A Low Peripheral Neutrophil-Lymphocyte Ratio Can Help to Exclude a Subarachnoid Hemorrhage

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Hematology, Medical General, medical procedures
More Tags – CT scan, Headache, HPC updates, subarachnoid hemorrhage
An elevated peripheral neutrophil-lymphocyte ratio is an indicator of inflammation. Investigators from a Turkish university hospital hypothesized that this ratio might differ in patients with subarachnoid hemorrhage (SAH) versus those with other headache syndromes. They performed a retrospective study of…
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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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Semi-upright vs Supine Position for Emergency Intubations

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Endotracheal Intubation, medical procedures, Respiratory diseases
More Tags – emergent intubation, endotracheal intubation, HPC updates, intubation, rapid sequence intubation
Prior studies have suggested that patients should be intubated emergently in an upright, head-forward position rather than in the traditional supine position.  This is especially true for intubations of morbidly obese patients where it is known that pre-oxygenation and intubation in…
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Antimicrobial Stewardship Recommends Shorter Duration of Antibiotics for Community-Acquired Pneumonia and Healthcare-Associated Pneumonia

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Infections, medical procedures, Respiratory diseases
More Tags – antibiotic stewardship, antimicrobial stewardship, CAP, community-acquired pneumonia, HCAP, healthcare-associate pneumonia, HPC updates, pneumonia
The Infectious Diseases Society of America (IDSA) guidelines remain the gold standard guidelines for infectious disease problems.  The IDSA recommends treating patients with community-acquired pneumonia (CAP) for 5 days and it recommends treating those with healthcare-associated pneumonia (HCAP) for 7-8…
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Continuous Infusion of Beta-Lactam Antibiotics is Superior to Intermittent Dosing for Sepsis

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Hospital Procedures, Infections, medical procedures
More Tags – antibiotics, beta-lactam antibiotics, HPC updates, sepsis, septic shock
The bactericidal activity of antibiotics depends on the class of antibiotic used. Some antibiotics like vancomycin, aminoglycosides and fluoroquinolones are dose-dependent for their bactericidal activity. Other antibiotics like beta-lactam antibiotics are time-dependent antibiotics.  Time-dependent antibiotics have increased bactericidal activity the…
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Think PE in Elderly Patients Hospitalized for Syncope

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Hospital Procedures, Medical General, medical procedures, Respiratory diseases
More Tags – CT pulmonary angiogram, D-dimer, HPC updates, pulmonary embolism, syncope, ventilation-perfusion lung scan
Although pulmonary embolism (PE) occasionally presents with syncope, patients with syncope are infrequently assessed for PE. This prospective study from Italy studied 560 elderly adults (mean age, 76) who were hospitalized for syncope. Those excluded from the study included patients…
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Misdiagnosed Cellulitis Increases Unnecessary Hospital Admissions and Antibiotic Use

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Dermatology, Emergency Procedures, Gastrointestinal diseases, Hematology, Infections, medical procedures
More Tags – cellulitis, contact dermatitis, gout or pseudogout, HPC updates, skin infection, venous stasis dermatitis, venous thrombosis
There are multiple noninfectious medical disorders that mimic cellulits.  In this retrospective study, researchers focused on misdiagnosis of cellulitis in 259 patients hospitalized with presumed diagnoses of lower extremity cellulitis at a Boston teaching hospital. Patients with complicating factors (e.g.,…
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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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Shock Index Predicts Increased Mortality Risk in General Emergency Department Patients

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Medical General, medical procedures
More Tags – emergency department triage, HPC updates, shock, shock index
The shock index — the ratio of heart rate to systolic blood pressure — is a new measure that may predict a poor outcome. Most of the studies using the shock index have been in trauma patients and those with…
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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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Accuracy of Urine Electrolytes to Assess Etiology of Acute kidney injury

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Central line, medical procedures, Nephrology
More Tags – acute glomerulonephritis, acute interstitial nephritis, acute kidney injury, acute tubular necrosis, diuretics, HPC updates, prerenal azotemia
Both the fractional excretion of sodium (FENa) and the fractional excretion of urea (FEUrea) have an established role as part of the work-up for determining if acute kidney injury (AKI) is due to a prerenal or intrarenal cause. Although both…
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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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Continuous-Infusion Beta-Lactam Antibiotics is Superior to Intermittent Dosing in Septic Patients?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Infections, Medical General, medical procedures
More Tags – beta-lactam antibiotics, critical illness, HPC updates, sepsis, septic shock, severe sepsis
The bactericidal activity of antibiotics depends on the class of antibiotic used. Some antibiotics like vancomycin, aminoglycosides and fluoroquinolones are dose-dependent for their bactericidal activity. Other antibiotics like beta-lactam antibiotics are time-dependent antibiotics which depend on maintaining drug concentrations above…
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Pulmonary Embolism Is Common in Elderly Patients Hospitalized for Syncope

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Hematology, Medical General, medical procedures, Respiratory diseases
More Tags – D-dimer, HPC updates, pulmonary embolism, syncope, venous thromboembolism, Wells score
Although pulmonary embolism (PE) occasionally presents with syncope, patients with syncope are infrequently assessed for PE. In this prospective study from Italy, researchers determined the prevalence of PE in 560 elderly adults (mean age, 76) who were hospitalized for their…
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