A few people were asking for a quick reference regarding age related proBNP cutoffs.
Embedded below are links to both the PRIDE and ICON-RELOADED trials which investigated proBNP cutoffs in the emergency department.
The optimal age-independent cutoff for ruling out acute heart failure is <300 pg/ml
The optimal age-adjusted cutoffs for ruling in acute heart failure are:
<50 years old – 450 pg/ml
50-75 years old – 900 pg/ml
>75 years old – 1800 pg/ml
Given the current weather it seems appropriate to post some guidance for patients suffering significant cold exposure. Below are concise guidelines from OSU medical center and the Wilderness Medical Society (pre-hospital). Both have useful information in regards to management along the spectrum of exposure.
OSU Management of Accidental Hypothermia
At this time we are referring all all ECMO transfers to Montefiore’s Cardiothoracic Surgical ICU. Although most ECPR cases are not typically candidates for on-site cannulation and transfer, in some rare hypothermic cases (eg. young patient, short downtime) there may be an exception.
To initiate possible transfer first call 718-920-ECMO and provide the following: Patient name, Diagnosis and Location. The transfer center will connect you with a CT surgeon with whom you can discuss the case and decide whether the patient is a candidate for potential transfer.
If ECMO is deemed appropriate, next call the AOD in order to initiate the emergency credentialing process for the surgeon.
EXCLUSIONS to CPR
Appropriate situations in which to terminate efforts for performing CPR in hypothermic patients with cardiac arrest:
- Body is frozen solid (cannot perform chest compressions, no chest recoil)
- Obvious non-survivable injury (eg. Decapitation, truncal transection, incineration/decomposition of whole body)
- Airway obstruction (snow/ice) with downtime greater than 1 hour (more for avalanche victims than urban recoveries)
Thoracic lavage should be reserved only for pulseless patients. A few variations of the procedure are possible including single and dual tube methods. A good review can be found here THORACIC LAVAGE
Thank you to Neil Dubey and Mark Andreae for their help with this post.
Steps to follow in the event of a needle stick, splash or any accidental exposure in the ED
In case of a needle stick, splash or any accidental exposure in the ED:
- Inform the charge nurse
Register at triage to open an ED visit (you should be seen in Fast track promptly)
**DO NOT GIVE YOUR HEALTH INSURANCE CARD**THIS IS WORKER’S COMP **
- Get evaluated by an MD
- Obtain Incident report from ED administrator from charge nurse
- Get incident report signed by your supervisor (attending who sees you as a patient).
- *This form is very important! The completed form must be submitted to Fabio in ED admin office in order for it to be sent along to appropriate departments.
- If you receive a bill, please give it to Fabio and do not pay it upfront.
- If you don’t complete an incident report you are going to receive a bill from the city and it can’t be voided.
For quick, concise clinical info at the bedside on palliative care (want to manage dyspnea in a dying patient, have a conversation about code status, prognosticate in a patient with advanced cancer…)
EPERC Fast Facts
Amazing resource for all things EM and pal care
Want to improve your communication skills? The site below was created for oncologists but the skill set is universal. Watch the videos for a great demonstration of these skills in action!
The creators of Oncotalk also wrote a terrific book, Mastering Communication with Seriously Ill Patients: balancing honesty with empathy and hope, if you want to go a step further.
Want to significantly improve your palliative care knowledge and skills?
Palliative Care Goal Setting Pocket Card