Emergency medicine clinics of North America
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Emerg. Med. Clin. North Am. · Aug 2019
ReviewExtubation in the Emergency Department and Resuscitative Unit Setting.
A subset of intubated patients can safely be extubated in the emergency department (ED). The emergency medicine provider should be prepared for both common and life-threatening complications if considering ED extubation. ⋯ Intensive nursing care, close monitoring, and the ability to reintubate are minimum requirements for EDs considering ED extubation. This article provides a framework for determining appropriate patients for extubation and a practical approach on how to safely perform the procedure.
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Acute ischemic stroke (AIS) is a medical emergency that requires prompt recognition and streamlined work-up to ensure that time-dependent therapies are initiated to achieve the best outcomes. This article discusses frequently missed AIS in the emergency department, the role of various imagining modalities in the work-up of AIS, updates on the use of intravenous thrombolytics and endovascular therapy for AIS, pearls on supportive care management of AIS, and prehospital and hospital process improvements to shorten door-to-needle time.
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Emerg. Med. Clin. North Am. · Aug 2019
ReviewEmergency Department Management of Acute Kidney Injury, Electrolyte Abnormalities, and Renal Replacement Therapy in the Critically Ill.
Acute kidney injury (AKI) is a common sequela of critical illness. Clinical manifestation of AKI varies and can include electrolyte abnormalities, anion gap, or non-anion-gap metabolic acidosis. ⋯ Conservative management should first be attempted for patients with AKI. If conservative management fails, renal replacement therapy or hemodialysis can be used.
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Although cardiogenic shock is uncommon in the emergency department, it is associated with high mortality. Most cardiogenic shock is caused by ischemia, but nonischemic etiologies are essential to recognize. Clinicians should optimize preload, contractility, and afterload. ⋯ Vasopressors are important to restore end-organ perfusion, and inotropes improve contractility. Intubation and positive pressure ventilation impact hemodynamics, which, depending on volume status, may be beneficial or deleterious. Knowing indications for mechanical circulatory support is important for timely consultation or transfer as indicated.
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Emerg. Med. Clin. North Am. · Aug 2019
ReviewTargeted Temperature Management and Postcardiac arrest Care.
Despite recent advances, care of the post-cardiac arrest patient remains a challenge. In this article, the authors discuss an approach to the initial care of post-cardiac arrest patients with particular focus on targeted temperature management (TTM). ⋯ It also reviews controversial topics, including TTM for nonshockable rhythms, TTM dose, and surface versus endovascular cooling. The article concludes with a brief review of other key aspects of post-arrest care: coronary angiography, hemodynamic optimization, ventilator management, and prognostication.