Emergency medicine clinics of North America
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Emerg. Med. Clin. North Am. · Nov 2014
ReviewEmergency Department Antimicrobial Considerations in Severe Sepsis.
Severe sepsis and septic shock are common problems in the emergency department patient population and require expert clinical skill by members of the emergency department team to maximize optimal patient outcomes. Although various guidelines have been developed for the management of these patients, issues around antimicrobial-related considerations in critically ill patients require further evidence-based attention. In this review article, important factors related to patient illness, microorganism, timing of antimicrobial administration, and source control are discussed.
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Neurocritical care aims to improve outcomes in patients with life-threatening neurologic illness. The scope of neurocritical care extends beyond the more commonly encountered and important field of cerebrovascular disease, as described previously. This article focuses on neuromuscular, neuroinfectious, and neuroimmunologic conditions that are significant causes of morbidity and mortality in the acutely neurologically ill patient. As understanding continues to increase regarding the physiology of these conditions and the best treatment, rapid identification, triage, and treatment of these patients in the emergency department is paramount.
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Critically ill patients with undifferentiated shock are complex and challenging cases in the ED. A systematic approach to assessment and management is essential to prevent unnecessary morbidity and mortality. The simplified, systematic approach described in this article focuses on determining the presence of problems with cardiac function (the pump), intravascular volume (the tank), or systemic vascular resistance (the pipes). With this approach, the emergency physician can detect life-threatening conditions and implement time-sensitive therapy.
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Shock is a physiologic state associated with high morbidity and mortality rates. The clinician has several tools available to evaluate volume status. ⋯ Although the search for the Holy Grail of a perfect intravascular monitor continues, we must remember the importance of early, aggressive, and goal-directed interventions for patients in shock. Finally, there is no substitute for the most important intervention-the frequent presence of the physician at the patient's bedside.
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The role for temporary and durable mechanical circulatory support is rapidly expanding. As the use of these technologies continues to grow, the emergency physician has an increasing opportunity to participate in the advancement of these potentially life-saving technologies. This review discusses the current role of the intra-aortic balloon pump in cardiogenic shock, describes the complications and management strategies for the critically ill patient with a left ventricular assist device, and explores the emerging role of ECMO in the emergency department for patients presenting in refractory cardiogenic shock and cardiac arrest.