Tactical Medicine News Blog

You are working at a Level 1 Trauma Center; a 35-year-old female arrives via EMS from the scene of a motor vehicle accident. She was an unrestrained passenger, ejected 50 feet. She was hypotensive and hypoxic on scene with concern for head injury with a GCS of 7. She is clearly in shock on arrival with weak pulses, clammy skin, and a BP of 80/50mmHg, HR 140, sats 85%.  She is intubated, a chest tube is placed on the left (with improvement in O2 sats to 95%), and a pelvic binder is placed for suspected pelvic fracture. eFast demonstrates free fluid in the pelvis. Massive Transfusion Protocol (MTP) has been activated appropriately, and despite rapid delivery of 4 units Packed Red Blood Cells (PRBCs), 2 units of Fresh Frozen Plasma (FFP) and 1 pack of Platelets, she remains hypotensive, with presumed hemorrhagic shock. The patient is destined for the OR, but you ask yourself, in traumatic hemorrhagic shock, is there a role for vasoactive agents?

A 66-year-old otherwise healthy man presents by Emergency Medical Services (EMS) after being found unconscious on the ground. On arrival to your emergency department, he is back to his baseline normal mental status and without complaints. His vital signs are within normal limits and his physical exam is unremarkable. Is it a syncope? What are the key features of his history and physical exam that should affect your medical decision making? What should this patient’s work-up entail?

A high-stakes component in a medical student’s application for an emergency medicine (EM) residency is the Standard Letter of Evaluation, or SLOE. This is a standardized templated letter, written by an group (e.g. department) or faculty from an EM-residency program. This episode of EM Match Advice gives a behind-the-scenes peek into what letter writers are thinking and a deeper dive into the mechanics of the SLOE.

Background: Saline (0.9% sodium chloride) has historically been one of the most common intravenous fluids administered in critically ill adults.  However, the supraphysiologic chloride concentration can cause hyperchloremia, metabolic acidosis, renal vasoconstriction and alter immune function.  There is nothing normal about normal saline. Balanced crystalloids (i.e. lactated Ringer’s solution, Plasma-Lyte A, etc) contain electrolyte compositions that are closer to physiologic levels.  Recently, the Isotonic Solutions and Major Adverse Renal Events Trial (SMART) [2] compared balanced crystalloids to saline among critically ill adults and found that balanced crystalloids decreased the composite outcome of death, new renal replacement therapy, or persistent renal dysfunction (This composite outcome was primarily driven by mortality benefit).  Interestingly, in the subgroup analyses of septic patients, balanced crystalloids seemed to have its biggest benefit in MAKE30 compared to saline.

A 3-year-old Hispanic female with no significant past medical or surgical history presents to the Emergency Department with her mother for a 3 day history of crampy abdominal pain, intermittent bloody diarrhea and fever. There has been no recent travel, admissions, or antibiotic use. Her older sister reports similar symptoms, which have resolved. The patient saw her pediatrician the day prior, who recommended supportive care including oral rehydration.