Podcast From St Mungo's

Acute kidney injury is a common finding in patients in the emergency department. The vast majoreity of these can be reversed by a foley catheter and a bag or two of crystalloids, however understanding what to do for the remainder is an important and often confusing topic. Dr. Topf boils down the science to present acute kidney injury with a practical bent. He covers the common causes as well as the less common diagnosis with an emphasis of what to look for in order to dig deeper, rather than presenting a comprehensive diagnostic algorithm. He also discusses the recent data of the treatment of metabolic acidosis, the initiation of dialysis and how to use and interpret the furosemide stress test.

This talk will serve as an introduction to the term "frailty" and how the assessment of frailty is an underutilized and important part of acute care medicine. The increased adverse outcomes associated with increased frailty will be discussed, and the differentiation between advanced age and frailty will be highlighted. There are many existing tools for frailty assessment, so after a brief overview of their historical roots, notable and well-studied assessment tools for the emergency department will be presented. The lecture concludes with implementation ideas and initial steps for investing in frailty-aware care.

This talk explores the acute management of traumatic brain injury (TBI) with a focus on

severe traumatic brain injured patients. We review the global burden of TBI and societal

impact. We discuss characterizing TBI severity. We review the imaging to obtain based

on various factors related to the injury. We discuss the critical role of the provider in

preventing secondary injury in brain injured patients and how to manage a brain injured

patient in the acute setting. Throughout the presentation, we review evidence-based

guidance.

Status epilepticus is a life-threatening emergency. However, there are different forms of status epilepticus: focal to bilateral tonic-clonic status epilepticus and focal status epilepticus. Focal status epilepticus may have prominent motor symptoms, often with impaired awareness, or may be nonconvulsive. The implications of this are important: the treatment of focal to bilateral tonic-clonic seizures requires immediate action. Evidence for first-line therapy is clear that benzodiazepines should be administered in adequate doses we will review those studies. New evidence for second-line treatment has emerged, as well. In those with focal status epilepticus, urgent treatment is still indicated but the approach is more nuanced and less likely to require an escalation to third-line agents, such as anesthetics. We review these concepts and provide some guidance for clinical practice.

A review of oxygenation in the context of critical illness and Rapid Sequence Intubation. What are the historical recommendations, how has this changed over time, and what does the evidence support currently?

This talk goes over the most common causes of inhirted bleeding disorders.  There are two major types of hemophilia – deficiency in factor VIII and IX – which predominant occur in men.  Hemophilia A is deficiency of factor VIII and is the most common form of hemophilia treated with factor concentrate.  Hemophilia B is less common but treatment principles are the same.  There are multiple types of von Willebrand Disease as this is a complex molecular that both carries factor VIII and forms large multimers essential for platelet function.   Mild forms of vWD can be treated by desmopressin but von Willebrand factor is needed for more severe types.

Pain is one of the most common reasons for patients to visit the emergency department and other acute care settings. Due to the extensive number of visits related to pain, ED clinicians across the globe and should be aware of the various therapeutic options available to them to treat patients with a variety of acute and chronic painful syndromes. With a huge improvement in understanding of the neurobiological aspect of pain by utilizing channels/enzymes/receptors concept, ED clinicians should consider patient-centered, pain syndrome-specific approach by using multimodal approach that include non-pharmacological modalities and pharmacological ones that include non-opioid and opioid analgesics. Additionally, availability and cost -effectiveness of analgesics need to be factored in treatment plan across the globe.

This talk highlights how a quick scroll through a non contrasted head CT can provide important information about the severity of illness. We review normal anatomy and easily recognized distorsions of neuroanatomy that suggest severe brain injury and impending herniation. The talk focuses on how these brain injured patients can be managed to prevent further injury and how simple bedside exams findings coupled with neuroradiologic findings can guide bedside management.

Airway management in the ED and other acute care settings has followed the ‘ABC’ priority paradigm. Open the airway, apply oxygen then support oxygenation and ventilation with a ‘definitive’ airway A.K.A a tracheal tube. The challenge and focus of airway management in emergencies has been on the technical imperative of laryngoscopy and intubation and therefor success is usually referenced by correct placement of the tube. First pass success (FPS) has been the primary outcome in a majority of publications examining airway management. This reverse rationalization is supported by numerous publications in every setting demonstrating an association between increasing number of attempts and patient morbidity and mortality. The focus of airway management is to support oxygenation and ventilation while maintaining physiologic homeostasis. The tube provides neither benefit nor harm airway management and success should therefor, be defined by a broader contextual surrogate for patient outcomes. Clinicians should strive for FPS rates >90%, without critical hypoxemia or hypotension performed in a timely manner.

Eoghan and Alasdair discuss the current dilemmas in fluid resuscitation in septic patients. Despite many research studies over the past 15 years, many questions still exist: what are the ideal endpoints for volume resuscitation?; what are the best fluids to give?; and when and how to start vasopressors?. Alasdair covers what we know and what we don’t, and how we might get the right answers.