The workup of febrile infants (<60 days) can be extensive and invasive. This post and podcast covers a recent paper by the PECARN research group that sought an answer to the question: What is the prevalence of bacteremia and/or bacterial meningitis (“invasive bacterial illness”, ISI) in febrile infants ≤60 days of age with a positive urinalysis (UA) result?
Read MoreBoarding of admitted patients in the ED and subsequent overcrowding of ED’s continues to plague hospitals in the United States and Internationally. The Covid-19 pandemic exacerbated an already growing problem regarding capacity management and patient flow. In this current climate, the Emergency Physician’s responsibilities continue to shift toward the front-end of the process, mainly patients waiting to be seen in the lobby. As such, identifying sick patients in a timely manner and utilizing additional resources to predict patients at risk of clinical deterioration will be paramount moving forward.
Read MoreSepsis, including severe sepsis and septic shock, is a frequently encountered condition in the emergency department and carries a high mortality rate. One of the primary pathophysiologic mechanisms involves complex cascade of host dysregulation in response to an infectious stimulus (Evans, Rhodes et al. 2021, Jarczak, Kluge et al. 2021). Recent meta-analyses and systematic reviews evaluating mortality in patients with septic shock reported mortality as high as 35% and 38% at 30 and 90 days, respectively (Vincent, Jones et al. 2019, Bauer, Gerlach et al. 2020). Despite the complexity and heterogeneity of patients with sepsis, there have been few interventions which have been demonstrated to decrease mortality: early antimicrobial and fluid administration (Levy, Evans et al. 2018, Kuttab, Lykins et al. 2019, Evans, Rhodes et al. 2021, Im, Kang et al. 2022), ideally with antibiotics administered within one hour of sepsis recognition by the treating provider (Evans, Rhodes et al. 2021). Each subsequent one-hour delay in antimicrobial administration increases mortality by 35% in patients with septic shock (Im, Kang et al. 2022).
Read MoreThe management of atrial fibrillation with rapid ventricular response is often complicated by the presence of heart failure with reduced ejection fraction. The presence of HFrEF limits pharmacologic options for rate control. This podcast will cover a retrospective study looking at the use of metoprolol vs diltiazem in patients with A fib with RVR and concomitant heart failure
Read MoreEarly recognition and resuscitation of patients in septic shock are critical skills for an emergency medicine physician. Many clinical decision-making tools have been developed and validated in their use to identify and define those who are in sepsis or septic shock, as well as predict a patient’s overall risk of morbidity and mortality, including tools like the SIRS criteria and SOFA score. The diastolic blood pressure is determined by vascular tone, and thus it can be assumed that a decrease in the diastolic blood pressure should correlate with the pathologic vasodilation in septic shock. As a result, the authors of this study hypothesized that the relationship between heart rate and the diastolic blood pressure (i.e. the diastolic shock index) could provide providers a tool to quickly identify patients that are at risk for unfavorable outcomes.
Read MoreSpontaneous subarachnoid hemorrhage (SAH) is a can’t miss diagnosis for patients presenting to the emergency department with a headache. The diagnosis is associated with a 30% mortality at 30 days, and approximately 30% of survivors may have long-term neurocognitive deficits (Rincon et al., 2013). The majority of spontaneous SAH are secondary to a ruptured arterial aneurysm (80%) while non-aneurysmal SAH are often due to low pressure venous bleeds, arteriovenous malformations, and other more rare causes. This post will recap the existing literature on the diagnosis of aSAH and will focus on breaking down a recently published paper by Vincent, et al which may inform our future practice.
Read MoreDuring a cardiac arrest resuscitation, finally palpating a pulsatile flow beneath your gloved fingertips brings a sense of satisfaction like no other. But just as you go to finally breathe a sigh of relief and wipe the beading sweat off your brow, your now widening pupils focus on the patient’s steadily plummeting blood pressure. As you begin to sense your own heart palpitating, you think about medications to utilize in hopes of staving off another round of chest compressions. Since you’ve already given four doses of code-dose epinephrine, maybe an epinephrine infusion is best? You also recall that norepinephrine seems to be a popular choice in patients with shock, so maybe you should start that instead?
Read MoreCardiac arrests are an inevitable reality for emergency medicine providers. There is often a debate on whether family members presence during CPR will lead to more emotional burdens on the family members who witnessed these resuscitations. This study aimed to determine if there are increased rates of PTSD-related symptoms of close relatives who witnessed CPR of a family member.
Read MoreDoes the patient need a pause? Is an ultrasound better than palpation? Join us as we review recent literature review comparing the two
Read MoreIn this podcast, Dr. Courtney Kein breaks down a recently published article examining the effects of a bolus of IVF at the time of intubation. Does a push of fluid prevent peri-intubation hemodynamic collapse?
Read MoreIn this Journal Club paper breakdown, Dr Bailee Stark recaps the findings of a recently published study by Driver et al looking at the effect of bougie aided intubation vs standard stylet intubation.
Read MoreIn this Journal Club podcast, PGY-3 Tony Fabiano breaks down a paper from the Journal of Trauma comparing the effectiveness and patient perception of pigtail catheters versus standard chest tubes for hemothorax in the setting of trauma. Is a tiny tube effective at all in draining blood from the chest?
Read MoreTime is myocardium, and minimizing door-to-activation time improves outcomes in patients with acute coronary occlusion. There are a number of existing quality metrics used to help drive improvements in the time-based care of STEMI patients. Could a new quality metric help the decision making time of Emergency Physicians?
Read MoreThe paradigm of STEMI vs NSTEMI is one of the most well known in Emergency Medicine. Could a change in thinking shift this paradigm to OMI vs NOMI and result in a more complete identification of patients with significant morbidity and mortality?
Read MoreOne of the first tests ordered for a patient with ROSC following cardiac arrest is an EKG. Many of these EKGs are profoundly abnormal. Current practice is to evaluate for STEMI and to activate the cardiac cath lab if one is found. But, the test characteristics (sensitivity and specificity) of post-ROSC EKGs are likely different than the test characteristics for patients presenting to the ED with complaints of chest pain/symptoms concerning for ACS. This meta-analysis looked to pull together the existing literature and determine those test characteristics for this critically ill patient population. Read the summary after the link and listen to the podcast to hear a breakdown of this study.
Read MoreSRU (pronounced "shrew") = Shock Resuscitation Unit
Training in, and managing, the SRU is one of the crown jewels of our residency. It is where the sickest of the sick patients are found in our ED. It is a crucible, a test of knowledge and strength, and a true manifestation of the tripartite mission of our department: Leadership, Excellence, and Opportunity.
Training in, and managing, the SRU is one of the crown jewels of our residency. It is where the sickest of the sick patients are found in our ED. It is a crucible, a test of knowledge and strength, and a true manifestation of the tripartite mission of our department: Leadership, Excellence, and Opportunity.
