Author Archive for: srrezaie

The Protocolised Management in Sepsis (ProMISe) Trial

17 Mar
March 17, 2015

ProMISeSince 2002, the surviving sepsis campaign (SSC) has stated that best practice in sepsis care includes: early recognition, source control, appropriate/timely antibiotic therapy, resuscitation with intravenous fluids (IVF) and vasoactive medications. Resuscitation of the septic patient in the emergency department has been largely based off the 2001 Rivers trial. This single center study’s focus was to optimize tissue oxygen delivery following several parameters including, central venous pressure (CVP), mean arterial pressure (MAP), and central venous oxygen saturation (SCVO2) to guide IVF, vasoactive medications, and packed red blood cell (PRBC) transfusions. Well today, part 3 of the sepsis trilogy was published in the saga of Early Goal Directed Therapy (EGDT) versus “usual” care. The 3 parts to this saga consist of:

  1. Protocolized Care for Early Septic Shock (ProCESS) – 31 Emergency Departments in the United States
  2. Australasian Resuscitation in Sepsis Evaluation (ARISE) – 51 Emergency Departments in Australia, New Zealand, Finland, Hong Kong, and Ireland
  3. The Protocolised Management in Sepsis (ProMISe) Trial – 56 Emergency Departments in the United Kingdom Read more →

The New Age of Sepsis Management

16 Mar
March 16, 2015

SepsisThere are more than 750,000 cases of severe sepsis and septic shock in the US each year.  Most patients who present with sepsis receive their initial care in the emergency department.  In 2001, there was a landmark study by Rivers et al that reported that among patients with severe sepsis or septic shock mortality was significantly lower among those who received a 6 hour protocol of Early Goal-Directed Therapy (EGDT) (i.e. 30.5% vs 46.5%). The premise of EGDT was that “usual care” lacked aggressive, timely assessment and treatment. The EGDT protocol used central venous catheterization (CVC) to monitor central venous pressure (CVP) and central venous oxygen saturation (SCVO2) to guide the use of intravenous fluids (IVFs), vasopressors, packed red blood cell (PRBC) transfusions, and dobutamine in order to achieve pre-specified physiological targets.  Since the publication of this landmark article, physicians have become more aggressive in the management of sepsis which raises the question of whether all elements of the protocol are still necessary.  Read more →

Epinephrine in Out-of-Hospital Cardiac Arrest Poll

15 Mar
March 15, 2015

epinephrineRecently, I wrote a post on the use of epinephrine in out-of-hospital cardiac arrest (OHCA) and this triggered some interesting discussion on twitter. Are we at a point that we can just stop using epinephrine in OHCA?  Has anyone stopped actually using epinephrine in OHCA and if so, why or why not? The evidence seems to point to no “good” neurologic benefit over basic life support (BLS).  I would love to hear more peoples thoughts on this. Read more →

Is It Time to Abandon Epinephrine in Out-Of-Hospital Cardiac Arrest?

11 Mar
March 11, 2015

epinephrineEpinephrine is widely used and recommended by Advanced Cardiovascular Life Support (ACLS) in out-of-hospital cardiac arrest (OHCA), but its effectiveness in neurologic outcomes has never been truly established.  To verify effectiveness of epinephrine confounders, such as patients, CPR quality, CPR by bystanders, time from call to arrival at scene or hospital, and much much more, must be controlled for in a trial. This type of study is not easily performed due to ACLS being the current standard of care. Read more →

March 2015 REBELCast

09 Mar
March 9, 2015

REBELCastWelcome to the March 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics that come up frequently in clinical practice in the emergency department. Today we are going to specifically tackle:

  • Topic #1: Oseltamivir (Tamiflu) in the Treatment of Influenza
  • Topic #2: Use of the HEART Score in Low Risk Chest Pain Patients Read more →

Video Laryngoscopy or Direct Laryngoscopy for Trainees

05 Mar
March 5, 2015

Glidescope Video LaryngoscopyAccording to a 2012 meta-analysis difficult and failed intubations in the operating room occur 1.8 – 5.8% and 0.13 – 0.30% of the time respectively. Emergent intubation, outside of this environment (i.e emergency department, ICU, and medical ward) is typically associated with a much higher risk of difficulty and complications due to many patients rapidly deteriorating. Recently, I had a discussion on twitter with Jeffrey Hill (@_drjeffy) and Taylor Zhou (@canibagthat) about what is the best way to teach trainees to intubate: Video Laryngoscopy (VL) or Direct Laryngoscopy (DL) for Trainees?

PLEASE BE SURE TO VOTE AT THE BOTTOM OF THIS POST!!!

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How Long Does a Cough From Respiratory Illness Last?

02 Mar
March 2, 2015

Cough and VirusCough from respiratory illness is one of the most common reasons that patients seek care in both the outpatient primary care setting and the emergency department (ED).  Cough due to respiratory illness is a self-limited condition in the majority of cases, but patients still seek care at clinics and EDs seeking relief or their symptoms. Maybe the reason for this is patients’ expectations of duration of cough and the actual natural history of cough from respiratory illness are mismatched. So how long does a cough from respiratory illness last? Read more →

Any Benefit to Adjunct Prednisone Therapy in Community Acquired Pneumonia?

18 Feb
February 18, 2015

PneumoniaBackground: Respiratory tract infections and pneumonia are the 3rd leading cause of death worldwide.  Although morbidity and mortality has improved slightly with the advent of antibiotics, there is still a significant long-term morbidity and mortality associated with this disorder.  It is well known that in pneumonia, there is an excess release of circulating inflammatory cytokines which cause further pulmonary dysfunction. Maybe the use of systemic corticosteroids, which have anti-inflammatory effects, could help attenuate this systemic inflammatory process and thus improve outcomes. So is there any benefit to adjunct prednisone therapy in community acquired pneumonia?

Read more →

February 2015 REBELCast

09 Feb
February 9, 2015

REBELCast LogoWelcome to the February 2015 REBELCast, where Swami, Matt, and I are going to tackle two critical care topics that come up frequently in clinical practice in both the pre-hospital setting as well as the emergency department.  Today we are going to specifically tackle:

Topic #1: Administration of Rapid Sequence Intubation (RSI) Medications via an Intraosseous line.

Topic #2: Compressions During Charging (CDC) in Out of Hospital Cardiac Arrest (OHCA)

Read more →

The PROPPR Randomized Clinical Trial

04 Feb
February 4, 2015

The PROPPR Randomized Control TrialIn the United States, trauma is the leading cause of death among patients between the ages of 1 and 44 years of age and the third leading cause of death overall. Approximately 20 to 40% of trauma deaths occur after hospital admission and are a result of massive hemorrhage.  There have been no large, multi-center, randomized clinical trials with survival as a primary end point that support optimal trauma resuscitation practices with approved blood products and therefore there are many conflicting recommendations. The Prosective Observational Multicenter Major Trauma Transfusion (PROMMT) Trial demonstrated that many clinicians were transfusing patients with blood products in a ratio of 1:1:1 or 1:1:2 and that early transfusion of plasma was associated with improved 6-hour survival after admission.

The Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial was designed to address the effectiveness and safety of 1:1:1 transfusion ratio vs 1:1:2 in patients with trauma who were predicted to receive a massive transfusion.

Read more →