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Emanuel Rivers is a physician born and raised in River Rouge, Michigan which is a suburb of Detroit, MI. He is board certified in emergency medicine, internal medicine and critical care medicine. Rivers has published extensively in the field of shock, sepsis and resuscitation. [1]
Emanuel Rivers is Vice Chairman and Director of Research for the Department of Emergency Medicine. He is a Senior Staff Attending Physician in the Surgical Critical Care Unit and the Emergency Department at Henry Ford Hospital in Detroit, Michigan.
He received his Bachelor of Science, Master of Public Health, and Doctorate in Medicine from the University of Michigan in Ann Arbor, Michigan. He completed a residency in emergency and internal medicine at Henry Ford Hospital, Detroit, Michigan, followed by a fellowship in critical care medicine at the University of Pittsburgh, PA. He is Board certified in Critical Care Medicine, Emergency Medicine and Internal Medicine. He also has a special competency in Hyperbaric Medicine.
Rivers is a national or international research award recipient from the Society of Academic Emergency Medicine (2010), American College of Emergency Physicians (2005), Society of Academic Emergency Medicine (2000), American College of Chest Physicians (2000), Society of Critical Care Medicine and European Society of Critical Care Medicine Research Award (2000). He is a fellow of the American Academy of Emergency Medicine, American College of Chest Physicians and long standing member of the Society of Critical Care Medicine.
He was the first physician in the history of Henry Ford Hospital to be inducted into the Institute of Medicine, National Academy of Sciences in 2005 and has been called to serve on task forces to advise the United States government on health care issues. He was voted one of the Top Docs in the city of Detroit for the years 2006 to 2010. He is also a quality consultant to 3 of the top ten health care delivery systems in the United States. Rivers' practice and research are based out of the Henry Ford Hospital in Detroit, MI.
Rivers' interests include the examination and treatment of critical illness or the critically ill in the earliest stages of hospital presentation, which includes the Emergency Department and Intensive Care Unit. Diseases, which are included in this area, are patients presenting with shock of all kinds (septic or severe infection, trauma or hemorrhage, heart attacks, blood clots to the lung and other shock states such as cardiac arrest). He is examining new ways to improve upon early detection and aggressive treatment of these diseases, which cost many lives and consume tremendous health care resources. He is further interested in evaluating the number of patients who can be saved at this stage and how well we are treating these patients as well as the epidemiology and outcome evaluation of early critical illness. [2]
The algorithm of emergent resuscitation in the setting of severe sepsis and/or septic shock has been formally conceptualized by Emanuel Rivers in a landmark paper in November 2001 [3] using early goal directed therapy (EGDT) in the emergency department. EGDT has been used and validated for years in the intensive care unit, but Rivers's paper expanded the idea to incorporate all those initially presenting to the ED with signs of severe sepsis or septic shock. Many hospitals across the United States such as Kaiser and Catholic Health Care West have rapidly incorporated the protocol developed by Rivers in their ED treatment algorithms, as well as use it as a quality improvement data point. EGDT has also been cited by the Joint Commission of Hospital Accreditation as a quality improvement initiative for the last two years.
The EGDT study is a reflection of expert opinion for sepsis management by the American College of Critical Care Medicine. His Early Goal Directed Therapy recommendations have been replicated in over 33 publications[ citation needed ] since 2001 comprising over 8,000 patients with equal efficacy and improvement in health care costs[ citation needed ]. Three recent multi center trials (ProCESS investigators, ARISE investigators, and ProMISe investigators) published in the New England Journal of Medicine compared EGDT versus other protocol-directed care versus standard care. [4] There was no significant difference in the primary outcome of mortality. However, the authors of these trials conclude that this is because Rivers' 2001 study was so well known that it improved the level of standard care such that it is similar to EGDT.[ citation needed ] Evidence-based medicine experts have argued that these three trials reaffirm the principles of early recognition of sepsis, early broad-spectrum antibiotic use and intravenous fluid resuscitation. The invasive monitoring involved in EGDT is probably unnecessary.
In 2014 the ProCESS study was published. Process enrolled 1,341 patients, of whom 439 were randomly assigned to protocol-based EGDT (Rivers EGDT), 446 to protocol-based standard therapy, and 456 to usual care. There was no significant difference in 90-day and 1-year mortality between groups. However, in the sickest sub-group of patients (those with a baseline lactate >5.3 mmol/L) the mortality was significantly higher in the EGDT group as compared to usual care (38.2 vs. 26.4; p = 0.05). ProCESS has now clearly established that EGDT should be abandoned. [5]
Shock is the state of insufficient blood flow to the tissues of the body as a result of problems with the circulatory system. Initial symptoms of shock may include weakness, fast heart rate, fast breathing, sweating, anxiety, and increased thirst. This may be followed by confusion, unconsciousness, or cardiac arrest, as complications worsen.
Sepsis, also known as septicemia, septicaemia, or blood poisoning, is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs.
Fluid replacement or fluid resuscitation is the medical practice of replenishing bodily fluid lost through sweating, bleeding, fluid shifts or other pathologic processes. Fluids can be replaced with oral rehydration therapy (drinking), intravenous therapy, rectally such as with a Murphy drip, or by hypodermoclysis, the direct injection of fluid into the subcutaneous tissue. Fluids administered by the oral and hypodermic routes are absorbed more slowly than those given intravenously.
Septic shock is a potentially fatal medical condition that occurs when sepsis, which is organ injury or damage in response to infection, leads to dangerously low blood pressure and abnormalities in cellular metabolism. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defines septic shock as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by requiring a vasopressor to maintain a mean arterial pressure of 65 mm Hg or greater and having serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia. This combination is associated with hospital mortality rates greater than 40%.
In immunology, systemic inflammatory response syndrome (SIRS) is an inflammatory state affecting the whole body. It is the body's response to an infectious or noninfectious insult. Although the definition of SIRS refers to it as an "inflammatory" response, it actually has pro- and anti-inflammatory components.
Stress hyperglycemia is a medical term referring to transient elevation of the blood glucose due to the stress of illness. It usually resolves spontaneously, but must be distinguished from various forms of diabetes mellitus.
Henry Ford Hospital (HFH) is an 877-bed tertiary care hospital, education and research complex at the western edge of the New Center area in Detroit, Michigan. The flagship facility for the Henry Ford Health System, it was one of the first hospitals in the United States to use a standard fee schedule and favor private or semi-private rooms over large wards. It was the first hospital in the country to form a closed, salaried medical staff. As founder Henry Ford viewed tobacco as being unhealthy, the hospital was one of the first in the United States to institute a total ban on smoking. Henry Ford Hospital is staffed by the Henry Ford Medical Group, one of the nation's largest and oldest group practices with 1,200 physicians in more than 40 specialties.
Hydroxyethyl starch (HES/HAES), sold under the brand name Voluven among others, is a nonionic starch derivative, used as a volume expander in intravenous therapy. The use of HES on critically ill patients is associated with an increased risk of death and kidney problems.
The Surviving Sepsis Campaign (SSC) is a global initiative to bring together professional organizations in reducing mortality from sepsis. The purpose of the SSC is to create an international collaborative effort to improve the treatment of sepsis and reduce the high mortality rate associated with the condition. The Surviving Sepsis Campaign and the Institute for Healthcare Improvement have teamed up to achieve a 25 percent reduction in sepsis mortality by 2009. The guidelines were updated in 2016 and again in 2021.
Early goal-directed therapy was introduced by Emanuel P. Rivers in The New England Journal of Medicine in 2001 and is a technique used in critical care medicine involving intensive monitoring and aggressive management of perioperative hemodynamics in patients with a high risk of morbidity and mortality. In cardiac surgery, goal-directed therapy has proved effective when commenced after surgery. The combination of GDT and Point-of-Care Testing has demonstrated a marked decrease in mortality for patients undergoing congenital heart surgery. Furthermore, a reduction in morbidity and mortality has been associated with GDT techniques when used in conjunction with an electronic medical record.
Critical illness–related corticosteroid insufficiency is a form of adrenal insufficiency in critically ill patients who have blood corticosteroid levels which are inadequate for the severe stress response they experience. Combined with decreased glucocorticoid receptor sensitivity and tissue response to corticosteroids, this adrenal insufficiency constitutes a negative prognostic factor for intensive care patients.
The following outline is provided as an overview of and topical guide to emergency medicine:
The Sepsis Six is the name given to a bundle of medical therapies designed to reduce mortality in patients with sepsis.
Slow code refers to the practice in a hospital or other medical centre to purposely respond slowly or incompletely to a patient in cardiac arrest, particularly in situations for which cardiopulmonary resuscitation (CPR) is thought to be of no medical benefit by the medical staff. The related term show code refers to the practice of a medical response that is medically futile, but is attempted for the benefit of the patient's family and loved ones. However, the terms are often used interchangeably.
Extracorporeal cardiopulmonary resuscitation is a method of cardiopulmonary resuscitation (CPR) that passes the patient's blood through a machine in a process to oxygenate the blood supply. A portable extracorporeal membrane oxygenation (ECMO) device is used as an adjunct to standard CPR. A patient who is deemed to be in cardiac arrest refractory to CPR has percutaneous catheters inserted into the femoral vein and artery. Theoretically, the application of ECPR allows for the return of cerebral perfusion in a more sustainable manner than with external compressions alone. By attaching an ECMO device to a person who has acutely undergone cardiovascular collapse, practitioners can maintain end-organ perfusion whilst assessing the potential reversal of causal pathology, with the goal of improving long-term survival and neurological outcomes.
Vasopressin infusions are in use for septic shock patients not responding to fluid resuscitation or infusions of catecholamines to increase the blood pressure while sparing the use of catecholamines. These argipressins have much shorter elimination half-life than synthetic non-arginine vasopresines with much longer elimination half-life of many hours. Further, argipressins act on V1a, V1b, and V2 receptors which consequently lead to higher eGFR and lower vascular resistance in the lungs. A number of injectable arginine vasopressins are in clinical use in the United States and the European Union. Pitressin among others, is a medication most commonly used in the treatment of frequent urination, increased thirst, and dehydration such as that resulting from diabetes insipidus, which causes increased and diluted urine. It is used to treat abdominal distension following some surgeries, and in stomach roentgenography. Vasopressin is a hormone that affects the kidneys and reduces urine flow.
Paul Ellis Marik is a medical doctor and former professor of medicine who until his resignation in January 2022 served as chair of the Division of Pulmonary and Critical Care Medicine at Eastern Virginia Medical School in Norfolk, Virginia, and was also a critical care doctor at Sentara Norfolk General Hospital. His research interests include sepsis and tissue oxygenation. In August 2023 the American Board of Internal Medicine informed Marik his certification was to be revoked for spreading misinformation.
Vasodilatory shock, vasogenic shock, or vasoplegic shock is a medical emergency belonging to shock along with cardiogenic shock, septic shock, allergen-induced shock and hypovolemic shock. When the blood vessels suddenly relax, it results in vasodilation. In vasodilatory shock, the blood vessels are too relaxed leading to extreme vasodilation and blood pressure drops and blood flow becomes very low. Without enough blood pressure, blood and oxygen will not be pushed to reach the body's organs. If vasodilatory shock lasts more than a few minutes, the lack of oxygen starts to damage the body's organs. Vasodilatory shock like other types of shock should be treated quickly, otherwise it can cause permanent organ damage or death as a result of multiple organ dysfunction.
Intravenous Ascorbic Acid, is a process that delivers soluble ascorbic acid directly into the bloodstream. It is not approved for use to treat any medical condition.
Frank LoVecchio is an American emergency medicine physician, medical toxicologist, academic and researcher. He is the medical director of Clinical Research at College of Health Solutions, the Director of Good Samaritan Regional Poison Center, the Research Director of Maricopa Medical Center Emergency Medicine Program, and clinical professor at Arizona College of Osteopathic Medicine. He also serves as an attending physician at Valleywise Health, Phoenix Children's Hospital, and in the Department of Medical Toxicology at Banner University Medical Center.