Stage: A 42-year-old man is admitted to the intensive care unit (ICU) with an acute exacerbation of asthma associated with community-acquired pneumonia. He is treated with cefotaxime and azithromycin, nebulized albuterol, and intravenous hydrocortisone.
The past several years have seen a number of reports of superbugs: methicillin-resistant Staphylococcus aureus, the so-called ESKAPE organisms (an acronym for Enterococcus faecium, S. aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and enterobacter species), and others.1
Fifty years ago, Belding Scribner and his colleagues at the University of Washington developed a blood-access device using Teflon-coated plastic tubes, which facilitated the use of repeated hemodialysis as a life-sustaining treatment for patients with uremia.1,2
The use of recombinant activated factor VII (rFVIIa) on an off-label basis to treat life-threatening bleeding has been associated with a perceived increased risk of thromboembolic complications. However, data from placebo-controlled trials are needed to properly assess the thromboembolic risk. To address this issue, we evaluated the rate of thromboembolic events in all published randomized, placebo-controlled trials of rFVIIa used on an off-label basis.
2010 Sep 23 - CLINICAL THERAPEUTICS: Targeted Temperature Management for Comatose Survivors of Cardiac Arrest
A 62-year-old man collapses on the street, and emergency medical personnel who are called to the scene find that he is not breathing and that he has no pulse. The first recorded cardiac rhythm is ventricular fibrillation. Advanced cardiac life-support measures, including intubation, a total dose of 2 mg of epinephrine, and six defibrillation attempts, restore spontaneous circulation 22 minutes after the onset of the event.
In this issue of the Journal, Papazian and colleagues1 present intriguing results of their study examining neuromuscular blockade in patients with severe, early acute respiratory distress syndrome (ARDS). The investigators randomly assigned 340 patients to receive the neuromuscular blocking agent cisatracurium or placebo for a period of 48 hours.
In patients undergoing mechanical ventilation for the acute respiratory distress syndrome (ARDS), neuromuscular blocking agents may improve oxygenation and decrease ventilator-induced lung injury but may also cause muscle weakness. We evaluated clinical outcomes after 2 days of therapy with neuromuscular blocking agents in patients with early, severe ARDS.
Global control of tuberculosis is hampered by slow, insensitive diagnostic methods, particularly for the detection of drug-resistant forms and in patients with human immunodeficiency virus infection. Early detection is essential to reduce the death rate and interrupt transmission, but the complexity and infrastructure needs of sensitive methods limit their accessibility and effect.
Aspirin and clopidogrel are mainstays of therapy for patients presenting with an acute coronary syndrome. National guidelines dictate that at the time of the patient's presentation to an emergency department, these therapies should be given expeditiously, whether or not percutaneous coronary intervention is planned.
In this issue of the Journal, Mehta et al. report on the results of the Clopidogrel and Aspirin Optimal Dose Usage to Reduce Recurrent Events–Seventh Organization to Assess Strategies in Ischemic Syndromes (CURRENT–OASIS 7) trial, which evaluated alternative dosing regimens for both of these agents.1
Clopidogrel and aspirin are widely used for patients with acute coronary syndromes and those undergoing percutaneous coronary intervention (PCI). However, evidence-based guidelines for dosing have not been established for either agent.
2010 Aug 19 - Case Records of the Massachusetts General Hospital:Case 25-2010 — A 24-Year-Old Woman with Abdominal Pain and Shock
Dr. Franklin W. Huang (Medicine): A 24-year-old woman was transferred to this hospital because of abdominal pain, vomiting, ascites, and shock.
2010 Jul 29 - Images in Clinical Medicine: Pneumothorax — An Uncommon Complication of a Common Procedure
A 92-year-old woman was admitted to the hospital with a severe left-sided ischemic stroke causing altered mental status (i.e., a score of 9 on the Glasgow Coma Scale, on which scores range from 3 to 15, with higher scores indicating increased consciousness), weakness on the right side, and dysphagia.
Emergency medical dispatchers give instructions on how to perform cardiopulmonary resuscitation (CPR) over the telephone to callers requesting help for a patient with suspected cardiac arrest, before the arrival of emergency medical services (EMS) personnel. A previous study indicated that instructions to perform CPR consisting of only chest compression result in a treatment efficacy that is similar or even superior to that associated with instructions given to perform standard CPR, which consists of both compression and ventilation. That study, however, was not powered to assess a possible difference in survival. The aim of this prospective, randomized study was to evaluate the possible superiority of compression-only CPR over standard CPR with respect to survival.
Fifty years have passed since Kouwenhoven, Jude, and Knickerbocker1 proposed external chest compression to provide circulation of blood to the brain and heart after cardiac arrest.
The role of rescue breathing in cardiopulmonary resuscitation (CPR) performed by a layperson is uncertain. We hypothesized that the dispatcher instructions to bystanders to provide chest compression alone would result in improved survival as compared with instructions to provide chest compression plus rescue breathing.
Background Cyclophosphamide and glucocorticoids have been the cornerstone of remission-induction therapy for severe antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis for 40 years. Uncontrolled studies suggest that rituximab is effective and may be safer than a cyclophosphamide-based regimen.
Background Cyclophosphamide induction regimens for antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis are effective in 70 to 90% of patients, but they are associated with high rates of death and adverse events. Treatment with rituximab has led to remission rates of 80 to 90% among patients with refractory ANCA-associated vasculitis and may be safer than cyclophosphamide regimens.
The clinical presentation of acute pulmonary embolism ranges from shock or sustained hypotension to mild dyspnea.
Septic shock is traditionally viewed as an excessive systemic inflammatory reaction to invasive microbial pathogens, yet efforts to improve the outcome of patients with sepsis by means of inhibitors of proinflammatory cytokines and mediators have been unsuccessful.
Background Carotid-artery stenting and carotid endarterectomy are both options for treating carotid-artery stenosis, an important cause of stroke.