Emergency medicine clinics of North America
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Emerg. Med. Clin. North Am. · Nov 2020
Review Historical ArticleFluid Resuscitation: History, Physiology, and Modern Fluid Resuscitation Strategies.
Intravenous (IV) fluids are among the most common interventions performed in the emergency department. They are at times lifesaving, but if used recklessly can be harmful. Given their ubiquity, it is important to understand the history, physiology, and current strategies that govern the use of IV fluids during the resuscitation of the critically ill.
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Sepsis care has evolved significantly since the initial early goal-directed therapy (EGDT) trials. Early fluid resuscitation, source control, and antibiotic therapy remain cornerstones of care but overall understanding is more nuanced, particularly regarding fluid selection, vasopressors, and inotropic support. ⋯ Recent research has explored immunomodulation, β-blockade, and vitamin supplementation. A renewed emphasis on early, aggressive resuscitation reaffirms the importance of emergency medicine providers knowledgeable and skilled in sepsis management.
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Excellent resuscitation requires technical skills and knowledge, but also the right mindset. Expert practitioners must master their internal affective state, and create the environment that leads to optimal team performance. ⋯ Providers should have explicit plans for recovery after traumatic cases, including developing resilience and self-compassion. Experts in resuscitation can improve their performance (and that of their team) by consciously incorporating psychological skills into their armamentarium.
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Emerg. Med. Clin. North Am. · Nov 2020
ReviewPearls and Pitfalls in the Crashing Geriatric Patient.
The geriatric population is growing and is the largest utilizer of emergency and critical care services; the emergency clinician should be comfortable in the management of the acutely ill geriatric patient. There are important physiologic changes in geriatric patients, which alters their clinical presentation and management. ⋯ Premorbid functional status, frailty, and severity of illness should be considered carefully for the geriatric population. Emergency clinicians should have honest conversations about goals of care based not only a patient's clinical presentation but also the patient's values.
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Care of the critically ill pregnant patient is anxiety-provoking for those unprepared, as the emergency physician must consider not only the welfare of the immediate patient, but of the fetus as well. Familiarity with the physiologic changes of pregnancy and how they affect clinical presentation and management is key. Although some medications may be safer in pregnancy than others, stabilizing the pregnant patient is paramount. Emergency physicians should target pregnancy-specific oxygen and ventilation goals and hemodynamics and should be prepared to perform a perimortem cesarean section, should the mother lose pulses, to increase chances for maternal and fetal survival.