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Showing posts from February, 2017

Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis: The HYPRESS Randomized Clinical Trial

Journal Club Summary
Methodology Score: 3/5                    Usefulness Score:  2.5/5
KehD, et al. JAMA.2016Nov 1;316(17):1775-1785 Abstract Link In this multicenter placebo-controlled double-blind RCT, the authors concluded that in adults with severe sepsis, hydrocortisone IV infusion does not prevent progression of severe sepsis to septic shock. While this study was well done overall, the group had concerns about the removal of patients with adverse events from the modified intention-to-treat analysis, the lack of reporting of time to antibiotics, powering the study to detect a very high (15%) difference between groups. This not being an ED study the results are not applicable to our population. By: Dr. Stephanie Barnes
EDITORIAL: Yende S,et al. Evaluating Glucocorticoids for Sepsis: Time to Change Course.  JAMA.2016Nov 1;316(17):1769-1771.
Epi lessonRandomization by Pocock minimization algorithmFebruary 2017
A random allocation of …

REBOA: Resuscitative Endovascular Balloon Occlusion of the Aorta

The use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has become a topic of considerable interest as of late, primarily to treat non-compressible truncal hemorrhage (NCTH). However, it is beginning to expand into other causes of non-compressible bleeding.  Why do we care? Bleeding is the 2nd leading cause of traumatic death behind only traumatic brain injury (TBI). Additionally, it is the number one cause of preventable death in trauma, causing 85% of all preventable trauma deaths.  Furthermore, 35% of all pre-hospital deaths and over 40% of deaths within the first 24 hours following trauma are attributed to bleeding (Kauvar, Lefering, & Wade, 2006).  One article states that there are around 60 000 civilian deaths per year in the US secondary to traumatic bleeding (Sauaia et al., 1995). Is this REBOA thing new?! Nope. 
The concept and use of REBOA has been around since at least 1954, when Lieutenant Colonel Carl Hughes of the US military published an article desc…

Focus on POCUS: Pleuritic Chest Pain with Tachycardia - Pericarditis or PE?

Case DescriptionA young, previously healthy male in his 30s presents to the ED from his family physicians office with chest pain and an abnormal ECG. He has a 3-4 day history of non-radiating upper back pain and sensation of chest tightness that is pleuritic in nature and worse when supine. In addition there is a history of fever, chills, myalgias and night sweats. He has no recent travel history. He denies any SOB, cough, orthopnea, PND or syncope. 
There is no IV drug use, immunocompromise or diabetes. He has no previous cardiac history other than a possible history of pericarditis a year ago. There is no personal history of PE/DVT.
On initial presentation the patient was febrile at 38.1C and tachycardic in the 120s. His blood pressure was normal at 114/79. Respiratory rate and oxygen saturation were normal on room air.
His cardiovascular exam was normal, other than an S3. There was no pericardial rub. Respiratory exam was unremarkable.
Laboratory investigations were unremarkable, inc…

The Top 10 Most Important Articles of 2016 (and some from 2015)

This is a summary of a talk given by Drs. Krishan Yadav and Maggie Kisilewicz at the National Capital Conference in Emergency Medicine. Below are brief summaries and a bottom line, but of course you'll have to read the literature yourself to make your own decisions! 1) Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage ATACH-2  Qureshi et al. N Engl J Med 2016; 375: 1033 – 1043.
DOI: 10.1056/NEJMoa1603460.

• RCT to assess if aggressive SBP reduction within 4.5 hours of spontaneous intracranial hemorrhage results in decreased death or disability at 3 months.
• Main Finding: No difference in death or disability at 3 months for Intensive BP (110 – 139 mmHg) vs. Standard BP (140 – 179 mmHg) group.
o Caution: this trial really compared SBP targets of 129 mmHg vs. 141 mmHg (see Figure 1)
• Bottom Line: BP reduction to 140 mmHg is safe. Aim for a SBP target of 160 mmHg in  spontaneous ICH – if the patient continues to deteriorate, revise target to 140 mmHg.