The AMACING Trial: Prehydration to Prevent Contrast Induced Nephropathy (CIN)?

24 Mar
March 24, 2017

Background: In patients with compromised renal function, the use of intravascular iodinated contrast material is generally not given to avoid contrast induced nephropathy (CIN). Currently, there is no treatment for contrast-induced nephropathy, therefore the focus has been on prevention. Guidelines recommend prophylactic prehydration in the prevention of CIN in high risk patients.  These recommendations are based on expert consensus and until now, there has not been a prospective randomized trial of IV hydration versus no hydration in high-risk patients. Read more →

Episode 34 – The Death of Mechanical CPR (mCPR)?

23 Mar
March 23, 2017

Background: The two most important things that we can do in cardiac arrest to improve survival and neurologically intact outcomes is high quality CPR, with limited interruptions and early defibrillation. In the case of the former, the 2015 AHA/ACC CPR updates recommended a compression rate of 100 -120/min, a depth of 2 – 2.4in, allowing full recoil, and minimizing pauses. This is a lot to remember during a stressful code situation and one way many providers are offloading themselves cognitively is by the use of mechancical CPR (mCPR) devices.  In theory these devices compress at a fixed rate, and depth, with the added benefit that the machine simply does not tire out.  Additionally, use of this device allows another provider to be available for other procedures and interventions. A recent systematic review and meta-analysis in  looked at five randomized clinical trials with over 10,000 patients with out-of-hospital cardiac arrest (OHCA) (Gates 2015).  They concluded that there was no difference in ROSC, survival or survival with good neurological outcomes with the use of these devices compared to manual CPR. It is important to state that none of these studies showed increased harm either.  A new paper just published in Circulation however, argues that mCPR during OHCA was associated with lower neurologically intact survival. Read more →

Contrast Induced Nephropathy (CIN): Fact or Myth?

20 Mar
March 20, 2017

Background: Use of contrast media in CT scans has been cited as one of the most common causes of iatrogenic acute kidney injury.  Its use however improves the diagnostic accuracy of CT scans.  Some studies have even reported an incidence of contrast induced nephropathy (CIN) as high as 14%.  Many of the studies coming to these conclusions were performed before the use of low- and iso-osmolar contrast agents. Also to date, all controlled studies on this topic have been observational and not randomized controlled trials.  More recent propensity-scored analyses have had conflicting results. One study found no increased risk of acute kidney injury, dialysis or mortality regardless of baseline renal function, while others have found increased acute kidney injury in patients with renal dysfunction. This current study tried to clarify the incidence of acute kidney injury attributable to IV contrast media administration. Read more →

Etomidate vs Ketamine in Trauma RSI

16 Mar
March 16, 2017

Background: Etomidate and ketamine are both routinely used as induction agents during rapid sequence intubation (RSI) in trauma patients. It is well established that etomidate transiently suppresses the adrenal gland through inhibition of the 11-beta hydroxylase enzyme. Though adrenal suppression in theory can cause deleterious outcomes, there is no high-quality evidence demonstrating a change in patient centered outcomes with it’s use in comparison to alternate agents. Ketamine has long been an alternative induction agent to etomidate but historical concerns, though disproven in more recent literature, limited it’s use due to concerns over increasing intracranial pressure. Read more →

The Benefit of Lung Protective Ventilation in the ED Should be LOV-ED

13 Mar
March 13, 2017

Background: Intubation and mechanical ventilation are commonly performed ED interventions and although patients optimally go to an ICU level of care afterwards, many of them remain in the ED for prolonged periods of time. It is widely accepted that the utilization of lung protective ventilation reduces ventilator-associated complications, including acute respiratory distress syndrome (ARDS). Additionally, it is believed that ventilatory-associated lung injury can occur early after the initiation of mechanical ventilation thus making ED management vital in preventing this disorder. Despite this, intubated ED patients are not optimally ventilated used lung-protective strategy on a routine basis. Read more →

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