The Skeptics' Guide to EM

JUNE 18, 2022

The paramedic asks you, “we have saline, and we also have red-cells and this fancy new lyophilised plasma. Should we give our shocked patient saline or plasma / red cells en route to the ED?” It was a pragmatic, randomised, single-centre trial done at the Denver looking at the use of plasma in the prehospital setting.

Plasma 100

Plasma Critical Care Paramedic ALS 100

Emergency Medicine Cases

FEBRUARY 9, 2021

Until the results of lab testing come back and hemorrhage pace is slowed, what ratio of plasma to RBCs should we target? Once the dust settles, what do we need to tell the patient and/or their family about the consequences of being massively transfused? What should be the lab resuscitation targets? How do we mitigate the risk of hypothermia?

Plasma 130

Plasma ED OR FFP 130

ALiEM

OCTOBER 4, 2023

Note that succinylcholine is contraindicated as it is metabolized by plasma pseudocholinesterase. This kit has historically been issued to US service members for treating nerve agent toxicity from agents such as soman, sarin, tabun, and VX, all of which are organophosphates and cause a cholinergic toxidrome. What are nerve agents? [1-3]

Plasma 195

Plasma OR ED 195

Core EM

JULY 23, 2024

Hyperkalemia Cardiac conduction partially depends on a gradient of lower extracellular (plasma) potassium levels and higher intracellular potassium levels. The patient was admitted to the medical intensive care unit and emergent underwent dialysis. His EKG on discharge is shown below.

Plasma 130

Plasma Emergency Department Overdose OR 130

REBEL EM

SEPTEMBER 13, 2023

Bradykinin Mediated Plasma globulins called kininogens release bradykinin and cause vascular permeability. Image: ( Morgan 2010 ) Features Absence of urticaria and pruritus Insidious onset (24-36 hours) ACE Inhibitors Inhibition of ACE hinders the degradation of bradykinin and can lead to idiosyncratic angioedema.

Frozen Plasma 101

Frozen Plasma Allergic Reaction FFP Plasma 101

REBEL EM

MAY 25, 2023

JAMA 2015 [7] The PROPPR Trial 680 severely injured adult trauma patients Patients randomized to Plasma, Platelets, and PRBCs in a 1:1:1 ratio vs 1:1:2 ratio No difference in overall mortality at 24 hrs BUT 1:1:1 achieved hemostasis faster and fewer experienced death due to exsanguination at 24hrs Crombie N et al.

E-9-1-1 145

E-9-1-1 Plasma ALS OR 145

Core EM

OCTOBER 16, 2024

Author: Natalie Bertrand, MD Editor: Naillid Felipe, MD Background: Definition: adverse reaction to blood product administration Incidence: more common in children than adults, except for delayed hemolytic transfusion reactions Allergic (non-anaphylaxis) – Platelets 1-3%; RBCs 0.1-0.3% mg IF requiring IM Epi >3x, switch to IV Epi, 0.05-0.1

Allergic Reaction 188

Allergic Reaction Plasma ED Epinephrine 188

Core EM

JANUARY 24, 2024

Hyperkalemia Cardiac conduction partially depends on a gradient of lower extracellular (plasma) potassium levels and higher intracellular potassium levels. The patient was admitted to the medical intensive care unit and emergent underwent dialysis. His EKG on discharge is shown below.

Plasma 130

Plasma Emergency Department Overdose OR 130

ALiEM

OCTOBER 20, 2023

Necrobiosis Lipoidica – This patient had a previous skin biopsy with histopathologic changes demonstrating a granulomatous dermatitis involving the dermis and subcutaneous tissues with necrobiosis of collagen and inflammatory infiltrates of lymphocytes and plasma cells consistent with a diagnosis of necrobiosis lipoidica.

Plasma 161

Plasma Coronary Emergency Department OR 161

ESO

MARCH 15, 2024

Balance resuscitation strategy, often in a 1:1:1 ratio of PRBCs with fresh frozen plasma and platelets. The 2023 Trauma Index revisits the metric surrounding whole blood and packed red blood cell (PRBC) transfusions for trauma patients with an Early Blood Transfusion Needs Score (EBTNS) greater than five.

Frozen Plasma 111

Frozen Plasma Plasma FFP OR 111

Chicago EMT Training

AUGUST 6, 2021

Various assistant/tech roles around the hospital/Plasma Donation Centers I personally became an Anesthesia Technician at Northwestern solely off of my experience as a paramedic and have been fortunate to bring on coworkers who were EMT students of ours. It opens many doors in various industries.

EMT 130

EMT EMT Paramedic Plasma 130

Core EM

JANUARY 24, 2024

Background Around 6 million people in the U.S. 2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. Background Around 6 million people in the U.S. Background Around 6 million people in the U.S.

FFP 130

FFP Frozen Plasma Plasma ALS 130

Pediatric EM Morsels

JUNE 14, 2024

(Tavasoli 2018, Wolf 2012) More common in adults; children comprise 20% of total cases (Pidcock 2007, Wang 2019) Bimodal age distribution (Absoud 2016) Children < 5 years Children > 10 years Symptoms evolve over 2-4 days and peak at 5-6 days (Absoud 2016) ATM may occur alone OR as part of another disorders (e.g.

Plasma 143

Plasma ALS OR EMS 143

Pediatric EM Morsels

AUGUST 9, 2024

Neonates presenting to the Emergency Department often cause a lot of uncertainty. Is this scalp swelling normal? Is this bloody stool concerning? Are this odd movements part of normal development? Is that umbilical area ok or concerning? Fortunately, we have addressed many neonatal issues in the PedEMMorsels. May be on soles of feet !

E-9-1-1 154

E-9-1-1 Plasma Emergency Department OR 154

Don't Forget the Bubbles

JUNE 30, 2023

You ask your anaesthetist to get ready to sedate or intubate depending on their status – Significant risk to the department – you make sure security is aware And your patient arrives. Ranulf is quite a sweet, round-faced boy, accompanied by his traumatised-looking mother as he is wheeled to your trauma bay.

E-9-1-1 139

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

Dr. Smith's ECG Blog

MAY 22, 2024

Don't forget beta agonists in the treatment of hyperkalemia: Terbutaline and Albuterol for Lowering of Plasma Postassium (includes many abstracts) The below abstracts show that beta 2 adrenergic agonists are effective at treating hyperkalemia. Both together are VERY likely to be due to hyperkalemia. Is This a Simple Right Bundle Branch Block?

Plasma 116

Plasma ICU OR 116

The Skeptics' Guide to EM

DECEMBER 17, 2022

The transfusion tech calls to remind you that your protocol is currently under review, and asks if would you like the 1:1 or the 1:3 version of fresh-frozen plasma (FFP) to packed red blood cells (pRBC)? Noting with some relief that at least he isn’t anticoagulated, you activate the hospital massive transfusion protocol. years ( 2 ).

Frozen Plasma 130

Frozen Plasma FFP Emergency Medical Services Plasma 130

The Skeptics' Guide to EM

APRIL 6, 2019

In contrast, protamine could be used for heparin and LMWH reversal and vitamin K, fresh frozen plasma and prothrombinase complex concentrate could be used to reverse coumadin ( Hunt and Levi BMJ 2018 ). Level A One of the concerns clinicians had with DOACs was there was no way to reverse these new anti-coagulants when they were introduced.

Frozen Plasma 130

Frozen Plasma Plasma ALS EMS 130

EMDocs

APRIL 10, 2024

Metabolism of ester anesthetics is by plasma cholinesterase, whereas amides are metabolized by the cytochrome P450 system in the liver. [6] 6] Action of local anesthetics is dependent upon the molecule crossing the plasma membrane in a unionized form. [2] 2] This linking group can be either an amide (e.g., lidocaine) or an ester (e.g.,

E-9-1-1 109

E-9-1-1 Plasma Epinephrine Overdose 109

Medgadget

SEPTEMBER 20, 2023

The researchers used a relatively simple plasma etching technique to create such nanopillars on titanium surfaces, and tested their ability to kill multi-drug resistant Candida cells, a fungal pathogen behind many medical device infections. “As it slowly stretches, the weakest point in the latex will become thinner and eventually tear.

Plasma 89

Plasma OR 89

Emergency Medicine Ireland

APRIL 16, 2024

This time the tonicity is high from something else such as high glucose or mannitol drawing water from cells into plasma. A normal sane and functioning kidney will try and lose water to conentrate the plasma in order to bring the sodium back up to normal, in other words the kidney should be producing a dilute urine with a low osm.

Critical Care 74

Critical Care Plasma OR ED 74

EMDocs

JULY 11, 2023

Today on the emDOCs cast, Brit Long, MD ( @long_brit) covers hemophilia, including background, severity, evaluation, and management. Episode 81: Hemophilia What is hemophilia? Bleeding disorder due to a deficiency in one or more of the proteins (factors) involved in the coagulation pathway. Most common site is hemarthrosis (70-80% of cases).

Plasma 74

Plasma ALS OR Emergency Department 74

REBEL EM

JUNE 26, 2023

Severe acute traumatic coagulopathy = PT >1.5 to 3.33; P = 0.72 NOT STATISTICALLY SIGNIFICANT Also no difference in individual components given Thromboembolic Events: 4F-PCC: 35% Placebo: 24% Absolute Diff: 11%; 95% CI 1 to 21% Relative Risk 1.48; 95% CI 1.04 to 2.10; P = 0.03 Severe acute traumatic coagulopathy = PT >1.5 to 3.33; P = 0.72

FFP 139

FFP Frozen Plasma ALS Plasma 139

Critical Care Scenarios

JANUARY 10, 2021

You may consider remdesevir or convalescent plasma at this point in the science, but don’t expect too much effect.* .* Worsening tachypnea, distress, and ventilatory (not hypoxic) failure are a marker to upgrade care and/or intubate a borderline COVID patient.* Prone early, when the lungs are still recruitable and salvageable. .*

Critical Care 100

Critical Care Plasma ICU OR 100

Critical Care Scenarios

OCTOBER 31, 2021

Plasma free hemoglobin levels may be a useful marker that changing your oxygenator could improve gas exchange.* Cannulation can be done by whomever is skilled and trained, such as cardiac surgery, trauma surgery, trained intensivists, etc.* Anticoagulate most patients on VV ECMO with heparin to a PTT of 45-55.

Interfacility Transport 100

Interfacility Transport Plasma ICU EMS 100

Pediatric EM Morsels

MARCH 17, 2023

Since we all inhabit the same beautiful world , and sometimes we humans overtake previous habitats of animals, we inevitably will cross paths with an animal that bites us. Usually, animals bite from fear or defense of their offspring ( ex, Brown Recluse ). Sometimes it’s a beloved pet who gets surprised or has an “off” day ( Dog Bites and PTSD ).

Frozen Plasma 130

Frozen Plasma Plasma First Aid OR 130

EMDocs

MAY 23, 2024

3 Measured in analytical testing : Laboratories measure plasma concentration using osmometers which measures values as a function of kilograms of solvent. Choice of the best equation for plasma osmolality calculation: Comparison of fourteen formulae. Validation of equations used to predict plasma osmolality in a healthy adult cohort.

Plasma 83

Plasma EMS ED OR 83

Medgadget

MAY 11, 2023

Red cells are healthy monocytes, green and yellow are plasma cells. In such cancers, finding the right drug or drug combination for a given patent is critical. The approach involves seeding the cancer cells into 384-well plates, and then placing different drugs or drug combinations into each well.

Plasma 79

Plasma OR 79

Emergency Medicine Ireland

APRIL 29, 2024

If it’s rising too quick it’s often because the patient is losing lots of water through the kidneys which concentrates the plasma raising the Na in the blood. But as we all know in critical care we often work with less than ideal information and have to begin treatment while the diagnostic process is ongoing.

Critical Care 75

Critical Care Plasma OR ED 75

The Overrun Podcast

MARCH 14, 2023

Enrolled 789 patients RePHILL Study Question and Methods: Multicenter RCT out of the UK that investigated prehospital resuscitation using PRBCs and plasma versus normal saline to improve tissue perfusion or mortality in adult trauma patients with hemorrhagic shock.

Plasma 52

Plasma CPR OR 52

Emergency Medicine Ireland

MARCH 7, 2022

On the other hand, lymphoid cells have a much smaller and narrower family tree differentiating into different types of lymphocytes and plasma cells. This is a cancer of plasma cells which are the grown up and left home versions of B lymphocytes. They are also distinct in histology and outcomes from the solid organ malignancies.

Critical Care 52

Critical Care Plasma ICU OR 52

Core EM

OCTOBER 2, 2024

Author: Natalie Bertrand, MD Editor: Naillid Felipe, MD Background: Definition: adverse reaction to blood product administration Incidence: more common in children than adults, except for delayed hemolytic transfusion reactions Allergic (non-anaphylaxis) – Platelets 1-3%; RBCs 0.1-0.3% mg IF requiring IM Epi >3x, switch to IV Epi, 0.05-0.1

Allergic Reaction 100

Allergic Reaction Plasma ED Epinephrine 100

Emergency Medicine Ireland

JUNE 7, 2021

In the plasma itself, 50% is ionised, 40% is plasma bound and 10% is chelated to various anions. There is a large gradient between the ionised calcium in the plasma and the tiny ionised fraction in the cells. So as an important starter, the serum level of calcium does not tell us much about overall levels in the body.

Critical Care 52

Critical Care Plasma ICU OR 52

Emergency Medicine Ireland

MARCH 13, 2023

In broad terms we can compare dialysis (the movement of small molecules across a membrane along an osmotic gradient) with ultrafiltration (the squeezing of plasma through a big sieve that retains the big bits of the plasma and lets the other bits leak out). These rejoice in the acronyms CVVH, CVVHD and CVVHDF respectively.

Critical Care 52

Critical Care Plasma ICU OR 52

Emergency Medicine Ireland

FEBRUARY 11, 2021

Up front there are some problems with the terminology * Plasmapheresis = process of removing plasma from the blood. Welcome back to the tasty morsels of critical care podcast. Plasmapheresis (or PLEX) is one of the machines we tend not to have responsibility for in the ICU. Unlike CRRT we tend to defer to another specialty to do this.

Critical Care 40

Critical Care Plasma ICU OR 40

EMDocs

NOVEMBER 20, 2023

For patients on VKAs to prevent stroke in nonvalvular atrial fibrillation who require reversal, 4-factor prothrombin complex concentrate (PCC) is preferred to fresh frozen plasma (FFP) because of the rapidity of INR reduction (Conditional recommendation, very low-quality evidence). Conditional recommendation, low-quality evidence).

Frozen Plasma 99

Frozen Plasma FFP Plasma OR 99

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. What is the ideal blood component ratio for massive transfusion in traumatic hemorrhage? in the 1:1:1 group vs. 17.0%

E-9-1-1 52

E-9-1-1 Plasma ACS ALS 52