PEM Practice Changing Paper: Clinical Trial of Fluid Infusion Rates for Pediatric DKA

Most protocols for managing pediatric patients with diabetic ketoacidosis (DKA) are based on a theoretical association between fluid resuscitation and subsequent neurological decline. Although the evidence for an association between IV fluids and cerebral edema comes from retrospective reviews, for over 20 years, it is an accepted teaching principle of pediatric DKA.

Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis, published just days ago in the New England Journal of Medicine, challenges this teaching with the first randomized controlled trial designed to investigate the relationship between IV fluids and cerebral edema. We review this publication and present a behind-the-scenes podcast interview with lead authors Dr. Nathan Kuppermann and Dr. Nicole Glaser from the Pediatric Emergency Care Applied Research Network (PECARN). (more…)

By Derek Monette, MD|2021-07-01T21:14:43-07:00Jun 15, 2018|Critical Care/ Resus, Endocrine-Metabolic, Neurology, Pediatrics|

The Myth of Vasopressors and Ischemia

Despite the widespread clinical use, and their well-documented life-saving properties, vasopressors are often maligned, accused of causing ischemia to fingers, toes, mesentery, kidneys, and so forth. Not only is the evidence that this happens poor, but, a fear of this dreaded complication can unwarrantedly lead good clinicians to limit or withhold potentially life- and organ-saving medications. This article showcases the importance of end-organ perfusion and explains how vasopressors may in fact be one of the most important therapies in an emergency physician’s armamentarium.
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By Susan Wilcox, MD|2018-06-11T08:02:01-07:00Jun 11, 2018|Critical Care/ Resus, Tox & Medications|

The Problem

Emergency ultrasound (EUS) has quickly become a fundamental aspect of emergency medicine (EM) residency training. While still relatively novel to the field, there has been a significant focus on curriculum development in accordance with the core ultrasound application guidelines set forth by the American College of Emergency Physicians (ACEP).¹ Currently, there is no consensus on the optimal approach to EUS education that will provide learners with true clinical competence post-matriculation. Furthermore, a recent survey demonstrated that there is conflict between what ACEP guidelines consider to be competence in EUS and resident opinion on the matter.² One potential identified issue with our current model is the focus on early ultrasound learning in junior EM residents with a lack of ongoing EUS education in senior years.
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By Michael Macias, MD|2018-06-06T09:33:25-07:00Jun 10, 2018|IDEA series, Ultrasound|

Trigger Point Injection for Musculoskeletal Pain in the ED

Musculoskeletal pain is a common ED presentation and emergency providers can often manage it with NSAIDs alone.¹ On the other hand, when patients present with small localized areas of intense muscle spasm called trigger points, NSAIDs won’t cut it. A trigger point injection (TPI), however, is a safe and easy way to treat the underlying cause of trigger point pain, and requires only basic equipment already available in most the EDs.

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By Alexis LaPietra, DO|2018-06-07T20:29:26-07:00Jun 8, 2018|Orthopedic, Tox & Medications|

Nuclear Attack: What Emergency Physicians Working in the ED Need to Know

Ever wonder what would happen if you were working in the emergency department (ED) when a nuclear attack happens? We’ve all had questions on boards or inservice exams about the long-term effect of radiation exposure, but would you know what to ACTUALLY DO if a nuclear attack happened? What do you do in the first few minutes? First few hours? We know that if you are in the immediate bomb vicinity, there is not much you can do. But what if you are 5 miles away? Or 10 miles?

If you look for information regarding nuclear attacks, there are no great summary resources on what to do in the immediate aftermath if you are in the ED. In order to bring this to you in an easily digestible format, we have broken this post up into a few topic areas: This blog post will cover (1) what physically happens in a nuclear attack and (2) what this means in the ED.

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By Andrea G. Tenner, MD|2018-06-01T14:16:29-07:00Jun 4, 2018|EMS, Trauma|

ECMO for ARDS: Key Pearls for Emergency Physicians from the EOLIA Trial

The role of extracorporeal membrane oxygenation (ECMO) in the management of acute respiratory distress syndrome (ARDS) has been a source of debate within the critical care community.¹ The use of ECMO has steadily increased over the past decade;² however, evidence to support the widespread adoption of this expensive and invasive technology is limited. As advances in ECMO technology have rapidly outpaced evidence, clinicians have been left to speculate as to ECMO’s true value. Is ECMO a promising tool to advance the care of patients with respiratory failure³ or an expensive distraction that has inappropriately supplanted evidence-based strategies?⁴

All who care for patients with ARDS have been eagerly awaiting the results of the Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome (EOLIA) trial which were recently published in May 2018’s New England Journal of Medicine.⁵

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By Mac Walter, MD|2018-05-31T07:46:14-07:00May 31, 2018|Critical Care/ Resus, Pulmonary|

Treating Opioid Withdrawal in the ED with Buprenorphine: A Bridge to Recovery

The Emergency Department (ED) is the frontline of the opioid crisis, treating patients with opioid-related infections, opioid withdrawal, and overdose. These encounters can be difficult or even downright confrontational. But that does not have to be the case! With the use of buprenorphine, we can “flip the script” for these encounters, encouraging patient-provider collaboration in the treatment of opioid addiction as medical disease.