Administration 137

Taming the SRU

JULY 31, 2024

Barometric pressure, humidity, and temperature changes may influence stroke and fall incidence (especially in elderly patients with cardiovascular risk factors). Nice people are not more likely to get cancer. Black clouds don’t exist (but I still sort of think they do).

EKG/ECG 52

EKG/ECG Sepsis Documentation/Coding Stroke 52

Emergency Medicine Ireland

APRIL 29, 2024

Hopefully what follows will provide enough broad brush strokes to get you through a night on call or even worse a viva. But as we all know patients often have multiple reasons to be obtunded including sepsis or intoxication or multiple other causes. We’ll start with truly emergent situations.

Seizures 75

Seizures Sepsis Stroke Administration 75

ACEP Now

OCTOBER 29, 2024

For example, experienced emergency physicians have great clinical gestalt and accuracy to predict sepsis in critically ill patients at just 15 minutes from patient arrival—more so than scoring tools like the qSOFA, MEWs, and even machine-learning trained artificial intelligence models. Gut feelings: the intelligence of the unconscious.

Emergency Department 59

Emergency Department Mass Casualty Incidents Documentation/Coding Sepsis 59

RebelEM

FEBRUARY 8, 2024

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 for every 10 years Radial Arterial Line Location: aOR 1.74; 95% CI 1.16

Resuscitation 126

Resuscitation Outcomes EMS Sepsis 126

The Skeptics' Guide to EM

SEPTEMBER 28, 2019

But you remember seeing in the news there was a study claiming vitamin C could cure sepsis. Background: There was a huge buzz in the media a few years ago about a vitamin C cocktail (vitamin C, hydrocortisone and thiamine) as a possible cure for sepsis. You wonder if giving vitamin C will affect her outcome?

Sepsis 52

Sepsis Shock Outcomes Stroke 52

Northwestern EM Blog

JUNE 16, 2024

The most common symptoms include: Lightheadedness Syncope Chest pain Exercise intolerance Fatigue **Important note: The heart rate at which patients experience symptoms may vary based on their ability to increase stroke volume.

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia Infectious Diseases Stroke Poisoning 52

Taming the SRU

AUGUST 30, 2023

Sepsis PCT may have some utility in guiding posttest probability for sepsis when the diagnosis is unclear. A 2013 meta-analysis of 30 studies including 3,244 patients published in The Lancet found PCT to have a pooled sensitivity of 77% and specificity of 79% for sepsis in critically ill patients [52]. Cleland DA, Eranki AP.

Infectious Diseases 88

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

PulmCCM

MAY 22, 2023

More patients (9% vs 4%) had adverse events in the early mobilization group, including 7 serious events in the early-mobilization group (mostly arrhythmias and one stroke) vs 1 in the usual care group. centers, patients with sepsis and systolic blood pressure <100 mm Hg all received at least 1000 mL of crystalloid.

Fluid Resuscitation 68

Fluid Resuscitation Resuscitation Hospitals Sepsis 68

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%

Blood Transfusions 40

Blood Transfusions Fluid Resuscitation Resuscitation Stroke 40

EB Medicine

JANUARY 10, 2020

MACE= Major Adverse Cardiovascular Event: including re-infarction, stroke, dysrhythmia, heart failure, cardiogenic shock, and death. This can be the result of hypotension, tachycardia, sepsis, PE, etc. MACE= Major Adverse Cardiovascular Event: including re-infarction, stroke, dysrhythmia, heart failure, cardiogenic shock, and death.

Emergency Department 40

Emergency Department EKG/ECG Shock Sepsis 40

ACEP Now

MAY 9, 2024

However, only one case—a patient who decompensated during her procedure and suffered a stroke but ultimately survived to hospital discharge—was presumed to be attributable to PFE. While both conditions rely on supportive care as the mainstay of treatment, plastic surgery literature suggests better outcomes with microscopic fat embolism.

Emergency Department 52

Emergency Department Operations Ultrasounds Hospitals 52

Taming the SRU

FEBRUARY 5, 2024

The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. C., & Solomon, T. The Journal of infection , 72 (4), 405–438. van de Beek, D., Cabellos, C., Dzupova, O., Esposito, S., Leib, S.

Infectious Diseases 97

Infectious Diseases Seizures Ultrasounds Sepsis 97

ACEP Now

JULY 7, 2024

These seizures are detectable only with EEG monitoring and, similar to convulsive seizures, nonconvulsive seizures that are prolonged or repetitive can present a neurological emergency termed nonconvulsive status epilepticus.

Seizures 52

Seizures Emergency Department Outcomes EMS 52

Dr. Smith's ECG Blog

AUGUST 23, 2017

Slow atrial flutter (flutter rate 240, ventricular rate 120) Misdiagnosed as sinus tach Here is the case: Sepsis with Pulmonary Edema and Elevated Right Sided Pressures Atrial Flutter rate: Atrial flutter is usually at a rate of 300, but can be anywhere between 240 and 360. Same stroke precautions as atrial fib

Stroke 52

Stroke Sepsis Emergency Department EMS 52

Pediatric Emergency Playbook

SEPTEMBER 1, 2015

Pediatric status epilepticus is analogous to the multi-organ dysfunction syndrome in severe sepsis. Case 3: Headache and Arteriovenous Malformation Unlike in adults, stroke in children is divided evenly between hemorrhagic and ischemic etiologies. Pediatric Seizures and Strokes: Beyond Benzos and Brain Scans. October 8th, 2009.

Pediatrics 40

Pediatrics Seizures Stroke Radiology 40

All Ohio EM

OCTOBER 26, 2018

Coiling decreases lifespan by 2 years due to stroke and aneurysm rupture, while the lifetime rupture rate is 0.23% if the aneurysm is under 3 mm. Corey Slovis would be horrified that I’m not listing 5 things for him, but the one pearl I wanted to emphasize: refractory acidosis in DKA, think abscess, sepsis, or dead gut.

CPR 52

CPR Sepsis Stroke EMS 52

Pediatric Emergency Playbook

MAY 1, 2016

For altered adults, use AEIOU TIPS (Alcohol-Epilepsy-Insulin-Overdose-Uremia-Trauma-Infection-Psychosis-Stroke). meningoencephalitis, overwhelming alternate source of sepsis) T – Toxins (e.g. sludge phenomenon, secondary sepsis, hypoglycemia from supply-demand mismatch) S – Seizure (e.g. V – Vascular (e.g. V – Vascular (e.g.

Seizures 40

Seizures Sepsis Stroke Pediatrics 40

Taming the SRU

APRIL 13, 2023

stent, percutaneous nephrostomy) by urology or IR Hypokalemia evaluate for EKG changes assess for underlying cause and factors that may influence ability to replete (i.e. Vaishnav Hyperthermia: abnormally high body temperature due to thermoregulatory failure Severe hyperthermia: temp greater than 40.5C

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia Poisoning EKG/ECG Seizures 52

Pediatric Emergency Playbook

APRIL 1, 2016

Less common causes of troponemia are: Kawasaki disease, pediatric stroke, or neuromuscular disease. Lactate A sick child with sepsis syndrome? In the adult literature, we know that a lactate level above 4 mmol/L in patients with severe sepsis was associated with the need for critical care. The short answer – yes.

Pediatrics 52

Pediatrics Sepsis Shock Outcomes 52

PulmCCM

JANUARY 4, 2022

For example, should a fluid challenge fail to raise stroke volume [SV], a state of physiological preload intolerance exists and additional volume is arguably harmful ; further attempts to increase tissue perfusion might then be best achieved with vasoactives. .’ For what are intravenous fluids diagnostic?

Wellness 40

Wellness Outcomes Sepsis Stroke 40

Pediatric Emergency Playbook

NOVEMBER 1, 2015

Case 1: Sepsis Laura is a 2-month-old baby girl born at 32 weeks gestational age who today has been “breathing fast” per mother. She is in respiratory failure from bronchiolitis and likely viral sepsis. Induction Agent in Sepsis The consensus recommendation for the induction agent of choice for sepsis in children is ketamine.

Shock 40

Shock Sepsis Airway Management Pediatrics 40

Pediatric Emergency Playbook

JUNE 1, 2016

Distributive Shock The most common cause of distributive shock is sepsis, followed by anaphylactic, toxicologic, adrenal, and neurogenic causes. Children with sepsis come in two varieties: warm shock and cold shock. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.

Shock 40

Shock Sepsis Pediatrics Ultrasounds 40

Northwestern EM Blog

MAY 16, 2022

He endorses nausea without vomiting and denies fever. were hospitalizations during f/u period; 26.4%

Ultrasounds 52

Ultrasounds Radiology Radiology Outcomes 52

Taming the SRU

MAY 1, 2023

Exertional Hyperthermia Patients with heat stroke will present with Temp > 104, AMS, or seizures. EMS was bagging him on arrival Primary notable for Compromised Airway Protection, bilateral Breath sounds, strong pulses,GCS 3 CT images of Head, Chest, Abdomen, Pelvis, and Spine No acute findings pH of 6.75

Poisoning 52

Poisoning Hyperthermia / Hypothermia Emergency Department Seizures 52