March 25, 2019

Background: TXA is a synthetic lysine derivative that binds with the lysine site on plasminogen and inhibits fibrinolysis.  TXA is not a new drug. Studies from the late 1960s and early 1970s have shown reduced bleeding and need for transfusions in many surgical and medical settings.  Fast forward to today and we are finding all kinds of uses for TXA other than trauma including post-partum hemorrhage, epistaxis, hemoptysis, gastrointestinal hemorrhage, and many more.

March 23, 2019

The management of the critically hemorrhaging trauma patient has seen a large amount of change over last decade, from bringing care far forward to the field to early use of blood products to civilian translation and application tourniquets to name a few. The reality unfortunately is that there is still a subgroup of patients who continue to suffer early mortality from hemorrhage, primarily because they are bleeding in the torso.  This is particularly challenging for both prehospital and in-hospital clinicians to manage as these areas do not allow control through direct compression. Enter resuscitative endovascular balloon occlusion of the aorta (REBOA) – a technique that builds on principles from vascular surgery and sees the placement of a balloon catheter into the aorta via the femoral artery.  Acting as an internal tourniquet, it temporarily occludes flow to the bleeding vessel thus providing circulatory support and precious time to get the patient to definitive care. With the alternative being death from hemorrhage, REBOA came as a breath of fresh air – a minimally invasive means of achieving hemorrhage control in these extremely sick patients. There were innovators and early adopters and reports of fantastic saves – patients were surviving who would never have survived before. 

March 18, 2019

Background: With CMS core measures requiring timely use of antibiotics in patients with fever and suspected sepsis, many patients receive antibiotics up front that may ultimately end up having another non-bacterial etiology as the cause of their fever.  On the one hand overuse of antibiotics can increase bacterial resistance, healthcare costs, and potential side effects. On the other hand, withholding antibiotics from patients with bacterial infections can increase morbidity and mortality. The authors of this trial wanted to determine whether a procalcitonin-guided algorithm could be used to reduce antibiotic regimens in the ED.

March 14, 2019

Background: Chest pain is a complaint commonly seen in the emergency department.  Getting a good history is an essential part of working up patients with chest pain, as the history may guide us to be concerned for the cause of life-threatening chest pain including, pulmonary embolism, aortic dissection, tension pneumothorax, or acute coronary syndrome. In regard to acute coronary syndrome, many of us learned that the classic description of ischemic chest pain was chest pressure radiating to the left arm.  But as sometimes is the case, classic teachings are based on antiquated evidence and simply not correct.

March 11, 2019

Background: Based on the Surviving Sepsis Campaign, hemodynamic resuscitation of sepsis patients is done by repeating serum lactic acid levels every 2 – 4 hours until normalization. The issue with this strategy is that there are other things that may elevate lactate levels other than sepsis and hypoperfusion.  Another, potentially useful marker to guide hemodynamic resuscitation could be capillary refill time.  Its easy-to-use, requires no resources, and costs nothing.  To answer this question the ANDROMEDA-SHOCK randomized controlled trial tried to evaluate the use of a peripheral perfusion-targeted resuscitation strategy during septic shock in adults.
0