What's New | Decker

Paige Armstrong, MD, MHS, Hamid Shokoohi, MD, MPH, RDMS, RDCS

The importance of prompt administration of intravenous fluids and vasoactive medications (norepinephrine or dopamine as the first choice) and the limitations of protocol-based therapy, as guided by recent evidence, should be emphasized.
There is significant controversy surrounding Early Goal-Directed Therapy (EGDT) in the management of severe sepsis and septic shock. Recently, a few, large, multicenter randomized trials, including ProCESS (Protocolized Care for Early Septic Shock), ARISE (Australasian Resuscitation in Sepsis Evaluation), and ProMISe (Protocolised Management In Sepsis) failed to provide similar conclusive supporting evidences.

Anne E. Dixon, MA, BMBCH, Haitham Nsour, MBBS

ATS guidelines for exercise-induced bronchoconstriction, asthma in the elderly, and asthma in the workplace
ERS/ATS guideline for severe asthma discusses pharmacologic modalities of asthma management and bronchial thermoplasty.
2020 GINA practice guidelines no longer recommend treatment with SABA alone, without inhaled ICS. Recommend that all adults and adolescents with asthma should receive ICS-containing controller treatment.
2020 NAEPP practice guidelines delineating optimal treatment steps in adolescents and adults with asthma. This includes bronchial thermoplasty and immunotherapy.

Status epilepticus has a distinct pathophysiology that remains poorly understood; interestingly, in animal models, many of the basic underlying mechanisms appear to be common regardless of how seizures are initiated. A single seizure is transformed into a self-perpetuating and pharmacoresistant disorder through a cascade of extrinsic signaling followed by intrinsic nuclear events.
Detailed treatment approaches for status epilepticus, delineating first-line, second-line, and third-line antiepileptic drugs.
STESS prognostication scores primarily being used for research purposes but may have indication in clinical settings.

Endovascular treatment of acute ischemic stroke (AIS) enables access to occluded intracranial vessels for local administration of thrombolytics, mechanical embolectomy, and/or angioplasty. There are currently four mechanical devices cleared by the Food and Drug Administration (FDA) for recanalization of arterial occlusion in patients with AIS; however, despite being cleared by the FDA, none of these devices have an FDA clinical indication due to the need for randomized comparison with medical therapy devices. Endovascular interventions are extremely time dependent, and reduced time from symptom onset to reperfusion is highly correlated with better clinical outcomes.
CTA with CT perfusion or MRA with diffusion-weighted MRI with or without MR perfusion is recommended for certain patients (2019 AHA/ASA recommendation on head imaging).
2019 AHA/ASA updates on IV alteplase indications and management in acute ischemic stroke patients.

Anne E. Dixon, MA, BMBCH, Haitham Nsour, MBBS

ATS guidelines for exercise-induced bronchoconstriction, asthma in the elderly, and asthma in the workplace
ERS/ATS guideline for severe asthma discusses pharmacologic modalities of asthma management and bronchial thermoplasty.
2020 GINA practice guidelines no longer recommend treatment with SABA alone, without inhaled ICS. Recommend that all adults and adolescents with asthma should receive ICS-containing controller treatment.
2020 NAEPP practice guidelines delineating optimal treatment steps in adolescents and adults with asthma. This includes bronchial thermoplasty and immunotherapy.

Bedside right lower quadrant ultrasonography to assess for acute appendicitis is rapid and noninvasive and does not involve ionizing radiation. Studies have validated that nonradiologist clinicians, when trained properly, can safely and accurately perform this examination, with sensitivities and specificities similar to those achieved by radiologists.
Ultrasonographic detection of either a complex fluid collection or abscess is reported to be 99% specific for diagnosis of a perforated appendix but only 36% sensitive.
A recent randomized controlled trial of amoxicillin-clavulanate versus appendectomy demonstrated the noninferiority of antibiotics for treatment of acute noncomplicated appendicitis but did not demonstrate an increased rate of complications in the appendectomy group. However, a Cochrane review of antibiotic therapy versus operative management did not find conclusive data to support antibiotic therapy and concluded that appendectomy remains the gold standard treatment.

Steven B Bird, MD , Emily Gordon, MD

Intravenous lipid emulsion (ILE) therapy is a more recent addition to the armamentarium employed to increase toxin elimination. Most data are in the form of case reports, and a recent review of ILE was unable to provide absolute indications for its use. However, ILE was reported to be most useful in overdoses of local anesthetics (e.g., bupivacaine, ropivacaine, mepivacaine), haloperidol, lipophilic tricyclic antidepressants and beta blockers, some calcium channel blockers, and bupropion. ILE is recommended in the resuscitation of patients exhibiting hemodynamic instability in the setting of an acute overdose of lipophilic substances.

Acute Care