Background: One of the most feared complications associated with rapid sequence intubation (RSI) is hypoxemia ultimately leading to cardiac arrest. The FELLOW Trial, a recent randomized controlled trial demonstrated no difference in hypoxemia rates between patients that received apneic oxygenation and those that did not (i.e. “usual practice”) in the ICU. What many forget about this trial is 1/3 of the patients were pre-oxygenated with a bag valve mask and another 1/3 of the patients with a BIPAP device, meaning that 2/3rds of these patients were not truly apneic during the period that induction medications were pushed up to laryngoscopy. Currently, there is a lack of high quality research on the use of apneic oxygenation in the ED setting. Many still use the intervention as it is cheap, easy to do, with no increase in patient harm, but there are still naysayers that do not feel the intervention is warranted in standard RSI practice. Read more →
Background: In 2016 the annual incidence of out-of-hospital cardiac arrest (OHCA) in the United States was roughly 360,000 and 209,000 for in-hospital cardiac arrest (IHCA) (Mozaffarian 2016). Though survival rates are relatively dismal, arrests in the setting of shock amenable rhythms – ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) – have an overall better rate of return of spontaneous circulation (ROSC). While cardiac defibrillation may be effective in terminating VF/VT, defibrillation does not prevent recurrence of VF/VT. According to the advanced cardiovascular life support (ACLS) algorithm, amiodarone is still the recommended first-line medication for shock refractory VF/VT. These recommendations stem from two hallmark studies which demonstrated improved ROSC and survival rates to admission after amiodarone was administered (Dorian 2002, Kudenchuk 1999). However, ROSC does not represent a clinically meaningful endpoint. Subsequent studies have questioned the utility of amiodarone in cardiac arrest from the perspective of improving survival to hospital discharge or survival with a good neurological outcome. Read more →
Background: It has been common practice in trauma to place patients in cervical collars and on long backboards (LBBs) to achieve spinal immobilization. LBBs are used to help prevent spinal movement and facilitate extrication of patients. Cervical collars (C-Collars) are used to help prevent movement of the cervical spine and often are combined with lateral head blocks and straps. The theory behind this is that spine immobilization prevents secondary spinal cord injury during extrication, transport, and evaluation of trauma patients by minimizing movement. Most of this information has been passed on from historical teachings, like the Advanced Trauma Life Support (ATLS) courses, and not from scientific research. To date there has been no high-quality evidence that use of spinal immobilization improves patient outcomes. In this post, we will review the evidence associated with spinal immobilization in trauma patients. Read more →
The provision of high-quality compressions with minimal interruptions is central to the management of cardiac arrest. Along with defibrillation, high-quality compressions are the only interventions proven to improve patient-oriented outcomes. Recently, point-of-care ultrasound (POCUS) has gained greater use in cardiac arrest care for determination the cause of arrest as well as guiding the resuscitation and interventions. Performance of POCUS during cardiac arrest can be challenging particularly in terms of obtaining cardiac windows. Among these challenges is obtaining images of the heart during compressions. As a result, cardiac POCUS is often performed during rhythm checks when there is a scheduled pause in compressions. Despite the potential benefit from POCUS, prolonged interruptions in compressions while attempting to get optimal windows is unlikely to benefit the patient and, may be harmful. Read more →
Background: Fluid resuscitation with crystalloid is one of the most basic initial management approaches to adult and pediatric patients with severe sepsis and septic shock. However, which fluid should we be giving, and does it matter? Should we give an unbalanced, chloride rich solution such as normal saline or a balanced, chloride restrictive fluid, such as lactated ringers, Plasma-Lyte, or Normasol? Interestingly, the 2016 Surviving Sepsis Guidelines, added resuscitation with balanced fluids into the guidelines, although a weak recommendation with low quality of evidence.
This recommendation was based on some growing adult data, albeit retrospective, showing that resuscitation strategies using normal saline may be harmful and associated with increased risk of AKI (1), need for CRRT (1) and increased mortality (2-3). The effects of balanced fluids however, have not been studied in the resuscitation of children in severe sepsis and septic shock. Read more →