QI/KT: MASSIVE AND SUBMASSIVE PE WITH DRS. BANNING AND GOLDEN

BACKGROUND

Definitions:

Sub-massive PE
- Radiographic evidence of strain
  - RV dilation and dysfunction on US
  - EKG strain
- Evidence of myocardial necrosis
  - New block
    - Troponin leak
- No hemodynamic instability
- ***OFTEN DIVIDED INTO LOW or HIGH RISK (No formal definition. Operative definition defined below)***
  - Low risk: Radiographic evidence of strain OR evidence of myocardial necrosis
  - High risk: Radiographic evidence of strain AND evidence of myocardial necrosis
Massive PE:
- Sub-massive criteria PLUS
- Hemodynamic Instability
  - Pulselessness
  - Bradycardia (HR<40)
  - Shock
  - Hypotension (SBP<90 mmHg for >15 minutes)

Incidence and Mortality

Overall incidence is increasing
- Likely 2/2 increased testing/scanning
- Overall healthcare cost 7-10 billion dollars annually
Mortality
- 100,000 deaths annually
- 30% mortality if untreated
  - 52% of fatal cases due to massive PE
  - 15% of fatal cases due to sub-massive PE

Pathophysiology/disease progression

Clot in PA => Increased PA pressure => RV dilation => Tricuspid regurgitation => Decreased cardiac output => Poor coronary perfusion => Myocardial necrosis

Management and Treatment Algorithms

QUICK NOTE on Pulmonary Embolism Response Teams (PERT):

Multidisciplinary team created to help coordinate and expedite PE treatment (Similar to concept of stroke team)
Goals of dedicated PERT
- Rapid evaluation of patients with PE
- Formulation of treatment plan
- Mobilization of resources
Now present in over 60 institutions nationwide
COMING TO CINCINNATI
- Already present during certain hours
- Multidisciplinary team currently being assembled

MASSIVE PE PROTOCOL (Hyperlink to Algorithm)

SEE ALGORITHM FOR STEP BY STEP MANAGEMENT
Evidence behind management
- Thrombolysis with TPA
  - Indicated for all massive PEs without contraindications (List of contraindications in algorithm)
    - Only absolute contraindication is massive bleeding
    - If others exist, risk benefit discussion with family is warranted
  - Recommend weight based dosing
    - >65 Kg => 100mg/2 hours
    - <65 Kg => 50mg/2 hours
    - ***Studies examining "Full vs. Half" dose of TPA showed statistically significant increase in bleeding risk for patients <65kg with similar efficacy***
- Thrombolysis + Embolectomy
  - Large review with 600 patients
  - Success rate of 86.5%
  - Results
    - Improved hypoxia
    - Improved hemodynamics
    - Major complication rate of 8%
- Catheter directed TPA
  - Local deliver over extended period of time shown to be beneficial
  - Ex. EKOS catheter
- Surgical excision of thrombus
  - Retrospective review of 115 cases demonstrated the following
    - 42% had massive PE
    - 52% had contra-indications to thrombolysis
    - 1 year mortality was 30%
- ECMO
  - Systematic review including 80 patients
  - Improved survival with 70% survival rate
  - Many go on to require additional procedure (ex. thrombectomy, TPA, etc)
  - Risks associated with ECMO

SUB-MASSIVE PE PROTOCOL

SEE ALGORITHM FOR STEP BY STEP MANAGEMENT
Evidence behind management
- High risk sub-massive PE
  - Heparin PLUS thrombolytics
    - PEITHO Trial
      - Compared heparin alone vs. heparin + tenecteplase
      - Showed decrease in death and decompensation
      - However, high risk of bleed
        10 fold increase in ICH
        5 fold increase in ECH
    - 2017 PEITHO Follow up study
      - 2 year mortality for heparin alone and heparin + tenectaplase was similar
      - No change in long term functionality
      - No difference in pulmonary HTN.
    - MOPPETT
      - Compared heparin alone vs. heparin + 1/2 dose alteplase
      - USED LOWER DOSE OF HEPARIN THAN PEITHO
      - Mortality benefit and decreased recurrent PE in heparin + alteplase group
      - Less bleeding complications with 1/2 dose
      - However, definition of sub-massive PE excluded certain patients
      - Unable to compare to PEITHO because different thrombolytic
    - SUMMARY AND RECOMMENDATION
      - Does not improve long term outcomes
      - May be beneficial in extremely high risk (near massive) sub-massive PE
  - Catheter directed thrombolysis in sub-massive PE vs. heparin alone
    - Seattle II Trial (US facilitated catheter directed lysis)
      - Decreased RV dilation, pulm HTN, clot burden
      - 0 Cases of ICH
      - BUT, increased hospital stay
    - PERFECT Trial
      - 101 patients
      - Showed improved MPAP
      - Follow up echo showed decreased heart strain
- Low risk sub-massive PE
  - Stick with heparin

GLOBAL HEALTH: RE-EMERGING INFECTIOUS DISEASES WITH DR. LAGASSE

Background

Definition of Re-emerging Disease: Diseases recently increased in incidence in geographic range or host range

Causes of Re-emergence (Biocomplexity Model)

Environmental changes
- Irrigation
- Agriculture
- Habitat loss and mixing of species
- Human expansion
Public health infrastructure
- Decrease surveillance and monitoring
- Inappropriate information on methods of control (Insecticides, etc.)
Climate Change/Disaster
- Floods
- Droughts
Pathogen and host evolution/adaptation

Significant re-emerging diseases

CHOLERA
- MOST WELL STUDIED RE-EMERGING DISEASE
- Symptoms
  - Vomiting
  - Voluminous diarrhea
- Cause of re-emergence
  - Tied to increase in dry, warm weather
  - Tied to blooms in zooplankton, with which it has a symbiotic relationship
  - *** Climate change presents risk of increasing water temps => zooplankton => increased cholera outbreaks
ARBOVIRUSES (i.e. Dengue Fever, Yellow Fever, Chikungunya, Zika, West Nile)
- DENGUE = MOST RAPIDLY SPREADING MOSQUITO BORNE ILLNESS IN WORLD
- Dengue symptoms
  - Fever (Usually high, 104 range)
  - + 2 other symptoms
    - headache
    - nausea and vomiting
    - muscle aches
    - arthralgias
    - rash
    - pain behind the eyes
- Reason for re-emergence/spread
  - Climate change increasing range of mosquito vector
  - Globalization
CHAGAS DISEASE (Trypanosoma cruzi)
- US has 7th highest chronic infection rate
  - (Transfusion, transplant, vertical transmission)
- Symptoms
  - Acute diseae
    - Fever
    - Malaise
    - Hepatosplenomegaly
    - Lymphadenopathy
    - Chagoma: Inflammatory nodule at site of riduvid bug bite (Vector)
    - Romana's Sign: Unilateral peri-orbital swelling within 1 week of infection
  - Chronic complications
    - Cardiac: Cardiomyopathies / channelopathies
    - GI abnormalities
    - Reactivation (Often in setting of HIV or Immunosuppression in solid organ transplant)
      - Rash (Skin plaques, nodules)
      - Fevers
- Treatment
  - Benzonidazole: Approved recently for use in children
  - Nifurtimox
- Reason for re-emergence/spread
  - Vector (riduvid bug) often found in thatched roofs/poor dwelling construction
  - Emigration of people from endemic areas

Strategies for Reducing Re-emergence and Impact

Increased surveillance
Encourage research and development of vaccines and therapeutics
Improved vector control

DISCHARGE, TRANSFER, OR TREAT: BABY EDITION WITH DR. BRYANT

Background

General Statistics in Pediatrics

Discharge
- 95% discharged
Transfer
- 2% transferred
- Most common causes of transfer
  - Orthopedic injuries
  - Non-surgical abdomen
  - Viral gastroenteritis
  - Traumatic head injuries
- Pediatric psychiatric complaints 12 x more likely to be transferred than adult patients
Admit
- Both admission and transfer are going to vary greatly on hospital resources and location relative to large referral center

Cases to Ponder

Case 1: 15 year old girl with suicidal ideation
- Suicidal ideation in children is high risk
  - Mostly impulsive, most deliberation time as short as 10 minutes
  - Safety contracts largely ineffectual
  - Suicide completion is increasing
- Who do we discharge?
  - Great, well established follow up
  - Good ancillary and family support
- Who do we transfer?
  - Most patients
Case 2: 3 year old girl with cough. VS: T 100.2, HR 130, RR 40, BP 90/60, O2 92%
- Symptoms:
  - Barky cough
  - Runny nose
  - Stridor at rest
  - Faint, suprasternal retractions
- Diagnosis: Croup
- Discharge
  - Comfortable breathing
  - Stridor resolved despite steroids, possible rac-epi X 1
  - No return of stridor after observation period
- Admit (Setting of local hospital with pediatric hospitalist. No specialty or ICU services)
  - Stridor at rest 4 hours following steroids
  - Biphasic stridor
  - Requiring repeat epinephrine doses
- Transfer
  - Biphasic stridor or persistent retractions despite steroids and epi X 2
  - Multiple episodes within 1 year (May be ENT abnormality, benefit from ENT Consult)
Case 3: 8 year old boy presented following a trip and fall. Has significant tenderness over distal radius
- 3a: X-Rays demonstrate signs of Buckle Fracture
  - DISCHARGE in removable splint
- 3b: X-Rays demonstrate signs of Greenstick Fracture
  - DISCHARGE
  - More likely to receive a cast over splinting
  - Ortho follow up
- 3c: X-Rays demonstrate distal radius and ulnar fracture with displacement
  - DISCHARGE
    - If pt. under 8 years old => <15-20 degrees of angulation acceptable
    - If pt. over 8 years old => <10 degrees of angulation
      - *** "Less than 10 over 10" ***
    - Avoid rotational defects and ulnar or radial deviation
  - TRANSFER
    - If any of the above criteria aren't met
- 3d: Supracondylar fracture
  - DISCHARGE
    - Very rarely
    - If non-displaced
    - If reliable parents
    - Strict return precautions given
    - Splint elbow in extension >90 degrees
  - TRANSFER
    - Neurovascular injury
      - 20% with brachial artery injury
      - 10% with nerve injury
    - Any displacement
  - ADMIT
    - Non- displaced
    - No neurovascular injury
    - Lean towards admit for compartment checks
    - ***HIGH RISK FOR COMPARTMENT SYNDROME***
Case 4: 2 year old girl tripped and fell from standing height hitting her face. She appears pale, nauseous, and has vomited X 10.
- Differences with head injuries in children
  - Fewer
    - TBIs (Dispensable skulls)
    - ICH and hemorrhagic contusions (Dispensable skulls)
  - Increased
    - Swelling
    - DAI
    - Hypoxia
    - Seizures
    - Delayed presentations/symptoms
- DISCHARGE
  - Ruled out with criteria (etc. PECARN Rules)
  - Negative CT scan
  - Return to baseline
- ADMIT (Often for neuro checks)
  - Very concerning story/initial exam
  - Negative CT early in presentation (Higher incidence of delayed complications)
  - Young age
- TRANSFER
  - Positive head CT
  - Hospitalist/hospital uncomfortable with neuro checks
Case 5: 17 month old boy with fever to 102.2 for 4 days. Normal PO intake, wet diapers. No rash. No other focal symptoms. Exam otherwise benign. Consider UA
- Risks for UTI
  - Female under 24 months
  - Boys under 6 months
  - Uncircumcised boys under 24 months
  - Fever > 48 hours
  - Fever > 39 degrees
  - Prior history of UTI
- Who to cath
  - < 3 months either sex
  - 3-24 months
    - All girls
    - Uncircumcised boys with >1 Risk factors (listed above)
    - Circumcised boys with >2 risk factors (listed above)
    - Symptomatic
  - >24 months
    - All girls
    - Uncircumcised boys with 1 symptom
    - Circumcised boys with multiple symptoms
- DISCHARGE
  - Normal mental status
  - Will be able to complete antibiotic course
  - Good return precautions and reliable to return
Case 6: 3 year old girl with runny nose, cough, sneezing. VS: Fever 104 F, HR 130, RR 45, BP 100/60, 93% on O2. Chest X-Ray concerning for pneumonia.
- Things to consider
  - Exam
  - Overall appearance
  - Vitals
  - Work of breathing
  - Vaccination status
- DISCHARGE
  - Normal work of breathing (Mild retractions acceptable)
  - Mildly elevated respiratory rate is tolerable
    - <1 year old => Less than 70 ok
    - >1 year old => Greater than 50 ok
- ADMIT
  - Babies 3-6 months
  - Hypoxia <90%
  - Dehydration (Scales exist!)
  - Respiratory distress
    - Grunting
    - Flaring
    - Retracting
  - Effusion or multifocal pneumonia
  - Outpatient treatment failure
    - Inability to fill prescriptions
    - Unable to tolerate dose
    - Recent outpatient failure
- TRANSFER
  - Severe respiratory distress requiring intubation
  - Kids requiring quarternary care center
Case 7: 18 day old boy with fever x 1
- DISCHARGE?: NO
- ADMIT:
  - Gets infectious workup (CXR, LP, UA, Cultures, etc)
  - Admit with abx
- TRANSFER
  - Risk of neonatal issues
  - Any previous NICU time, underlying comorbidities
  - Premature
Case 8: 2 week old first born male, vomiting, seems happy, good appetite. Concern for pyloric stenosis.
- DISCHARGE
  - Labs OK (Renal panel, maybe LFTs)
  - Can arrange outpatient US the following day
- ADMIT/TRANSFER
  - Dehydration
  - Laboratory abnormalities
  - Know hospital radiolographic capabilities
  - Know surgical capabilities
Case 9: 7 year old boy with fever for 2 days, diarrhea X2, Temp 100.5, HR 110, RR 20, BP 92/55.
- DISCHARGE
  - Nonfocal abdominal exam
  - Improvement with symptom control
  - Tolerating PO
- **Patient returns with diffuse abdominal pain**
  - Consider ruptured appy
    - CRP and CBC not useful within 24 hours of symptoms
    - Utility goes up after 24 hours
    - Alvarado score (Low risk score still has 30% appy rate)
    - Abdominal US
      - May visualize appendix
      - If not visualized, still useful
        Free fluid
        Lymph nodes
        Echogenic fat
        All have negative predictive values
    - If US low risk or indeterminate, consider:
      - Low dose CT
      - Admit and serial exams
      - DIscharge and return in 24 hours (Sensitivity of US increases over time)

STROKE UPDATES WITH DR. ADEOYE

The Evolution of Stroke Treatment

Stroke 1.0: tPA Only

Evidence
- NINDS Trial established 3 hour window
  - 624 Patients
  - Double blinded, placebo controlled study
  - NIH Sponsored
  - First of many studies to show benefit, related to time of administration
- ECASS III Trial established 4.5 hour window
  - 821 Patients
  - Double blinded, placebo controlled study
  - 52% good outcomes compared to 45.2% in placebo group at 90 days
Results
- Led to increased tPA use
- Most patients who received tPA alone still had modified rankin scores of 2-3 (Slight to moderate disability)

Stroke 2.0: Endovascular Therapy within 6 Hours

Evidence
- MERCI Retreiver (2004)
  - Treatment within 8 hours
  - First retrieval device
    - FDA Approved
  - ***Endovascular devices then proliferated.
- IMS III Trial
  - Compared thrombolytics and retrieval to thrombolytics alone
  - No significant difference
  - ***Led to doubt about endovascular devices***
- Device companies funded multiple studies that showed benefit
  - MR CLEAN Trial in 2014
  - ESCAPE
  - EXTEND
  - SWIFT PRIME
  - REVASCAT
Results
- Recommendations changed
  - tPA PLUS stent retrieval if:
    - Pre-stroke Modified Rankin Score 0-1
    - Causative ICA or proximal MCA (M1) occlusion
    - Acute ischemic stroke with tPA received within 24 hours

Stroke 3.0: Possible Future Directions

New Directions
- Additional medications
  - MOST TRIAL comparing the following is in progress
    - Compares TPA plus eptifibitide
    - Compares TPA plus argatroban
    - TPA Alone
- Additional interventions
  - Delayed endovascular therapy
  - New Devices
  - Adjunctive therapies
  - DAWN - Wake up stroke treatment with CTP

MASTERING MINOR CARE: "GET IT OUT!" WITH DR. LAFOLLETTE

Aural Foreign Bodies

Alive (Bugs, larvae, etc)
- Studies examined various fluids to suffocate bug
  - Mucosal 2% lidocaine
  - 1% Lidocaine
  - EMLA
  - Benzocaine
  - **Lidocaine and benzocaine both effective**
Not Alive
- When bugs die, they tend to adhere
- Lyse adhesions
  - 1/2 strength 3% hydrogen peroxide is effective
  - Safety in ruptured TM?
    - Mixed data
    - Avoid in perforated TM

Cutaneous Foreign Bodies

Foot Foreign Body
- Obtain imaging
  - X-Ray
    - 1/3 of foreign bodies missed
    - Materials visible
      - All Metallic objects visible
      - All glass is visible (85% seen by rads >2mm)
  - Ultrasound
    - Detects a variety of materials (wood, plastic, etc)
    - Dynamic imaging during incision and drainage
- Pre I&D Considerations
  - Know anatomy
    - Blood supply
    - Know innervation (Both for complications and regional anesthesia)
- Incision and Drainage
  - Preparation is key
  - Positioning of patient
  - Pain control
- Post Incision and Drrainage
  - Irrigation?
    - Literature suggests no benefit
    - Ensure adequate drainage
    - More in contaminated wounds
  - Antibiotics?
    - Consider, especially if:
    - Concern for deep space involvement
    - Especially if traveling through rubber, shoe, etc.
Retained Needle
- Common occurrence: 70 IVDU patients polled => 20 % had needle break and retained needle
- Needles often dirty: 61% of retained needles were re-used
- Removal not 100% necessary if not causing issues
- When do you remove?
  - Signs of infection
  - Vascular involvement

General Summary

Remove objects if:
- Infected
- Vascular involvement
- Alive
- Painful

TAMING THE SRU WITH DR. SABEDRA

Case: Elderly male patient with a history of thyroid cancer and known metastatic bronchial lesions who presented with cough productive of chronic brown sputum and occasional streaking. Initial workup was negative but quickly developed massive hemoptysis.

Massive Hemoptysis:

Background
- 1-5% of all hemoptysis is massive
- Definition is vague: Ranges > 100-600 cc of blood within 24 hours
- 80% Mortality rate
- Usually 2/2 disruption of bronchial arteries
Common causes
- Bronchial disease
  - Trauma
  - Mets
  - Foreign body
- Parenchymal disease
  - TB
  - Pneumonia
  - Vasculitidies
- ***Consider GI causes and hematemesis***
Predictors of mortality
- Infiltrates involving >2 quadrants on CXR
- Mechanical ventilation
Approach to diagnosis
- Assess vital signs (Hemodynamics, hypoxia)
- Labs
  - CBC
  - Coags
  - Type and Screen
  - Rapid TEG
- Imaging
  - Chest X-Ray
  - Chest CT
Management
- Identify which lung
  - History (Known mass, etc)
  - Imaging
  - Remains unknown in 10-15%
- Position patient
  - Place in lateral decubitous position
  - Affected lung down, clear lung up
- Establish patent airway
  - Use large ET tube amenable to bronch (8.0)
  - May attempt mainstem intubation of good lung
    - Rotate tube 90 degrees in direction of desired lung placement
      - No difference in success for R mainstem
      - Improved placement in L mainstem
    - Bougie is great adjunct: improves first attempt success
  - Double lumen ETT tubes also exist, but less available
    - Difficult to use, may require special ventilatory equipment
- Manage hemodynamics
  - Reverse any coagulopathies
    - TXA shown to be of some benefit in Thai and Peruvian studies but not conclusive
  - Bronchoscopy
    - Balloon tamponade
    - Iced saline lavage
    - Topical thrombotics
    - Laser therpay and electrocautery
  - Embolization
  - Surgical consult as final attempt

R4 CASE FOLLOW UP: HYPERTHERMIC SYNDROMES WITH DR. DANG

Case:

HPI: Middle aged female with PMHx significant for COPD, DVT, epilepsy, bipolar depression, migraine who presents to the ED via EMS after they were called for AMS and seizures. She was not cooperative and was given 10mg IM midazolam in route. She is responsive on arrival. Patient states she did not remember what happened but states that she gets seizures not infrequently.

ROS: Largely negative.

PMHx as above

PSHx: Appendectomy, cholecystectomy, vulvar surgery

Medications: Extensive but unclear which ones she is taking. Notable include:

Anti-epileptics
- Depakote?
- Lamotrigene?
- Lacosamide?
Psychiatric meds
- Quetiapine
- Venlafaxine
- Lithium
- Mirtazapine
Migraine medications
- Sumatriptan

SH: Positive for tobacco

Physical Exam:

HEENT: Benign
CV: normal
PULM: Diminished but CTAB
ABD: Soft
NEURO:
- AO X 4
- CN II-XII in tact
- Mild tremor in both hands
- Right arm flexed into body
- Legs extended
- Hyperreflexia

Notable Labs:

WBC 20.7
Lactic Acid: 2.3
Lithium: 1.7
pH: 7.23
TSH: 10.58

1 Hour Reassessment: Vital signs show increasing temp to 99.3, RR 22

Exam:
- HEENT: Benign
- CV: normal
- PULM: Tachypnea
- ABD: Soft
- NEURO:
  - Confused
  - CN II-XII in tact
  - Increased tremor
  - Legs extended
  - RIGIDITY IN ALL 4 EXTREMITIES

2 Hour Reassessment: Vital signs T: 101 F HR 133 RR 42

Exam:
- HEENT: Benign
- CV: Tachycardic
- PULM: Tachypnea
- ABD: Soft
- NEURO:
  - Confused
  - Agitated
  - Increased tremor
  - Legs extended
  - Diffuse rigidity

Hyperthermic Toxidromes

Definitions:

Fever:
- New set point in hypothalamus
- Usually triggered by cytokines/infection/inflammation
Hyperthermia
- Unregulated process
- Body temp elevation
- Differntial
  - Seratonin syndrome
  - Neuroleptic malignant syndrome
  - Malignant hypothermia
  - Anticholinergic toxicity
  - Sympathomimetic toxicity
  - Strychnine toxicity
  - GABA withdrawal
**Cant miss diagnoses for AMS and pyrexia**
- Infection (Sepsis, sepsis, sepsis)
- Thyroid storm
- Heat stroke
- Hypothalamic stroke

Concern in this case: Serotonin Syndrome VS. Neuroleptic Malignant Syndrome

Serotonin Syndrome
- Pathogenesis: Excess serotonin in synaptic cleft
  - 5HT 1A stimulation:
    - Myoclonus
    - Hyperreflexia
    - Mental status change
  - 5HT 2A stimulation:
    - HTN
    - Tachycardia
    - Fever
    - Neuromuscular Excitation
- Common culprit medications
  - SSRIs
  - MAOIs
  - Drugs of abuse
  - Fentanyl, tramadol, Dextromethorphan
  - Linezolid
  - Lithium
  - **Patient on Vimpat, Sumatriptan, Lithium, Amphetamines**
- Clinical Presentation
  - ONSET IS RAPID: 12-36 hours
    - Classic triad:
      1. AMS
      2. Autonomic Instability (Tachycardia, GI upset, etc)
      3. Increased Neuromuscular Activity
        Hyperreflexivity and clonus
        More pronounced in lower extremities
    - Symptoms present on a spectrum
Neuroleptic Malignant syndrome
- Pathogenesis: Decreased stimulation at dopamine receptor
  - Dopamine antagonism
  - Cessation of dopamine agonism
- Culprit medications
  - Beware of these medications
    - Haloperidol (Most common)
    - Anti-emetics
    - Lithium
    - **Patient on lithium and quetiapine**
- Clinical presentation
  - ONSET IS SLOWER: 3-7 days
    - Classic tetrad
      - AMS
      - Rigidity
      - Hyperthermia
      - Autonomic instability

ED Management:

STOP Offending agent
Supportive Care
- Agitation and rigidity => Benzos
  - Hyperhermia => Cooling
    - Rhabdo => Fluids
  - Respiratory support
Intubation and paralysis may be necessary
1. Paralytics: Use non-depolarizing agents (Avoid fasciculations / Heat generation)
2. Sedation: Propofol and precedex
Syndrome specific treatments: INVOLVE A TOXICOLOGIST
1. SS:
  1. Cyproheptadine
  2. Chlorpromazine
2. NMS:
  1. Dantrolene
  2. Bromcriptine
  3. Amantadine
  4. L-Dopa

Blog

QI/KT: MASSIVE AND SUBMASSIVE PE WITH DRS. BANNING AND GOLDEN

BACKGROUND

Management and Treatment Algorithms

GLOBAL HEALTH: RE-EMERGING INFECTIOUS DISEASES WITH DR. LAGASSE

Background

Strategies for Reducing Re-emergence and Impact

DISCHARGE, TRANSFER, OR TREAT: BABY EDITION WITH DR. BRYANT

Background

STROKE UPDATES WITH DR. ADEOYE

The Evolution of Stroke Treatment

MASTERING MINOR CARE: "GET IT OUT!" WITH DR. LAFOLLETTE

TAMING THE SRU WITH DR. SABEDRA

R4 CASE FOLLOW UP: HYPERTHERMIC SYNDROMES WITH DR. DANG

Case:

Hyperthermic Toxidromes

Taming the SRU

SRU (pronounced "shrew") = Shock Resuscitation Unit

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