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practice updates

A #FOAMed Roadmap to Permissive Hypotension

Included below is a summary of numerous blog posts and podcasts that discuss the sometimes controversial issue of permissive hypotension or minimum volume resuscitation in the bleeding trauma patient.

The Basics

  • Idea of keeping BP low in traumatic hemorrhage to avoid “popping the clot”
  • Based mostly on data from animal trials and penetrating trauma in humans
  • Common practice in most major trauma centers in USA
  • The exact approach still remains controversial around the world
Disclaimer: These are highlights as interpreted by the author of this article and should not replace listening to the original podcast or reviewing the background research.  Posts are in chronological order and many of the below podcasts go beyond the scope of permissive hypotension. [...]

intern report

Echocardiograms in Typical vs Incomplete Kawasaki’s

On my first shift in the Children’s ED, I saw a child with what appeared to be Kawasaki’s Disease. She was a referral patient who had been seeing her PCP throughout her current illness. The child’s PCP had done appropriate lab work on her, and the results combined with the child’s clinical picture warranted a referral to our ED for further evaluation and management. When she presented to us, her symptoms seemed to be resolving. She had bilateral conjunctivitis that her mom stated was improving, she had a mild rash and swelling of her tongue and she had a dry and peeling rash in her genital region. Her mother stated that her limbs had been swollen but were now returning to normal size and that her fever had been high and unrelenting for several days, but was normal (36.7 and 37.0) in our ED. To me, this child was healing and did not require treatment at this time. But the question was whether or not an echocardiogram was indicated for this patient. [...]

practice updates

End Tidal CO2 in TBI

Does End Tidal CO2 correlate with PaCO2 in Traumatic Brain Injury? Your neurosurgeons and trauma team have accepted a transfer to your hospital for intensive management of a trauma patient who presented to a small community hospital with a traumatic subarachnoid hemorrhage and epidural hematoma after being involved in a motorcycle accident. Upon arrival with the critical care transport team, the patient is already intubated and stable on a a ventilator with appropriate sedation and stable hemodynamics. However, the neurosurgeons are in the operating room managing a spontaneous intraparenchymal hemorrhage and there are no available ICU beds due to multiple gun shot victims from a gang fight that you finished admitting. While the patient is in the ED, the neurosurgeons recommend maintaining eucapnea for the patient since while there are no acute signs of herniation.(1) Can you use the end tidal CO2(etCO2) or do you need to rely on arterial blood gas (ABG) measurements to maintain PaCO2 between 35-40 mm Hg? [...]

intern report

Rib Fractures in the Elderly

Why is it important to aggressively and appropriately manage rib fractures in elderly trauma patients? Recently, an 82 year-old male suffered a fall from standing, striking his left posterior flank against a cinder block, sustaining fractures of the left 7th-11th ribs with displacement of the 8th-11th ribs, causing a moderate L hemopneumothorax. After placement of a chest tube, drainage of the hemothorax, and reinflation of the L lung, the patient was then transferred to our facility “for management of his rib fractures”. Given that this patient was going to be managed non-operatively, I found myself wondering why would this patient require transfer for such a seemingly common problem among trauma patients. Rib fractures are present in 10% of all traumas, and in 30% of chest trauma specifically. After assuming care of the patient, I quickly began to realize why this patient was given such a high level of attention. [...]

practice updates

Concussion Update

Concussion is a type of mild traumatic brain injury (TBI) that classically occurs in sports-related incidents but can be due to any traumatic force to the brain. The term concussion stems from the Latin word, concussus, which means “to shake violently." While sport is the most common cause of concussion in children, the most common causes of concussion in adults are falls and motor vehicle accidents. Young children have the highest rate of concussions in all age groups. [...]

practice updates

The Sick Neonate

Rapid evaluation and management of the sick neonate is a required skill for the emergency physician. Here we present a brief but comprehensive strategy for resuscitating and stabilizing the critically ill neonate as well as some mnemonics for help remembering the differential diagnosis.