Author: Don Stader, MD
- 8014 patients with out-of-hospital cardiac arrest randomized to epinephrine vs placebo
- 30-day survival was not dramatically better between groups (3.2%in the epinephrine group and 2.4% in the placebo group)
- Functional neurological outcome was nearly identical at 2.2% and 1.9% of patients
- Adds to literature that epinephrine provides little important benefit in cardiac arrest – focus on chest compressions and early defibrillation
Editor’s note: NNT for epinephrine to prevent one death in this study was 115 – compared to bystander CPR (NNT 15) and defibrillation (NNT 5) from prior studies.
Perkins GD et. al. . A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2018 Aug 23;379(8):711-721. doi: 10.1056/NEJMoa1806842. Epub 2018 Jul 18.
Kitamura T, Kiyohara K, Sakai T, et al. Public-access defibrillation and out-of-hospital cardiac arrest in Japan. N Engl J Med 2016;375:1649-1659.
Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2015;372:2307-2315.
Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA. 2012 Mar 21;307(11):1161-8. doi: 10.1001/jama.2012.294. PubMed PMID: 22436956.
Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. JAMA Intern Med. 2015 Feb;175(2):196-204. doi: 10.1001/jamainternmed.2014.5420.
Author: Erik Verzemnieks, MD
- In the panic of a precipitous ED delivery, remember: Warm. Dry. Stim. It will solve most of your problems in most scenarios
- Start compressions if heart rate is less than 60
- Put the pulse ox on the right hand – it may make a difference as it is preductal
Editor’s note: detecting a heart rate can be tough in a newborn – you can feel the umbilical stump or just listen with your stethoscope
Gary Weiner & Jeanette Zaichkin. Textbook of Neonatal Resuscitation (NRP), 7th Ed, 2016. American Academy of Pediatrics & American Heart Association.
Author: Nick Hatch, MD.
- A common concern using vasopressors is the risk of digital and mesenteric ischemia.
- The absolute risk of digital ischemia and/or mesenteric ischemia is pretty low. Norepinephrine at its highest doses carries a 5% digital ischemia rate and a 2% mesenteric ischemia rate.
- The studies demonstrating this complication were predominately patients with pre-existing liver disease.
- Providers commonly mistake purpura fulminans, a common complication of sepsis, for digital ischemia.
Brown, SM. et al. Survival After Shock Requiring High-Dose Vasopressor Therapy. Chest. 2013. 143(3), 664?671. http://doi.org/10.1378/chest.12-1106.
Malay MB et al. Heterogeneity of the vasoconstrictor effect of vasopressin in septic shock. Critical Care Medicine. 2004. 32(6), 1327-31.
Author: Chris Holmes, MD
- Epidemiology: 80% male, ages 1-4 at greatest risk, African-American > Caucasian.
- Freshwater and ocean water may have more bacteria than pool water.
- Salt water is hyperosmolar, which theoretically increases risk of pulmonary edema.
- Greatest physiologic insult is from hypoxia secondary to fluid aspiration or laryngeal spasm. Patient survival is related to presentation on arrival.
- Workup includes CXR and ABG; consider C-spine immobilization/imaging when cervical injury is strongly suspected (i.e. diving injury).
- Treatment consists of supplemental oxygen therapy. Consider CPAP or intubation.
Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. Drowning. N Engl J Med. 2012. 366(22):2102-10. doi: 10.1056/NEJMra1013317.
Schmidt A, Sempsrott J. Drowning In The Adult Population: Emergency Department Resuscitation And Treatment. Emerg Med Pract. 2015. 17(5):1-18.
Author: Dylan Luyten, MD
- Resuscitative thoracotomies are most commonly used for treatment of cardiac tamponade and to selectively perfuse the brain and heart in setting of hemorrhage control.
- Resuscitative thoracotomies are indicated in patients with penetrating injuries who lose vitals in the ED or those who had vitals within the last 10 minutes.
- Do not perform resuscitative thoracotomies on patients who have no signs of life on scene, asystole as their presenting rhythm, or no vitals > 10 minutes.
- Resuscitative thoracotomies are not indicated in patients with blunt trauma unless vitals are present in ED.
- Do not perform CPR on trauma patients.
Karmy-Jones R, Namias N, Coimbra R, et al. (2014).Western Trauma Association critical decisions in trauma: penetrating chest trauma. Journal of Trauma Acute Care Surgery. 77:994.
Seamon MJ, Shiroff AM, Franco M, et al. (2009) Emergency department thoracotomy for penetrating injuries of the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers. Journal of Trauma. 67:1250.
Author: Nick Hatch, MD
- Recent study argues that CHF patients receiving furosemide within 60 minutes of arrival had a lower in-hospital mortality than those receiving it after (2.3% vs. 6.0%, p=0.002).
- A flaw in the study is that there were significant baseline differences between groups.
Matsue Y et al. Time-to-Furosemide Treatment and Mortality in Patients Hospitalized With Acute Heart Failure. JACC 2017. PMID: 28641794
Author: Don Stader, M.D.
- Pulmonary embolism is one of the leading causes of maternal mortality.
- There is disagreement among different medical societies about the value of D-dimer as a screening modality. If you use it, consider the rational D-dimer approach whereby you add 250 to your cut-off for every trimester.
- A useful screening modality is an ultrasound of bilateral lower extremities looking for DVT.
- Keep in mind, both a V/Q scan and CT scan have a significant amount of radiation. CTA is probably the right diagnostic test (less radiation than CT w&w/o).
- Always use the shared decision-making model and clinical acumen to choose your tests.
Leung AN, et. al. (2011). An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: evaluation of suspected pulmonary embolism in pregnancy. American Journal of Respiratory and Critical Care Medicine. 184(10):1200-8
Polak JF, Wilkinson DL. (1991). Ultrasonographic diagnosis of symptomatic deep venous thrombosis in pregnancy. American Journal of Obstetrics and Gynecology. 165(3):625-9.
Sachs BP, et. al. (1987). Maternal mortality in Massachusetts. Trends and prevention. New England Journal of Medicine. 316(11):667-72.
Check out this episode!
Author: Michael Hunt, M.D.
- 1% of patients presenting to ED with alcohol intoxication end up going to the ICU.
- Most common critical illnesses were acute hypoxic respiratory failure, sepsis, and intracranial hemorrhage.
- Predictive markers: Vital abnormalities (hypoxia, tachycardic, tachypneic, hypothermic, hyperthermia, hypoglycemia) and patients receiving parenteral sedatives had higher incidence of ICU admission.
Klein, LR; et al. (2018). Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication. Annals of Emergency Medicine. 71(3):279-288
Author: Gretchen Hinson, M.D.
- Controversial topic.
- Pathophysiology – acidosis leads to an extracellular potassium shift. Patients in DKA will be intracellularly potassium deplete, but will have a falsely normal/elevated serum potassium.
- 3 risk of giving bicarb in DKA – alkalosis will drive potassium intracellularly but can overshoot (hypokalemia) and increase risk of arrhythmias; bicarb slows clearance of ketones and will transiently increase their precursors; bicarb can cause elevated CSF acidosis.
- 3 instances when appropriate to give bicarb in DKA: DKA in arrest; hyperkalemic in DKA with arrhythmia; fluid and vasopressor refractory hypotension.
Bratton, S. L., & Krane, E. J. (1992). Diabetic Ketoacidosis: Pathophysiology, Management and Complications. Journal of Intensive Care Medicine, 7(4), 199-211. doi:10.1177/088506669200700407
Chua, H., Schneider, A., & Bellomo, R. (2011). Bicarbonate in diabetic ketoacidosis – a systematic review. Annals of Intensive Care, 1(1), 23. doi:10.1186/2110-5820-1-23