Critical Care Horizons

11 Jun
June 11, 2014

Critical Care Horizones

Please welcome a new development in critical care publishing with the launch of a new open access critical care journal: CRITICAL CARE HORIZONS!!!  This will be a fresh, new, original voice in the critical care literature, offering thought provoking, cutting-edge commentary, opinion papers, plus state-of-the art review articles. Read more →

R.E.B.E.L. ECG of the Week: LBBB and STEMI

09 Jun
June 9, 2014

R.E.B.E.L. ECG of the Week

89 year old male with PMH of hypertension, stage 3 chronic kidney disease with chief complaint of shortness of breath. Several days ago patient had a laminectomy for radicular pain. He was doing fine post-operatively and began to develop gradual shortness of breath.  He had no complaints of chest pain, nausea/vomiting, fevers, diaphoresis, but did have some weakness.  There were no prior ECGs for comparison.

BP: 98/48 HR: 103 RR: 18 O2 on RA: 94% Temp: 38.6

JVD to the angle of the mandible
Bibasilar Crackles
Sinus Tachycardia
Bilateral lower extremity pitting edema

Labs: Na 125, K+ 4.2, Creatinine 2, BNP > 2500

ECG from triage is shown… Read more →

Left Ventricular Assist Device

29 May
May 29, 2014

Left Ventricular Assist Device (LVAD)The first left ventricular assist device (LVAD) was performed in 1984 and since that time there is an increasingly growing population of patients with LVADs.  This means ED physicians will be seeing more and more of these patients in the ED and should have a basic understanding of how these devices work and have an adequate understanding of common complications and an approach to evaluate these patients. LVADs are typically used for end-stage heart failure for both a bridge to transplantion and for long-term quality of life improvement. Most of the information for this post comes from a great review article written by Chris Partyka et al in EMA 2014. Read more →

Rivaroxaban for Treatment of Symptomatic Pulmonary Embolism

26 May
May 26, 2014

Pulmonary EmbolismTypically, the treatment of acute pulmonary embolism consists of administration of unfractionated heparin or low molecular weight heparin (i.e. enoxaparin) overlapped with vitamin K antagonists (i.e. warfarin).  This can be a very effective treatment regimen, but also very complex.  New direct Xa inhibitors are being used more and more in clinical practice with prevention of venothromboembolism (EINSTEIN-DVT Trial), after major orthopedic surgery (RECORD1 Trial), prevention of stroke in patents with atrial fibrillation (ROCKET-AF Trial) , and in the treatment of acute coronary syndromes.  Recently, the EINSTEIN-PE Trial evaluated oral rivaroxaban for treatment of symptomatic pulmonary embolism. Read more →

Any Benefit to Sodium Bicarbonate in DKA?

12 May
May 12, 2014

Sodium BicarbonateIn a prior post, we discussed the use of an initial insulin bolus in the management of diabetic ketoacidosis (DKA).  Today we will address another facet of DKA management, for which there is less than optimal evidence and that is: Any benefit to sodium bicarbonate in DKA?  Consensus guidelines for the management of DKA recommended administering sodium bicarbonate to DKA patients who present with an initial blood gas pH of < 7.0. That recommendation was updated and changed in 2009 to limit sodium bicarbonate use to DKA patients with blood gas pH of < 6.9.  More recently, Chua et al. published a systematic review of 44 articles discussing bicarbonate administration and Duhon et al. published the largest retrospective review of DKA patient with presenting pH of < 7.0.
Read more →

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