Is the use of greater than 1 L of intravenous crystalloids associated with worse outcomes in trauma patients?

OBJECTIVE: Advanced Trauma Life Support guidelines recommend only 1 L of intravenous (IV) crystalloid before transitioning to blood products. We sought to determine if receiving >1 L of IV crystalloid during the initial resuscitation is associated with worse outcomes. We also sought to determine if receiving no crystalloids is associated with better outcomes. METHODS: We performed a single center retrospective study using trauma registry data, which was supplemented by manual chart review. We only included patients who had an initial heart rate ≥ 100 beats/min or a systolic blood pressure ≤ 90 mmHg. For each patient, we determined the total amount of IV crystalloid administered in the first 3 h after arrival to the hospital plus prehospital crystalloid. We performed multivariate regression analyses to determine if there is an association between the administration of >1 L of crystalloids or no crystalloids with in-hospital mortality, hospital length of stay (LOS), or packed red blood cells (PRBCs) transfused. RESULTS: Between January 1, 2018 and September 30, 2019, there were 878 who met criteria for enrollment. Among those, 55.0% received ≤1 L of IV crystalloids, and 45.0% received >1 L. Multivariate analyses showed no significant association between receiving >1 L and mortality (p = 0.61) or PRBCs transfused (p = 0.29), but patients who received >1 L had longer hospital LOS (p = 0.04). We found no association between receiving no crystalloids and mortality, PRBCs transfused, or LOS. CONCLUSION: On a multivariate analysis of trauma patients, we did not find an association between the administration of >1 L of IV crystalloid and in-hospital mortality or the volume of PRBCs transfused. However, receiving >1 L of crystalloids was associated with a longer hospital LOS. We found no benefit to completely withholding crystalloids.

Using Tenecteplase for Acute Ischemic Stroke: What Is the Hold Up?

Alteplase is the only Food and Drug Administration-approved intravenous (IV) thrombolytic medication for acute ischemic stroke. However, multiple recent studies comparing tenecteplase and alteplase suggest that tenecteplase is at least as efficacious as alteplase with regards to neurologic improvement. When given at 0.25 milligrams per kilogram (mg/kg), tenecteplase may have less bleeding complications than alteplase as well. This narrative review evaluates the literature and addresses the practical issues with regards to the use of tenecteplase versus alteplase for acute ischemic stroke, and it recommends that physicians consider tenecteplase rather than alteplase for thrombolysis of acute ischemic stroke.

A Pilot Curriculum to Integrate Standardized Patient Simulation into Clinical Pastoral Education.

INTRODUCTION: We describe a novel means of experiential learning for clinical pastoral care residents using standardized patient (SP) simulations. METHODS: A prospective cohort study involving 7 clinical pastoral care residents was performed. All residents underwent 2 verbatim SP sessions and 2 simulation sessions. After all sessions, residents completed a self-evaluation. Faculty completed an evaluation and then provided a debriefing session to all residents. RESULTS: Performance ratings were globally higher on simulated scenarios when compared to the verbatim sessions. CONCLUSIONS: More research in the field of pastoral care is needed to validate the learned professional skills that enhance a comprehensive training program through the use of medical simulation, verbatim reports, and clinical pastoral education (CPE) competencies. Medical simulation provides a promising teaching methodology for the training of CPE residents.

Emergency medicine residency boot Camp curriculum: a pilot study.

INTRODUCTION: Establishing a boot camp curriculum is pertinent for emergency medicine (EM) residents in order to develop proficiency in a large scope of procedures and leadership skills. In this article, we describe our program's EM boot camp curriculum as well as measure the confidence levels of resident physicians through a pre- and post-boot camp survey. METHODS: We designed a one-month boot camp curriculum with the intention of improving the confidence, procedural performance, leadership, communication and resource management of EM interns. Our curriculum consisted of 12 hours of initial training and culminated in a two-day boot camp. The initial day consisted of clinical skill training and the second day included code drill scenarios followed by interprofessional debriefing. RESULTS: Twelve EM interns entered residency with an overall confidence score of 3.2 (1-5 scale) across all surveyed skills. Interns reported the highest pre-survey confidence scores in suturing (4.3) and genitourinary exams (3.9). The lowest pre-survey confidence score was in thoracostomy (2.4). Following the capstone experience, overall confidence scores increased to 4.0. Confidence increased the most in defibrillation and thoracostomy. Additionally, all interns reported post-survey confidence scores of at least 3.0 in all skills, representing an internal anchor of "moderately confident/need guidance at times to perform procedure." CONCLUSION: At the completion of the boot camp curriculum, EM interns had improvement in self-reported confidence across all surveyed skills and procedures. The described EM boot camp curriculum was effective, feasible and provided a foundation to our trainees during their first month of residency.