Tactical Medicine News Blog

You’ve probably noticed by now, but ALiEM is going through some pretty significant changes–especially in the way that the site looks and feels. We’ve shifted the platform that was used to create ALiEM and taking a few minutes to explain why.

On the last day of the last SMACC conference, Dr. Ken Milne (The SGEM) and I had a cage match debating four critical care controversies. It was all done in good fun with both of us taking our opportunities to poke a little fun at each other. While we took a pro vs con approach to the presentation, our positions are much closer than the debate demonstrates. Although the literature is far from perfect, development of critical appraisal skills and application of evidence-based medicine to the literature is what we should be using to inform our care but not dictate our care. It is equally as important to incorporate clinical judgment and ask our patients what their values and preferences are before making decisions about care.

Background: In an older study published in Resuscitation 1998 [1], ED physicians, ICU physicians, and nurses tried to identify a carotid pulse in a healthy male volunteer with normal blood pressure. 43.1% of the health professionals required >5 seconds to detect the carotid pulse and another 4.3% required >10 seconds.  Something I have advocated for in cardiac arrest is the death of pulse checks, as our fingers are poorly sensitive for detecting which patients have a pulse in a shock state.  A visible rhythm on the monitor, along with the absence of a pulse with digital palpation, does not always indicate the presence of true pulseless electrical activity (PEA).  Our reflexive action when we don’t feel a pulse is to begin CPR and give 1mg epinephrine which may not be beneficial in these patients.  Patients in profound shock don’t necessarily need cpr and 1mg of epinephrine, they need augmentation of cardiac output with either push dose pressors or hemodynamically driven epinephrine drips.  Now another study published in Resuscitation looked to compare the efficiency of cardiac ultrasonography (CUSG), doppler ultrasonography (DUSG) and manual pulse palpation to check the pulse in cardiac arrest patients [2].

Welcome to Leg Day #3 of the SplintER Series! Performing a fast and focused history and physical examination of a patient with an acute knee injury is an important skill that has the potential to be overlooked in our busy Emergency Departments. Our hope is that after reviewing this post and with enough practice you will be able to complete your exam within 2 minutes! These are can’t-miss points and expert tips on the knee exam for your next shift in the ED.

In this podcast Dr. Sara Gray, intensivist and emergency physician, co-author of The CAEP Sepsis Guidelines, answers questions such as: How does one best recognize occult septic shock? How does SIRS, qSOFA and NEWS compare in predicting poor outcomes in septic patients? Which fluid and how much fluid is best for resuscitation of the septic shock patients? What are the indications for norepinephrine, and when in the resuscitation should it be given, in light of the CENSER trial? What are the goals of resuscitation in the patient with sepsis or septic shock? When should antibiotics administered, given that the latest Surviving Sepsis Campaign Guidelines recommend that antibiotics be administered within one hour of arrival for all patients suspected of sepsis or septic shock? What are the indications for a second vasopressor after norepinephrine? Given the conflicting evidence for steroids in sepsis, what are the indications for steroids? Should we be considering steroids with Vitamin C and thiamine for patients in septic shock? What are the pitfalls of lactate interpretation, and how do serial lactates compare to capillary refill in predicting poor outcomes in light of the ANDROMEDA trial? Is procalcitonin a valuable prognostic indicator in septic patients? and many more... The post Ep 122 Sepsis and Septic Shock – What Matters from EM Cases Course appeared first on Emergency Medicine Cases.