Emergency medicine clinics of North America
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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.
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Emerg. Med. Clin. North Am. · Aug 2019
ReviewResuscitating the Critically Ill Geriatric Emergency Department Patient.
The emergency department resuscitation of the critically ill geriatric patient is challenging and can be fraught with peril. The anatomic and physiologic changes that occur with aging can significantly influence the recognition of critical illness and the logistics of resuscitation itself. This article discusses the relevant physiologic changes with aging, the effect of these changes on clinical manifestations of critical illness in older adults, and the core principles of resuscitation in this population, with specific attention to sepsis and trauma care. In addition, end-of-life care is also discussed.