Background: The assessment and management of the acute onset headache from the perspective of the emergency department is a point of contention and discussion commonly faced by emergency providers. The Ottawa Subarachnoid Hemorrhage Rule is a clinical decision making instrument that was created to help identify patients who need further workup beyond a basic history and physical exam. It does not define the extent of workup required, specifically whether or not a CT versus CT and LP are required to rule out a subarachnoid hemorrhage. In a 2010, Perry et al (1) published results from a prospective cohort study which attempted to formulate a collection of sensitive, high risk characteristics that could identify patients who require workup for subarachnoid hemorrhage. The three separate collections of high-risk features were all found to be highly sensitive (100% sensitivity with 95% CI) and so further investigation was found to be warranted. An additional prospective cohort by Perry et al (2) was designed to further assess the sensitivity, specificity, and overall applicability of these 3 decision making rules to identify patients who require subarachnoid hemorrhage workup. The initial results of this study showed one of the clinical decision making instruments to have a superior sensitivity of 98.5% (95% CI, 94.6%-99.6%). The rule was then redefined to include “thunderclap” headache and limited neck flexion on exam, and then reassessed utilizing a recursive partitioning analysis in order to obtain 100% sensitivity. The Perry et al 2017 (3) study was designed to validate the collection of high-risk characteristics this group has identified as warranting possible workup for subarachnoid hemorrhage. Read more →
This past week, one hundred clinicians went back to work inspired. They were reinvigorated, motivated and full of knowledge. They were the delegates, faculty and volunteers of #resusTO. This inaugural event (hopefully) laid the groundwork for many more to come as it was a success by any measure.
ResusTO, the brain child of human factors guru and EM doc Chris Hicks, who along with the organizing committee of Andrew Petrosoniak, Jesse Spurr and Kari White, and a plethora of volunteers, orchestrated a human performance, education and simulation extravaganza! The conference held in Toronto, Canada sept 13th– 14th, 2018, was a special conference for so many reasons and you could feel it the moment you stepped up to the registration desk and received your name tag that noted, “Awesome human delegate.” Read more →
Background: Venous thromboembolism (VTE) occurs frequently in patient with cancer. Treatment in this group entails a number of challenges including a higher rate of thrombosis recurrence and a higher risk of bleeding. Standard therapy in 2018 for both symptomatic and asymptomatic VTE is with low-molecular-weight heparin (LMWH) based on this study. Prior to 2003, patients were treated with warfarin after bridging with either unfractionated or LMWH. This approach requires frequent monitoring due to unpredictable anticoagulation levels associated with drug interactions, malnutrition and vomiting. Due to these issues, treatment with LMWH alone may be both more efficacious as well as preferred by patients. Read more →
Background: The mis- and overuse of antibiotics continues to be a growing problem in medicine; the results of which are increased health-care costs, increased antibiotic resistance and, ultimately, patient harm. Unnecessary antibiotics are particularly prevalent in the treatment of lower respiratory tract infections (LRTIs) including asthma exacerbations and bronchitis. While it would be nice to simply stop using antibiotics when they’re not indicated, issues in stewardship abound. Amongst these are legitimate concerns by providers that the patient may have a bacterial infection causing their symptoms and, thus, benefit from a course of antibiotics.
Procalcitonin has been touted in recent years as a lab test that can help with this conundrum. Ideally, an elevated procalcitonin level would indicate the presence of a bacterial infection and, thus, suggest benefit from use of antibiotics while a low procalcitonin level would suggest a viral or non-bacterial etiology and suggest an absence of benefit from antibiotics. A recent Cochrane review showed potential for a procalcitonin approach but, there was minimal Emergency Department based evidence. Read more →
Warning: Limited Published Evidence on this Topic
You have just intubated a 4 year old with sepsis from a bad pneumonia. Post intubation BP is 70 systolic, while waiting for the epinephrine (adrenaline) infusion to come up from pharmacy you watch the BP decline into the 60 systolic range and start to use fluids to resuscitate. You are an accomplished adult resuscitationist, and are comfortable mixing, and pushing push dose epi in your adult patients.
The following questions arise as you consider mixing a batch of push dose epi:
- How much push dose epinephrine should you give this septic 4 year old?
- Do pediatric patients need more or less epi when given in push dose format?
- How do some pediatric intensivists and pediatric emergency physicians manage this problem?