practice updates

Editor’s note: This post was listed in the LITFL Review 153‘s “Best of #FOAMed” category.

Venous thromboembolism (VTE) (deep vein thrombosis or pulmonary embolism) has an incidence of roughly 1 in 1,000 with an incidence of PE with or without DVT of 2.3 per 10,000.

One major factor to consider is that VTE is much more common in the elderly and has a mortality highly associated with co-morbidities such as cancer and underlying cardiovascular disease.

In the distant past any diagnosis of DVT and/or PE would result in admission for heparin bridging to oral anticoagulation therapy. This was largely due to a fear that outpatient management would lead to an increase in fatal embolic or major bleeding events. However, there is a great amount of literature that has established the safety of outpatient management of “low-risk” DVT; outpatient treatment has become standard of care for these patients.

“Low-risk” patients were those with no prior VTE, no PE, no prior heparin use, and no confounding co-morbidities (cancer, infection, stroke, etc).

So what about PE?
If outpatient management is standard of care for a select group of DVT patients, then can we treat PE as an outpatient? […]

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. […]

Diagnose your patients faster, improve ED flow, and avoid unnecessary ionizing radiation,

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?

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! […]

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. […]