EM Quick Hits 36 – Surviving Sepsis, Angle Closure Glaucoma, Bougies, Frostbite, Hot/Altered Patient, Central Cord Syndrome

Topics in this EM Quick Hits podcast Brit Long on Surviving Sepsis Campaign: 2021 Updates (0:38) Nour Khatib on rural medicine case: angle closure glaucoma (11:59) Reuben Strayer on bougie vs endotracheal tube and stylet on first-attempt intubation (20:51) Justin Hensley on management of frostbite (31:35) Sarah Foohey on the hot and altered patient (39:50) Andrew Petrosoniak on central cord syndrome (47:47) Podcast production, editing and sound design by Anton Helman Podcast content, written summary & blog post by Raymond Cho, edited by Anton Helman Cite this podcast as: Helman, A. Long, B. Khatib, N. Strayer, R. Hensley, J. Foohey, S. Petrosoniak, A. EM Quick Hits 36 - Surviving Sepsis, Angle Closure Glaucoma, Bougies, Frostbite, Hot/Altered Patient, Central Cord Syndrome. Emergency Medicine Cases. March 2022. https://emergencymedicinecases.com/em-quick-hits-march-2022/. Accessed [date]. Surviving Sepsis Campaign: 2021 Updates relevant to EM Screening for Sepsis * New guidelines recommend against using qSOFA as a single screening agent * Commentary: NEWS score is likely a better single screening tool that is easy to use and can be done at triage Resuscitation * Fluids * Guidelines now only suggest rather than recommend using 30 cc/kg of IV crystalloid within the first 30 minutes of resuscitation * Balanced crystalloids such as Plasmalyte and Lactated Ringer's recommended as a first line over normal saline * Vasopressors * In most patients, norepinephrine is the first-line vasopressor, followed by vasopressin, then epinephrine * In patients with cardiac dysfunction, use norepinephrine as first line then dobutamine or epinephrine alone * In septic shock resistant to vasopressors, guidelines now support using IV hydrocortisone * Monitoring resuscitation * Use dynamic parameters (e.g. passive leg raise, stroke volume/pulse pressure variation, ultrasound) rather than using static parameters * Point-of-care ultrasound can be used to assess volume status (IVC, B-lines, cardiac activity) * For patients in septic shock, target a MAP of 65 mmHg * Adjunctive markers: use capillary refill, lactate to guide resuscitation * Antimicrobial therapy * In patients with possible sepsis without shock, consider investigating for other causes for up to 3 hours before starting antimicrobial therapy (adjusted from 1 hour from previous guidelines) * Choice of antimicrobials in the empiric phase * High risk of multi-drug resistant organisms: 2 agents with gram negative coverage * Low risk of multi-drug resistant organisms: 1 agent with gram negative coverage * High risk of MRSA: provide coverage for MRSA (eg. vancomycin) * No risk factors for MRSA: no routine MRSA coverage * Other * IV vitamin C is not recommended in septic shock Update 2023: A multicenter randomized controlled trial including 1563 patients with sepsis-induced hypotension refractory to initial treatment with 1-3L of IV fluids comparing a restrictive fluid strategy (prioritizing vasopressors and low intravenous fluid volumes) and a liberal flu...