Emerg Med Clin North Am
· 2023 Nov · PMID 37758424
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The adrenal glands drive physiologic homeostasis, with dysregulation in any direction causing multisystem dysfunction. Adrenal excess states include hyperaldosteronism which manifests with refractory hypertension and ele...The adrenal glands drive physiologic homeostasis, with dysregulation in any direction causing multisystem dysfunction. Adrenal excess states include hyperaldosteronism which manifests with refractory hypertension and electrolyte abnormalities including hypernatremia and hypokalemia. Paragangliomas including pheochromocytoma can cause multisystem end-organ dysfunction due to catecholaminergic storm, which require rapid blood pressure control with phentolamine and identification of lesions amenable to surgical resection. Adrenal insufficiency states in contrast can result in hypotension and decompensation refractory to vasopressor administration, requiring adrenal supplementation via hydrocortisone.
Emerg Med Clin North Am
· 2023 Nov · PMID 37758423
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Diabetes management has continued to evolve with new treatments and technology. This article discusses the approach to evaluation and management of two distinctive subsets of patients: (1) patients who manage their diabe...Diabetes management has continued to evolve with new treatments and technology. This article discusses the approach to evaluation and management of two distinctive subsets of patients: (1) patients who manage their diabetes with an insulin pump (artificial pancreas) and (2) patients who have received a pancreas transplant. The most current literature is reviewed and pearls and pitfalls distinctive to these two patient populations are discussed. Relevant diagnostics are reviewed with emphasis on recognition of complications faced in the emergency department management of these unique patient populations.
Emerg Med Clin North Am
· 2023 Nov · PMID 37758422
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Hyperthyroidism is a diagnosis existing along a spectrum of severity. Patients present with a variety of signs and symptoms: tachycardia, elevated heart rate, anxiety, changes in mental status, gastrointestinal disturban...Hyperthyroidism is a diagnosis existing along a spectrum of severity. Patients present with a variety of signs and symptoms: tachycardia, elevated heart rate, anxiety, changes in mental status, gastrointestinal disturbances, and hyperthermia. Management of subclinical hyperthyroidism and thyrotoxicosis without thyroid storm is heavily dependent on outpatient evaluation. Thyroid storm is the most severe form of hyperthyroidism with the highest mortality. Management of thyroid storm follows a stepwise approach, with resuscitation and detection of the precipitating cause being paramount. Special attention should be paid to cardiac function in patients with thyroid storm before treatment, as these patients may develop cardiac collapse.
Emerg Med Clin North Am
· 2023 Nov · PMID 37758421
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Thyroid hormone affects every human organ system and is a vital component of metabolism. Common and easily treatable, hypothyroidism does not usually require emergency management. However, myxedema coma is the decompensa...Thyroid hormone affects every human organ system and is a vital component of metabolism. Common and easily treatable, hypothyroidism does not usually require emergency management. However, myxedema coma is the decompensated form of hypothyroidism and can be life threatening if not treated expediently.
Emerg Med Clin North Am
· 2023 Nov · PMID 37758420
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Hypoglycemia is commonly encountered in the emergency department. Patients can present with a myriad of symptoms and its presentation can mimic other more serious diagnoses. Despite the relative ease of its management, c...Hypoglycemia is commonly encountered in the emergency department. Patients can present with a myriad of symptoms and its presentation can mimic other more serious diagnoses. Despite the relative ease of its management, clinicians often miss the diagnosis or mismanage it even when discovered. Glucose is an important energy source for the brain and failing to recognize hypoglycemia or mismanaging it can lead to permanent neurologic disability or death. Although it is important to replenish glucose in a rapid fashion, it is equally important to discover and manage the underlying etiology to prevent further episodes of hypoglycemia.
Emerg Med Clin North Am
· 2023 Nov · PMID 37758419
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Abnormalities in serum potassium are commonly encountered in patients presenting to the emergency department. A variety of acute and chronic causes can lead to life-threatening illness in both hyperkalemia and hypokalemi...Abnormalities in serum potassium are commonly encountered in patients presenting to the emergency department. A variety of acute and chronic causes can lead to life-threatening illness in both hyperkalemia and hypokalemia. Here we summarize the relevant causes, risks, and treatment options for these frequently encountered disorders.
Emerg Med Clin North Am
· 2023 Nov · PMID 37758418
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Sodium imbalances are a common occurrence in the emergency department. Although recognition and diagnosis are relatively straightforward, discovering the cause and management should be approached systematically. The most...Sodium imbalances are a common occurrence in the emergency department. Although recognition and diagnosis are relatively straightforward, discovering the cause and management should be approached systematically. The most important history items to ascertain is if the patient has symptoms and how long this imbalance has taken to develop. Treatment rapidity depends on severity of symptoms with the most rapid treatment occurring in only the severely symptomatic. Overcorrection has dire consequences and must be approached in a careful and systematic fashion in order to prevent these devastating consequences.
Emerg Med Clin North Am
· 2023 Nov · PMID 37758417
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Hyperosmolar hyperglycemic state (HHS) is an underrecognized diabetic emergency with high morbidity and mortality. Many features of HHS overlap with those of diabetic ketoacidosis but key differentiators for HHS are seru...Hyperosmolar hyperglycemic state (HHS) is an underrecognized diabetic emergency with high morbidity and mortality. Many features of HHS overlap with those of diabetic ketoacidosis but key differentiators for HHS are serum osmolality greater than 320 mOsm/kg, lack of metabolic acidosis, and minimal to no presence of ketones. HHS is often triggered by an underlying illness-most commonly infection but may also be triggered by stroke, acute coronary syndrome, and other acute illnesses. Treatment guidelines recommend aggressive volume-repletion of osmotic losses in addition to insulin therapy, plus treatment of the underlying cause.
Emerg Med Clin North Am
· 2023 Nov · PMID 37758416
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This article reviews the most current literature on diabetic ketoacidosis, including how to make the diagnosis and management. It discusses euglycemic diabetic ketoacidosis and the risk factors for this rare but dangerou...This article reviews the most current literature on diabetic ketoacidosis, including how to make the diagnosis and management. It discusses euglycemic diabetic ketoacidosis and the risk factors for this rare but dangerous disease process. Pertinent pearls and pitfalls encountered by the emergency physician when managing these patients are included. Because these patients often stay in the emergency department for prolonged periods, recommendations on transitioning to subcutaneous insulin are included, along with dosing recommendations. Finally, the article reviews how to disposition patients with diabetic ketoacidosis and examines important factors that lead to a successful discharge home.
Kongkatong M, Ottenhoff J, Thom C
… +1 more, Han D
Emerg Med Clin North Am
· 2023 Aug · PMID 37391255
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Rapid diagnostic tools available to the emergency physician caring for cardiac arrest patients are limited. Focused ultrasound (US), and in particular, focused echocardiography, is a useful tool in the evaluation of pati...Rapid diagnostic tools available to the emergency physician caring for cardiac arrest patients are limited. Focused ultrasound (US), and in particular, focused echocardiography, is a useful tool in the evaluation of patients in cardiac arrest. It can help identify possible causes of cardiac arrest like tamponade and pulmonary embolism, which can guide therapy. US can also yield prognostic information, with lack of cardiac activity being highly specific for failure to achieve return of spontaneous circulation. US may also be used to aid in procedural guidance. Recently, focused transesophageal echocardiography has been used in the emergency department setting.
Emerg Med Clin North Am
· 2023 Aug · PMID 37391254
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A structured approach to postcardiac arrest care is needed. Although immediate goals include obtaining a blood pressure reading and ECG immediately after return of spontaneous circulation, other more advanced goals inclu...A structured approach to postcardiac arrest care is needed. Although immediate goals include obtaining a blood pressure reading and ECG immediately after return of spontaneous circulation, other more advanced goals include minimizing CNS injury, managing cardiovascular dysfunction, reducing systemic ischemic/reperfusion injury, and identifying and treating the underlying cause to the arrest. This article summarizes the current understanding of the hemodynamic, neurologic, and metabolic abnormalities encountered in postarrest patients.
Emerg Med Clin North Am
· 2023 Aug · PMID 37391253
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There has been only a small improvement in survival and neurologic outcomes in patients with cardiac arrest in recent decades. Type of arrest, length of total arrest time, and location of arrest alter the trajectory of s...There has been only a small improvement in survival and neurologic outcomes in patients with cardiac arrest in recent decades. Type of arrest, length of total arrest time, and location of arrest alter the trajectory of survival and neurologic outcome. In the post-arrest phase, clinical markers such as blood markers, pupillary light response, corneal reflex, myoclonic jerking, somatosensory evoked potential, and electroencephalography testing can be used to help guide neurological prognostication. Most of the testing should be performed 72 hours post-arrest with special considerations for longer observation periods in patients who underwent TTM or who had prolonged sedation and/or neuromuscular blockade.
Emerg Med Clin North Am
· 2023 Aug · PMID 37391252
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Resuscitations are complex events that require teamwork to succeed. In addition to the technical skills involved, a host of nontechnical skills are critical for optimal medical care delivery. These skills include mental...Resuscitations are complex events that require teamwork to succeed. In addition to the technical skills involved, a host of nontechnical skills are critical for optimal medical care delivery. These skills include mental preparation; planning for tasks and roles; leadership to guide resuscitation progress; and clear, closed-loop communication. Concerns and error detection should be escalated in an established format. Debriefing after the event helps identify learning points to carry forward for the next resuscitation. Support of the team providing this intense form of care is crucial to protect the mental health and function of providers.
Emerg Med Clin North Am
· 2023 Aug · PMID 37391251
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There is no single resuscitation strategy that will uniformly improve cardiac arrest outcomes. Traditional vital signs cannot be relied on in cardiac arrest, and the use of continuous capnography, regional cerebral tissu...There is no single resuscitation strategy that will uniformly improve cardiac arrest outcomes. Traditional vital signs cannot be relied on in cardiac arrest, and the use of continuous capnography, regional cerebral tissue oxygenation, and continuous arterial monitoring are options for use early defibrillation are critical elements of resuscitation. Cardio-cerebral perfusion may be improved with the use of active compression-decompression CPR, an impedance threshold device, and head-up CPR. In refractory shockable arrest, if ECPR is not an option, consider changing defibrillator pad placement and/or double defibrillation, additional medication options, and possibly stellate ganglion block.
Emerg Med Clin North Am
· 2023 Aug · PMID 37391250
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The effectiveness of pharmacologic management of cardiac arrest patients is widely debated; however, several studies published in the past 5 years have begun to clarify some of these issues. This article covers the curre...The effectiveness of pharmacologic management of cardiac arrest patients is widely debated; however, several studies published in the past 5 years have begun to clarify some of these issues. This article covers the current state of evidence for the effectiveness of the vasopressor epinephrine and the combination of vasopressin-steroids-epinephrine and antiarrhythmic medications amiodarone and lidocaine and reviews the role of other medications such as calcium, sodium bicarbonate, magnesium, and atropine in cardiac arrest care. We additionally review the role of β-blockers for refractory pulseless ventricular tachycardia/ventricular fibrillation and thrombolytics in undifferentiated cardiac arrest and suspected fatal pulmonary embolism.
Emerg Med Clin North Am
· 2023 Aug · PMID 37391249
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Appropriate airway management is critical to successful cardiac arrest resuscitation. However, the timing and method of airway management during cardiac arrest have traditionally been guided by expert and consensus opini...Appropriate airway management is critical to successful cardiac arrest resuscitation. However, the timing and method of airway management during cardiac arrest have traditionally been guided by expert and consensus opinion informed by observational data. In the last 5 years, recent studies, including several randomized controlled trials (RCTs), have provided additional clarity to help guide airway management. This article will review both current data and guidelines for airway management in cardiac arrest, a stepwise approach to airway management, the utility of various airway adjuncts, and best practices for oxygenation and ventilation in the peri-arrest period.
Emerg Med Clin North Am
· 2023 Aug · PMID 37391248
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Defibrillation is one of the few interventions known to favorably impact survival in cardiac arrest. In witnessed arrest, survival improves with defibrillation as early as possible, whereas it may improve outcomes to adm...Defibrillation is one of the few interventions known to favorably impact survival in cardiac arrest. In witnessed arrest, survival improves with defibrillation as early as possible, whereas it may improve outcomes to administer high-quality chest compressions for 90 seconds before defibrillation in unwitnessed arrest. Minimizing pre-, peri-, and post-shock pauses has been shown to have mortality benefits. Refractory ventricular fibrillation has high mortality rates, and there is ongoing research into promising adjunctive treatment modalities. There remains no consensus on optimal pad positioning and defibrillation energy level, however, recent data suggest anteroposterior pad placement may be superior to anterolateral placement.
Emerg Med Clin North Am
· 2023 Aug · PMID 37391247
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Cardiac arrest is the loss of organized cardiac activity. Unfortunately, survival to hospital discharge is poor, despite recent scientific advances. The goals of cardiopulmonary resuscitation (CPR) are to restore circula...Cardiac arrest is the loss of organized cardiac activity. Unfortunately, survival to hospital discharge is poor, despite recent scientific advances. The goals of cardiopulmonary resuscitation (CPR) are to restore circulation and identify and correct an underlying etiology. High-quality compressions remain the foundation of CPR, optimizing coronary and cerebral perfusion pressure. High-quality compressions must be performed at the appropriate rate and depth. Interruptions in compressions are detrimental to management. Mechanical compression devices are not associated with improved outcomes but can assist in several situations.