Emergency medicine practice
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Review Case Reports
Advances in diagnosis and management of hypokalemic and hyperkalemic emergencies.
With up to 56% of individuals taking diuretics likely to develop hypokalemia, and comorbid disease and many other types of medications having the potential to induce hyperkalemia, potassium abnormalities are some of the most commonly seen electrolyte abnormalities in the emergency department (ED). Unless recognized and treated appropriately, they can also be some of the most deadly. ⋯ Recognition and treatment of life-threatening dysrhythmias in hypokalemia and hyperkalemia are key to managing these potassium abnormalities. Electrocardiogram (ECG) findings, treatment algorithms, and controversies on treating potassium abnormalities in the ED are discussed, with recommendations on criteria for disposition.
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A number of concerns have been raised regarding the advisability of the classic principles of aggressive crystalloid resuscitation in traumatic hemorrhagic shock. This issue reviews the advances that have led to a shift in the emergency department (ED) protocols in resuscitation from shock state, including recent literature regarding the new paradigm for the treatment of traumatic hemorrhagic shock, which is most generally known as damage control resuscitation (DCR). ⋯ The primary conclusions include the administration of tranexamic acid (TXA) for all patients with uncontrolled hemorrhage (Class I), the implementation of a massive transfusion protocol (MTP) with fixed blood product ratios (Class II), avoidance of large-volume crystalloid resuscitation (Class III), and appropriate usage of permissive hypotension (Class III). The choice of fluid for initial resuscitation has not been shown to affect outcomes in trauma (Class I).
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Appendicitis is the most common cause of acute abdominal pain requiring surgical treatment in persons under 50 years of age, with a peak incidence in the second and third decades. Women have a greater risk of misdiagnosis and a higher negative appendectomy rate. Atypical presentations of appendicitis are commonly misdiagnosed, resulting in increased morbidity, mortality, and potential litigation. ⋯ Patients presenting with possible appendicitis should be risk stratified based on history, physical examination, and laboratory data. An elevated white blood cell (WBC) count alone (> 10,000 cells/mm3) offers poor diagnostic utility; however, combining WBC count > 10 and C-reactive protein (CRP) level > 8 achieves notable predictive power in the diagnosis of acute appendicitis. Imaging studies play a vital role in diagnosis, particularly in equivocal presentations.
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There are approximately 12 million emergency department (ED) visits related to mental health/substance abuse annually. Approximately 650,000 patients are evaluated annually for suicide attempts. Evidence to guide the management and treatment of depression and suicidal ideation in the ED is limited. ⋯ Recognition of depression by emergency clinicians has proved poor. Suicide is associated with multiple risk factors, of which a prior history of suicide attempts is the single strongest predictor. A systematic approach is required in the ED to identify patients with or at risk of having depression, and screening tools may offer utility to identify high-risk patients.
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Review Case Reports
Current evidence in therapeutic hypothermia for postcardiac arrest care.
The ring of the red notification phone breaks the relative calm of an otherwise typical Monday morning and heralds the arrival of a critically ill patient. The dispatcher announces that EMS is on the way with a 57-year-old man in cardiac arrest, with an ETA of 3 minutes. Shortly after preparations for their arrival are complete, EMS personnel enter with CPR in progress and the patient already intubated. ⋯ During the next rhythm check, QRS complexes are noted on the monitor and a pulse is palpated. The patient has had a return of spontaneous circulation, apparently 50 minutes from onset of the arrest. As you initiate postresuscitation care, you consider the patient's prognosis and wonder if he qualifies for therapeutic hypothermia; ie, will therapeutic hypothermia make a difference in his outcome?