This week we were led through the evaluation and management of the difficult pediatric airway with Dr. Carleton in our quarterly airway grand rounds, and discussed cranial nerve abnormalities with Dr. Neel in our recurring EM-neuro combined conference. Dr. Jarrell presented an interesting case of a child with a cough and weight loss, and Dr. Jensen walked us through the clinical utility of BNP. Finally, Dr. Miller presented an interesting case of a patient with multisystem organ failure and cecum perforation.Read More
This week Drs. Jarrell and Nagel kicked off Grand Rounds with their evidence based review of the hypertension management in the ED. Drs. Gorder, Lagasse, O'Brien, and Polsinelli discussed the difficult management of the patient in both cardiogenic and septic shock, reviewed heart murmurs, and endocarditis. Dr. Bryant made us squirm with her Global Health quick hit case review of parasitology, Dr. Lane led a great group discussion about the utility of procalcitonin in adults, and Drs. Habib and Roche ended Grand Rounds with a great CPC case!Read More
In this week's Grand Rounds, we led with our first Morbidity and Mortality conference of the year. Dr. Lagasse walked us through cognitive biases, the management of early obstetric emergencies, and the management of skin and soft tissue infections in the diabetic foot. In our leadership curriculum, Drs Hill and Stettler discussed the fundamentals of being a leader, and we got to hear from a panel of accomplished physicians within our department about their own leadership journey. Finally, in our Consultant of the Month series, Dr. Martha Ferguson discussed the management of ano-rectal conditions in the Emergency Department.Read More
This week we learned about risk stratification for PE and how to work it up in special populations. We covered neonatal resuscitation and pediatric hematologic emergencies. We got a crash course in the returning traveler with fever. We reviewed current guidelines for treatment of sexually transmitted infections.Read More
Next to STEMI and neurologic emergencies such as spontaneous ICH, SAH, and ischemic stroke, one of the most common pathologies we transfer from one facility to another on Air Care is sepsis. However, unlike many of the other patients we transfer, these patient’s are usually being transferred from the ICU of an outlying facility to the ICU of a tertiary referral center that can deliver a higher intensity of care. I sat down and discussed with Dr. Bill Knight, a former flight MD and now Emergency Medicine and Neurocritical care physician, about some of the complexities of caring for these patients.Read More
In March of 2014, Derek Angus and colleagues published the ProCESS trail in the NEJM (1)(N Engl J Med 2014;370:1683-93. DOI: 10.1056/NEJMoa1401602). In ProCESS, they explore the time-honored theory in EM-resuscitation that EGDT as described by Rivers (NEJM 2001) is the dominant strategy to improve survival in severe sepsis and septic shock. Despite the marked reduction in mortality that is reported in Rivers’ study, the study itself has not been successfully reproduced in a multicenter trial.Read More
"Around every 3rd heartbeat someone dies of sepsis"
Blood Product Administration:
- Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic heart disease, we recommend that red blood cell transfusion occur only when hemoglobin concentration has decreased to < 7.0 g/dL to target a hemoglobin concentration of 7.0-9.0 g/dL in adults (grade 1B).
- FFP NOT be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures (grade 2D).
We routinely transport patients with severe sepsis and septic shock by both air and ground. Take a few moments to review these high yield management pearls from the 3rd edition of the Surviving Sepsis Campaign Guidelines.
- Goals during the first 6 hours of resuscitation:
- CVP 8-12 mmHg (a debate on the utility of CVP or lack their of is beyond the scope of this LIT)
- MAP > 65 mmHg
- Urine output > 0.5ml/kg/hr
- Central venous or mixed venous oxygen saturation 70% or 65% respectively (grade 1c)
- In patients with elevated lacate levels we should target resuscitation to normalize lactate (grade 2c)