Safety of Thoracentesis with Coagulopathy or Thrombocytopenia

Thoracentesis Course
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Featured Procedure, Hematology, medical procedures, Thoracentesis
More Tags – coagulopathy, featured, featured procedure, HPC updates, thoracentesis, thrombocytopenia
Historically, it was felt that a platelet count below 50,000 or an INR>1.5 was a contraindication to thoracentesis because of an increased bleeding risk.  These were arbitrary cut-offs that have since been challenged with newer kits and the use of…
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Intubation During In-Hospital CPR Decreases Survival and Neurological Outcomes

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Endotracheal Intubation, medical procedures
More Tags – cardiac arrest, CPR, endotracheal intubation, HPC updates
This study was an observational cohort study of adult patients who had an in-hospital cardiac arrest between 2000 through 2014.   A US-based multicenter registry of in-hospital cardiac arrest was studied and included 108,079 adult patients at 668 hospitals. Two…
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Drones Deliver AEDs Faster than Ambulances in Out-of Hospital Cardiac Arrests

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Emergency Procedures, medical procedures
More Tags – automated external defibrillators, cardiac arrest, HPC updates, ventricular fibrillation, ventricular tachycardia
Out-of-hospital cardiac arrests (OHCA) have a survival rate of only 8-10%.  The most critical factors for patient survival is the early administration of good bystander CPR and early defibrillation in shockable rhythms.  Currently, defibrillators are transported to OHCA victims only…
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A Negative High-Sensitivity Troponin and Reassuring EKG Can Rule out Acute MI

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Emergency Procedures, medical procedures, Traumatology
More Tags – acute coronary syndrome, acute myocardial infarction, chest pain, HPC updates
One of the more common presenting complaints to an ED is the adult presenting with chest pain.  In addition, one of the most common reasons for admission to a hospitalist service is the “Chest pain rule out MI” admitting diagnosis.…
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2017 Consensus Guidelines on the Approach to Syncope in Adults and Children

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Emergency Procedures, Medical General, Oncology, Respiratory diseases, Traumatology
More Tags – Aortic dissection, aortic stenosis, AV block, cancer, Cardiac ischemia, cardiac syncope, Cardiac tamponade, diabetes mellitus, GI bleed, heart block, Heart failure, HPC updates, Hypertrophic cardiomyopathy, pulmonary embolism, Severe prosthetic valve dysfunction, syncope, trauma
Key Recommendations 1). Initial evaluation Conduct physical exam, history (with careful attention to factors in Tables 1 & 2) and resting electrocardiogram (ECG) to identify a possible cause (see Tables 2 & 3). 2). Disposition from the emergency department (ED)…
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Extended cardiac monitoring is indicated for evaluation of cryptogenic strokes in elderly patients

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Central line, Medical General, medical procedures, Neurological diseases
More Tags – atrial fibrillation, cardiac monitoring, cryptogenic strokes, HPC updates, ischemic strokes, stroke
Prior studies have found that in patients with cryptogenic ischemic strokes, extended post-stroke cardiac monitoring detects intermittent atrial fibrillation (AF) in up to 20% of cases. Now, an industry-sponsored study from Germany randomized 400 patients all over 60 years old…
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When to Stop CPR for Out-of-Hospital Cardiac Arrest?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Emergency Procedures, Hematology, Medical General, medical procedures
More Tags – cardiac arrest, CPR, HPC updates, out of hospital cardiac arrest, return of spontaneous circulation, ROSC
The Universal Termination of Resuscitation Guidelines suggest that resuscitation should be terminated if at least four rounds of CPR have occurred and the following three criteria are met: The arrest was NOT witnessed by emergency medical services (EMS) There has…
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To Intubate or Not Intubate During In-Hospital Codes?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Emergency Procedures, Gastrointestinal diseases, Medical General, medical procedures, Respiratory diseases
More Tags – advanced airway, asystole, cardiac arrest, CPR, HPC updates, intubation, PEA, pulseless electrical activity, ROSC, ventricular fibrillation, ventricular tachycardia
The 2015 American Heart Association Advanced Cardiovascular Life Support guidelines deemphasizes advanced airway placement during the initial resuscitation. Out-of-hospital–arrest data suggest lower survival among patients who are intubated in the field.  Therefore, it is important to determine the importance of…
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Summary of Sepsis and Septic Shock Treatment in 2017

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Arterial line, Cardiovascular diseases, Central line, Hematology, Infections, Mechanical Ventilation, medical procedures, Respiratory diseases
More Tags – ARDS, Arterial lines, central lines, hemodynamic monitoring, HPC updates, mechanical ventilation, sepsis, septic shock, vasopressors
Definitions Presumed source with SIRS criteria = infection Infection with life-threatening organ dysfunction = sepsis Sepsis refractory to intravenous fluid challenge = septic shock Treatment of sepsis or septic shock Draw blood cultures x 2 Analyze any fluid that may…
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Elevated Cardiac Troponin Levels Are Not Always Due to Acute Coronary Syndromes

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Hospital Procedures, Infections, Medical General, medical procedures, Respiratory diseases
More Tags – Aortic dissection, cardioversion, HPC updates, myocardial infarction, myocarditis, NSTEMI, pulmonary embolus, pulmonary hypertension, sepsis, stroke, troponin
Cardiac troponin assays have gone through a tremendous evolution since they were introduced into clinical labs in 1995 until the most recent ultra-sensitive assays became prevalent in 2007.  The original troponin T (TnT) and troponin I (TnI) assays had a…
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Lidocaine or Amiodarone for Cardiac Arrest with a Shockable Rhythm?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Emergency Procedures, Medical General, medical procedures
More Tags – Amiodarone, cardiac arrest, Defibrillation, HPC updates, Lidocaine, Shockable Rhythm
After three defibrillation attempts, recommendations state that amiodarone or lidocaine may be considered for patients with cardiac arrest and persistent shockable rhythm.  A randomized, controlled trial was conducted and showed there was no significant difference between amiodarone and lidocaine and…
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How to Manage Patients with Atrial Fibrillation and Prior Intracranial Hemorrhage

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Emergency Procedures, medical procedures
More Tags – atrial fibrillation, CHADS2-VASc score, HPC updates, intracranial hemorrhage
It has always been a therapeutic dilemma whether to anticoagulate patients with Afib and a history of prior intracranial hemorrhage (ICH).  This study used a Taiwanese national database to identify 12,917 patients with an ICH history and new AF and…
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Factors that influence Pleural Fluid pH after Thoracentesis

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Chest Tube, medical procedures, Respiratory diseases, Thoracentesis
More Tags – chest tube, HPC updates, pleural fluid analysis, thoracentesis, tube thoracostomy
Pleural fluid pH is an important measure for determining the clinical management of pleural diseases. For example, a pleural fluid pH <7.2 in patients with suspected pleural infection should mandate the placement of a chest tube. However, pleural fluid pH…
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The Risk that Chest Pain Represents Acute Coronary Syndrome

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, medical procedures, Thoracentesis, Traumatology
More Tags – acute coronary syndrome, chest pain, HPC updates, unstable angina
This meta-analysis examined 58 prospective ED studies that involved diagnostic test accuracy among patients with suspected Non-ST elevation ACS. The meta-analysis found that the following clinical findings predicted excess ACS risk in patients presenting with chest pain: hypotension (systolic blood…
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