We’re excited to announce our next AMA: Kevin Klauer will be with us TODAY: Tuesday, September 2nd, from 2-4pm CST.
- Chief Medical Officer of Emergency Medicine Physicians, one of the leading providers of emergency medical services in the nation
- Has received the ACEP National Faculty Teaching Award and the EMRA Robert J. Dougherty Teaching Fellowship Award
- He is the ACEP Council Vice Speaker and serves as Medical Editor-in-Chief for ACEP Now
- Co-author of two risk management books: Emergency Medicine Bouncebacks: Medical and Legal and Risk Management and the Emergency Department: Executive Leadership for Protecting Patients and Hospitals
Hope you can join us!
Upper GI bleed (UGIB) is a common cause of presentation in the ED with an incidence of 102 per 100,000 hospitalizations. Mortality can range from 2-15%, with a rebleeding risk of up to 10-30%. It is important to identify high-risk patients that are candidates for early endoscopy or if monitored management is more appropriate. Low-risk patients may be identified and safely discharged from the ED. [...]
Prevent and Identify – the ED’s equivalent of Search & Rescue when managing elevated Intracranial Pressures (ICP). The causes of elevated ICP are typically described in the context of Traumatic Brain Injury (TBI), however many other pathologies can benefit from standardized ICP management. Such problems exist either intracranially (edema, hematoma, seizure, etc) and/or extracranially (coughing, fever, hypoxia, hypercarbia, pain, airway obstruction, etc).(1) Tintinalli describes the primary goals in managing TBI: prevent further secondary brain injury, identify treatable mass lesions, and other life-threatening injuries.(2)
An estimated 10 million TBI cases lead to hospitalization and death annually.(1) Mortality in severe injuries, defined as a Glasgow Coma Scale (GCS) score of less than 8, approaches up to 60%.(3) In the information-scarce, time-limited environment emergency physicians work in, having a high index of suspicion for elevated ICP while implementing interventions early goes a long way between patient presentation and definitive management.
How can we minimize further elevations? There are several stepwise approaches described in the literature. In May 2014, the New England Journal of Medicine released a TBI review, where within Stochetti et al discuss a traditional “staircase approach to the treatment of increased intracranial pressure.” Dr. Scott Weingart confers his “tiered” management in EMCrit Podcast 78; all of these are either linked or referenced below. Historically, there is a wide scope of traditional management, ranging from head of bed elevation (see picture above) to the potential use of steroids, barbiturates, etc. – these won’t be discussed in this update. Here we discuss the most current analyses of therapies in the elevated ICP patient, via the trusted ABC’s… and D (and a conceptually interesting E). [...]
A quick case: A 57 y/o F with a PMH of DM, HTN, and Afib on warfarin presents to the emergency department (ED) complaining of spitting out a blood clot when she woke up in the morning. Upon waking she felt something in her mouth, spit out a small blood clot, and continued to have slow oral bleeding over the next several hours leading to presentation in the ED. She is not able to see where the blood is coming from, denies any other symptoms and states her last INR was 2.3. All other ROS is negative. On physical exam, it is noted that the patient has a broken upper left molar that is slowly bleeding. All other physical exam and vitals were normal. The attending physician suggested using tranexamic acid (TXA) for treatment. But what’s that? I didn’t learn about that in med school.
Clinical Question: What studied uses are there for tranexamic acid in the Emergency Department? [...]
Continuous quantitative waveform capnography, also known as end-tidal carbon dioxide, PetCO2, or ETCO2, is a measurement of the partial pressure of CO2 in the exhaled breath. This technology has been around since the mid-19th century and only relatively recently has its potential in emergency medicine begun to be explored. [...]