Friday

TTP: Rapid diagnosis and management

You are working at a tertiary care center and a 55-year-old woman is transferred to you from an outside hospital for severe persistent thrombocytopenia of unknown origin. On arrival, she is mildly confused and tachycardic. The platelet count is 7K and the hemoglobin is 5.8. Peripheral blood smear demonstrates schistocytes consistent with microangiopathic hemolytic anemia. The diagnosis of thrombotic thrombocytopenic purpura (TTP) is suspected. TTP is a hematologic emergency: what are the next steps in management?

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Tracheostomy decannulation: To cap or not to cap?

A 49-year-old woman was intubated for acute hypoxemic respiratory failure secondary to pneumonia, which was complicated by empyema. She failed extubation and ultimately required tracheostomy for prolonged mechanical ventilation. After transfer to the intermediate care unit, she was successfully weaned from the ventilator for over 24 hours. She tolerated prolonged deflation of her tracheostomy cuff and swallowed water without aspiration. She underwent a tracheostomy tube occlusion test and there was no obstruction to air flow with a size 7 fenestrated tracheostomy tube in place. She is requiring suctioning once every 12 hours. You are assessing her readiness for tracheostomy decannulation and are considering the utility of a capping trial.    

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Another take on balanced crystalloids vs. saline

It’s a familiar call ahead to the ED - an adult patient who is febrile, hypotensive, with suspicion towards infection.  While setting up the room, the patient’s bedside nursing team asks if you’d like them to get saline or lactated Ringer’s (LR) ready for resuscitation.  You wonder if there’s any new evidence examining the use of saline versus balanced crystalloids in the emergency department.

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VA-ECMO for massive pulmonary embolism

A 60-year-old man presents to the ED after an episode of syncope. He is initially hemodynamically stable and undergoes CT demonstrating saddle pulmonary embolism. He returns from radiology with tachycardia and hypotension refractory to fluids and requiring vasopressor support. Bedside echo reveals RV dilation and severely reduced RV systolic dysfunction with septal flattening consistent with RV pressure overload. As you start systemic anticoagulation with heparin, you consider the indications for thrombolysis, surgical embolectomy and VA-ECMO.   

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