practice updates

The transplant patient is always sicker than they appear. It is important to be aggressive in these patients since they are severely immunocompromised which not only puts them at greater risk of infection but also blunts their normal signs to infection. Always contact the transplant team to help with management as many centers have specific protocols for treatment of rejection and infection. Often it is very difficult to differentiate between rejection and infection. In these cases, treat on the side of infection as it would be the greatest immediate threat to life in the patient. […]

There have been a number of new publications reviewing our approach to managing sepsis. Both the ProCESS Trial and ARISE trial published in 2014 editions of the New England Journal question whether invasive procedures and rigid protocols are required to have positive patient outcomes. Other studies included in this power review examine the importance of early antibiotic therapy, effects of different mean arterial pressure parameters, and impact of chloride heavy versus chloride restricted solutions.

Update: This AMA will be happening Friday, December 12th from Noon-1:30pm EST.

We’re very pleased to announce that our next Ask Me Anything will be with Mike Stone, MD, RDMS. Dr. Stone is the Division Chief of Emergency Ultrasound and the Emergency Ultrasound Fellowship Director at Brigham and Women’s Hospital in Boston, MA, and can be found on Twitter as @bedsidesono.

For your Friday afternoon, here’s another batch of excellent write-ups from the EM interns at UT Southwestern. Our ongoing intern report series is the product of first-year residents exploring clinical questions they have found to be particularly intriguing, with an intended audience of med students & junior residents. Enjoy!

[Note: These are PDF files.]

• CHF Exacerbation by Meaghan Dehning, MD
• Use of Ultrasound in Endotracheal Intubation by Andrew Fredericks, MD
• Ventilator Strategy for an Acute COPD Exacerbation by Andrew Fredericks, MD
• Wernicke’s Encephalopathy by Richard Moleno, DO; edited by Larissa Velez, MD
• Serotonin Syndrome by Andrew Fredericks, MD; edited by Larissa Velez, MD
• Steroids for Sciatica by Christina Smith, MD
• Post-Partum Fever by Meaghan Dehning, MD
• Pressor Choice In Shock by Chris Chase, MD
• Procedural Sedation in the ED by Chris Chase, MD
• RSI Pharmocology for the EM Physician by Richard B. Moleno, DO
• Management of Traumatic Subungual Hematoma by Lindsay Schroeder, MD
• Leukocytosis in the Immunocompromised by John R. Corker, MD
• H&P for Ovarian Torsion by Gray Millsap, MD
• Pericarditis by Ashley Phipps, MD
• Estrogen for Uterine Bleeding by John R. Corker, MD
• Treatment of Intractable Hiccups by Ashley Phipps, MD
• Central Venous Access Site Comparisonby Kevan Beth Meadors, MD
• COPD Exacerbations and Managementby Stace Breland, D.O.
• Epistaxis by by Gray Millsap, MD
• Energy Drink Toxicityby Kevan Beth Meadors, MD
• Delayed Neuro Injury Following Electrocution: Two Case Reports by Brandon Morshedi, MD
• Compartment Syndrome by Alex Cohen, MD
• Appy In Pregnancy by Christina Smith, MD
• Benzo Resistant Alcohol Withdrawal Seizures by William Fox, MD, edited by Larissa Velez, MD
• Benzodiazepines in Alcohol Withdrawal Syndrome: Preventing “Kindling” by William Fox, MD, edited by Larissa Velez, MD
• APAP Overdose by Alex Cohen, MD

Our AMA with Dr. Mike Mallin & Dr. Matt Dawson from the Ultrasound Podcast, held on Friday, November 14th from 2-3:30pm EST.

These children are often a mixed picture of viral bronchitis/bronchiolitis PLUS an asthma exacerbation. Treatment with albuterol, ipratropium, magnesium sulfate, steroids, fluids, etc are all reasonable and prudent in this population. If they begin to clinically improve within 30 minutes then you can feel good about soothing their reactive airways. However, they still have underlying viral issues which may require non-invasive positive pressure ventilation (either high-flow nasal cannula or BIPAP). If they do not improve within 30 minutes then you should begin to plan for IMC/ICU admission as these patients will require significant monitoring and respiratory support.

Trying to predict the future is a task that is riddled with risk. There is a very high potential that I will be wrong and my thoughts will end up being complete baloney. I’m okay with this. According to Strengths Finder 2.0, I’m futuristic, meaning that I’m inspired by the future and what could be, and hopefully will inspire you. With this in mind, two quotes that I believe should frame our conversation:

“The future is already here, it’s just not very evenly distributed.”
-William Gibson

“We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next 10.”
-Bill Gates

With these in mind, here are some trends that I see emerging. […]

Aortic dissection is a life-threatening yet infrequent diagnosis, estimated at about three cases in every 100,000 person years (1,2). Because of its low frequency and emergency nature, large randomized controlled trials are difficult to conduct (3). Thus, the International Registry of Acute Aortic Dissection (IRAD) was established in 1996 to obtain up-to-date data on patients with acute aortic dissection. Currently, 30 large referral centers in 11 countries participate. Most novel research on aortic dissection is based on IRAD data. […]

Naloxone has been proven to reduce the incident of death in acute opioid overdoses. So why aren’t we using it more often?