Sepsis 3.0

24 Feb
February 24, 2016

Sepsis 3.0Background: Systemic Inflammatory Response Syndrome (SIRS) is something that has been beat into the heads of medical students, residents, fellows, and all physicians in general. However, the derivation of SIRS occurred in 1991, where the focus was on the then-prevailing inflammatory response of the host immune system. In 2001, a task force recognized the limitations of these definitions but did not really offer alternatives due to a lack of supporting evidence. What we have been left with is the definitions of sepsis being largely unchanged for more than 2 decades, until now. Enter Sepsis 3.0. Read more →

Complications of Procedural Sedation

22 Feb
February 22, 2016

Procedural SedationBackground: As Emergency Department (ED) physicians it is not uncommon to give patients procedural sedation and analgesia (PSA) to help facilitate painful procedures. Performing PSA requires close monitoring and is not without potential adverse events. There are numerous analgesic, sedative, and anesthetic agents that can be used in combination for PSA in the ED. Adverse event reporting for PSA has been heterogeneous. The purpose of this systematic review and meta-analysis is to determine the incidence of adverse events during PSA in the ED, including the frequency of events with individual drugs and different drug combinations. Read more →

Management and Disposition of Low Risk Chest Pain

18 Feb
February 18, 2016

Low Risk Chest PainChest Pain (CP) is a very common complaint seen in emergency departments around the world.  In the US specifically  anywhere from 8 – 10 million patients present to the ED complaining of CP.  Many use liberal testing strategies to prevent missing acute coronary syndrome (ACS) or other major adverse cardiac events (MACE), but this is not without increase in healthcare cost and false positive testing leading to more downstream testing.  In recent years there have been several diagnostic protocols developed to help determine a portion of these patients as low risk to facilitate early discharge, prevent this over testing, while still having a >99% NPV for MACE at 30 days.

Disclaimer: To be clear, this is the way I manage low risk chest pain and certainly there is more than one way, but I think at the current time in the US, this is the best we have.  Also, at the time of this post being written, we DO NOT have high sensitivity troponins in the US. Read more →

Sensitivity of Early Brain CT to Exclude Aneurysmal Subarachnoid Hemorrhage

11 Feb
February 11, 2016

Subarachnoid HemorrhageBackground: Headache accounts for approximately 2% of all ED visits. One of the most serious etiologies of headache is aneurysmal subarachnoid hemorrhage (SAH), which accounts for 4 – 12% of ED patients with thunderclap headache. There have been several studies in the past few years suggesting that in neurologically intact patients, the sensitivity of modern CT scanners for SAH approaches 100% if performed within 6 hours of headache onset and interpreted by qualified radiologists. If true this data suggests that an LP may not be necessary to rule out SAH and an initial negative CT can be considered a rule-out test. Read more →

Should we be Using Apneic Oxygenation (ApOx) in the ED?

08 Feb
February 8, 2016

Apneic OxygenationBackground: Tracheal intubation is a procedure that is often performed in the ED on patients in critical condition. Because of this, there is the potential for complications such as hypoxemia, hypotension, dysrhythmias, aspiration, and cardiac arrest. Apneic Oxygenation (ApOx) is a concept first explored decades ago in the anesthesia literature and more recently, has gained acceptance in the ED. Studies in the operating room (OR) show that delivery of oxygen through the use of nasal cannula during periods of apnea significantly delays the onset of oxygen desaturation. These studies however, were in controlled settings with elective surgical patients who were not in critical condition. Physiologically, ApOx makes sense, its low cost, and low complexity and could improve the safety of RSI in the ED, by extending the safe apnea time. To date there have been no RCTs on ApOx in the ED. The recently published Fellow Trial questioned the use of ApOx in critically ill patients, but had some significant issues with 2/3 of the usual care arm not being apneic (i.e. Bag Valve Mask Ventilation or Non-Invasive Ventilation) prior to intubation. Read more →

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