The Rebellion in EM Clinical Conference

04 Jan
January 4, 2018

Rebellion in EM
May 11th – 13th, 2018
San Antonio, TX
Venue: Pearl Stable
Website: www.rebellioninem.com Read more →

Effect of POCUS in Cardiac Arrest on Compression Pauses

14 Dec
December 14, 2017

Background: The provision of high-quality compressions with minimal interruptions is central to the management of cardiac arrest. Along with defibrillation, high-quality compressions are the only interventions proven to improve patient-oriented outcomes. Recently, point-of-care ultrasound (POCUS) has gained greater use in cardiac arrest care for determination the cause of arrest as well as guiding the resuscitation and interventions. Performance of POCUS during arrest can be challenging particularly in terms of obtaining cardiac windows. Among these challenges is obtaining images of the heart during compressions. As a result, cardiac POCUS is often performed during rhythm checks when there is a scheduled pause in compressions. Despite the potential benefit from POCUS in cardiac arrest, prolonged interruptions in compressions while attempting to get optimal windows is unlikely to benefit the patient and, may be harmful. Read more →

Topical TXA in Epistaxis

07 Dec
December 7, 2017

Background: Epistaxis is a common Emergency Department (ED) complaint with over 450,000 visits per year and a lifetime incidence of 60% (Gifford 2008, Pallin 2005). Standard anterior epistaxis treatment consists of holding pressure, use of local vasoconstrictors, topical application of silver nitrate and placement of an anterior nasal pack. ED patients with epistaxis often fail conservative management and end up with anterior nasal packs which are uncomfortable. This is even more common in the group of patients who are taking antiplatelet agents like aspirin or clopidogrel. Recently, the use of topical tranexamic acid (TXA) has been described in patients with anterior epistaxis with shorter time to epistaxis control and shorter ED length of stay (Zahed 2013). However, prior studies have not focused specifically on patients taking antiplatelet agents. Read more →

Bacterial Endocarditis

04 Dec
December 4, 2017

Background:

  • Definition
    • Infective Endocarditis (IE) = Inflammation of the endothelium of the heart, heart valves (or both) (Osman 2013)
  • Epidemiology
    • Annual incidence = 5-7 cases per 100,000 (Fraimow 2013)
    • 40,000 to 50,000 new cases in the US per year. Average hospital charges in excess of $120,000 per patient (Bor 2013)
    • Slightly higher male predominance (1.5:1 – 2:1) (Moreillon 2010)
    • In-hospital mortality of 14–22% and 1-year mortality of 20-40% (Gomes 2017, (Habib 2006)
    • Before antibiotics and surgery it was almost universally fatal  (Aretz 2010, Osman 2013)
  • Pathophysiology (Moreillon 2010, Faza 2013, Tan 2014, Osman 2013, Kokowski 2018)
    • The normal, undamaged valve endothelium is very resistant to colonization and infection by circulating bacteria
    • Micro-trauma (caused by turbulent flow, intracardiac devices, etc) or chronic diseases (rheumatic heart disease, congenital heart disease, prosthetic valves, previous IE) can cause damage to the endothelium
    • Damage to endothelium produces a fibin and platelet sterile thrombus.  Microbes can seed that thrombus during transient episodes of bacteremia, fungemia and viremia
  • Risk factors –  (Faza 2013, Moreillon 2010).
    • Diseased/damaged heart (highest risk)
    • IV drug use (IVDU)
    • Low immune function –
    • Poor oral hygiene. (Faza 2013)
    • Nosocomial

Read more →

Door to Furosemide (D2F) in Acute CHF…Really?

27 Nov
November 27, 2017

Background: Acute congestive heart failure (AHF) is a common complaint seen in the ED and associated with a high morbidity, mortality, cost, and resources.  Many patients with AHF, ultimately end up being admitted and interventions in the ED can make a huge difference in the outcomes of these patients.  The REALITY-AHF (Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure) was a prospective, multicenter, observational study with the primary goal of evaluating the door to furosemide time in the treatment of AHF and clinical outcomes. Read more →

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