TamingtheSRU

Severe trauma is the leading cause of death worldwide for adults younger than 50 years of age. Acute traumatic life support (ATLS) guidelines endorse early and aggressive usage of supplemental oxygen in patients with severe trauma, at least until abnormalities of airway or breathing can be safely ruled out. However, unclear target concentration, duration or saturation goals often leads to hyperoxemia. Emerging studies in the intensive care unit (ICU) setting suggest that liberal supplemental oxygen therapy and hyperoxemia is associated with increased mortality. Limited evidence in the trauma population suggests similar outcomes.

We know that the d-dimer can be a helpful test for patients who have a low pre-test probability of pulmonary embolism. But can the test be pushed into use for higher risk patients? Will it still have useful negative predictive value or will we risk missing too many PEs?

Can a nitro slurry help with food bolus impaction? Glucagon and effervescent beverages have limited evidence for benefit. Can an old drug used in a new way help these patients?

Current screening tools for pediatric septic shock and sepsis are highly specific but lack sensitivity. This study substituted age adjusted vital sign measures and a pediatric shock index into currently existing pediatric sepsis scoring systems to create the qPS4.When utilizing a cut off of ≧ 2 points, the qPS4 was highly sensitive and specific, and identified pediatric septic shock far sooner into a patient's course.

There is a wide variation in practice, particularly in obtaining neuro-imaging in patients presenting with vertigo. Many patients are imaged and subjected to a longer length of stay, and on the other side of the coin, some patients with serious pathology fall through the cracks. The authors of this study set out to create a risk score to apply to patients who present to the ED with vertigo which would identify the patients at risk for serious pathology (which they defined as stroke, TIA, vertebral artery dissection, or brain tumor).

Sepsis remains an increasingly common emergency department condition that is tied to higher morbidity and mortality across the United States as well  as the rest of the world. Sepsis as a disease process has been difficult to both clearly define and quickly recognize. Many metrics for recognition and management of sepsis are dependent upon various scoring systems, including SIRS, SOFA, qSOFA, and MEWS, none of which were designed for the acute detection of sepsis within the emergency department. This journal club recap will look at an article by Knack et al looking at physician gestalt vs scoring systems for the detection of sepsis.

In patients with cirrhosis and ongoing bleeding, it can be challenging to determine whether or not patients are hyper or hypocoagulable. Traditional markers of coagulation status like INR can be difficult to interpret in patients with abnormal synthetic function and potentially increase consumption of coagulation factors. Can TEG (thromboelastography) be a helpful too in these situations? In this journal club recap, Dr. Grisoli recaps a recent article by Rout et al that addresses this issue.

In this journal club recap, Dr Sarah Moulds recaps a recent meta-analysis of papers looking at the therapeutic effect of TXA in patients with severe trauma. Are their higher rates of thromboembolic complications? Is mortality improved? This article by Fouche et al attempts to answer these questions.

Out of hospital cardiac arrest (OOHCA) represents a great cause of morbidity and mortality. Approximately 350,000 cardiac arrests occur in North America annually and 20% can be attributed to Ventricular tachydysrhythmias (i.e. ventricular tachycardia [v fib] and ventricular tachycardia [v tach]without a pulse). In this journal club recap, Dr Kelly Tillotson recaps an article comparing different ways of defibrillation and their effect on outcomes in OOHCA

In this most recent Journal Club recap podcast, Dr. Cole Davis covers a paper investigating the use of sterile vs clean gloves for laceration repair in the ED.

In this journal club breakdown, we analyze an article examining the relationship between invasive arterial line blood pressure measurements and non-invasive cuff measurements.

Can the addition of high-dose methylprednisolone to the treatment of out-of-hospital cardiac arrest make a meaningful difference? In this post-hoc analysis of a placebo-controlled randomized control trial comparing high-dose methylprednisolone versus placebo in out-of-hospital cardiac arrest (OHCA), the authors aimed to assess the hemodynamic effects of prehospital high-dose glucocorticoid treatment in resuscitated comatose OHCA patients.

In this podcast, Dr Charlie Brower PGY-3 at the University of Cincinnati leads a discussion of a recent journal club article looking at the impact of a subcutaneous insulin treatment pathway for mild and moderate DKA. We explore the financial and operational impacts of this pathway as compared to traditional treatment with IV insulin

Pain from rib fractures can be severely limiting in the acute setting. In this recap from our most recent Journal Club, Dr Olivia Gobble leads us through a paper looking at the effectiveness of Serratus Anterior Plane Blocks for treating pain from rib fractures in the Emergency Department.

Ultrasound is an increasingly ubiquitous tool to augment the physical exam in the Emergency Department. Dr Jazmyn Shaw walks us through a paper that looks at whether or not US is a useful adjunct to physical exam for the diagnosis of shoulder dislocation in the Emergency Department

Dr Casey Glenn walks through a study analyzing the 'lever test' for the diagnosis of ACL tears in the acute setting. Given significant swelling and pain the acute diagnosis of ligamentous injury can be both challenging and painful to patients. The lever test is a promising physical exam maneuver that may be more accurate and better tolerated that traditional exam maneuvers.

In this journal club podcast we break down 2 articles. Do we need to reduce doses of ketamine or etomidate in RSI to avoid post-intubation hypotension? Should video laryngoscopy fully and finally replace direct laryngoscopy in the ED?

Drs. Wilson and Arnold discuss the latest research that went into their development of a protocol for managing Acute Liver Failure

Dr Marlena Wosiski-Kuhn recaps a recent journal club covering the paper by Mahajan and colleagues: Serious Bacterial Infections in Young Febrile Infants with Positive Urinalysis Results.

Boarding of admitted patients in the ED and subsequent overcrowding of ED's continues to plague hospitals in the United States and Internationally. The Covid-19 pandemic exacerbated an already growing problem regarding capacity management and patient flow. In this current climate, the Emergency Physician's responsibilities continue to shift toward the front-end of the process, mainly patients waiting to be seen in the lobby. As such, identifying sick patients in a timely manner and utilizing additional resources to predict patients at risk of clinical deterioration will be paramount moving forward. This recap covers a paper that looks to see if EtCO2 can play a bigger and better role in the triage process

Dr Gillespie breaks down the recently published CLOVERS trial that looked into the early administration of vasopressors in sepsis

The management of atrial fibrillation with rapid ventricular response is often complicated by the presence of heart failure with reduced ejection fraction. The presence of HFrEF limits pharmacologic options for rate control. This podcast will cover a retrospective study looking at the use of metoprolol vs diltiazem in patients with A fib with RVR and concomitant heart failure

Early recognition and resuscitation of patients in septic shock are critical skills for an emergency medicine physician. Many clinical decision-making tools have been developed and validated in their use to identify and define those who are in sepsis or septic shock, as well as predict a patient's overall risk of morbidity and mortality, including tools like the SIRS criteria and SOFA score. The diastolic blood pressure is determined by vascular tone, and thus it can be assumed that a decrease in the diastolic blood pressure should correlate with the pathologic vasodilation in septic shock. As a result, the authors of this study hypothesized that the relationship between heart rate and the diastolic blood pressure (i.e. the diastolic shock index) could provide providers a tool to quickly identify patients that are at risk for unfavorable outcomes.

In this podcast, Dr. Justin Milligan covers a recently published retrospective review that could inform our future practice. We all rely on a negative CT within 6 hours for diagnosing SAH, but what if we could through the time limits out the window?

During a cardiac arrest resuscitation, finally palpating a pulsatile flow beneath your gloved fingertips brings a sense of satisfaction like no other. But just as you go to finally breathe a sigh of relief and wipe the beading sweat off your brow, your now widening pupils focus on the patient's steadily plummeting blood pressure. As you begin to sense your own heart palpitating, you think about medications to utilize in hopes of staving off another round of chest compressions. Since you've already given four doses of code-dose epinephrine, maybe an epinephrine infusion is best? You also recall that norepinephrine seems to be a popular choice in patients with shock, so maybe you should start that instead?

Cardiac arrests are an inevitable reality for emergency medicine providers. There is often a debate on whether family members presence during CPR will lead to more emotional burdens on the family members who witnessed these resuscitations. Dr Melanie Yates summarizes this recent study that aimed to determine if there are increased rates of PTSD-related symptoms of close relatives who witnessed CPR of a family member.

Palpating a pulse during a resuscitation can be more challenging than it seems. Digital palpation of femoral pulses may lack sensitivity and specificity needed to accurately detect the presence of a pulse. In this Journal Club recap, Dr Martina Diaz summarizes a recently published paper looking at the use of Doppler ultrasound for pulse checks.

In this podcast, Dr. Courtney Kein breaks down a recently published article examining the effects of a bolus of IVF at the time of intubation. Does a push of fluid prevent peri-intubation hemodynamic collapse?

In this Journal Club paper breakdown, Dr Bailee Stark recaps the findings of a recently published study by Driver et al looking at the effect of bougie aided intubation vs standard stylet intubation.

In this Journal Club podcast, PGY-3 Tony Fabiano breaks down a paper from the Journal of Trauma comparing the effectiveness and patient perception of pigtail catheters versus standard chest tubes for hemothorax in the setting of trauma. Is a tiny tube effective at all in draining blood from the chest?

Time is myocardium, and minimizing door-to-activation time improves outcomes in patients with acute coronary occlusion. There are a number of existing quality metrics used to help drive improvements in the time-based care of STEMI patients. Could a new quality metric help the decision making time of Emergency Physicians?

The paradigm of STEMI vs NSTEMI is one of the most well known in Emergency Medicine. Could a change in thinking shift this paradigm to OMI vs NOMI and result in a more complete identification of patients with significant morbidity and mortality?

One of the first tests ordered for a patient with ROSC following cardiac arrest is an EKG. Many of these EKGs are profoundly abnormal. Current practice is to evaluate for STEMI and to activate the cardiac cath lab if one is found. But, the test characteristics (sensitivity and specificity) of post-ROSC EKGs are likely different than the test characteristics for patients presenting to the ED with complaints of chest pain/symptoms concerning for ACS. This meta-analysis looked to pull together the existing literature and determine those test characteristics for this critically ill patient population. Read the summary after the link and listen to the podcast to hear a breakdown of this study.

This is part 3 of 3 recapping our most recent journal club where we looked at the evidence for the safety and efficacy of droperidol for treating acute agitation in the ED. In this final episode, Dr. Christa Pulvino will share her summary of the DORM trial done by Isbister et al which looked at IM droperidol vs midazolam for violence and acute behavioral disturbance in the ED.

This is our second in a 3 part series looking at the evidence for the safety and efficacy of droperidol for acute agitation in the ED. In this episode, Dr. Shawn Hassani leads us in a discussion of an article by Taylor et al which was a randomized trial of droperidol vs droperidol + midazolam vs olanzapine.

This is part 1 of our 3 part series recapping our most recent journal club. In this podcast, Dr Jeff Hill leads a discussion of a paper by Calver et al which was a multicenter prospective trial looking at the safety and efficacy of droperidol for acutely agitated patients in the ED

This is the final of 3 podcasts recapping our most recent journal club. In this podcast Dr. Olivia Urbanowicz walks us through a meta-analysis by Wu et al published in the Journal of Emergency Medicine in 2020. We tackle the question as to whether or not there is evidence that supports the routine use of sodium bicarbonate in patients with cardiac arrest.

In this, our second podcast recapping our most recent journal club, Dr. Colleen Laurence summarizes a recent pilot study by Cheskes et al looking at standard defibrillation vs vector change defibrillation vs dual sequence defibrillation. Could we be on the verge of a significant practice change in how we deliver defibrillation to patients with refractory V Fib/Tac?

This is our first of 3 podcasts recapping our most recent journal club. In this podcast, Dr. Sarah Wolochatiuk summarizes the meta-analysis by Gottlieb et al entitled "Beta-blockade for the treatment of cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia: A systematic review and meta-analysis" published in Resuscitation in 2019.

We cover a trio of papers related to the care of the trauma patient - should we be adding some vasopressin in patients needing >6 units of blood? Is VL really superior to DL in trauma patients? Should we stop wasting time of IVs and just grab the IO drill?

A dive into 3 articles looking at the use of ketamine in the Emergency Department. 01:23 - Slow vs rapid infusion of ketamine for pain control in the ED 13:42 - Hemodynamic effects of ketamine vs etomidate for RSI 21:59 - Effect of versed or haldol vs placebo for emergence agitation in ketamine procedural sedation

We recap 3 recently published articles that look at various aspects of caring for pediatric cardiac arrest patients. Is Epi helpful? Therapeutic hypothermia or normothermia - which is better? Is old school lidocaine better than amiodarone?

In this podcast, we recap our most recent journal club which look at 3 papers on the topic on influenza. One recently published in the BMJ looking at usual care vs oseltamivir for community treatment of influenza-like illness, one looking at baloxavir for treatment of influenza, and a 3rd paper looking at the association of cardiovascular events and influenza infections.

In this latest episode of our Research Corner series, Dr. Hill sits down with PGY-3 Adam Gottula, MD and Amanda Peck, PharmD to discuss their recently published case report describing the use of dexmedetomidine for the management of acute intrathecal baclofen withdrawal. The discussion encompasses the mechanisms of action of baclofen, dexmedetomidine, and how dexmedetomidine might be useful in the management of these complex patients.

Over the past 5 years, there has been a dramatic expansion of the treatment strategies used to treat patients with acute ischemic stoke. As some of these treatments involve specific resources only available at certain institutions, appropriate triage of patients in the prehospital environment is becoming ever important. On one hand a patient who would best benefit from endovascular treatment triaged to a center without that capability will undoubtedly suffer a delay in care. On the other hand, over-triaging stroke patients to a comprehensive stroke center could overwhelm the resources of that center, potentially impacting the care of patients at that center. In the podcast below, we talk with Dr. Jason McMullan of the UC EM Division of EMS and Dr. James Li, PGY-3 who both have recent publications focusing on this phase of patient care.

Transporting a VV ECMO and sweating? Hearing beeps in your sleep and fearing the flow alarm? Bolster your VV ECMO knowledge with Dr. Liz Powell and Paige Barger interviewed by Dr. Adam Gottula.

We recap a trio of recent articles looking into various aspects of the care and management of patients with sepsis. Are balanced fluids truly better than plain old normal saline? Are steroids a friend or foe in patients with severe sepsis? Can assessing capillary refill really be better than drawing repeat lactates?

Dr. Mel Otten, tox and wilderness guru and past president of the Wilderness Medical Society, takes us through his new 2019 WMS Guidelines on the prevention and treatment of heat illness.

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.

Should patient who have a V fib or V tac cardiac arrest take a trip to the cardiac Cath lab even if their post-ROSC EKG shows no evidence of ST-elevation? Drs Ham, Habib, and Klaszky breakdown several articles that address this clinical question and then we speak with Dr. Justin Benoit, the site PI for the ongoing ACCESS trial which is also looking into this question

Dr. Adam Gottula interviews Paige Barger and Liz Powell, MD on the basics of LVADs and how to troubleshoot them prehospital and in the ED