Early Sepsis Screening in the Emergency Department

10 Dec
December 10, 2018

Background Information: Sepsis is a complex syndrome frequently encountered in the ED. This infection-triggered, multifaceted disorder of life-threatening organ dysfunction is due to the body’s dysregulated response to pathologic and biochemical abnormalities.2-4 There has been significant debate regarding the use of clinical decision tools such as Systemic Inflammatory Response Syndrome (SIRS) and quick Sepsis-related Organ Failure Assessment (qSOFA) in the early recognition of sepsis.2,5-7­ Multiple studies have shown SIRS to not be specific enough for the early detection of sepsis as many non-infectious processes, including exercise, can often meet many of its criteria.8-10 On the other hand, qSOFA has been criticized as having poor sensitivity and moderate specificity for short-term mortality.11,12 Furthermore, qSOFA  has been described as clinically valuable but an imperfect marker of sepsis as some forms of organ dysfunction, such as hypoxemia and renal failure, are not assessed using qSOFA.5 Another severity score known as the National Early Warning Score (NEWS) focuses on inpatient deterioration in detecting patients with increased risk of early cardiac arrest, unanticipated ICU admission and death.13 One study showed that utilization of NEWS in the emergency department (ED) has been shown to be effective in recognizing patients with sepsis who are at a higher risk of adverse outcomes.14  The authors of this study sought to review the use of NEWS as an early sepsis screening score, a predictor of severe sepsis/septic shock, and compare it to SIRS and qSOFA in an ED triage setting. Read more →

Blunt Cardiac Injury (BCI)

06 Dec
December 6, 2018

Friday, 2300 hours:

A 24 year-old woman presents to your Emergency Department after a motor vehicle collision. She was the restrained driver of a car that collided head-on with another vehicle. She is complaining only of chest pain and appears uncomfortable and anxious.  The monitor shows sinus tachycardia and you spot a sternal fracture on her chest x-ray.  After IVF and Fentanyl, she remains slightly tachycardic and you wonder:

  • Do I need to send a troponin?
  • If the troponin is negative does this patient need to be admitted?
  • What other testing should I consider in the Emergency Department?

Read more →

TXA for Everyone: Inhaled TXA for Hemoptysis

03 Dec
December 3, 2018

Background: Use of tranexamic acid (TXA), an antifibronlytic medication,  has certainly become popular for numerous indications (i.e. trauma, uterine bleeding, epistaxis).  Patients with hemoptysis, frequently come through EDs, and as an ED healthcare provider, I am unable to provide the definitive therapies of bronchial artery embolization and bronchoscopy for these patients at many of the institutions in which I work.  And, of course, it’s not like I can just put my finger on the bleeder. There is no real effective medical therapy for hemoptysis, other than antibiotics for infection.  I often find myself helpless with these patients as all I can do is transfer them to larger institutions where definitive therapies can be done.  Well hold on…It turns out inhaled TXA may be an option to reduce bleeding in patients with hemoptysis.  Thus far the evidence for this has  only been from small case series.  There have been no prospective studies evaluating nebulized TXAs effectiveness as an inhaled treatment for hemoptysis.  I have certainly used this treatment for post-tonsillectomy bleeding and have at times used it for hemoptysis, with great success, but it would be nice to see some evidence to support this practice. Read more →

D-Dimer in Pregnancy: Limiting Radiation with Pre-test Probability

29 Nov
November 29, 2018

Background: Pulmonary embolism is the leading cause of death in pregnancy and the puerperium – accounting for nearly 20% of maternal deaths in the United States – making rapid and accurate diagnosis critically important for emergency physicians, OB/GYNs, and all who take care of these women on a regular basis. Diagnosis is made more difficult by the frequency of concerning and suggestive signs and symptoms in this population, particularly dyspnea (a common symptom in pregnancy related to an increase in progesterone levels) and tachycardia (as resting heart rate is typically expected to increase by up to 25% in normal pregnancy).

While the use of the D-dimer in conjunction with a low pre-test probability for pulmonary embolism is well-established for ruling out PE in the non-pregnant population, pregnant women were excluded from studies that derived and validated models assessing pretest clinical probability of PE, and no specific tool to assess pretest probability is available in this setting. This lack of a pretest probability assessment tool and the lack of prospective data confirming the safety of ruling out PE on the basis of a negative D-dimer result have limited the adoption of the D-dimer test in pregnant patients. Indeed, the American Thoracic Society guidelines [1] recommend specifically against the use of D-dimer to exclude PE in pregnancy. The DiPEP study, published in the British Journal of Haematology, attempted to add to this literature base [2], and was reviewed here on REBEL EM. The DiPEP authors’ conclusion, that D-dimer should not be recommended for use in the diagnostic work-up of PE in pregnancy, was echoed in our review, however this study was likely fundamentally flawed in that it did not risk stratify patients prior to application of D-dimer testing, a critical step in all validated applications.

Recently, a group of French and Swiss authors published a prospective diagnostic management outcome study for diagnosis of PE in pregnant women that sought to better define the role of D-dimer when paired with pre-test risk stratification. [3] Read more →

Delirium in Critical Illness: Haloperidol vs Ziprasidone?

26 Nov
November 26, 2018

Background Information: Delirium is defined as an acute disorder of consciousness which can occur in up to 80% of mechanically ventilated ICU patients.1-5 This acute cognitive dysfunction is associated with prolonged hospital stay, increased mortality, longer periods of mechanical ventilation and long-term cognitive impairment compared to patients without delirium.4-8  Haloperidol, remains one of the most commonly used typical antipsychotics used to treat delirium internationally and within the United States.9,10 The Society of Critical Care Medicine’s recent guidelines do not suggest the use of Haloperidol in the prevention or treatment of delirium11 and understandably so as two randomized trials showed no reduction in duration of ICU delirium.5,12 Alternative therapies for delirium include atypical antipsychotics such as ziprasidone, however the literature shows conflicting evidence, with one study showing a benefit and another showing no effect.5,13 The authors of this study sought to examine the effects of these two treatments in a large multicenter, randomized, double-blinded, placebo-controlled trial.       Read more →