Choosing Wisely Recommendations by American College of Emergency Physicians

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Medical General, medical procedures, Nephrology, Respiratory diseases, Traumatology
More Tags – back pain, CT scans, HPC updates, nephrolithiasis, pulmonary embolus, sinusitis, syncope
Choosing Wisely is an initiative by the American Board of Internal Medicine that solicits evidence-based recommendations by other specialty associations to identify tests or procedures in their field which are unnecessary.  The following are a set of five recommendations that…
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New GOLD Guidelines for COPD Exacerbations

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Endocrinology, Mechanical Ventilation, Medical General, Respiratory diseases
More Tags – COPD, HPC updates, mechanical ventilation, noninvasive ventilation, procalcitonin, steroids
Beta2-agonists and anticholinergics are the initial bronchodilators Prednisone 1 mg/kg/day (up to 60 mg/day) or steroid equivalent for moderate-severe exacerbations x 5-7 days Antibiotics indicated for moderate-severe exacerbations with pulmonary infiltrate or sputum purulence –procalcitonin level >0.25 ng/mL supports antibiotic…
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Prophylactic Corticosteroids Decrease Stridor and Reintubation in High-risk Extubations

ICU Equipment and Nurse in Mechanical Ventilation Course
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Mechanical Ventilation, medical procedures, Respiratory diseases
More Tags – extubation, HPC updates, mechanical ventilation
The overall incidence of extubation failure is about 15%, but this failure rate may be increased in patients with high risk characteristics.  Patients who have prolonged mechanical ventilation, those with high cuff pressures, poor cuff leaks, and those who have…
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Blood Cultures are Not Recommended for Most Non-Severe Cases of UTI, Cellulitis, or Pneumonia

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Arterial line, Dermatology, Emergency Procedures, Infections, medical procedures, Nephrology, Respiratory diseases
More Tags – bacteremia, cellulitis, community-acquired pneumonia, HPC updates, pneumonia, UTI
In many hospitals, blood cultures have become a reflexive habit for patients presenting to the ER with any suspected infection.  This was, in part, due to the inappropriate addition of routine blood cultures as a core measure in 2001 by…
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Safe Ways to Rule Out Pulmonary Embolism without Using a CT Pulmonary Angiogram

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Hematology, medical procedures, Respiratory diseases
More Tags – D-dimer, deep venous thrombosis, HPC updates, pulmonary embolism
Pulmonary embolism (PE) is one of the most difficult to diagnose and potentially fatal disorders in medicine.  Because of this, CT pulmonary angiograms (CTPA) are over utilized so as to not miss this potentially fatal problem.  There are three ways…
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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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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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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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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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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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The HACOR Score can Predict Failure of Noninvasive Positive Pressure Ventilation or BiPAP

ICU Equipment and Nurse in Mechanical Ventilation Course
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Endotracheal Intubation, medical procedures, Respiratory diseases
More Tags – BiPAP, HACOR, HPC updates, noninvasive positive pressure ventilation, NPPV, Ventilation
Use of noninvasive positive pressure ventilation (NPPV) or BiPAP can temporarily support ventilation during initial treatment in some patients with respiratory failure. However, many patients fail NPPV and ultimately need intubation. Early intubation or close observation can benefit patients at…
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Predictors of Difficult Intubation with Hypercurved Glidescope or C-MAC devices

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Gastrointestinal diseases, Glidescope Intubation, medical procedures, Respiratory diseases
More Tags – C-MAC D-blade, Difficult Intubation, GlideScope, HPC updates, intubation, Videolaryngoscopy
Investigators have conducted a secondary analysis in order to identify predictors of difficult or prolonged intubation with hypercurved videolaryngoscopes. The analysis was of a randomized control trial of 1100 elective surgery patients. After anesthesia and neuromuscular blockade, these patients were…
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