Clinical Pearls from ACEP 2018 – San Diego, CA

18 Oct
October 18, 2018

This year ACEP 2018 took place in San Diego, CA from Oct 1st– 4th, 2018.  There were lots of amazing speakers and topics as was evidenced by the eruption of everyone’s twitter feeds with the #ACEP18 hashtag.  I was fortunate enough to not only attend, but also speak at this amazing conference.  I was approached by several attendees requesting that I put together a list of my favorite pearls from this conference, as I have done in years past on REBEL EM.  Below is my top 10 list, in no particular order. Read more →

Approach to the Critically Ill Child: Shock

15 Oct
October 15, 2018

If you mainly treat adults or both adults and children like me, then you have probably heard the (very annoying) quote, “kids are not just small adults”, and so I won’t say it again. Well, I guess I just did, but at least I wont stop at this quote, but attempt to explain how kids are not small adults, and how this may impact their care in the emergency department and the intensive care unit.

Nearly all organ systems of young children are immature and developing throughout childhood and on into adulthood, including the cardiovascular system. Without a basic understanding of the key physiologic differences, the emergency and intensive care physicians will be ill equipped to care for the critical ill child.

To understand how kids with shock present differently than adults, it’s important to discuss a few basic differences regarding intravascular volume and cardiovascular system in children especially neonates and infants (1-24 months of age). Also remember shock is defined the exact same way as it would be in adults even though the presentation and underlying physiology may differ. Shock is simply a state where tissue/organ blood flow is inadequate to meet tissue/organ metabolic demands. Read more →

Coronary Computed Tomography Angiography (CCTA): The Holy Grail of “Low Risk” Chest Pain Evaluation?

11 Oct
October 11, 2018

Background: CCTA has become a popular modality in the ED setting to assess anatomic atherosclerotic disease in patients presenting with chest pain.  Advocates of CCTA feel that CCTA has a greater accuracy in identifying obstructive coronary artery disease and identification of high-risk disease compared to standard physiologic testing.  However, many published trials on CCTA were not adequately powered to evaluate patient oriented end points.  The aim of the current published study was to perform a systematic review and meta-analysis comparing CCTA with other standard of care (SOC) approaches in evaluation of patients with acute chest pain. Read more →

Accidental Hypothermia

08 Oct
October 8, 2018

Definition:

  • Accidental hypothermia is an unintentional core body temperature of < 35°C when heat loss to surroundings is greater than heat generation
  • Most frequent cause is environmental exposure
  • Patient with impaired thermoregulation can develop hypothermia in relatively warm environments
    • Elderly, underlying illness, trauma, intoxication, or malnutrition (Brown 2012)

Read more →

LOMAGHI Trial: Magnesium Sulfate for Rapid Atrial Fibrillation?

04 Oct
October 4, 2018

Background: Currently, several medications are recommended for the management of atrial fibrillation with rapid ventricular response in the emergency department including calcium channel blockers, beta blockers and digoxin (the optimal choice is still up for debate). Magnesium sulfate may play a role as a supplemental medication based on its ability to decrease the frequency of sinus node depolarization, prolongation of the refractory period of the atrioventricular node, and acting as a calcium antagonist inhibiting calcium currents in cardiomyocytes.  In addition,panerai radiomir replica intravenous magnesium is safe and cheap.  Most previous trials on the use of magnesium sulfate have rather small sample sizes or were performed in post-cardiac surgery patients.  Also, the exact dose of magnesium used in previous studies varied significantly making it difficult to determine which dose would be the most optimal in these patients.  Recently, the LOMAGHI study was just published trying to answer the questions behind many of these issues. Read more →