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practice updates

Ask Me Anything with Scott Weingart, MD (@emcrit)

Live Blog Ask Me Anything with Scott Weingart
 

practice updates

D-List Superbugs: Influenza

Influenza is spread primarily through large respiratory droplets or contamination of surfaces. About 4 days after exposure patients will typically start to develop an abrupt onset of fever, headache, myalgias or dry cough—generally this presentation will be considered an uncomplicated influenza illness. Symptoms usually resolve after 3-7 days from onset. Patients can have a more complicated course if they have primary influenza pneumonia, exacerbation of underlying medical conditions like COPD, or secondary bacterial pneumonia (Strep pneumoniae, Staph aureus, community-acquired MRSA, Haemophilus influenza are the more common pathogens). There is not a validated and widely used decision rule to help distinguish influenza from other viral pathogens based on signs and symptoms. We do know that there is some seasonal variance with influenza being more common in winter months. We also have laboratory tests like respiratory panels to screen for influenza. However, the poor sensitivity and uncertain utility of these tests makes their value in the typical uncomplicated influenza presentation questionable. Treatment recommendations, supported by the CDC, IDSA, and WHO have come under recent scrutiny—we should ALL be familiar with the recent data on influenza treatment. [...]

practice updates

Ask Me Anything with Rob Rogers, MD, FACEP

Live Blog Ask Me Anything with Rob Rogers, MD, FACEP
 

electrocardiography

EKG Practice

Ray Fowler, MD is Professor of EM / EMS at UTSW / Parkland. Edited by Alex Koyfman, MD.

45 male with intense epigastric pain radiating to his left arm with associated NV and diaphoresis. ekg1


55 female with crushing anterior chest pain and diaphoresis. ekg2
ekg3
A sinus tachycardia is present in this 54 year old man with severe chest pain radiating to the left arm.

ekg4


This is a narrow complex tachycardia in a 31 year-old female that is perfectly clock regular. There is no obvious atrial activity seen. The QRS is narrow. ekg5
This 65 year-old woman presents with lightheadedness and worsening dyspnea on exertion. ekg6
This 81 year old man had a syncopal episode. He presents a little confused, GCS 14 (lies with his eyes closed), and is “not right” per his wife. His BP is 110/76, and he has the cardiogram below. ekg7
ekg8
This is an odd 12 lead ECG to have done in this 54 year old man. The rate is profoundly slow, in the 20’s or so. The rhythm is regular. There is no evident atrial activity. The QRS is very widened. ekg9

practice updates

Lyceum Bullets: DKA

Questions Addressed:

  • When you are suspicious for DKA do you obtain a VBG or an ABG? How good is a VBG for determining acid/base status?
  • Do you use serum or urine ketones to guide your diagnosis and treatment of DKA?
  • Do you use IV bicarbonate administration for the treatment of severe acidosis in DKA? If so, when?
  • When do you start an insulin infusion in patients with hypokalemia? Do you give a bolus followed by a drip?

practice updates

Nuances in Resuscitation Part III: Diabetic Ketoacidosis

Thus far we have discussed resuscitation in trauma and sepsis.  What distinguishes those two from the resuscitation goals in DKA is timing.  In trauma and sepsis, it’s all about early recognition, aggressive and quick optimization, and understanding all the possible treatment options at your disposal.  In the management of DKA, it’s quite the opposite.  If you remember anything from this discussion, it’s that slow and steady wins the race!  In fact, overaggressive resuscitation is what leads to the most significant morbidity and mortality in DKA patients.  Patients in DKA don’t die from the disease process – they die because we kill them! [...]

practice updates

Nuances in Resuscitation Part II: EGDT In Sepsis

In November 2001, Dr. Manny Rivers and his colleagues published an article in the New England Journal of Medicine on Early Goal Directed Therapy in Sepsis.  At the time, sepsis was not a new concept, nor was the treatment of it.  Where I believe the real genius in EGDT lies is in a fanatical focus on early recognition of sepsis by utilizing SIRS criteria, as well as developing an algorithm with definable objective treatment goals to assist providers in understanding if their treatment selections are in fact working.  The basic questions in EGDT therapy are:

  1. How much fluid is enough?
  2. Are the vital organs being perfused appropriately?
  3. Is there adequate oxygen delivery and utilization by those vital organs?
Since Rivers published his article in 2001, it has been met with both acclaim and controversy.  EGDT utilizes central venous pressure monitoring, lactate trending, SvO2 monitoring, vasopressor therapy, and sometimes, blood transfusions to optimize resuscitation of the septic patient.  I believe the controversy is not in whether or not it works, as multiple studies have demonstrated a reduction in morbidity and mortality.  Instead, the controversy lies in what is the best modality to answer the basic questions of sepsis resuscitation, and whether some of the aggressive steps recommended in the initial study are necessary or even practical in many emergency departments across the country. [...]