Emergency medicine clinics of North America
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Pulmonary embolism is a challenging pathology commonly faced by emergency physicians, and diagnosis and management remain a crucial skill set. Inherent to the challenge is the breadth of presentation, ranging from asymptomatic pulmonary emboli to sudden cardiac death. ⋯ Management of pulmonary emboli revolves around appropriate anticoagulation, which for most of the patients will comprise newer oral agents. However, there remains a substantial degree of practice variation and ambiguity when it comes to higher risk patients with submassive or massive pulmonary emboli.
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Acute respiratory distress syndrome (ARDS) occurs in up to 10% of patients with respiratory failure admitted through the emergency department. Use of noninvasive respiratory support has proliferated in recent years; clinicians must understand the relative merits and risks of these technologies and know how to recognize signs of failure. The cornerstone of ARDS care of the mechanically ventilated patient is low-tidal volume ventilation based on ideal body weight. Adjunctive therapies, such as prone positioning and neuromuscular blockade, may have a role in the emergency department management of ARDS depending on patient and department characteristics.
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Acute respiratory failure requiring invasive mechanical ventilation is a common presentation in the emergency department. Providers can further improve care for these patients by understanding common modes of mechanical ventilation, recognizing changes in respiratory mechanics, and tailoring ventilator settings and therapies accordingly.
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Emerg. Med. Clin. North Am. · Aug 2022
ReviewEvaluation and Management of Asthma and Chronic Obstructive Pulmonary Disease Exacerbation in the Emergency Department.
Obstructive lung disease includes asthma and chronic obstructive pulmonary disease (COPD). Exacerbation of asthma or COPD can result in significant morbidity and mortality, and emergency department (ED) care is often required. ED evaluation should assess risk factors for severe exacerbation and the patient's hemodynamic and respiratory status. ⋯ First-line treatments for acute exacerbation include bronchodilators and corticosteroids. Noninvasive ventilation, magnesium, ketamine, and epinephrine should be considered in those with severe exacerbation. Mechanical ventilation is challenging and should use an obstructive lung strategy with permissive hypercapnia.