0413.sepsis

-PAGE 2| Surviving Sepsis Campaign: International Guidelines For Manage-ment Of Severe Sepsis And Septic Shock: 2012

Critical Care Medicine

PAGE 6| Editorial Comment

PAGE 9 | References

PAGE 10| CME Questions

Current Guidelines For The Management Of Severe Sepsis And Septic Shock

This issue of EM Practice Guidelines Update reviews the 2012 international Surviving Sepsis Campaign guidelines on the management of severe sepsis and septic shock. Sepsis is a systemic, deleterious inflammatory host response to infection that can lead to severe sepsis (acute organ dysfunction secondary to documented or suspected infection) and septic shock (severe sepsis plus hypotension not reversed with fluid resuscitation). The mortal-ity of severe sepsis and septic shock is high, as much as 51%.1 The incidence of severe sepsis and septic shock is increasing, with ap-proximately 660,000 cases diagnosed in the United States in 2000.2 The Surviving Sepsis Campaign guidelines were created to provide clinicians in the intensive care unit (ICU) or non-ICU setting with an evidence-based approach to managing this syndrome. A key portion of this guideline focuses on initial resuscitation, so it is important for emergency clinicians to be familiar with these recommendations.

Practice Guideline Impact Resuscitation of patients with sepsis-induced tissue hypoperfu-

sion should be guided by quantitative targets.

Early antibiotic administration is critical.

Crystalloids are the resuscitation fluid of choice.

Norepinephrine should be the first-line vasopressor in most patients.

Use low tidal volumes and plateau pressures in patients with sepsis-induced acute respiratory distress syndrome (ARDS).

Integrate palliative care, focusing on providing care that the patient would have wanted.

Benign Paroxysmal Positional Vertigo And Acute Otitis Externa In The ED: Current Guidelines

IIn this issue of EM Practice Guidelines Update, we review 2 guidelines that address the diagnosis and management of benign paroxysmal positional vertigo (BPPV) and 1 guideline on the topic of acute otitis externa (AOE). BPPV is the most common cause of vertigo, with a lifetime prevalence of 2.4%, and while it is not dangerous per se, it is an important cause of patient discomfort and missed work as well as falls, particularly in the elderly. The most common emergency department therapies for BPPV (antihistamines, anticholinergics, and sedatives) are not recommended by specialists.

The second topic for review, AOE, is a prevalent and painful condition seen by emergency clinicians whose management can be complicated by several common pitfalls.

Practice Guideline Impact: Vestibular suppressant medications of the benzodiazepine,

anticholinergic, and antihistamine classes have a limited role in the management of BPPV.

A particle repositioning maneuver is the therapy of choice in the management of BPPV and should be performed in the ED or arranged from the ED.

Systemic antibiotics should be avoided in most cases of diffuse AOE.

PAGE 2 | Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo

PAGE 3 | Practice Parameter: Therapies For Benign Paroxysmal Positional Vertigo (An Evidence-Based Review): Report Of The Quality Standards Subcom-mittee Of The American Academy of Neurology

PAGE 5 | Clinical Practice Guideline: Acute Otitis Externa

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GUIDELINES UPDATENovember 2009

Volume 1, Number 2

Editor-In-Chief

Reuben J. Strayer, MDAssistant Professor of Emergency Medicine, Mount Sinai School of Medicine, New York, NY

Editorial Board

Andy Jagoda, MD, FACEPProfessor and Chair, Department of Emergency MedicineMount Sinai School of Medicine, New York, NY

Erik Kulstad, MD, MS Research Director, Advocate Christ Medical CenterDepartment of Emergency Medicine, Oak Lawn, IL

Eddy S. Lang, MDCM, CCFP (EM), CSPQAssociate Professor, McGill University, SMBD Jewish General Hospital, Montreal, Canada

Lewis S. Nelson, MDDirector, Fellowship in Medical Toxicology, New York City Poison Control Center, Associate Professor, Department of Emergency Medicine, NYU Medical Center, New York, NY

Gregory M. Press, MD, RDMSAssistant Professor, Director of Emergency Ultrasound, Emergency Ultrasound Fellowship Director, Department of Emergency Medicine, University of Texas at Houston Medical School, Houston, TX

Scott M. Silvers, MDChair, Department of Emergency MedicineMayo Clinic, Jacksonville, FL

Scott Weingart, MD FACEPAssistant Professor, Department of Emergency Medicine, Elmhurst Hospital Center, Mount Sinai School of Medicine, New York, NY

Prior to beginning this activity, see Physician CME Information on page 7.

+ IMPROVING CARE THROUGH EVIDENCE

Editors Note: Introduction to a New SeriesEM Practice Guidelines Update is a new publication from EB Medicine that will help emergency department clini-cians stay current with practice guidelines. To read more about this publication and the background and method-ologies for practice guideline development, http://www.ebmedicine.net/introduction

April 2013Volume 5, Number 4

AuthorsNeil Singh, MDDepartment of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY

Scott D. Weingart, MD, FCCMAssociate Professor, Department of Emergency Medicine, Director, Division of ED Critical Care, Icahn School of Medicine at Mount Sinai, New York, NY

Editors-In-ChiefLuke K. Hermann, MDAssociate Professor of Emergency Medicine, Director of Quality and Finance, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY

Sigrid Hahn, MDAssociate Professor of Emergency Medicine, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY

Editorial BoardNicole C. Bouchard, MD, FRCPCAssistant Clinical Professor, Assistant Site Director; Director of Medical Toxicology, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY

Andy Jagoda, MD, FACEPProfessor and Chair, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY

Erik Kulstad, MD, MS Research Director, Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, IL

Eddy S. Lang, MDCM, CCFP (EM), CSPQSenior Researcher, Alberta Health Services; Associate Professor, University of Calgary; Adjunct Professor, McGill University, Montreal, Quebec, Canada

Lewis S. Nelson, MDAssociate Professor of Emergency Medicine, New York University School of Medicine; Director, Fellowship in Medical Toxicology, New York City Poison Control Center, New York, NY

Gregory M. Press, MD, RDMSAssistant Professor, Director of Emergency Ultrasound, Emergency Ultrasound Fellowship Director, Department of Emergency Medicine, University of Texas at Houston Medical School, Houston, TX

Maia S. Rutman, MDMedical Director, Pediatric Emergency Services, Dartmouth-Hitchcock Medical Center; Assistant Professor of Pediatric Emergency Medicine, Dartmouth Medical School, Lebanon, NH

Scott M. Silvers, MDChair, Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL

Scott D. Weingart, MD, FCCMAssociate Professor, Department of Emergency Medicine, Director, Division of ED Critical Care, Icahn School of Medicine at Mount Sinai, New York, NY

Editors Note: To read more about this publication and the background and methodologies for practice guideline development, go to: http://www.ebmedicine.net/introduction

Prior to beginning this activity, see CME Information on page 11.

Current Guidelines For Management Of Severe Sepsis And Septic Shock

EM Practice Guidelines Update 2013 2 www.ebmedicine.net April 2013

| print | SUBSCriBE | WEBSitE

These guidelines are an update of the 2008 Surviving Sepsis Campaign guidelines for the management of severe sepsis and septic shock. They are intended to be used by ICU physicians as well as non-ICU physicians, including emergency department (ED) physicians. The guidelines were created by a consensus committee of 68 international experts representing 30 international organizations. Leaders of the committee were chosen by the governing bodies of the Society of Critical Care Medicine and the European Society of Inten-sive Care Medicine and included experts with interests in sepsis who were appointed to each committee.

The Surviving Sepsis Campaign formed a conflict-of-interest policy that was enforced throughout the creation of the guidelines. Declared conflict-of-interest disclosures from 19 members were deemed not rel-evant to the formation of the guideline content process. Nine members with disclosures were reassigned to groups that would lead to the least impact from their conflict of interest, and they were required to disclose their conflict of interest during any discussions or votes.The Surviving Sepsis Campaign states that the guidelines were formed independent of industry findings.

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate literature by the committee members. Evidence was ranked from high-quality evidence such as a randomized trial (grade A) to expert opinion pieces (grade D), with the overall quality of the study determining its grade. Recom-mendations were made based on the GRADE system and were labeled either strong (grade 1) or weak (grade 2). Strong recommendations were based on: (1) higher-quality evidence; (2) a larger difference be-

Surviving Sepsis Campaign: International Guidelines For Management Of Severe Sepsis And Septic Shock: 20123

Critical Care Medicine. 2013;41(2):580-637. Link: http://www.sccm.org/Documents/SSC-Guidelines.pdf

tween desirable and undesirable consequences of an intervention; and (3) greater certainty about those benefits, taking into account values, preferences, and cost. Some recommendations were left ungraded, as the committee felt they were not conducive to the GRADE process.

The following recommendations from the guidelines are relevant to emergency medicine. Original guideline numbering has been retained.

A. Initial Resuscitation1. Protocolized, quantitative resuscitation of patients with sepsis-in-

duced tissue hypoperfusion (defined in this document as hypoten-sion persisting after initial fluid challenge or blood lactate concen-tration 4 mmol/L). Goals during the first 6 hours of resuscitation: Central venous pressure 8 to 12 mm Hg Mean arterial pressure (MAP) 65 mm Hg Urine output 0.5 mL/kg/h Central venous (superior vena cava) or mixed venous oxygen

saturation 70% or 65%, respectively (grade 1C)2. In patients with elevated lactate levels, targeting resuscitation to

normalize lactate (grade 2C).

B. Screening For Sepsis And Performance Improvement1. Routine screening of potentially infected seriously ill patients for se-

vere sepsis to allow earlier implementation of therapy (grade 1C).2. Hospital-based performance improvement efforts in severe sepsis

(ungraded).

Continued on page 3 >>




7. Antimicrobial agents should not be used in patients with severe inflam-matory states determined to be of noninfectious cause (ungraded).

E. Source Control1. A specific anatomical diagnosis of infection requiring consideration

for emergent source control be sought and diagnosed or excluded as rapidly as possible, and intervention be undertaken for source control within the first 12 hours after the diagnosis is made, if fea-sible (grade 1C).

2. When infected peripancreatic necrosis is identified as a potential source of infection, definitive intervention is best delayed until ad-equate demarcation of viable and nonviable tissues has occurred (grade 2B).

3. When source control in a severely septic patient is required, the effective intervention associated with the least physiologic insult should be used (eg, percutaneous rather than surgical drainage of an abscess) (ungraded).

4. If intravascular access devices are a possible source of severe sepsis or septic shock, they should be removed promptly after other vascular access has been established (ungraded).

G. Fluid Therapy Of Severe Sepsis1. Crystalloids as the initial fluid of choice in the resuscitation of se-

vere sepsis and septic shock (grade 1B).2. Against the use of hydroxyethyl starches for fluid resuscitation of

severe sepsis and septic shock (grade 1B).3. Albumin in the fluid resuscitation of severe sepsis and septic shock

when patients require substantial amounts of crystalloids (grade 2C).4. Initial fluid challenge in patients with sepsis-induced tissue hypo-

perfusion with suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (a portion of this may be albumin equiva-lent). More-rapid administration and greater amounts of fluid may be needed in some patients (grade 1C).

5. Fluid challenge technique be applied wherein fluid administration is continued as long as there is hemodynamic improvement either based on dynamic (eg, change in pulse pressure, stroke volume variation) or static (eg, arterial pressure, heart rate) variables (ungraded).


C. Diagnosis1. Cultures (as clinically appropriate) before antimicrobial therapy if no

significant delay (> 45 min) in the start of antimicrobial(s) (grade 1C). At least 2 sets of blood cultures (both aerobic and anaerobic bottles) should be obtained before antimicrobial therapy with at least 1 drawn percutaneously and 1 drawn through each vascular access device, unless the device was recently (< 48 h) inserted (grade 1C).

3. Imaging studies performed promptly to confirm a potential source of infection (ungraded).

D. Antimicrobial Therapy1. Administration of effective intravenous antimicrobials within the first

hour of recognition of septic shock (grade 1B) and severe sepsis without septic shock (grade 1C) as the goal of therapy.

2. Initial empiric anti-infective therapy of 1 or more drugs that have activity against all likely pathogens (bacterial and/or fungal or viral) and that penetrate in adequate concentrations into tissues pre-sumed to be the source of sepsis (grade 1B). Antimicrobial regimen should be reassessed daily for potential de-escalation (grade 1B).

3. Use of low procalcitonin levels or similar biomarkers to assist the clinician in the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infec-tion (grade 2C).

4. Combination empirical therapy for neutropenic patients with severe sepsis (grade 2B) and for patients with difficult-to-treat, multidrug-resistant bacterial pathogens such as Acinetobacter and Pseudo-monas spp (grade 2B). For patients with severe infections associ-ated with respiratory failure and septic shock, combination therapy with an extended spectrum beta-lactam and either an aminoglyco-side or a fluoroquinolone is for Pseudomonas aeruginosa bacte-remia (grade 2B). A combination of beta-lactam and macrolide for patients with septic shock from bacteremic Streptococcus pneu-moniae infections (grade 2B). Empiric combination therapy should not be administered for more than 3 to 5 days. De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility profile is known (grade 2B).

6. Antiviral therapy initiated as early as possible in patients with se-vere sepsis or septic shock of viral origin (grade 2C).




J. Corticosteroids1. Not using intravenous hydrocortisone to treat adult septic shock

patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (see goals for initial resus-citation). In case this is not achievable, we suggest intravenous hydrocortisone alone at a dose of 200 mg/day (grade 2C).

2. Not using the adrenocorticotropic hormone (ACTH) stimulation test to identify adults with septic shock who should receive hydrocorti-sone (grade 2B).

3. In treated patients, hydrocortisone tapered when vasopressors are no longer required (grade 2D).

4. Corticosteroids not be administered for the treatment of sepsis in the absence of shock (grade 1D).

5. When hydrocortisone is given, use continuous flow (grade 2D).

K. Blood Product Administration1. Once tissue hypoperfusion has resolved and in the absence of

extenuating circumstances, such as myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic heart disease, we recommend that red blood cell transfusion occur only when hemo-globin concentration decreases to < 7 g/dL to target a hemoglobin concentration of 7 to 9 g/dL in adults (grade 1B).

3. Fresh frozen plasma not be used to correct laboratory clotting ab-normalities in the absence of bleeding or planned invasive proce-dures (grade 2D).

4. Not using antithrombin for the treatment of severe sepsis and sep-tic shock (grade 1B).

5. In patients with severe sepsis, administer platelets prophylactically when counts are < 10,000/mm3 (10 x 109/L) in the absence of ap-parent bleeding. We suggest prophylactic platelet transfusion when counts are < 20,000/mm3 (20 x 109/L) if the patient has a significant risk of bleeding. Higher platelet counts ( 50,000/mm3 [50 x 109/L]) are advised for active bleeding, surgery, or invasive procedures (grade 2D).


H. Vasopressors1. Vasopressor therapy initially to target a MAP of 65 mm Hg

(grade 1C).2. Norepinephrine as the first-choice vasopressor (grade 1B).3. Epinephrine (added to and potentially substituted for norepineph-

rine) when an additional agent is needed to maintain adequate blood pressure (grade 2B).

4. Vasopressin 0.03 units/min can be added to norepinephrine with intent of either raising MAP or decreasing norepinephrine dosage (ungraded).

5. Low-dose vasopressin is not recommended as the single initial vasopressor for treatment of sepsis-induced hypotension and vasopressin doses higher than 0.03-0.04 units/minute should be reserved for salvage therapy (failure to achieve adequate MAP with other vasopressor agents) (ungraded).

6. Dopamine as an alternative vasopressor agent to norepineph-rine only in highly selected patients (eg, patients with low risk of tachyarrhythmias and absolute or relative bradycardia) (grade 2C).

7. Phenylephrine is not recommended in the treatment of septic shock except in circumstances where: (a) norepinephrine is asso-ciated with serious arrhythmias, (b) cardiac output is known to be high and blood pressure persistently low, or (c) as salvage therapy when combined inotrope/vasopressor drugs and low-dose vaso-pressin have failed to achieve MAP target (grade 1C).

8. Low-dose dopamine should not be used for renal protection (grade 1A).

9. All patients requiring vasopressors have an arterial catheter placed as soon as practical if resources are available (ungraded).

I. Inotropic Therapy1. A trial of dobutamine infusion up to 20 micrograms/kg/min be ad-

ministered or added to vasopressors (if in use) in the presence of: (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypo-perfusion, despite achieving adequate intravascular volume and adequate MAP (grade 1C).

2. Not using a strategy to increase cardiac index to predetermined supranormal levels (grade 1B).




lar blockade following discontinuation. If neuromuscular blocking agents must be maintained, either intermittent bolus as required or continuous infusion with train-of-four monitoring of the depth of blockade should be used (grade 1C).

Q. Glucose Control1. A protocolized approach to blood glucose management in ICU pa-

tients with severe sepsis commencing insulin dosing when 2 con-secutive blood glucose levels are > 180 mg/dL. This protocolized approach should target an upper blood glucose 180 mg/dL rather than an upper target blood glucose 110 mg/dL (grade 1A).

2. Blood glucose values be monitored every 1 to 2 hours until glucose values and insulin infusion rates are stable and then every 4 hours thereafter (grade 1C).

3. Glucose levels obtained with point-of-care testing of capillary blood be interpreted with caution, as such measurements may not accu-rately estimate arterial blood or plasma glucose values (ungraded).

S. Bicarbonate Therapy1. Not using sodium bicarbonate therapy for the purpose of improving

hemodynamics or reducing vasopressor requirements in patients with hypoperfusion-induced lactic acidemia with pH 7.15 (grade 2B).

W. Setting Goals Of Care1. Discuss goals of care and prognosis with patients and families

(grade 1B).2. Incorporate goals of care into treatment and end-of-life care plan-

ning, utilizing palliative care principles where appropriate (grade 1B).

3. Address goals of care as early as feasible, but no later than within 72 hours of ICU admission (grade 2C).

O. Mechanical Ventilation Of Sepsis-Induced Acute Respiratory Distress Syndrome1. Target a tidal volume of 6 mL/kg predicted body weight in patients

with sepsis-induced ARDS (grade 1A vs 12 mL/kg).2. Plateau pressures be measured in patients with ARDS and initial

upper limit goal for plateau pressures in a passively inflated lung be 30 cm H2O (grade 1B).

3. Positive end-expiratory pressure (PEEP) be applied to avoid alveo-lar collapse at end expiration (atelectotrauma) (grade 1B).

4. Strategies based on higher rather than lower levels of PEEP be used for patients with sepsis-induced moderate or severe ARDS (grade 2C).

5. Recruitment maneuvers be used in sepsis patients with severe refractory hypoxemia (grade 2C).

6. Prone positioning be used in sepsis-induced ARDS patients with a Pao2/Fio2 ratio 100 mm Hg in facilities that have experience with such practices (grade 2B).

7. That mechanically ventilated sepsis patients be maintained with the head of the bed elevated to 30 to 45 to limit aspiration risk and to prevent the development of ventilator-associated pneumonia (grade 1B).

8. That noninvasive mask ventilation (NIV) be used in that minority of sepsis-induced ARDS patients in whom the benefits of NIV have been carefully considered and are thought to outweigh the risks (grade 2B).

11. A conservative rather than liberal fluid strategy for patients with established sepsis-induced ARDS who do not have evidence of tis-sue hypoperfusion (grade 1C).

12. In the absence of specific indications such as bronchospasm, not using beta2-agonists for treatment of sepsis-induced ARDS (grade 1B).

P. Sedation, Analgesia, And Neuromuscular Blockade In Sepsis1. Continuous or intermittent sedation be minimized in mechanically

ventilated sepsis patients, targeting specific titration endpoints (grade 1B).

2. Neuromuscular blocking agents be avoided if possible in the septic patient without ARDS due to the risk of prolonged neuromuscu-




Editorial Comment

The Surviving Sepsis Campaign's update of the 2008 guidelines on the management of severe sepsis and septic shock was intended for use by clinicians in the ICU as well as the non-ICU setting. Overall, the guidelines are a useful and comprehensive guide to help improve the care of the severely septic patient, and they were created using an evidence-based development process. In this edito-rial comment, we discuss the most important points for clinicians in the ED and critique the recommendations that, in our opinion, do not necessarily reflect the best approach to care in the ED setting.

A. Initial Resuscitation: The guidelines strongly recommend the quantitative, protocolized resuscitation of patients with sepsis-induced tissue hypoperfusion. This grade 1 recommendation specifies that during the first 6 hours, the goals include achieving all of the follow-ing: (1) a central venous pressure (CVP) of 8 to 12 mm Hg, (2) mean arterial pressure (MAP) > 65 mm Hg, (3) urine output of 0.5 mL/kg/h, and (4) superior vena cava oxygenation saturation (ScvO2) or mixed venous oxygen saturation (SvO2) at 70% or 65%, respectively. One of the most controversial aspects of these guidelines is the inclusion of CVP as one of these core target measures. A key goal in the initial resuscitation of patients with sepsis-induced tissue hypoperfusion is the improvement of cardiac output, which is achieved, in part, by giving fluid-responsive patients crystalloids; however, CVP has been shown to be an unreliable marker of fluid responsiveness. Furthermore, it re-quires placement of a central line, an invasive procedure with potential complications that has also has been identified as one of the barriers to compliance with early goal-directed therapy.4,5 In their comments, the guideline authors acknowledge limitations of CVP as a marker of intravascular volume status and fluid responsiveness, but they held that a low CVP can generally be relied on as a marker of fluid respon-siveness, which is a statement without evidence-based support. Be-cause patients should be getting empiric initial fluid resuscitation at the beginning of their emergency department stay anyway, this obvi-

ates the benefits of identifying a low CVP. According to a 2012 meta-analysis, a safer and less resource-intensive alternative to identify a low-volume state is ultrasonography of the inferior vena cava.6

There are limitations to the utility of several of the other markers as well. Urine output may be reduced by sepsis-induced kidney dysfunc-tion, so urine output of 0.5 mL/kg/h is reassuring if it is present, but it is a nonspecific indicator if it is not. Central venous oxygen saturation (ScvO2) is another marker that requires the placement of a central line; however, there is evidence that ScvO2 measurements can be substi-tuted by lactate clearance. The guideline authors discuss the nonin-feriority trial that found that early quantitative resuscitation based on lactate clearance (decrease by at least 10%) was noninferior to early quantitative resuscitation based on achieving an ScvO2 of 70% or more clearance.7 However, they were concerned about the small number of patients requiring either ScvO2 normalization or lactate clearance. Thus, their recommendation to use lactate normalization as a resus-citation target is weaker than for the other quantitative targets and not listed as a replacement for ScvO2.

B. Screening For Sepsis And Performance Improvement: Early recognition of sepsis is a vital part of treatment and was given a strong recommendation, as it has been shown to decrease mortality. This should be incorporated into triage protocols, and nursing staff should be trained in early recognition of septic patients.

The guideline authors review their concept of bundles, which are a core set of recommendations that, when implemented as part of a performance improvement initiative, can lead to sustained, continuous quality improvement in sepsis care and have been associated with re-duced mortality. The bundles themselves were updated from the prior policy. The 2012 guideline describes bundles that should be completed within 3 and 6 hours. (See Table 1, page 7.)




versus other fluids. When using albumin over crystalloid during resus-citation, a meta-analysis of 17 randomized trials did show a relative risk reduction, but a multi-center randomized controlled trial showed a statistically insignificant absolute risk reduction.8 Taking these data as well as the higher cost of albumin into account, the Surviving Sepsis Campaign recommends using crystalloid as the primary fluid of re-suscitation. Resuscitation should continue until the patient shows no further hemodynamic improvement in response to further boluses.

The guidelines recommend using either static variables (MAP or heart rate) or dynamic variables (change in pulse pressure or stroke volume variation) to measure the hemodynamic response to fluid (volume) challenges. MAP, in particular, is a commonly used but insensitive measure of fluid responsiveness.9 In situations where the MAP is un-changed by fluid, stroke volume may continue to improve with further fluid administration. These cases can be identified by supplement-ing static measurements with dynamic measures. Dynamic variables are indices of intravascular volume status that include pulse pressure variation or stroke volume variation. These measurements can be calculated with devices as simple as an arterial line or as a complex as a cardiac index flow monitor. In order to obtain those dynamic measurements, several external factors must be present, including a mechanically ventilated patient with normal tidal volumes, absence of arrhythmias, and an adequately deep level of sedation.9 The use of serial blood pressure measurements can also be complemented by the use of bedside echocardiography to direct early fluid resuscitation.

H. Vasopressors: This guideline establishes norepinephrine as the first-line vasopressor for sepsis-induced hypotension. The Surviv-ing Sepsis Campaign's recommendation to use epinephrine as an adjunctor potentially even as a replacementfor norepinephrine is a weaker recommendation, but it is nonetheless a progressive step forward. Dopamine is no longer favored, and it should only be used in rare cases of bradydysrhythmia (if at all), as it is more arrhythmogenic than other options. Lower doses do not provide any renal benefit. Va-sopressin can be added, at a dosage of 0.03 units/min, which is a de-crease from prior recommendations of 0.04 units/min, to decrease the dose of norepinephrine. Lastly, phenylephrine is only recommended for

Table 1. Surviving Sepsis Campaign Care Bundles3

To be completed within 3 hours:1. Measure lactate level2. Obtain blood cultures prior to administration of antibiotics3. Administer broad-spectrum antibiotics4. Administer crystalloid 30 mL/kg for hypotension or lactate 4 mmol/LTo be completed within 6 hours:5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscita-

tion) to maintain a mean arterial pressure 65 mm Hg6. In the event of persistent arterial hypotension despite volume resuscitation (septic

shock) or initial lactate 4 mmol/L (36 mg/dL): Measure central venous pressure* Measure central venous oxygen saturation (ScvO2)*

7. Remeasure lactate if initial lactate was elevated*

*Targets for quantitative resuscitation included in the guidelines are central venous pressure of 8 mm Hg, ScvO2 of 70%, and normalization of lactate.

C. Diagnosis: Obtaining appropriate blood cultures is a priority during the initial resuscitation and should be done within the first 3 hours, as the Surviving Sepsis Campaign bundles outline. Obtaining 2 sets of aerobic and anaerobic cultures should be done as soon as possible, but this should not delay the administration of antibiotics more than 45 minutes, per the guidelines. There is a window of time (potentially up to several hours) after the administration of antibiotics before blood cultures will be sterile, so the clinician should not stop attempting to get samples once antibiotics are given if they could not be obtained previously. Cultures should be taken from all ports of an indwelling catheter. Site-specific cultures such as cerebrospinal, respiratory, and urine cultures should be taken based on suspicion; however, as above, obtaining these cultures should not delay the administration of empiric antibiotics.

G. Fluid Therapy Of Severe Sepsis: The Surviving Sepsis Campaign guidelines recommend using crystalloid as the initial fluid for resusci-tation. Large volumes of crystalloid are required, and the initial bolus should be 30 cc/kg. The guidelines also discuss the use of albumin, which is given a weaker recommendation than for crystalloid resusci-tation, and the recommendation is based largely on a meta-analysis with a marginally improved outcome for patients treated with albumin




Campaign recommends transfusing anemic patients (hemoglobin < 7 g/dL) when hypoperfusion has resolved. Myocardial ischemia, se-vere hypoxemia, acute hemorrhage, or ischemic heart disease may be indications for transfusions as well, per the discretion of the treatment team. Unfortunately, the Surviving Sepsis Campaign does not com-ment on blood administration when hypoperfusion persists despite fluid resuscitation, vasopressors, and inotropy for patients who have a hemoglobin > 7 g/dL. This decision will need to be made on a case-by-case basis by the providers.

O. Mechanical Ventilation Of Sepsis-Induced Acute Respiratory Distress Syndrome: As several multicenter trials have shown, a lung-protective ventilator strategy improves mortality. The Surviving Sepsis Campaign recommends aiming for tidal volumes of 6 cc/kg and pla-teau pressures of < 30 cm H2O. This may lead to hypercapnia, despite maximum tolerated set respiratory rates, but unless there are specific contraindications, this is acceptable. The use of elevated positive-end expiratory pressure (PEEP) can help avoid end-expiratory alveolar collapse and associated lung injury, and it can improve oxygenation. Higher rather than lower levels of PEEP may improve mortality in patients with moderate to severe ARDS. Once hypoperfusion has resolved, the guidelines advocate for conservative fluid management in patients with sepsis-induced ARDS; again, this is a recommenda-tion that applies mainly to ICU care. The guidelines emphasize caution when selecting patients for noninvasive ventilation, as septic patients can become more ill and lose their ability to clear secretions. Emer-gency clinicians should have a low threshold for intubation.

Q. Glucose Control: Over the past several years, glycemic control has been under scrutiny in the ICU setting, and the Surviving Sepsis Campaign has come to the consensus that if 2 point-of-care glucose readings are > 180 mg/dL, an insulin protocol should be initiated. This is a change from the earlier recommendation to start glycemic control at a glucose level of > 110 mg/dL.


shock states with high cardiac output or as an adjunct to norepinephrine and vasopressin, but it should also be considered in states where vaso-pressors are started peripherally while central access is secured. Phen-ylephrine is the best choice for peripheral administration (as infiltrated phenylephrine has a lower risk of complications), but norepinephrine could be started with reliable peripheral intravenous access, if needed. For all patients requiring vasopressors, it is recommended that an arte-rial line for proper monitoring be placed as soon as resources allow.

I. Inotropic Therapy: Use dobutamine if a patient remains hypoten-sive or does not have lactate clearance despite fluid resuscitation in a low cardiac-output state. A trial of dobutamine can be used if another assessment of cardiac output cannot be performed.

J. Corticosteroids: The use of steroids in septic shock remains con-troversial, and published trials still fail to provide a clear answer. The Surviving Sepsis Campaign recommends against the use of steroids in patients who are successfully resuscitated with fluids and vasopres-sors. In the subgroup of subjects who remain hypotensive despite these interventions, the Surviving Sepsis Campaign recommends hy-drocortisone 200 mg/day, given as a continuous infusion rather than as boluses, in order to avoid rapid changes in serum glucose. Within the ED, a bolus of hydrocortisone (either 50 mg every 6 h or 100 mg every 8 h) can still be considered a viable option in this subset of patients, as the continuous infusion can be started as soon as possible in the ICU. Lastly, when the severely septic or septic shock patient remains in the ED and the clinician is able to titrate down vasopressors, the Surviving Sepsis Campaign recommends titrating down steroids as well.

K. Blood Product Administration: In the landmark trial that estab-lished the protocol for early goal-directed therapy, patients with contin-ued hypoperfusion despite optimization with fluids, vasopressors, and inotropic agents were transfused to a hematocrit of 30%.10 In general, trials looking at the impact of transfusions have found a possible mor-tality benefit using a lower target hemoglobin of 7 to 9 g/dL;11 however, these trials were done in critically ill patients after initial resuscitation. Recognizing risks and benefits of transfusion, the Surviving Sepsis




W. Setting Goals Of Care: The guideline authors acknowledge that sometimes providing less-aggressive care or withdrawing care may be in the patients best interest. They recommend the use of proac-tive family care conferences to identify advance directives and treat-ment goals within 72 hours of ICU admission. Not only does this promote communication and understanding between the patients family and the care team, it has been shown to improve family satis-faction; decrease stress, anxiety, and depression in surviving rela-tives; facilitate end-of-life decision making; and shorten length of stay for patients who die in the ICU. Family discussions are aided by a discussion of prognosis and the level of uncertainty about that prognosis. Integration of palliative care can improve outcomes for the patient and the family. A key goal of palliative care is to provide care that the patient would have wanted, not necessarily what the family desires, helping families avoid the feeling of guilt when aggressive measures are withheld. There are many tools used in palliative care that can improve the process of death for the patient and the family, and these should be utilized promptly and appropriately by ICU and non-ICU departments.

References 1. Dombrovskiy VY, Martin AA, Sunderram J, et al. Fac-

ing the challenge: decreasing case fatality rates in severe sepsis despite increasing hospitalizations. Crit Care Med. 2005;33(11):2555. (Retrospective; 87,675 patients)

2. Martin GS, Mannino DM, Eaton S, et al. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med .2003; 348:1546-1554. (Retrospective; 10,319,418 cases)

3. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580-637. (Guidelines)

4. Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the lit-erature and the tale of seven mares. Chest. 2008;134(1):172-178. (Systematic review)

5. Carlbom DJ, Rubenfeld GD. Barriers to implementing proto-col-based sepsis resuscitation in the emergency department: results of a national survey. Crit Care Med. 2007;35(11):2525-2532. (Survey; 64 healthcare providers)

6. Dipti A, Soucy Z, Surana A, et al. Role of inferior vena cava diameter in assessment of volume status: a meta-analysis. AJEM. 2012;30:1414-1419. (Meta-analysis; 5 studies)

7. Jones AE, Shapiro NI, Trzeciak S, et al. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010;303(8):739-746. (Randomized controlled trial; 300 patients)

8. Delaney AP, Dan A, McCaffrey J, et al. The role of albumin as a resuscitation fluid for patients with sepsis: a systematic review and meta-analysis. Crit Care Med. 2011;39:386-391. (Meta-analysis)

9. Marik PE, Cavallazzi R, Vasu T, et al. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med. 2009;37:2642-2647. (Systematic review)

10. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368-1377. (Randomized controlled trial; 263 patients)

11. Hbert PC, Wells G, Blajchman MA, et al. A multicenter, ran-domized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340:409-417. (Randomized controlled trial; 838 patients)




CME Questions

To take the CME test, visit: www.ebmedicine.net/CME

1. A 65-year-old male with diabetes presents with community-acquired pneumonia, with a blood pressure of 100/60 mm Hg. Which se-rum blood test can aid in risk stratifying the patient as having severe sepsis?a. Sodiumb. Cortisolc. Troponind. Lactate

2. In the patient in question 1, the lactate level returns at 6 mg/dL. What measurement should NOT be used as a goal of the initial resus-citation?a. Lactate clearance by 10%b. MAP 65 mm Hgc. Heart rate < 100 beats per minuted. Urine output 0.5 mL/kg/h

3. In the patient in question 1, after appropriate fluid resuscitation, the MAP decreases to 50 mm Hg. Assuming a normal heart rate, which vasopressor would be the first choice?a. Dopamine b. Norepinephrinec. Dobutamined. Phenylephrine

4. In the patient in question 1, after fluid resuscitation and inotropic therapy, his MAP declines and bedside ultrasound shows decreased myocardial contractility compared to baseline. Which therapy can aid in resuscitation?a. Dobutamine b. Cardiac catherizationc. Nitroglycerind. Aspirin




CME information for EM Practice Guidelines UpdateTo take the CME test, visit: www.ebmedicine.net/cme

Date of Original Release: April 1, 2013. Date of most recent review: March 1, 2013. Termination date: April 1, 2016.

Accreditation: EB Medicine is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation: EB Medicine designates this enduring material for a maximum of 2 AMA PRA Cat-egory 1 Credits. Physicians should claim only credit commensurate with the extent of their participation in the activity.

Needs Assessment: The need for this educational activity was determined by a survey of practicing emergency physicians and the editorial board of this publication; knowledge and competency surveys; and evaluation of prior activities for emergency physicians.

Target Audience: This enduring material is designed for emergency medicine physicians, physician as-sistants, nurse practitioners, and residents.

Goals: Upon completion of this article, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence, (2) cost-effectively diagnose and treat the most critical ED presen-tations, and (3) describe the most common medicolegal pitfalls for each topic covered.

Objectives: Upon completion of this article, you should be able to: (1) describe the treatment goals in the initial resuscitation of patients with severe sepsis or septic shock, (2) utilize markers to initiate vasopres-sors, blood administration, and steroids for patients with severe sepsis or septic shock, and (3) discuss the hemodynamic and ventilatory management for patients with severe sepsis or septic shock.

Discussion of Investigational Information: As part of the newsletter, faculty may be presenting investi-gational information about pharmaceutical products that is outside Food and Drug Administration-approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.

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Commercial Support: This issue of EM Practice Guidelines Update did not receive any commercial support.

Method of Participation: Current, paid subscribers of Emergency Medicine Practice and EM Practice Guidelines Update who read this EM Practice Guidelines Update CME article and complete the online CME Evaluation survey at www.ebmedicine.net/CME are eligible for up to 2 hours of Category 1 credit toward the AMA Physicians Recognition Award (PRA). Hints will be provided for each missed question, and partici-pants must score 100% to receive credit. Results will be kept confidential. CME certificates may be printed directly from the website.

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To contact the Editor-In-Chief, email Luke Hermann, MD at: [email protected]

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Check Out The EM Practice Guidelines Update ArchivesPublication Date Issue Title Link # Of Free

CME CreditsJanuary 2012 Current Emergency Medical Services Guidelines: Traumatic Cardiopul-

monary Arrest And Prehospital Airway Management (Trauma CME)www.ebmedicine.net/CPR 2

February 2012 Low-Risk Chest Pain In The Emergency Department: Current Guidelines

www.ebmedicine.net/ChestPain 2

March 2012 Neck Trauma: Current Guidelines For Emergency Clinicians www.ebmedicine.net/NeckTrauma 2

April 2012 Unstable Angina And Non-ST-Elevation Myocardial Infarction In The Emergency Department: Current Guidelines

www.ebmedicine.net/NSTEMI 2

May 2012 Current Guidelines On Atrial Fibrillation In The Emergency Department www.ebmedicine.net/Afib 2

June 2012 Current Guidelines For The Management Of Hypertension In The Emergency Department

www.ebmedicine.net/Hypertension 2

July 2012 Current Guidelines For The Management Of Pneumothorax In The Emergency Department

www.ebmedicine.net/Pneumothorax 2

August 2012 Guidelines For The Management Of Cystitis And Pyelonephritis In The Emergency Department

www.ebmedicine.net/Cystitis 2

September 2012 Current Guidelines For Management of Acute Altitude Illness, Frost-bite, And Snake Envenomation (Trauma CME)

www.ebmedicine.net/Envenomation 2

October 2012 American Heart Association Guidelines For The Emergency Clinician: Cardiac Arrest In Special Situations And First Aid (Trauma CME)

www.ebmedicine.net/CardiacArrest 2

November 2012 Percutaneous Coronary Intervention: Current Guidelines For The Emergency Department

www.ebmedicine.net/PCI 2

December 2012 Current Guidelines For Evaluating And Managing Symptomatic Early Pregnancy In The Emergency Department

www.ebmedicine.net/EarlyPregnancy 2

January 2013 Current Guideline For The Neurodiagnostic Evaluation Of The Child With A Simple Febrile Seizure

www.ebmedicine.net/PedFebSeizure 2

February 2013 Current Guidelines For The Evaluation And Management Of Communi-ty-Acquired Pneumonia In The Emergency Department

www.ebmedicine.net/CAP 2

March 2013 Current Guidelines For Management Of Bell Palsy And Herpes Zoster In The Emergency Department

www.ebmedicine.net/BellPalsy 2




EM Practice Guidelines Update 2009 1 EBMedicine.net November 2009

Benign Paroxysmal Positional Vertigo and Acute Otitis Externa in the ED: Current Guidelines | PRINT | SUBSCRIBE | WEBSITE

EM Practice Guidelines Update 2009 1 ebmedicine.net November 2009

Benign Paroxysmal Positional Vertigo And Acute Otitis Externa In The ED: Current Guidelines | PRINT | SUBSCRIBE | WEBSITE

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AlltheCMEyouneedatnoextracharge:Earnupto48 AMA PRA Category 1 Credits,48ACEPCategory1,48AAFPPrescribed,or48AOACategory2Bcreditsoverthecomingyear-plusupto144creditsfromtheonlinerepositoryofarticles!

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Want to receive EM Practice Guidelines Update free?July 2009Volume 11, Number 7Authors

Lisa E. Thomas, MD Department of Emergency Medicine, Brigham & Womens

Hospital & Massachusetts General Hospital, Boston, MAJonathan Edlow, MDVice Chair, Department of Emergency Medicine

Beth Israel Deaconess Medical Center; Associate Professor of

Medicine, Harvard Medical School, Boston, MAJoshua N. Goldstein, MD, PhD, FAAEMInstructor in Surgery (Emergency Medicine), Harvard Medical

School, Department of Emergency Medicine, Massachusetts

General Hospital, Boston, MAPeer ReviewersE. Bradshaw Bunney, MD, FACEPAssociate Professor, Residency Director, Department of

Emergency Medicine, University of Illinois at Chicago,

Chicago, ILNeal Little, MD, FACEPAdjunct Clinical Assistant Professor, Department of Emergency

Medicine, University of Michigan Medical School, Ann Arbor, MI

CME Objectives Upon completion of this article, you should be able to:

1. Describe the classic presentation of an SAH as well as

discuss the wide spectrum of presentation. 2. Describe the diagnostic approach to a patient suspected of

having an SAH. 3. Identify the major limitations in interpreting the diagnostic

modalities. 4. Discuss general principles of acute SAH management in

the ED. 5. Identify common pitfalls in the diagnosis of SAH.Date of original release: July 1, 2009Date of most recent review: April 27, 2009

Termination date: July 1, 2012Medium: Print and onlinePrior to beginning this activity, see Physician CME

Information on page 27.

Evidence-Based Approach To Diagnosis And Management Of Aneurysmal Subarachnoid Hemorrhage In The Emergency DepartmentYou walk into a crowded evening shift in the emergency department (ED).

Your first patient is a middle-aged woman lying with her hands clutching

her head, complaining of the worst headache of her life. You are worried

about a subarachnoid hemorrhage (SAH). You treat her pain and order a

noncontrast head computed tomography (CT), which is negative. She now

says that her headache is better and that she needs to go home to pick up her

kids. Does she really need a lumbar puncture (LP)? She eventually agrees

to stay for an LP, which is also negative. Can she go home now? Does she

need any additional workup? While you are thinking about this, another patient with a history of

migraine arrives complaining of sudden-onset, severe headache that has

lasted 12 hours. Is this headache her usual migraine or could this be an

SAH? After further history is obtained, you are concerned about an SAH

and you obtain a CT, which is normal. You perform an LP, which shows

some clearing of red blood cells (RBCs) from tube 1 to tube 4, and you think

it may have been a traumatic tap, but how can you be sure? Just as you are

pondering this, the lab calls to say there is xanthochromia. You make the

diagnosis of SAH. After calling for neurosurgical consultation, what else

should you do in the ED to treat this patient?

Accreditation: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education

(ACCME) through the sponsorship of EB Medicine. EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr.

Thomas, Dr. Edlow, Dr. Bunney, Dr. Little, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s)

discussed in this educational presentation. Dr. Goldstein has received consulting fees from Genentech and CSL Behring. Commercial Support: This issue of Emergency Medicine

Practice did not receive any commercial support.

Editor-in-ChiefAndy Jagoda, MD, FACEP Professor and Chair, Department of Emergency Medicine, Mount Sinai School of Medicine; Medical Director, Mount Sinai Hospital, New York, NYEditorial BoardWilliam J. Brady, MD Professor of Emergency Medicine and Medicine Vice Chair of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA

Peter DeBlieux, MD Professor of Clinical Medicine, LSU Health Science Center; Director of Emergency Medicine Services, University Hospital, New Orleans, LA

Wyatt W. Decker, MD Chair and Associate Professor of Emergency Medicine, Mayo Clinic College of Medicine, Rochester, MNFrancis M. Fesmire, MD, FACEP Director, Heart-Stroke Center, Erlanger Medical Center; Assistant

Professor, UT College of Medicine,

Chattanooga, TNMichael A. Gibbs, MD, FACEP Chief, Department of Emergency Medicine, Maine Medical Center, Portland, ME

Steven A. Godwin, MD, FACEP Assistant Professor and Emergency Medicine Residency Director, University of Florida HSC, Jacksonville, FL

Gregory L. Henry, MD, FACEP CEO, Medical Practice Risk Assessment, Inc.; Clinical Professor of Emergency Medicine, University of Michigan, Ann Arbor, MIJohn M. Howell, MD, FACEP Clinical Professor of Emergency Medicine, George Washington University, Washington, DC;Director

of Academic Affairs, Best Practices, Inc, Inova Fairfax Hospital, Falls Church, VA

Keith A. Marill, MD Assistant Professor, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA

Charles V. Pollack, Jr., MA, MD, FACEP Chairman, Department of Emergency Medicine, Pennsylvania

Hospital, University of Pennsylvania Health System, Philadelphia, PAMichael S. Radeos, MD, MPH Assistant Professor of Emergency

Medicine, Weill Medical College of Cornell University, New York, NY.Robert L. Rogers, MD, FACEP, FAAEM, FACP Assistant Professor of Emergency

Medicine, The University of Maryland School of Medicine, Baltimore, MDAlfred Sacchetti, MD, FACEP Assistant Clinical Professor, Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA

Scott Silvers, MD, FACEP Medical Director, Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL

Corey M. Slovis, MD, FACP, FACEP Professor and Chair, Department of Emergency Medicine, Vanderbilt

University Medical Center, Nashville, TNJenny Walker, MD, MPH, MSW Assistant Professor; Division Chief, Family Medicine, Department of Community and Preventive Medicine, Mount Sinai Medical Center, New York, NY Ron M. Walls, MD Professor and Chair, Department

of Emergency Medicine, Brigham and Womens Hospital,Harvard Medical School, Boston, MAScott Weingart, MD Assistant Professor of Emergency

Medicine, Elmhurst Hospital Center, Mount Sinai School of Medicine, New York, NYResearch EditorsNicholas Genes, MD, PhD Chief Resident, Mount Sinai Emergency Medicine Residency, New York, NY

Lisa Jacobson, MD Chief Resident, Mount Sinai School of Medicine, Emergency Medicine Residency, New York, NY

International EditorsPeter Cameron, MD Chair, Emergency Medicine, Monash University; Alfred Hospital, Melbourne, Australia Amin Antoine Kazzi, MD, FAAEM Associate Professor and Vice Chair, Department of Emergency Medicine, University of California, Irvine; American University, Beirut, LebanonHugo Peralta, MD Chair of Emergency Services, Hospital Italiano, Buenos Aires, Argentina

Maarten Simons, MD, PhD Emergency Medicine Residency Director, OLVG Hospital, Amsterdam, The Netherlands

Improving Patient Care

Years

EM Practice Guidelines Update 2009 1 EBMedicine.net November 2009

Benign Paroxysmal Positional Vertigo and Acute Otitis Externa in the ED: Current Guidelines | PRINT | SUBSCRIBE | WEBSITE

EM Practice Guidelines Update 2009 1

Benign Paroxysmal Positional Vertigo And Acute Otitis Externa In The ED: Current Guidelines | PRINT | SUBSCRIBE | WEBSITE

Do you like what youre reading? Then subscribe at this special discounted rate: Just $249 for a full year (12 issues) of Emergency Medicine Practice. Plus, you receive EM Practice Guidelines Update absolutely FREE!

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Subscribe to Emergency Medicine Practice and youll receive EM Practice Guidelines Update at no additional charge! Plus, you receive all the benefits of Emergency Medicine Practice: A chief-complaint focus: Every issue starts with a patient complaint just like your daily practice. Youre guided step-by-step

in reaching the diagnosis often the most challenging part of your job.

An evidence-based medicine approach: The degree of acceptance and scientific validity of each recommendation is assessed based on strength of evidence.

Diagnosis and treatment recommendations solidly based in the current literature.

Abundant clinical pathways, figures, and tables: Youll find reliable solutions quickly. The easy-to-read format delivers solid information appropriate for real-time situations.

Unlimited online access: Search and access each monthly issue of Emergency Medicine Practice since inception in June 1999 plus print and read each new issue before it even hits the mail.

All the CME you need at no extra charge: Earn up to 48 AMA PRA Category 1 Credits, 48 ACEP Category 1, 48 AAFP Prescribed, or 48 AOA Category 2B credits over the coming yearplus up to 144 credits from the online repository of articles!

Subscribe to Emergency Medicine Practice today and receive EM Practice Guidelines Update at no additional charge! Or, subscribe to EM Practice Guidelines Update only at the discounted rate below. To subscribe, complete the order form below and mail or fax it to EB Medicine, or visit www.ebmedicine.net/subscribe.

Want to receive EM Practice Guidelines Update free?July 2009Volume 11, Number 7Authors

Lisa Thomas, MDADDJonathan Edlow, MD [_authorname] ADDPeer ReviewersADDADD ADDADDCME Objectives Upon completion of this article, you should be able to:

1. Describe the classic presentation of an SAH as well as

discuss the wide spectrum of presentation. 2. Describe the diagnostic approach to a patient suspected

of having SAH. 3. Identify the major limitations in interpreting the diagnostic

modalities. 4. Discuss general principles of acute SAH management in

the ED. 5. Identify common pitfalls in the diagnosis of SAH.Date of original release: July 1, 2009

Date of most recent review: ADDTermination date: July 1, 2012Medium: Print and onlineMethod of participation: Print or online answer form and

evaluationPrior to beginning this activity, see Physician CME Information on the back page.

Evidence-Based Approach To Diagnosis And Management Of Aneurysmal Subarachnoid Hemorrhage In The Emergency DepartmentYou walk into a crowded evening shift in the emergency department (ED).

Your first patient is a middle-aged woman lying with her hands clutching

her head, complaining of the worst headache of her life. You are worried

about a subarachnoid hemorrhage (SAH). You treat her pain and order a

noncontrast head computed tomography (CT), which is negative. She now

says that her headache is better and that she needs to go home to pick up her

kids. Does she really need a lumbar puncture (LP)? She eventually agrees to stay for an LP, which is also negative. Can she

go home now? Does she need any additional workup? While you are thinking about this, another patient with a history of mi-

graine arrives complaining of sudden-onset, severe headache that has lasted

12 hours. Is this headache her usual migraine or could this be an SAH?

You are concerned after further history is obtained about an SAH and you

obtain a CT, which is normal. perform an LP, which shows some clearing

of red blood cells (RBCs) from tube 1 to tube 4, and you think it may have

been a traumatic tap, but how can be sure? Just as you are pondering this,

the lab calls to say there is xanthochromia. You make the diagnosis of SAH.

After calling for neurosurgical consultation, what else should you do in the

ED to treat this patient?

Accreditation: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education

(ACCME) through the sponsorship of EB Medicine. EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr.

Thomas, Dr. Edlow, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this

educational presentation. Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.

Editor-in-ChiefAndy Jagoda, MD, FACEP Professor and Vice-Chair of Academic Affairs, Department of Emergency Medicine, Mount Sinai School of Medicine; Medical Director, Mount Sinai Hospital, New York, NYEditorial BoardWilliam J. Brady, MD Professor of Emergency Medicine and Medicine Vice Chair of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA

Peter DeBlieux, MD Professor of Clinical Medicine, LSU Health Science Center; Director of Emergency Medicine Services, University Hospital, New Orleans, LA

Wyatt W. Decker, MD Chair and Associate Professor of Emergency Medicine, Mayo Clinic College of Medicine, Rochester, MNFrancis M. Fesmire, MD, FACEP Director, Heart-Stroke Center, Erlanger Medical Center; Assistant

Professor, UT College of Medicine, Chattanooga, TN

Michael A. Gibbs, MD, FACEP Chief, Department of Emergency Medicine, Maine Medical Center, Portland, ME

Steven A. Godwin, MD, FACEP Assistant Professor and Emergency Medicine Residency Director, University of Florida HSC, Jacksonville, FL

Gregory L. Henry, MD, FACEP CEO, Medical Practice Risk Assessment, Inc.; Clinical Professor of Emergency Medicine, University of Michigan, Ann Arbor, MIJohn M. Howell, MD, FACEP Clinical Professor of Emergency Medicine, George Washington University, Washington, DC;Director

of Academic Affairs, Best Practices, Inc, Inova Fairfax Hospital, Falls Church, VA

Keith A. Marill, MD Assistant Professor, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA

Charles V. Pollack, Jr., MA, MD, FACEP Chairman, Department of Emergency Medicine, Pennsylvania

Hospital, University of Pennsylvania Health System, Philadelphia, PAMichael S. Radeos, MD, MPH Assistant Professor of Emergency

Medicine, Weill Medical College of Cornell University, New York, NY.Robert L. Rogers, MD, FACEP, FAAEM, FACP Assistant Professor of Emergency

Medicine, The University of Maryland School of Medicine, Baltimore, MDAlfred Sacchetti, MD, FACEP Assistant Clinical Professor, Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA

Scott Silvers, MD, FACEP Medical Director, Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL

Corey M. Slovis, MD, FACP, FACEP Professor and Chair, Department of Emergency Medicine, Vanderbilt

University Medical Center, Nashville, TNJenny Walker, MD, MPH, MSW Assistant Professor; Division Chief, Family Medicine, Department of Community and Preventive Medicine, Mount Sinai Medical Center, New York, NY Ron M. Walls, MD Professor and Chair, Department

of Emergency Medicine, Brigham and Womens Hospital,Harvard Medical School, Boston, MAScott Weingart, MD Assistant Professor of Emergency

Medicine, Elmhurst Hospital Center, Mount Sinai School of Medicine, New York, NYResearch EditorsNicholas Genes, MD, PhD Chief Resident, Mount Sinai Emergency Medicine Residency, New York, NY

Lisa Jacobson, MD Mount Sinai School of Medicine, Emergency Medicine Residency, New York, NY

International EditorsPeter Cameron, MD Chair, Emergency Medicine, Monash University; Alfred Hospital, Melbourne, Australia Amin Antoine Kazzi, MD, FAAEM Associate Professor and Vice Chair, Department of Emergency Medicine, University of California, Irvine; American University, Beirut, LebanonHugo Peralta, MD Chair of Emergency Services, Hospital Italiano, Buenos Aires, Argentina

Maarten Simons, MD, PhD Emergency Medicine Residency Director, OLVG Hospital, Amsterdam, The Netherlands

Improving Patient Care

Years

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