The Skeptics' Guide to EM

OCTOBER 3, 2021

Date: September 28th, 2021 Reference: Zampieri et al. Date: September 28th, 2021 Reference: Zampieri et al. Some bench work, observational studies, and now two large, unblinded, cluster-randomized single-center trials ( SMART and SALT-ED ) suggested a benefit to using balanced crystalloids (i.e. Reference: Zampieri et al.

OR 130

OR Critical Care ICU Plasma 130

Core EM

JANUARY 24, 2024

2017.09.1085 Gómez-Outes A, Alcubilla P, Calvo-Rojas G, et al. doi:10.1186/s13054-019-2492-8 Baugh CW, Levine M, Cornutt D, et al. 2019.09.001 Gilbert BW, Morton L, Huffman JB, et al. 2019.10.013 Patel IJ, Rahim S, Davidson JC, et al. 2019.04.017 Connolly SJ, Milling TJ Jr, Eikelboom JW, et al. J Am Coll Cardiol.

FFP 130

FFP Frozen Plasma Plasma ALS 130

EMDocs

APRIL 10, 2024

These medications are a vital tool in the care of ED patients, from simple local analgesia for a laceration repair to regional analgesia for painful procedures. Metabolism of ester anesthetics is by plasma cholinesterase, whereas amides are metabolized by the cytochrome P450 system in the liver. [6] lidocaine) or an ester (e.g.,

E-9-1-1 110

E-9-1-1 Plasma Epinephrine Life Support 110

Don't Forget the Bubbles

JUNE 30, 2023

All you know, back in ED, is that the ETA is 10 minutes, and there is a single stab wound to the chest. The ODP is caught up leaving theatres and has not yet made it down to ED. The trauma call goes out. You will be running the show today, and you want to use your preparation time well. to −0.5%]; P  = 0.03.). to −0.5%]; P  = 0.03.).

E-9-1-1 139

E-9-1-1 FFP Plasma Emergency Department 139

EMDocs

JUNE 12, 2024

Giancarelli et al found that 97% of patients who underwent massive transfusion protocols during trauma resuscitation were hypocalcemic (iCa < 1.1 Kyle et al demonstrated that transfusing a single unit of pRBCs can lead to significant decreases in Ca. How does this impact what you do in the ED? J Trauma Acute Care Surg.

ALS 105

ALS FFP Plasma Emergency Department 105

EMDocs

SEPTEMBER 7, 2023

DEG is rapidly absorbed when ingested and can reach peak plasma and brain tissue concentrations within four hours of ingestion. Metabolism of DEG adapted from Bessenhofer, et al. References: Abubukar et al. “Diethylene Glycol” in Goldfrank’s Toxicologic Emergencies , 11e Eds. Nelson, et al.

E-9-1-1 87

E-9-1-1 ALS Plasma Emergency Department 87

EMDocs

MARCH 4, 2024

Case: A 45-year-old woman presents to the emergency department (ED) with itching to bilateral palms. 5 Identification of obstructive physiology in the emergency department (ED) and referral for definitive management can spare patients from these damaging downstream consequences. Her triage vitals are within normal limits.

Emergency Department 104

Emergency Department E-9-1-1 ALS OR 104

AAEM RSA

APRIL 1, 2021

2,3 Here we examine some of the evidence behind the various components of MTPs, specifically calcium and factor VIIa, and the ratios in which the main products of red blood cells, plasma, and platelets should be administered. Holcomb JB, Tilley BC, Baraniuk S, et al. Cornelius B, Ferrell E, Kilgore P, et al. 2020;88(5):383-9.

E-9-1-1 52

E-9-1-1 Plasma ACS ALS 52

EMDocs

AUGUST 7, 2023

Schnapp, MD, MEd (Associate Program Director, University of Wisconsin) // Reviewed by: Joshua Lowe, MD (EM Attending Physician, USAF), Marina Boushra (EM-CCM, Cleveland Clinic Foundation); Brit Long, MD (@long_brit) Case A 36-year-old pregnant woman at 21 weeks gestation presents to the ED with chest pain. N Am J Med Sci. 2014;6(10):491-499.

E-9-1-1 91

E-9-1-1 ALS Plasma OR 91

ACEP Now

APRIL 5, 2024

2 TTP often presents abruptly, and most patients that develop it first visit the emergency department (ED) as their symptoms worsen. 1 Pregnant patients are particularly vulnerable to misdiagnosis of TTP in the ED. References Sukumar S, Lämmle B, et al. Kessler CS, Khan BA, et al. Li XM, Mo XY, et al. J Clin Med.

Frozen Plasma 40

Frozen Plasma Plasma Emergency Department FFP 40

FOAMfrat

AUGUST 15, 2024

Moreover, LTOWB also allows us to administer platelets and plasma, in addition to red cells, to promote clotting and homeostasis. If you don't have access to LTOWB and are administering component therapies such as PRBCs or plasma, this is still incredible and I highly encourage it! Minino AM, Heron MP, Murphy SL, et al.

Plasma 69

Plasma Ambulance ALS Emergency Department 69

ACEP Now

APRIL 2, 2024

An 18-year-old woman presented to the emergency department (ED) with symptoms of nausea, vomiting, diarrhea, and abdominal pain. Before arriving at our ED, the patient sought care at an urgent care clinic, where she was prescribed ondansetron without improvement. References Katibi OS, Olaosebikan R, et al. Am J Trop Med Hyg.

Plasma 40

Plasma ALS Emergency Department ED 40

ACEP Now

NOVEMBER 16, 2023

Fresh frozen plasma, or FFP, should only be given to cirrhotic patients as part of the massive transfusion protocol in cases of profound hypotension, as “patients with cirrhosis rarely have true enzymatic hypocoagulability, and FFP may worsen bleeding due to over-resuscitation and dilution of coagulation factors.” 6 Balloon tamponade (i.e.,

Frozen Plasma 52

Frozen Plasma FFP ALS Plasma 52

Dr. Smith's ECG Blog

JULY 27, 2023

On arrival to the ED, the patient was diaphoretic, tachycardic. I did not think it was due to ACS, but we ordered an ED ECG immediately: What do you think? Peak plasma concentration of amphetamines is rapid ( within minutes ) following inhalation or injection. and had dilated pupils. He was alert and oriented.

Coronary 52

Coronary ACS Naloxone Plasma 52

Dr. Smith's ECG Blog

APRIL 8, 2016

Here is his ED ECG: There is obvious infero-posterior STEMI. the associated loss is double, at 200-400 mEq.* [ Sterns RH, et al. Internal potassium balance and the control of the plasma potassium concentration. Plasma potassium ([K] p ) was measured at 15-minute intervals during and after the infusion in 31 patients.

STEMI 52

STEMI Plasma Defibrillator OR 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2019

They transported to the ED. The history, obtained subsequently, is interesting: The patient had been seen at an outside ED 2 days prior and the K was 2.5 Hospital admission had been recommended, but she left that ED against medical advice. the associated loss is double, at 200-400 mEq.* [ Sterns RH, et al.

Plasma 40

Plasma STEMI Defibrillator Overdose 40

Dr. Smith's ECG Blog

FEBRUARY 18, 2022

In fact, there is laboratory evidence that CO toxicity increases Plateletneutrophil aggregates and plasma myeloperoxidase (MPO) concentration and thus may precipitate ACS (though this is by no means clinically proven). Yelken B et al. Intravascular Neutrophil Activation Due to Carbon Monoxide Poisoning What do you think of this ECG?

ACS 52

ACS Plasma OR STEMI 52

Don't Forget the Bubbles

MAY 15, 2023

This response varies between individuals, age groups and developmental stages, so a single plasma concentration cannot be defined. How do I measure hypoglycaemia in the ED? If there is clinical concern for hypoglycaemia, plasma glucose concentration should be measured. Plasma glucose Beta-hydroxybutyrate (i.e.

ED 103

ED Plasma OR ALS 103

EMDocs

JUNE 3, 2023

The nuances of fracture patterns and delineating mechanically unstable pelvic fractures from stable ones is less important to the ED. This is less critical in ED management of the unstable pelvic fracture, as the optimal site for identification of rectal or vaginal tears is the operating room.

ED 61

ED Operating Room ALS Frozen Plasma 61

EMDocs

DECEMBER 18, 2023

On arrival to the ED, her blood pressure is 84/36 mmHg with a heart rate of 110 beats per minute. 3,4 Prompt recognition and management of sepsis and septic shock are paramount for the ED clinician. 8,9 Recently, monocyte distribution width (MDW) has shown promise in a large meta-analysis as a useful screening tool in the ED.

E-9-1-1 86

E-9-1-1 ALS Emergency Department Plasma 86

EMDocs

JUNE 7, 2023

F, HR 48, RR 28, BP 104/62, SPO2 88% on non-rebreather mask The patient’s friend who brought her to the ED tells you the patient made suicidal statements earlier in the day and was found in her yard shed. These are send-out labs with turn-around times that make them unlikely to affect the ED course or guide treatment. BMC Res Notes.

E-9-1-1 98

E-9-1-1 ICU Emergency Department ED 98

EMDocs

JUNE 14, 2023

These are send-out labs with turn-around times that make them unlikely to affect the ED course. This prevents ongoing exposure to the patient and ED staff. Boostani R, Mellat A, Afshari R, et al: Delayed polyneuropathy in farm sprayers due to chronic low dose pesticide exposure. In: Mattu A and Swadron S, ed. CorePendium.

E-9-1-1 92

E-9-1-1 Emergency Department Plasma ACS 92

Don't Forget the Bubbles

JULY 5, 2023

SCD, therefore, is not only a mechanical disease but there are also many other cellular and plasma factors as well as endothelial interaction that generate chronic inflammation. Haematology specialist clinics are key to manage the chronic side of the disease, while ED doctors should be able to act rapidly on the common acute emergencies.

E-9-1-1 126

E-9-1-1 ACS OR ICU 126

EMDocs

FEBRUARY 3, 2025

Treatment requiresaggressive anticoagulation, glucocorticoids, plasma exchange, and intravenous immunoglobulin (IVIG)(27). Aringer M, Costenbader K, Daikh D, et al. Meier AL, Bodmer NS, Wirth C, et al. Tani C, Elefante E, Arnaud L, et al. Bartels CM, Buhr KA, Goldberg JW, et al. 2024;331(17):1480-1491.

ED 66

ED E-9-1-1 ALS OR 66

ACEP Now

FEBRUARY 11, 2025

A 33-year-old male with a history of drug use presented to the emergency department (ED) for extreme agitation after receiving two doses of 2 mg naloxone by EMS for respiratory depression. If available, an in-house ED pharmacist is an incredible resource for guidance when there are questions regarding pharmacologic management.

NARCAN 89

NARCAN Naloxone Overdose Mental Health Services 89

EMDocs

JANUARY 22, 2025

In the ED, he develops recurrent respiratory depression and hypoxia to 80%. How long should they stay in the ED? DOI: [link] O’Donnell J, Tanz LJ, Miller KD, et al. Al-Azzawi M, Alshami A, Douedi S, Al-Taei M, Alsaoudi G, Costanzo E. Available at: [link] October 19, 2023 Kelly A, Kerr D, Dietze P, et al.

Naloxone 93

Naloxone E-9-1-1 Overdose NARCAN 93

Dr. Smith's ECG Blog

FEBRUARY 6, 2025

During observation in the ED the patient had multiple self-terminating runs of Non-Sustained monomorphic Ventricular Tachycardia (NSVT). The minimum effective plasma concentration of flecainide is about 200 ng/mL. This plasma concentration leads to a QRS prolongation of about 10 msec. and Brugada syndrome. Van Zyl, M., &

Plasma 72

Plasma ACS OR Coronary 72

EMDocs

MARCH 11, 2024

Louis) // Reviewed by: Joshua Lowe, MD (EM Staff Physician, USAF); Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit) Case A 25-year-old woman presented to the emergency department (ED) in Uganda with acute encephalopathy. How is this condition diagnosed and treated in the ED? References Montero DA, Vidal RM, Velasco J, et al.

ED 109

ED OR ALS Plasma 109

Core EM

JANUARY 16, 2025

While this guide isnt exhaustive, its designed by residents, for residents, to provide practical tips and foundational knowledge thats crucial in the fast-paced, high-stakes environment of the ED. Introduction Airway management is a critical ED skill to master. Figure 7: (modified from Tanoubi 2009).

E-9-1-1 130

E-9-1-1 EMS ALS OR 130

EMDocs

FEBRUARY 22, 2025

Although the concentration of chloride in the CSF is slightly higher than in plasma, measuring chloride (B) is not an accurate way to detect the presence of CSF. Callen AL, Timpone VM, Schwertner A, Zander D, Grassia F, Lennarson P, Seinfeld J, Lillehei KO, Birlea M, Thaker AA. His left face and eye have severe contusions.

EMS 62

EMS E-9-1-1 Plasma OR 62

EMDocs

NOVEMBER 2, 2024

A 51-year-old male with a history of AIDS presents to the ED accompanied by his partner with complaints of cognitive decline and confusion over one month. The development of an inflammatory process is largely due to the infiltration of lymphocytes and plasma cells which ultimately result in nerve damage (e.g., In: StatPearls.

EMS 112

EMS E-9-1-1 Plasma ALS 112

EMDocs

JANUARY 6, 2025

ED Evaluation Transport to the ED from the refugee reception center takes 1 hour. Labs Laboratory workup in the ED is notable for a leukocytosis of 41,000/L, hemoglobin of 6.5 She is sent to the medical ward after three days in the ED with the diagnoses of resolving septic shock, severe malaria, and AKI. 57 Table 2.

ED 73

ED E-9-1-1 ALS Emergency Department 73