Thursday, September 17, 2020

Resident Journal Review: Do Adjunctive Therapies Beyond Infection Control and Appropriate Fluid Resuscitation Change Outcomes in Sepsis and Septic Shock?

Authors: Jordan Parker MD; Sharleen Yuan, MA MD PhD; Megan Donohue, MD; Robert Brown, MD; Mark Sutherland, MD; Hannah Goldberg, MD; Akilesh Honasoge, MD
Editors: Kami M. Hu, MD FAAEM, Kelly Maurelus, MD FAAEM
Originally published: Common Sense
September/October 2020

Septic shock is an illness with complex pathophysiology and few available therapies, beyond infection control and appropriate fluid resuscitation, to reverse the disease state. It is one of the most prevalent and lethal disease states that a physician may manage, with 1.7 million cases of sepsis in the United States per year and a reported mortality rate of up to 34%.1,2 The pathogenesis of septic shock is thought to be driven by a dysregulated host response3 with the role of adjunctive therapies being to assist in reversing this dysregulated response. Treatments that have more recently been a hot topic of debate include vitamin C, corticosteroids and thiamine. Vitamin C (ascorbic acid) a role in numerous physiologic processes including endothelial permeability, micro and macrovascular function, cellular apoptosis, immune system function and endogenous catecholamines.4 Studies have shown that vitamin C deficiency is present in critically ill patients,4 and its role in these essential functions is the basis for its use as a potential treatment in septic shock. Thiamine also plays a role in key metabolic processes, including cellular energy production and generation of cellular antioxidants, and thiamine deficiency has been well-documented in sepsis, with observational studies indicating a signal for improved outcomes with supplementation.4 Steroids have been used in refractory septic shock for almost the past two decades5 but the recent rationale for its use includes its synergism with vitamin C. Glucocorticoids may be able to increase the activity of vitamin C by increasing expression of the transporter involved in its uptake into cells, sodium-vitamin C transporter (SVCT2).4 In return, vitamin C, as an antioxidant, may be able to facilitate the binding of glucocorticoids to their receptor, a coupling impeded by oxidizing molecules. We will review several of the high-profile trials that have attempted to elucidate the effectiveness of utilizing corticosteroids, vitamin C, and thiamine in the management of patients with sepsis and septic shock.

Friday, September 4, 2020

A Medical Student/Paramedic's Perspective on COVID-19

Image credit: Pexels
Matthew Carvey
Originally published: Common Sense
July/August 2020

Medic-1 is responding to an assault in a rural location. Dispatch notifies EMS that the patient has a fever and was put on mandatory self-isolation for 14 days. On arrival, EMS dons a sterile cap, goggles, an N95 mask, face shield, gown, and gloves. The patient, belligerent and intoxicated on alcohol and psilocybin, yells at EMS ‘I have the COVID!’. She rushes EMS, removes the practitioners mask, and coughs in his face. Police arrest the woman under the Mental Health Act, and EMS transports, only for her to spit and verbally abuse them the entire length of transport. EMS unloads the patient and awaits triage. After handing over care, EMS doffs all used PPE, and don’s new equipment to thoroughly clean the ambulance. One of the practitioner’s displays signs of COVID-19 three days later. This article is a medical student/paramedic’s perspective on COVID-19.

Thursday, August 27, 2020

Resident Journal Review: Available Evidence Regarding Targeted Temperature Management (TTM)

Rithvik Balakrishnan MD; Taylor M. Douglas, MD; Taylor Conrad, MD, MS; Theodore Segarra, MD; Christianna Sim, MD, MPH
Editors: Kelly Maurelus MD FAAEM, Kami Hu MD FAAEM
Originally published: Common Sense
July/August 2020

The ability to obtain good neurological outcomes after cardiac arrest is often limited. Interventions during the acute phase of treatment post return of spontaneous circulation (ROSC) are therefore critical.1 The primary goal of cardiopulmonary resuscitation (CPR) is to optimize coronary perfusion pressure and maintain systemic perfusion in order to prevent neurologic and other end-organ damage while working to achieve ROSC. While the utility of therapeutic hypothermia for preservation of neurologic function post-cardiac arrest had been suggested in the early 1950s and 1960s, 2-4 the studies were inconclusive, with high complication rates. It was not until the 1990s that studies showed possible benefits to mild hypothermia in animal models. 5-10 The results of the 2002 trial by the Hypothermia after Cardiac Arrest Study Group were the basis for the inclusion of therapeutic hypothermia in the American Heart Association’s post-cardiac arrest care guidelines.11 Subsequent trials have assessed the difference between therapeutic hypothermia to 33 degrees Celsius (ºC) and “targeted temperature management” (TTM) aiming for 36ºC, the duration of TTM, the method used to achieve and maintain it, and whether TTM confers a similar neurological benefit for cardiac arrests secondary to non-shockable rhythms; some of these trials will be discussed below and will help us answer the question at hand.

Thursday, August 20, 2020

New Florida Law Requiring Written Consent for Pelvic Exams: Stumbling Towards Trauma-Informed Care

Image credit: Flickr

Authors:Emily Lara S. Dawra, BS, MSII
University of Miami Miller School of Medicine MD Program

Kasha Bornstein, MSc Pharm, EMT-P, MSIV
University of Miami Miller School of Medicine MD/MPH Program
AAEM/RSA Modern Resident Blog Copy Editor

On June 18, 2020, Florida Governor Rick DeSantis approved Florida Senate Bill 698, which strictly prohibited and criminalized the non-emergent use of pelvic examinations without written consent of either the patient or legal guardian.1 The new measure has particular implications for the flow of operations in emergency departments across Florida, as the requirements are a potential source of confusion, additional legal jeopardy, and increased bureaucratic workload. Effective as of July 1, 2020, this legislation has already garnered strong reactions from medical professionals, including the American College of Obstetrics and Gynecology, who believe this serves a “gross intrusion in the patient-physician relationship,” and whose statement is further endorsed by the Florida Medical Association.2,3 This article describes and expands on the spoken concerns surrounding this bill as they may apply to the emergency clinician. 

Thursday, August 13, 2020

Lightning Strike Emergencies Part 2: Trauma Approach

Image Credit: Piqsels
Vivek Abraham, MD
PGY-1, Orthopedic Surgery

Additional Authors:
Ivan Yue, MD
PGY-1, Emergency Medicine
Naval Medical Center San Diego
AAEM/RSA Publications and Social Media Committee

Alexander Li, MD
PGY-1, Orthopedic Surgery
Naval Medical Center Portsmouth

Lightning strike triage and cardiac resuscitation was previously covered in part 1. Abnormal cardiac rhythms are the most common fatal complications of lightning strikes, but other complications of lightning strikes can cause high morbidity and mortality if left untreated. This article will go over injury patterns that may be seen and diagnosed in the emergency room.