recent articles

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. [...]

practice updates

Practical Nuances of Resuscitation – Part I: Not All Are Created Equal

One of my colleagues likes to tell our residents, “they don’t come to the ED to die, they come here to live.”  It is our skill in identifying critically ill patients and successfully resuscitating them that defines us as emergency medicine physicians.  Resuscitation in its simplest term means to revive from unconsciousness or apparent death.  However, there are a multitude of different disease processes that cause critical illness, and the approach to resuscitation of each illness is quite different.  It is important to have a confident grasp of different resuscitation options and endpoints so you can best help your patients.  If you try to resuscitate all of your patients in exactly the same manner, you will actually end up harming many of them instead. The goal here is to understand the resuscitation technique and endpoints in trauma, sepsis, and diabetic ketoacidosis.  The tried and true methods will be summarized, and areas where controversies exist will be discussed as well.  As a result, there is a wealth of information that we need to get through.  In order to lay it out for you in smaller, digestible bites, I am going to roll this out in installments.  First up….trauma! [...]

intern report

Intern Report Collection

Our ongoing intern report series is the product of first-year EM residents at UT Southwestern exploring clinical questions they have found to be particularly intriguing. For med students & junior residents - if you haven't encountered these issues yet, you will! We had been posting these individually, but moving forward will release them in groups for your reading convenience. Enjoy.

Ask Me Anything

Ask Me Anything – Haney Mallemat, MD

Live Blog Ask Me Anything with Haney Mallemat, MD

practice updates

Peripheral Vascular Injury Management


  • Peripheral vascular injury can be life-threatening or limb-threatening.  Proper understanding of pathology and management is important in the ER.
  • Vascular injuries can be internal and may not be obvious on presentation. Patients with blunt or penetrating trauma who remain hypotensive after a fluid bolus challenge may have internal hemorrhage.
  • Incidence of penetrating and blunt trauma in the US has been rising.
  • Blunt and penetrating causes of peripheral vascular injuries are about equal in the US.
  • Low velocity gunshot wounds are the second leading cause of death in the 15- to 34-year-old age group in the US.  Peripheral vascular injury has been reported to be present in up to 50% of these cases.

intern report

Post LP Headache

On my first month in the Parkland ED, I saw multiple patients with post-lumbar puncture headaches and even iatrogenically caused one myself.  Often I found myself wondering what proven preventative measures during an LP decrease the incidence of such headaches, what could I have done better, and what literature supports treatment of post-lumbar puncture headaches in the emergency department. [...]

clinical cases

Chief Complaint: "Seizures"

Chief Complaint: “Seizures” History of Present Illness: 25-year-old male with no PMHx, BIBEMS after he had episode of tonic-clonic seizure. As per wife, who gave medical history, the patient was found down in a hotel with "his whole body shaking."  Upon EMS arrival, he was given 5mg of Valium. On arrival to the ED, patient combative, not following commands with frothy oral secretions.  Wife endorses that patient has had weakness, dizziness, and malaise x 3 days, but no other complaints. Patient had another seizure while in the ER without regaining full consciousness. [...]

practice updates

ICP Management Update

Author: Albert Arslan, MD and Anthony Scoccimarro, MD (Resident Physicians, Lincoln Emergency Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)   Prevent and Identify – the ED’s equivalent of Search & Rescue when managing elevated Intracranial Pressures (ICP). The causes of elevated ICP are typically described in the context […]