ProCESS Study: Identify sepsis early and treat aggressively

Today, the New England Journal of Medicine just released a landmark paper by the ProCESS (Protocolized Care for Early Septic Shock) trial investigators. There has already been much buzz about this on various blogs and websites, including St. Emlyn’s, MedPageToday, and MDAware. I received an email from my colleague Dr. Michael Callaham, who shared some direct comments and pearls from Dr. Donald Yealy, (professor and chair of emergency medicine from the University of Pittsburgh Medical Center) who was the first author of this writing team. Thank you to Dr. Yealy for allowing me to share your team’s comments with the ALiEM readership.

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By Michelle Lin, MD|2019-01-28T21:51:09-08:00Mar 18, 2014|Infectious Disease|

Article: Elevated INR May Overestimate Coagulopathy in Trauma and Surgical Patients

A 55 year old woman presents as the driver of a motor vehicle collision. She has moderate abdominal tenderness diffusely and a seat belt sign, but has a negative abdominal/pelvis CT. Her INR, however, was noted to be 2.1. She is not on any vitamin K antagonists. The surgeons admit her to the hospital to observe for a potential hollow viscus injury and requests that you order 2 units of FFP for her. Seems reasonable… or is it? What is the logic?

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By William Paolo, MD|2016-11-11T19:19:39-08:00Mar 17, 2014|Heme-Oncology, Trauma|

Trick of the Trade: Nasopharyngeal Oxygenation

A 76-year-old obese male with a history of severe COPD presents to your emergency department (ED) in acute respiratory distress. The patient’s large beard prevents an adequate seal with the NIV (non-invasive ventilation) mask, and the patient continues to desaturate. You are fairly sure that this patient will be a difficult airway and optimizing oxygenation prior to and during your intubation attempt would be ideal. Now what?

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By Bradley Ching, MD|2016-11-11T19:19:38-08:00Mar 17, 2014|Critical Care/ Resus, Tricks of the Trade|

Upper Gastrointestinal Bleeding: Evidence-Based Treatment

Upper gastrointestinal bleeding remains a common reason for emergency department visits and is a major cause of morbidity, mortality, and medical care costs. Often when these patients arrive, the classic IV-O2-Monitor is initiated and hemodynamic stability is assessed. Some of the next steps often performed include:

Determination of the site and rate of bleeding (upper vs lower)
Initiation of proton pump inhibitors (PPIs)
Somatostatin analogs if variceal bleeding is suspected
Prophylactic antibiotics
Packed red blood cell (PRBC) transfusion for low hemoglobin and hematocrit levels

What is the evidence for these treatments, and do they affect morbidity and mortality?

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By Salim Rezaie, MD|2024-04-25T16:55:25-07:00Mar 12, 2014|Gastrointestinal|

Ocular Ultrasound: Retinal Detachment and Posterior Vitreous Detachment

It’s 3 am in the middle of your busy night shift and you begin your evaluation of a 65 year-old woman with diabetes with several hours of unilateral flashes of light in her left eye. Her visual fields seem normal, but you are unable to see her fundus with your direct ophthalmoscope. Luckily, you remembered the teaching from your ultrasound rotation during residency.

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By Arun Nagdev, MD|2016-11-13T09:43:25-08:00Mar 11, 2014|Ophthalmology, Ultrasound|

Trick of the Trade: Fist Bump to Reduce Pathogen Transmission

Handshaking has been practiced as far back as the 5th century BC and used today as a common way of greeting others. In the hospital setting this occurs multiple times throughout the day. Many alternatives to the handshake have been developed and utilized, but they have failed to replace the handshake as a form of greeting. Nosocomial infections have been identified as a major preventable complication of inpatient care and one of the most important initiatives to reduce this is hand hygiene. The authors of this study propose the fist bump as a safe and effective way to avoid hand-to-hand contact and therefore reduce transmission of infection. ¹ (more…)

By Salim Rezaie, MD|2019-09-10T13:34:31-07:00Mar 10, 2014|Infectious Disease, Tricks of the Trade|

Is the Patient Sober? Clinical Sobriety versus Blood Alcohol Concentration

There is significant practice variability when providers are asked to determine if a patient is intoxicated. Some providers will evaluate a patient to determine if a patient is “clinically sober”, while other providers will rely on a patient’s blood alcohol concentration (BAC) to evaluate a patient’s level of intoxication. There is very little data to suggest that either approach is superior; however, both practice patterns have significant limitations and carry a certain degree of medicolegal risk.

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By Matthew DeLaney, MD|2016-11-11T19:19:30-08:00Mar 6, 2014|Medicolegal, Tox & Medications|