Use of vasopressors is a common practice to support hemodynamics and optimization of tissue perfusion in patients presenting with shock.  Historically the administration of vasopressors was restricted to central venous catheters (CVC) due to concerns for local tissue injury resulting from vasoconstriction if extravasation occurred from a peripheral IV. The placement of CVCs, however, can delay vasopressor initiation, can cause procedural complications, and potentially result in bloodstream infections. The 2021 Surviving Sepsis Campaign Guidelines suggest starting vasopressors peripherally rather than delaying infusion until a CVC is placed [2]. Despite multiple studies published showing the safety of peripheral vasopressors, the recommendation is considered a weak based on low-quality evidence.

A 58-year-old female with a history of diabetes, hypertension, and chronic back pain presents to the ED with severe headache and nausea. Her symptoms started shortly after leaving the office of her pain management doctor, where she had an epidural steroid injection to alleviate her chronic back pain approximately 30 minutes before she arrived in the ED. The patient denies any trauma to the head, fevers, nuchal rigidity, changes in vision, focal weakness, paresthesia, or anticoagulation use. 

Acute liver failure patients (ALF) are those that had a previously normal liver and who for whatever reason (e.g. toxins, vascular occlusion), whereas the more common presentation in my practice is for patients to present with liver failure on a background of chronic liver disease (CLD).

The three commonest reasons for CLD in UK practice are alcohol, viruses and non-alcohol fatty liver disease (NAFLD), although there are a whole range of less common conditions such as Wilson’s disease, primary biliary cirrhosis and cancers that can also cause problems. The incidence of liver disease in the UK and in many high income nations is increasing, largely due to the failure to control alcohol consumption and the increase in obesity rates. In other words CLD is on the rise and that means that we are likely to see ever more of these patients passing through our departments. Obesity related liver disease is expected to rise a lot in the next decade with a 95% increase in grade 4 NAFLD (cirrhosis) predicted in Canada from 2019-2030.

A 43-year-old male, with no significant medical history, presents to the ED for right eye pain. The patient notes his pain as constant and sharp (8/10); associated with light-sensitivity, tearing, and blurred vision. He reports onset of his symptoms while mowing his lawn just prior to arrival and reports that he was not wearing eye protection. The man does not use glasses or contact lenses. He denies known ocular trauma or ocular surgical history.