Current screening tools for pediatric septic shock and sepsis are highly specific but lack sensitivity. This study substituted age adjusted vital sign measures and a pediatric shock index into currently existing pediatric sepsis scoring systems to create the qPS4.When utilizing a cut off of ≧ 2 points, the qPS4 was highly sensitive and specific, and identified pediatric septic shock far sooner into a patient's course.
Read MoreThere is a wide variation in practice, particularly in obtaining neuro-imaging in patients presenting with vertigo. Many patients are imaged and subjected to a longer length of stay, and on the other side of the coin, some patients with serious pathology fall through the cracks. The authors of this study set out to create a risk score to apply to patients who present to the ED with vertigo which would identify the patients at risk for serious pathology (which they defined as stroke, TIA, vertebral artery dissection, or brain tumor).
Read MoreSepsis remains an increasingly common emergency department condition that is tied to higher morbidity and mortality across the United States as well as the rest of the world. Sepsis as a disease process has been difficult to both clearly define and quickly recognize. Many metrics for recognition and management of sepsis are dependent upon various scoring systems, including SIRS, SOFA, qSOFA, and MEWS, none of which were designed for the acute detection of sepsis within the emergency department. This journal club recap will look at an article by Knack et al looking at physician gestalt vs scoring systems for the detection of sepsis.
Read MoreIn patients with cirrhosis and ongoing bleeding, it can be challenging to determine whether or not patients are hyper or hypocoagulable. Traditional markers of coagulation status like INR can be difficult to interpret in patients with abnormal synthetic function and potentially increase consumption of coagulation factors. Can TEG (thromboelastography) be a helpful too in these situations? In this journal club recap, Dr. Grisoli recaps a recent article by Rout et al that addresses this issue.
Read MoreIn this journal club recap, Dr Sarah Moulds recaps a recent meta-analysis of papers looking at the therapeutic effect of TXA in patients with severe trauma. Are their higher rates of thromboembolic complications? Is mortality improved? This article by Fouche et al attempts to answer these questions.
Read MoreOut of hospital cardiac arrest (OOHCA) represents a great cause of morbidity and mortality. Approximately 350,000 cardiac arrests occur in North America annually and 20% can be attributed to Ventricular tachydysrhythmias (i.e. ventricular tachycardia [v fib] and ventricular tachycardia [v tach]without a pulse). In this journal club recap, Dr Kelly Tillotson recaps an article comparing different ways of defibrillation and their effect on outcomes in OOHCA
Read MoreCan clean gloves (those in the box in the room) be used safely during the repair of traumatic lacerations in the ED? Should we break open the package of sterile gloves each time? This Journal Club recap covers a recent paper examining the use of clean vs sterile gloves for wound repair in the ED.
Read MoreSepsis is a leading cause of mortality for hospitalized patient’s both worldwide and in the United States. The surviving sepsis guidelines weakly recommend invasive arterial blood pressure monitoring (IABP) over noninvasive blood pressure monitoring (NIBP) with a blood pressure cuff supported by low quality evidence.(1) Data comparing the accuracy between IABP and NIBP measurements are limited. The largest analysis of 736 critically ill patients found a mean difference of 1 mmHg which was not statistically significant, however, there was only one measurement recorded per patient.(2) Arterial lines have several drawbacks compared with non-invasive methods such as: training requirements for caregivers, potential for pain and increased pain medications, limitation of participation in physical therapy, risk of digital ischemia, and risk of iatrogenic infection.(3) In this journal club recap, we analyze an article looking at the relationship between invasive arterial line blood pressure readings and non-invasive cuff measurements.
Read MoreCan the addition of high-dose methylprednisolone to the treatment of out-of-hospital cardiac arrest make a meaningful difference? In this post-hoc analysis of a placebo-controlled randomized control trial comparing high-dose methylprednisolone versus placebo in out-of-hospital cardiac arrest (OHCA), the authors aimed to assess the hemodynamic effects of prehospital high-dose glucocorticoid treatment in resuscitated comatose OHCA patients.
Read MoreWith the advent of fast-acting subcutaneous insulin analogs over the past 20 years, multiple studies have demonstrated that subcutaneous insulin protocols for treatment for treatment of mild-to-moderate severity DKA are safe and cost-effective when compared to intravenous insulin infusion protocols in non-ICU settings. In the context of increasing ED and hospital crowding as well as limited ICU availability, this study aimed to evaluate the impact of a subcutaneous insulin (SQuID) protocol in the treatment of DKA on emergency department length-of-stay (EDLOS) and ICU admissions
Read MoreRib fractures occur in up to 10% of all traumatically injured patients and these fractures are frequently associated with respiratory complications such a pneumonia. In the ED, our typical protocol to decrease the incidence of these respiratory complications is early initiation of aggressive pain control and pulmonary hygiene. These patients often will receive systemic analgesia with opiates to decrease the incidence of these respiratory complications, which leads to its own set of opiate associated-complications, including constipation, delirium and dependence.
Read MoreShoulder injury and dislocations are common reasons for patients to present to the emergency department (ED) for evaluation. As ED physicians we often must determine whether the shoulder is fractured, dislocated, or both. Most of the time this is done through the use of physical examination in addition to the use of a plain film radiograph of the shoulder.
The use of ultrasound in the diagnosis and management of musculoskeletal injuries is becoming more common. While it currently does not supplant the use of radiographs, it can be a useful adjunct to the management of these patients.
Read MoreThe anterior cruciate ligament (ACL) is one of the most commonly injured knee ligaments, with nearly 200,000 injuries annually in the US, with ~100,000 requiring reconstruction. The ACL prevents anterior translation of the tibia relative to the femur and is a secondary restraint to tibial and varus/valgus rotation. Accurately diagnosing ACL injuries in the ED after an acute knee injury remains difficult. The diagnosis is complicated because clinical tests are performed on an acutely injured knee, which is likely swollen and painful, leading to muscle contractures and patient apprehension. As Emergency Medicine physicians, we must have some confidence in suspicion of an ACL tear because not all patients can or should be referred for prompt orthopedic follow-up.
Read MoreMore than 1.5 million adults undergo tracheal intubation outside of the operating room each year in the United States. Traditionally, this has been performed with direct laryngoscopy, where a clinician displaces the patient’s tongue and epiglottis with a laryngoscope blade to visualize the vocal cords through the mouth, allowing for direct visualization of the passage of an endotracheal tube. An alternative method for tracheal intubation is video laryngoscopy, where a camera on the distal half of the blade transmits an image to a screen allowing for indirect visualization of the vocal cords and passage of an endotracheal tube without direct line of site.
Read MoreRapid sequence intubation (RSI) is frequently performed under emergent conditions in acutely ill patients. RSI is a technique for managing the emergency airway that induces immediate unresponsiveness (induction agent) and muscular relaxation (neuromuscular blocking agent). In properly selected patients, it is a quick, safe, and effective approach that results in optimal intubating conditions. However, one of the feared complications of RSI is post-intubation hypotension leading to cardiovascular collapse. Although there are multiple possible reasons for hypotension post-intubation, the choice and dosing of induction agents has been implicated.
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.
