practice updates

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.

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?

Editor’s note: This post was listed in both the #FOAMED Review from EM Curious AND in the LITFL Review 154 “Best of #FOAMed” section.

As an EM physician, it is difficult to have working knowledge of the hundreds of different types of rashes that exist. However, I argue that it is not the job of the EM physician to diagnose every rash that comes in the ED. That is the job of the dermatologist who has the luxury of time and biopsies. Rather, it is our duty, just like chest pain and syncope, to rule out the life-threatening causes of skin lesions, quickly identify a potentially lethal rash, and provide the appropriate initial stabilization, resuscitation and disposition (ICU, surgery).

Editor’s note: This post was listed in the #FOAMED Review (17th Ed.) from EM Curious. It ALSO appeared in LITFL Review 154’s “Best of #FOAMcc Critical Care” section.

Its 7:01am.  Your shift in your department’s high acuity area is just beginning, and you are waiting to receive sign out.  There hasn’t even been time to get your first sip of coffee.  Just as you are lifting your cup to your lips, the charge nurse grabs you and says, “Doctor, I need you!  This patient isn’t looking so good!” […]