REBEL Cast Wee: Early Cardiac Catheterization in OHCA Survivors with Non-STEMI

03 Aug
August 3, 2015

Early Cardiac Catheterization in OHCA Survivors with Non-STEMIBackground: We know that cardiac arrest is a devastating disease and that it occurs in approximately 400,000 Americans each year. In the few patients who achieve return of spontaneous circulation (ROSC) and survive past the pre-hospital stage, mortality rates range from 50 – 60% depending on which sources you read. Neurologic injury is the primary reason for mortality in cardiac arrest patients who do survive to hospital admission and while therapeutic hypothermia (TH) is now an established and recommended therapy to help improve survival and neurologic outcomes in cardiac arrest survivors, the mortality rate is still high in this population.   Acute coronary syndrome (ACS) accounts for the majority of cases of cardiac arrest in adults and some recent studies have shown that early cardiac catheterization (CC) and immediate percutaneous coronary intervention (PCI) are associated with improved survival following cardiac arrest. However, many of the patients included in these studies had ST-elevation myocardial infarction (STEMI). There is already a Class 1 recommendation for early CC & PCI in the setting of STEMI following cardiac arrest, but the data on early CC in comatose post-arrest patients without STEMI is very limited. Post-resuscitation electrocardiogram (ECG) is often unreliable and lack of ST-elevation has a poor sensitivity for the diagnosis of acute coronary occlusion. Recently the American College of Cardiology/American Heart Association (ACC/AHA) proposed and published a new consensus statement an algorithm to stratify cardiac arrest patients who are comatose for CC activation. As part of this algorithm non-ST elevation myocardial infarction (NSTEMI) was added as an indication for CC activation. So with that introduction today on REBEL Cast we are going to specifically tackle:

  • Topic: Early Cardiac Catheterization in OHCA Survivors with Non-STEMI

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Critical Care Horizons – A FOAM Critical Care Journal

30 Jul
July 30, 2015

Critical Care HorizonsAs the world of Free Open Access Medical Education has expanded over the last 5 years, one area that has been a laggard is the traditional journal. Although some journals release a limited number of articles in an open access format (NEJM, Annals of EM, Academic EM, EM Australasia, etc.) we haven’t seen a true open-access journal that is free to publish and free to read. This changed on June 24th, 2015 when the first issue of Critical Care Horizons was released. Read more →

The Challenge of Fever in Kids

27 Jul
July 27, 2015

FeverFEVER shows up beside the name of a new 3 year old that has just been checked into your department. This can be accompanied by many feelings when you see it from “Why are they here ?” to “I hope the child is not dying.” This is a reasonable range of thoughts depending on your level of experience and resources. Many variables are important with this “chief complaint” from how the temperature was actually obtained, to immunization status of the child, to how does the child look, and many more. In my estimation, fever gets a bad rap from general society. It’s our job to set the tone and fight “fever-phobia” when needed. Let’s examine some aspects of pediatric fever to change your mindset from apprehension, to “I’ve got this”. Read more →

Beyond ACLS: CPR, Defibrillation, and Epinephrine

23 Jul
July 23, 2015

Beyond ACLS - CPR, Defibrillation, & EpiAdvanced Cardiac Life Support (ACLS) provides a well structured framework for those who resuscitate infrequently. There is room to move beyond the algorithm to potentially provide better care for our patients for those who resuscitate frequently. I will describe some tweaks to the way CPR, defibrillation, and medications are delivered in the arrests I manage. Read more →

Minor Head Trauma in Anticoagulated Patients: Admit for Observation or Discharge?

20 Jul
July 20, 2015

Risk of ICH in Anticoagulated PatientsBackground: In elderly patients on chronic anticoagulation (i.e. warfarin and clopidogrel), falls have been shown to increase the incidence of intracranial hemorrhage (ICH) versus those not on anticoagulation (8.0% vs 5.3%). Mortality in those with ICH on anticoagulation is also higher than those who are not (21.9% vs 15.2%). Patients >65 years of age account for almost 10% of ED visits and 30% of admissions for traumatic brain injury. Even more frustrating is clinical decision rules on who to scan and not scan (i.e. Canadian CT Head Rule, New Orleans Criteria, and NEXUS-II criteria) do not apply to anticoagulated patients, because these patients were excluded in many of these studies. To date studies on patients taking warfarin who suffer minor head injuries have shown an incidence of ICH from 6.2 – 29%, suggesting that physicians should have a low threshold to scan these patients. Finally, several European guidelines suggest that all anticoagulated patients with head trauma should be admitted for observation, even if the initial head CT is negative, based on limited data. Unfortunately, the risk of traumatic intracranial hemorrhage after blunt head trauma for patients on warfarin and clopidogrel, has never really been studied in a large generalizable cohort or under a rigorous, prospective, multicenter designed studies. Therefore, knowledge of the true prevalence and incidence of immediate and delayed traumatic ICH in patients on anticoagulation would allow for evidence based decisions to be made about initial patient evaluation and disposition instead of admitting all patients for observation for concern of delayed ICH [1]. Read more →

Beyond ACLS: Dual Simultaneous External Defibrillation

16 Jul
July 16, 2015

Beyond ACLSBackground: Out-of-hospital cardiac arrest (OHCA) occurs in the United States at a rate of nearly 300,000 individuals per year. Even more concerning is the high mortality rate which is associated with this. The majority of OHCA is due to cardiac etiology with the most common initial rhythm being ventricular fibrillation (VF). What we all know is that high-quality, limited interruption cardiopulmonary resuscitation (CPR) and early defibrillation are the hallmarks of successful neurologic outcomes in OHCA. For many who have heard me speak about ACLS, you have heard me say that these guidelines are created for the providers who do not perform resuscitation as part of their daily routine. For those of us in the trenches of the emergency department, we have to think beyond ACLS at times. Although VF typically responds very well to the standard energies of defibrillation, maybe in patients with higher body mass index or morbid obesity we need higher energies to achieve successful defibrillation. Read more →

Beyond ACLS: From CPR to Cath – The New ACC/AHA Cardiac Arrest Algorithm

13 Jul
July 13, 2015

Cardiac ArrestSo you are minding your own business when a 60 year old patient comes in after witnessed Out-Of-Hospital Cardiac Arrest (OHCA).  She had a witnessed arrest, good bystander CPR and the prehospital team shocked her out of ventricular fibrillation (vfib), intubated her and brought her in after 25 min of total down time and 15 min of CPR.  She is now neurologically stunned but with a stable blood pressure.  You get an EKG which shows normal sinus rhythm with non-specific ST and T wave changes(NSR NSSTTW changes)  basic labs, and are hunting for a source.  Labs, chest x-ray (CXR), point of care ultrasound (POCUS) by you doesn’t reveal an alternate source to explain the arrest. You start hypothermic protocol and are thinking of sending her to the ICU.  Or maybe not?  What about the cath lab?  Your resident recalls some early data from European studies cathing some of these patients that trended towards favorable results and wants to know how you do things here?  The new ACC guidelines just published this month, July 2015 are here to answer that very question. Read more →

Journal Update – Beta Blocker vs. Calcium Channel Blocker for Rate Control in Atrial Fibrillation

09 Jul
July 9, 2015

Atrial FibrillationBackground: Atrial fibrillation (AF) is a commonly encountered dysrhythmia in the Emergency Department (ED). Atrial flutter is less common but its management is very similar to that of AF. In patients with chronic AF or unknown time of onset and a rapid ventricular response (RVR), rate control and consideration and initiation of anticoagulation therapy are the standard ED approach. Both beta-blockers and calcium channel blockers are commonly used for rate control in the ED but it is unclear whether one of these agents is superior to the other as there is scant high-quality data on the topic (Demircan 2005). Read more →

July 2015 REBELCast

06 Jul
July 6, 2015

July 2015 REBELCastWelcome to the July 2015 REBELCast, where Swami, Matt, and I are going to talk oxygen. It is important to remember that oxygen is a drug, and just like any drug we prescribe to patients it has potential side effects.  Although there is a paucity of clinical trial data to support routine use of supplemental oxygen, most health care providers still put oxygen on patients for possible physiological benefits.  So with that introduction today we are going to specifically tackle:

  • Topic #1: The AVOID Trial – Supplemental O2 vs Room Air for STEMI
  • Topic #2: The FLORALI Trial – High Flow Nasal Cannula (HFNC) for Acute Hypoxemic Respiratory Failure Read more →

SMACC Chicago

29 Jun
June 29, 2015

SMACC ChicagoThis year I was fortunate enough to attend the 3rd annual Social Media And Critical Care (SMACC) conference from June 23rd – 26th, 2015 in Chicago, IL. This year the conference was dubbed as SMACC Chicago and followed by the hashtag #smaccUS on twitter. I tried to keep track of all the great take home messages while at the conference for those not lucky enough to make it or who have not heard of it. For those of you who have not heard of SMACC, it is a modern, academic meeting, mixed with on-line technologies to deliver innovation in education in the fields of emergency medicine and critical care. This conference addresses important clinical issues in a format that is energetic, cutting edge, and yet reputable. If you wanna see what the conference was about last year checkout this link: smaccGOLD. So what did I learn this year? Well, a lot more than one post can give justice to, but some of the highlights are listed below. Read more →

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