Sepsis Journal Club Roundup

Sepsis Journal Club Roundup

The management of patients with sepsis can be exceptionally complex. As with many patient’s with complex critical illnesses, often times attention to seemingly minor aspects of the patient’s management can have significant impacts on the patient’s course of illness. In this recap of our most recent journal club, we review 3 such aspects of the care of patients with sepsis. Does the type of IV fluids really make a difference? Are steroids a friend or foe in the care of these patients? And can the simple bedside assessment of capillary refill replace serial measurements of lactate?

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Controversies in Kidney Stones

Controversies in Kidney Stones

Flank pain and pain due to ureterolithiasis are common ED presentations. There exist, however, a number of controversies when you dive into the literature addressing the diagnosis and treatment of nephrology/ureterolithiasis. Is IV lidocaine effective at treating pain in these patients? Is there a way to avoid CT scans? What about tamsulosin? Is it only good for big stones/small stones? Is there a benefit at all. For our most recent Journal Club, we tackled several of these controversies. Take a listen to the podcast below or over on iTunes.

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Is the Cath Lab the Place to be after V fib VTac Cardiac Arrest?

Is the Cath Lab the Place to be after V fib VTac Cardiac Arrest?

Ventricular dysrhythmias are commonly caused by coronary ischemia which is most frequently caused by acute coronary artery occlusions in the setting of coronary artery disease. It would seem somewhat logical that patients who suffer a V fib or V Tach cardiac arrest would benefit from a trip to the cardiac catheterization lab to identify and treat these possible acute coronary artery occlusions. Patient’s with EKGs showing ST-elevations following ROSC already go to the Cath lab. Since the EKG is not terrifically sensitive for MI, should V fib V Tach cardiac arrest patients without ST-elevations make a trip to the Cath lab? In this breakdown of our most recent journal club we look at several papers covering this topic. In the podcast below we also talk with Justin Benoit, MD the site PI for the ongoing ACCESS trial which is also looking into this question.

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Telling Tall Tales: Dogma in Emergency Medicine

Telling Tall Tales: Dogma in Emergency Medicine

In our training and education as Emergency Medicine providers, we often come to accept certain practice patterns as fact. When these established “facts” come along with fantastical clinical claims (don’t give your corneal abrasion patients tetracaine, it’ll melt their corneas; don’t use lido with epi for digital blocks, their finger will fall off; don’t use beta-blockers in patients on cocaine, their BP will skyrocket due to unopposed alpha-effects), we should probably look to question their supporting evidence.

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Pneumonia Alphabet Soup

Pneumonia Alphabet Soup

Pneumonia. It’s one of the first conditions we learn to diagnose as medical students. It was probably the cause of the first really sick, septic geriatric patient you saw in residency. Conversely you have also probably sent a fair share of patient’s home with an outpatient course of antibiotics and PCP follow-up.  While determining the appropriate treatment and disposition for patients on the extreme ends of illness severity is quite straight forward; that pesky majority in the middle can be a conundrum at times. Who can go home? Who needs broad spectrum? Who needs step-down? Over the last two decades there has been a smorgasbord of pneumonia related acronyms used in clinical practice to predict severity, guide therapeutics and recommend disposition. During our most recent resident Journal Club, we took a look at a handful of the more familiar acronyms as well as some new ones coming down the pipeline.

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A Weakness in the HEART?

A Weakness in the HEART?

In this month’s Journal Club Recap we take a look at some recently published literature about common heart related complaints in the ED. First, we look at the now nearly ubiquitously used HEART pathway. In a US population, do the benefits of decreased health care utilization sustain themselves to a year out of an index visit? Then we turn our attention to atrial fibrillation with RVR. Does the utility infielder of ED medications, Magnesium, actually help with more rapid rate control? And, should the results of a consensus panel sway us to treat A fib with RVR as an outpatient?

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Bug Juice Potpourri

Bug Juice Potpourri

In this month's Journal Club, we covered several articles that looked at the use of antibiotics in the Emergency Department.  Does adding Trimethoprim-Sulfamethoxazole to Cephalexin increase the rates of clinical cure in uncomplicated cellulitis? For patients receiving Vancomycin in the ED, how many are appropriately dosed and how many receive a sufficient number of doses to hopefully limit the emergence of resistant bacteria?  Are patients receiving Vancomycin and Piperacillin-Tazobactam really at increased risk of acute kidney injury?

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The Last Gasp

The Last Gasp

It is undoubted that effective airway management is a critical link in the care of patients with both in-hospital cardiac arrest and out-of-hospital cardiac arrest.  But how exactly should one manage the airway?  What results in the best outcomes for our patients? Should we be aiming to intubate every patient? Or, are extraglottic devices as effective (or more effective)? What about the good old bag-valve mask?  In our most recent Journal Club we explored the evidence surrounding airway management in cardiac arrest, covering 3 high impact articles.  We also touch on an abstract presented at the 2018 SAEM Academic Assembly which should add significantly to the body of literature when it is published in full.  Take a listen to our recap podcast below and/or read on for the summaries and links to the articles.

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Whole Blood - More than the Sum of Its Components?

Whole Blood - More than the Sum of Its Components?

Q: For a patient in hemorrhagic shock from acute blood loss, what is the best resuscitative fluid?  

A: If they've lost blood, give them blood.  

It's never quite that simple though right?  For a generation now, we have practiced primarily by transfusing patient's with acute blood loss varying ratios of blood product components.  Thanks to the PROPPR trial, we most recently arrived on a generally accepted ratio of 1:1:1 for Plasma, Platelets, and Red Blood Cells for severely injured bleeding trauma patients.  Recent military literature however, suggests that there may be another strategy (which is in and of itself a bit of a throwback) that could offer additional benefits over a component transfusion strategy.  If were are trying to recreate a whole blood with a 1:1:1 plasma:platetel:PRBC ratio, why not just give whole blood?

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A Pain in the Neck

A Pain in the Neck

There are some areas in our practice where the literature grants us a somewhat sure path forward in the evaluation of our patients.  The decision whether or not to pursue cervical spine imaging studies following a traumatic mechanism of injury is one of these areas.  The NEXUS criteria and Canadian C-Spine Rule are useful guides for the evaluation of these patients.  What comes after the imaging can be a bit more challenging.  What do we do with patients who have persistent pain but negative imaging? To what extent do we pursue the possibility of a ligamentous injury? Must we wait for all patients to be sober so that we can "clinically clear" them in addition to our radiographic clearance.   The 3 articles below seek to answer some of these challenging questions.  Take a listen to the podcast and read the summaries to familiarize yourself with some of the latest literature addressing these challenging patient care scenarios.

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The Future of Airway Management?

The Future of Airway Management?

What is the future of airway management in the ED?  How can we make our practice more effective and more efficient?  In this journal club recap, we focus on 2 topics emerging in the literature - flush rate O2 for pre-oxygenation and head of bed elevation during intubation.

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The Radioactive Heart

The Radioactive Heart

For Journal Club this past week we covered what is undoubtably one of the more controversial diagnostic tests used in the evaluation of patients presenting to physicians with chest pain.  The most recent NICE guidelines recommend Coronary CT as the first line test for patients with stable angina symptoms but don't Coronary CT's lead to increased downstream testing? more radiation exposure? To investigate this topic we took a look at 3 articles focused on the utility of Coronary CT scans. Take a listen to the podcast and read the recap to learn for yourself.

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A Significant Clot

A Significant Clot

Last week our Journal Club focused on the treatment of hemodynamically significant pulmonary emboli.  These are pulmonary emboli causing either frank hypotension (sometimes called massive or high risk PEs) or causing significant right heart strain as evidenced by CT findings, cardiac biomarker elevation, or bedside Echo findings.  Drs. Grace Lagasse, Kari Gorder, and Claire O'Brien led us in a discussion of the 3 papers linked in the article.  Read the papers yourself, listen to the podcast, read the summaries and get caught up on all things PE.

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Don't Kill the Beans: The Specter of Contrast-Induced Nephropathy

Don't Kill the Beans: The Specter of Contrast-Induced Nephropathy

Working in the Emergency Department, we often encounter patients with either pre-existing renal disease or an acute compromise of their renal function who also have a disease process necessitating a contrasted radiology study.  So what do we do with that patient with a creatinine of 1.8 who has a possible vascular dissection/traumatic injury/infection? What is the risk of contrast to that patient?  Should you compromise your diagnostic evaluation to avoid a harm to the patient's renal function?  Dr. Nick Ludmer, Dr Michael Miller, and Dr. Amanda Polsinelli recap 3 articles recently published looking into contrast induced nephropathy.  Take a listen to the podcast and read the blog post to get yourself acquainted with the current state of the literature.

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Vasopressin: A Second Class Pressor?

Vasopressin: A Second Class Pressor?

This week we'll be recapping the discussion of our most recent journal club where Dr. Christian Renne, Dr. Anita Goel, and Dr. Maika Dang led us in a discussion centering on the use of vasopressin both in sepsis and in vasoplegic shock states.  Take a listen to the podcast below and read the brief summaries of their articles to boost your understanding of Vasopressin.  Should you reach for it first or is it a second class pressor?

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