Early goal-directed therapy in the treatment of severe sepsis and septic shock

http://degreesofclarity.com/emsbasics/library/gilbert%20-%20Chart%20Reviews%20In%20Emergency%20Medicine%20Research-%20Where%20Are%20The%20Methods%3f.pdf

Chart Reviews In Emergency Medicine Research: Where Are The Methods?

The Glasgow Coma Scale (GCS) has been widely adopted. Failure to assess the verbal score in intubated patients and the inability to test brainstem reflexes are shortcomings. We devised a new coma score, the FOUR (Full Outline of UnResponsiveness) score. It consists of four components (eye, motor, brainstem, and respiration), and each component has a maximal score of 4. We prospectively studied the FOUR score in 120 intensive care unit patients and compared it with the GCS score using neuroscience nurses, neurology residents, and neurointensivists. We found that the interrater reliability was excellent with the FOUR score (kappa(w) = 0.82) and good to excellent for physician rater pairs. The agreement among raters was similar with the GCS (kappa(w) = 0.82). Patients with the lowest GCS score could be further distinguished using the FOUR score. We conclude that the agreement among raters was good to excellent. The FOUR score provides greater neurological detail than the GCS, recognizes a locked-in syndrome, and is superior to the GCS due to the availability of brainstem reflexes, breathing patterns, and the ability to recognize different stages of herniation. The probability of in-hospital mortality was higher for the lowest total FOUR score when compared with the lowest total GCS score.

https://www.rtjournalonline.com/Validation%20of%20a%20new%20coma%20scale%20-%20The%20FOUR%20score.pdf

Validation of a new coma scale: The FOUR score

The granzymes are cell death–inducing enzymes, stored in the cytotoxic granules of cytotoxic T lymphocytes and natural killer cells, that are released during granule exocytosis when a specific virus-infected or transformed target cell is marked for elimination. Recent work suggests that this homologous family of serine esterases can activate at least three distinct pathways of cell death. This redundancy likely evolved to provide protection against pathogens and tumors with diverse strategies for evading cell death. This review discusses what is known about granzyme-mediated pathways of cell death as well as recent studies that implicate granzymes in immune regulation and extracellular proteolytic functions in inflammation.

/pdf/death-by-a-thousand-cuts-granzyme-pathways-of-programmed-uz035pmm7v.pdf

Death by a thousand cuts: granzyme pathways of programmed cell death.

ObjectiveTo determine whether mortality rate after intracerebral hemorrhage (ICH) is lower in patients admitted to a neurologic or neurosurgical (neuro) intensive care unit (ICU) compared to those admitted to general ICUs.BackgroundThe utility of specialty ICUs is debated. From a cost perspective, h

Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage.

We sought to determine the reliability of the Glasgow Coma Scale (GCS) when used by emergency physicians and paramedics. We performed a prospective sequential trial in a classroom setting, with subjects blinded to others' scoring. Nineteen university-affiliated emergency physicians and 41 professional paramedics from an urban EMS system voluntarily participated. Participants viewed four videotaped scenes in which a patient is assessed by a paramedic. The first three scenes represented severe, intermediate, and no/mild alteration in level of consciousness (LOC). The findings in the fourth scene were identical to the first, allowing determination of intrarater reliability. The Kappa statistic was used to determine interrater reliability; the reliability coefficient determined intrarater reliability. Kappa was significant (p < 0.0001) for severe (kappa = 0.48), intermediate (kappa = 0.34), and no/mild (kappa = 0.85) conditions. Intrarater reliability (r1,2) for emergency physicians was 0.66 (p < 0.01) and for paramedics was 0.63 (p < 0.01). The GCS shows statistically significant reliability (i.e., significant agreement) between emergency physicians and emergency medical technician-paramedics. It also has a significant level of intrarater reliability.

Reliability of the Glasgow Coma Scale when used by emergency physicians and paramedics.

Objectives: Efforts to mitigate unexpected problems during transition of an active emergency department (ED) to a new physical plant are imperative to ensure effective health care delivery and patient safety. The authors used advanced medical simulation (SIM) to evaluate the capacity of a new ED for emergent resuscitative processes and assist facility orientation before opening day.



Methods: Operational readiness testing and orientation to the new ED of a large academic center were arranged through a Transportable Enhanced Simulation Technologies for Pre-Implementation Limited Operations Testing (TESTPILOT) project. Using a portable life-sized computerized manikin, the project required participants to perform assorted patient care interventions on-site. Cardiac arrest, multitrauma, uroseptic shock, and pediatric toxicology scenarios elicited the dynamics of real-life ED activities. Debriefings and surveys assessed participants' perceptions of the new facility's clinical readiness and identified areas needing administrative attention. Subjective utility of SIM orientation was compared with that of standard facility orientation.



Results: Fourteen ED clinicians and five SIM facilitators participated over two sessions. The new facility received mean (± SD) and median five-point Likert scale scores of 4.4 (± 0.8) and 5 for ability of clinical staff to perform resuscitations. The respective scores for ability of simulated scenarios to prepare staff for new ED function were 4.6 (± 0.5) and 5, compared with 4.2 (± 1.0) and 4 for non-SIM orientation (p = 0.22; not significant). Problems with equipment location, inadequate procedural surfaces, and insufficient orientation were discovered and rapidly corrected.



Conclusions: Transportable SIM was used to evaluate the clinical functions of a new ED. Significant operational issues identified by participants were corrected before opening of the facility. Limited comparison did not reveal SIM enhancement of orientation.

https://onlinelibrary.wiley.com/doi/pdf/10.1197/j.aem.2006.01.023

Portable Advanced Medical Simulation for New Emergency Department Testing and Orientation

As carbon monoxide (CO) toxicity may present with non-specific signs and symptoms and without history of exposure, screening for CO toxicity may identify occult cases The objective of this study was to determine whether non-invasive screening for CO exposure could be performed in all patients presenting to a high-volume urban emergency department (ED) and would identify patients with unsuspected CO toxicity A study of adult patients, who presented to the ED for any complaint, prospectively screened for carboxyhemoglobin concentration by a pulse CO-oximeter (SpCO) ED triage staff recorded SpCO on the patient's chart at triage Data, including SpCO and vital signs, were recorded in a database by two trained research assistants When available, carboxyhemoglobin concentration obtained by venous blood was also included in the data set There were 14,438 patients who presented to the ED and were entered in the study Data from 10,856 (75%) patients receiving screening for SpCO were analyzed Patients were 44 ± 19 years old and 51% female; 32% of the patients smoked The mean SpCO was 517% ± 378% among smokers and 290% ± 276% among non-smokers During the study period, 11 patients with presenting signs and symptoms not consistent with CO toxicity were identified through SpCO screening Screening for CO toxicity using a non-invasive pulse CO-oximeter can be conducted even in a busy tertiary center ED and identify patients with occult CO toxicity

Non-invasive pulse co-oximetry screening in the emergency department identifies occult carbon monoxide toxicity

Modern dental care and use of antibiotics for oral infections have made Ludwig's angina rare. To avoid acute airway obstruction, emergency physicians must be able to rapidly recognize and treat this condition. A typical case of Ludwig's angina is presented, followed by a review of clinical findings and therapeutic modalities. Emphasis is made on airway management, antibiotics, and surgical drainage.

Ludwig's angina: Case report and review

Objective:To study the natural outcome of patients refusing prehospital transportation (PT).Methods:A total of 188 consecutive patients who refused PT in an urban, advanced life support (ALS), emergency medical services (EMS) system were studied. Of these, 77 (41 %) were male, and the average age was 51 years. Patients were entered into the study group only once.Results:Only 94 (50%) patients could be reached by telephone follow-up. Seven (7%) of these 94 patients had abnormal vital signs, 33 (35%) had cardiopulmonary complaints, 16 (17%) had an altered level of consciousness, nine (10%) were involved in accidents, and eight (8%) had abdominal pain. Six (6%) patients were admitted to the hospital, two (2 %) received ALS-level treatment by the paramedics and then refused conveyance, and 31 (33 %) either saw or contacted a physician. Consultation with an EMS physician was initiated for nine (5%) refusals. Of all the patients contacted, six (6%) needed PT for hospitalization.Conclusion:As only 50% of the patients refusing prehospital transportation could be reached using follow-up telephone calls, the 6% figure probably underestimates the true number of patients requiring PT. Telephone follow-up is an inadequate means of determining the natural outcome for this patient population. The ALS nature of many of the complaints combined with the lack of consistent physician consultation, exposes the EMS system to an undefined medico-legal liability risk.

Andrew Sucov

Papers

Reliability of the Glasgow Coma Scale when used by emergency physicians and paramedics.

Portable Advanced Medical Simulation for New Emergency Department Testing and Orientation

Non-invasive pulse co-oximetry screening in the emergency department identifies occult carbon monoxide toxicity

Ludwig's angina: Case report and review

The Outcome of Patients Refusing Prehospital Transportation