REBEL Core Cast 7.0 – Oncologic Emergencies

20 Mar
March 20, 2019

Take Home Points on Oncologic Emergencies:

  1. Hyperviscosity Syndrome happens when elevated WBCs or severe hyperproteinemia cause high serum viscosity and micro-circulatory problems in patients with Waldenstrom’s macroglobulinemia, multiple myeloma or acute leukemia. Be suspicious of this syndrome in these patient’s when they present with the classic triad of mucosal bleeding, visual disturbances, and neurological symptoms or with any end organ failure.
  2. Tumor Lysis Syndrome results from high turnover of malignant cells resulting in severe metabolic derangements including hypocalcemia, hyperkalemia, hyperphosphatemia, hyperuricemia, AKI, metabolic acidosis. Be suspicious of this in patients presenting with edema, hematuria, fatigue, weakness, altered mental status or symptoms that go along with specific metabolic derangement, particularly if they recently received chemotherapy, radiation or high dose steroids.

 

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HiTEMP: Procalcitonin-Guided Antibiotic Therapy in the ED

18 Mar
March 18, 2019

Background: With CMS core measures requiring timely use of antibiotics in patients with fever and suspected sepsis, many patients receive antibiotics up front that may ultimately end up having another non-bacterial etiology as the cause of their fever.  On the one hand overuse of antibiotics can increase bacterial resistance, healthcare costs, and potential side effects. On the other hand, withholding antibiotics from patients with bacterial infections can increase morbidity and mortality. The authors of this trial wanted to determine whether a procalcitonin-guided algorithm could be used to reduce antibiotic regimens in the ED. Read more →

TRAPID-AMI: Predictive Symptoms of Acute Myocardial Infarction (AMI)

14 Mar
March 14, 2019

Background: Chest pain is a complaint commonly seen in the emergency department.  Getting a good history is an essential part of working up patients with chest pain, as the history may guide us to be concerned for the cause of life-threatening chest pain including, pulmonary embolism, aortic dissection, tension pneumothorax, or acute coronary syndrome. In regard to acute coronary syndrome, many of us learned that the classic description of ischemic chest pain was chest pressure radiating to the left arm.  But as sometimes is the case, classic teachings are based on antiquated evidence and simply not correct. Read more →

ANDROMEDA-SHOCK: Peripheral Perfusion vs Serum Lactate in Septic Shock

11 Mar
March 11, 2019

Background: Based on the Surviving Sepsis Campaign, hemodynamic resuscitation of sepsis patients is done by repeating serum lactic acid levels every 2 – 4 hours until normalization. The issue with this strategy is that there are other things that may elevate lactate levels other than sepsis and hypoperfusion.  Another, potentially useful marker to guide hemodynamic resuscitation could be capillary refill time.  Its easy-to-use, requires no resources, and costs nothing.  To answer this question the ANDROMEDA-SHOCK randomized controlled trial tried to evaluate the use of a peripheral perfusion-targeted resuscitation strategy during septic shock in adults. Read more →

Methotrexate Failure in Non-Ruptured Ectopic Pregnancy

07 Mar
March 7, 2019

Background: 1st trimester vaginal bleeding and abdominal pain is a common complaint seen in the ED.  As EM physicians it is important to make the diagnosis of ectopic pregnancy early in the clinical course as it can prevent rupture, difficulty with future fertility, and even death.  Typically, when non-ruptured, hemodynamically stable, ectopic pregnancy is diagnosed, our Ob/Gyn colleagues get consulted and the usual first-line treatment is methotrexate initiated in the ED with 24 – 72hours follow-up in an ideal world. Unfortunately, this does not always happen, and some patients will return to the ED for increased pain. It is important to be aware of methotrexate outcomes and have suspicion for failure of methotrexate in patients returning to the ED. Read more →