June 12, 2019

Take Home Points on Measles

  • There is a resurgence of measles worldwide
  • Incubation period is 10 – 14 days and patients are contagious 4 days before rash develops and up to 5 days after
  • Suspect measles in any patient with an acute febrile illness who is either un- or undervaccinated
  • Know about Post Exposure Prophylaxis (PEP) schedules and isolation times of various populations
  • Healthcare workers should wear N95 masks while taking care of patients with suspected measles, and report cases to their local health department.

June 10, 2019

Airway management as the first priority has been the backbone of resuscitation for years. “Address A first, before moving to B and C,” is what we are taught and what we go on to teach successive generations of learners. For appropriately trained clinical teams, either in- or prehospital, the completion of “A” may well mean performing a rapid sequence intubation (RSI) From its inception in the 1970s, there has been continued evolution in how we approach RSI (and airway management in general) in the physiologically threatened patient – this post will focus on the trauma patient. You can revisit some really well-done blogs and podcasts over the last few years that have highlighted various approaches to prevent peri- and post-intubation problems. Like cardiac arrest.

June 6, 2019

Mechanical Ventilation is a modality commonly used in the critically ill, but many providers, may not have a strong understanding of the basics of mechanical ventilation. Emergency Medicine and Critical Care Physicians need to have a firm grasp of the basic concepts of mechanical ventilation because without it, we can do serious harm to our patients. Airway management is not complete once the endotracheal tube is placed through the cords, and the proper selection of both the ventilator mode and initial settings is essential to ensure your patient has the best possible outcomes. You should not simply rely on the respiratory therapist to know your patients physiology. Clear communication with your therapist about the patient’s physiology and initial ventilator setting is crucial.

June 3, 2019

Background: Despite the lack of replication of the NINDS & ECASS-3 trials, guidelines recommend the use of tPA in the ≤4.5hr window after the onset of symptoms of acute ischemic stroke [2]. These recommendations used non-contrast computed tomography (NCHCT) for the selection of patients.  More recent endovascular studies have shown that perfusion-based imaging can show potential viable brain tissue beyond the 4.5 hour mark in patients with large vessel occlusions and result in good neurologic outcomes.  This advance has prompted investigators to look at perfusion-based technology to identify a larger cohort of patients without large vessel occlusion that may be candidates for systemic thrombolysis.  One of the big fears in stroke management is the concept of indication creep: finding more uses for a medication or product without strong evidence to support its use. The bigger question is, does this increase in use help the company’s bottom line or the patient? It is no wonder physicians are skeptical of industry sponsored trials, as we sometimes question the motives behind the study.  Now we have another industry sponsored trial: EXTEND. In this trial.

May 30, 2019

Background: Syncope, defined as a transient loss of consciousness with spontaneous and complete recovery to pre-event status, is a common emergency department (ED) presentation. Recently, we have discussed the lack of clinical utility in distinguishing syncope from near-syncope in terms of outcomes. In that discussion, we concluded: “In older adults (> 60 years of age), near-syncope appears to portend an equal risk of death or serious clinical event at 30 days when compared to syncope. These two entities should be considered as one when decisions are made in terms of evaluation in the ED.” While we argue for evaluation and disposition to be the same, we don’t address what the best disposition or plan is. While it is common to admit older patients with syncope/near-syncope from the ED, admission doesn’t inherently yield better outcomes.