Shock

Acute Heart Failure and Cardiogenic Shock

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Acute Heart Failure & Cardiogenic Shock

  1. There’s minimal or no role for the administration of loop diuretics (Furosemide/Lasix) early in the management of Acute Pulmonary Edema. The majority of patients aren’t volume overloaded.
  2. Immediate care should focus on Non-Invasive Positive Pressure Ventilation and administration of nitroglycerin.
  3. In patients with End Stage Renal Disease, dialysis is what’s ultimately going to fix the patient.

 

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Trauma Resuscitation Commandments

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Trauma Commandments

  1. The most important step in managing a bleeding trauma patient is surgical source control – most patients with massive hemorrhage need an operation to stay the hemorrhage. The state in which a patient arrives to the operating room or the intensive care unit – alive or near death, cold and coagulopathic or warm and well perfused – is up to you.
  2. ­Excessive crystalloid administration is associated with hypothermia, coagulopathy and death in bleeding patients. If you think your patient is bleeding and you have ready access to blood products, you can skip crystalloid all together and go straight for the good stuff.
  3. Trauma patients don’t just bleed red blood cells. They lose plasma, platelets and clotting factors, too. Give blood products (red cells, plasma, platelets) in a balanced 1:1:1 ratio (to mimic whole blood) or give whole blood.
  4. Tranexamic acid (TXA) is an anti-fibrinolytic agent that can/should be used early in the resuscitation of bleeding trauma patients. 1gm of TXA given as an early bolus followed by an infusion of 1gm over the ensuing 8 hours has been associated with an absolute risk reduction of 1.5%.
  5.  If you resuscitate based a trauma patient based on vital signs alone, you will under-resuscitate about 50% of trauma patients. The foley catheter is an essential adjunct during massive resuscitation. If your patient is making urine at a rate of > 50ml/h, your resuscitative efforts are probably adequate.

Mortality after Fluid Bolus in African Children with Severe Infection

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Mortality after Fluid Bolus in African Children with Severe Infection

Kathryn Maitland, M.B., B.S., Ph.D., Sarah Kiguli, M.B., Ch.B., M.Med., Robert O. Opoka, M.B., Ch.B., M.Med., Charles Engoru, M.B., Ch.B., M.Med., Peter Olupot-Olupot, M.B., Ch.B., Samuel O. Akech, M.B., Ch.B., Richard Nyeko, M.B., Ch.B., M.Med., George Mtove, M.D., Hugh Reyburn, M.B., B.S., Trudie Lang, Ph.D., Bernadette Brent, M.B., B.S., Jennifer A. Evans, M.B., B.S., James K. Tibenderana, M.B., Ch.B., Ph.D., Jane Crawley, M.B., B.S., M.D., Elizabeth C. Russell, M.Sc., Michael Levin, F.Med.Sci., Ph.D., Abdel G. Babiker, Ph.D., and Diana M. Gibb, M.B., Ch.B., M.D. for the FEAST Trial Group

N Engl J Med 2011; 364:2483-2495

Fluid boluses significantly increased 48-hour mortality in critically ill children with impaired perfusion in these resource-limited settings in Africa.