In-Hospital Cardiac Arrest: The First 15 Minutes

27 Apr
April 27, 2017

Background: Over the past few years there has been a shift in cardiac arrest from the mantra of ABC (Airway, Breathing, Circulation) to CAB (Circulation, Airway, Breathing).  There has been increased emphasis on circulation and a de-emphasis of airway management in cardiac arrest.  Physiologically, this makes sense as the only two interventions in cardiac arrest that have been shown to make a difference in neurological outcomes are early, high quality CPR and defibrillation.  The reason for this is increased coronary and cerebral perfusion pressure, which improve oxygenation to ischemic tissue.  The less ischemic cardiomyocytes are the more likely they will convert to a perfusing rhythm.  Similarly, the less ischemic neurons are, the more likely we will have a better neurologic outcome for our patients.  It has been fairly well established in the peer reviewed literature that advanced airway management in the prehospital setting is associated with decreased survival with good neurologic outcome.  There is considerably less literature exploring this area in in-hospital cardiac arrest. Read more →

The Easy IJ: Another Option for Difficult IV Access in Stable Patients?

24 Apr
April 24, 2017

Background: We have all taken care of patients in whom IV access is difficult due to a multitude of reasons including repeated prior IV access, advanced vascular disease and shock. This often creates delays in patient care, increases ED length of stay, and uses up ED staff that have other patients to care for. Many providers have resorted to using IO access, particularly in critically ill patients due to speed of establishing access.  In stable patients, however, this may be a less desirable.  Ultrasound guidance has been a great addition in these patients.  Ultrasound guided peripheral IVs and external jugular access would probably be the next “go to options” in these patients. The authors of this paper evaluate yet another option: The Easy IJ.  Read more →

Post Intubation Hypotension: The AH SHITE mnemonic

20 Apr
April 20, 2017

You have just secured the endotracheal tube following an uneventful intubation of a moderately ill  patient in your emergency department. They had a normal pre-intubation blood pressure.  As you are calling the admit in to the ICU the patient’s nurse tells you that the BP is now in the 70’s.

NOW WHAT?

  1. Blindly give a half gallon of saline and stay in your seat.
  2. Get up, walk to the patient’s room, and consider the possible causes of post intubation hypotension.

Read more →

Episode 36 – Resuscitate Before You Endoscopate?

17 Apr
April 17, 2017

Background: Upper gastrointestinal hemorrhage (UGIH) is a commonly seen complaint in the ED.  Currently, endoscopy is the standard therapy shown to not only help with diagnosis, but also risk stratify patients and potentially offer effective hemostatic treatment of acute nonvariceal UGIH.  What is frequently an area of debate, is the optimal timing of endoscopy. Even more frustrating is the different definitions of early endoscopy ranging anywhere from 1hr up to 24hrs after initial presentation.

Now on one hand, earlier timing of endoscopy could be associated with suboptimal resuscitation and potential hemodynamic instability.  On the other hand, delayed endoscopy delays hemostasis from endoscopic therapy and increases the risk of rebleeding and need for surgery.  I think we all agree that we should resuscitate our patients before endoscopy (or as I like to say resuscitate before you endoscopate), but is there a population of patients with UGIH that require sooner than later endoscopy? To talk about this topic we have a special guest Rory Spiegel.  You can find Rory on twitter as @EMNerd_ or on the EMCrit blog where he discusses methodological issues with studies Read more →

Are we Missing Acute MIs with Clinical Risk Scores?

13 Apr
April 13, 2017

Background: In 2011, we saw 7 million patients in the emergency department (ED) complaining of chest pain. Most of these patients did NOT have an acute coronary syndrome (ACS) or an acute myocardial infarction (AMI). Missing an AMI is one of the biggest fears we have in the ED. By using validated risk scores, we can help decrease the risk of missing AMI and the resultant adverse events. There are multiple scores available for our use. Thrombolysis in Myocardial Infarction (TIMI) predicts risk of adverse outcomes in the next 14 days. Global Registry of Acute Coronary Events (GRACE) predicts outcomes at 6 months. ED specific scores include HEART and Emergency Department Assessment of Chest Pain (EDACS). But, how well do these scores actually perform? Are we missing AMIs by using these clinical risk scores? Read more →

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