Mythbuster: Administration of Vasopressors Through Peripheral Intravenous Access

28 May
May 28, 2015

VasopressorsBackground: Vasopressors are frequently used in critically ill patients with hemodynamic instability both in the emergency department (ED) as well as intensive care units (ICUs). Typically, vasopressors are given through central venous catheters (CVCs) as opposed to peripheral intravenous (PIV) access due to the concerns about adverse events (i.e. tissue ischemia/necrosis) associated with extravasation through PIVs. In a truly hypotensive, critically ill patient the use of a PIV to administer vasopressors will allow the medication to stabilize the patient sooner and reduce the time to hemodynamic stability. The requirement to start vasopressors through a CVC may delay administration of pressors. Also, performing the insertion of a CVC in a hypotensive patient in an emergency circumstance versus an elective circumstance may increase the risk of adverse events from the procedure itself (i.e. bacteremia, pneumothorax, arterial puncture). Finally, most of the evidence cited for avoiding PIV administration of pressors is a sparse collection of case studies and expert opinion. Read more →

Cardiogenic Shock

25 May
May 25, 2015

Cardiogenic ShockAuthor’s Note: This post is one of the first written for a new site sponsored by the NYU/Bellevue Emergency Department called Core EM. This is a FOAM site dedicated to core content Emergency Medicine featuring a blog, podcast and procedure video section. The Core EM Project launches on June 1st, 2015. Thanks to Salim and the REBEL EM editorial staff for posting this here and come check out The Core EM Project at www.coreem.net.

Definition: Tissue hypoperfusion that is primarily attributable to damage to the heart.

Criteria: The cardiology literature focuses diagnostic criteria based on systolic blood pressure (SBP) (Gowda 2008)

  • SBP < 90 mm Hg
  • Decrease in MAP by 30 mm Hg

It is more important, however, to look for evidence of hypoperfusion. In the acute setting, this will typically manifest as a change in mental status (lethargy, decreased responsiveness, agitation, decreased cap refill, cool extremeties etc.). Read more →

7 Pediatric Hacks for Your ED

21 May
May 21, 2015

7 Pediatric Hacks for Your EDHacks are all the rage! There is even a current television show dedicated to “life hacks”. While the following may not be as cool as cutting cake with dental floss or cooking a pizza on your dash board (these were actually on that show) what I have learned from my training and experience in Pediatric Emergency Medicine (and my own 5 children) is that there are some hacks that can make things much easier for you, the kid, and the parents. The hacks presented here range from treatment for common (and often benign) conditions to serious situations. Read more →

A New Pulseless Electrical Activity Algorithm

18 May
May 18, 2015

Pulseless Electrical ActivityPatients with pulseless electrical activity (PEA) account for almost 1/3 of cardiac arrest and even more troublesome is that the survival rate is significantly worse than patients with shockable rhythms. Both the European and American ACLS guidelines stress the importance of quickly finding and addressing the cause of PEA. This is traditionally done with recalling the 5 to 6 H’s and T’s, but during cardiopulmonary resuscitation it is difficult to recall all 13 causes of PEA by trying to recall this list. In 2014 a review article was published that was developed by several departments from the Carolinas Medical Center in Charlotte, NC that tried to simplify the diagnostic approach to PEA. Read more →

May 2015 REBELCast

14 May
May 14, 2015

May 2015 REBELCastWelcome to the May 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of articles just published this year.  First, there is a lack of research examining the efficacy of steroids in patients with allergic reactions or anaphylaxis. Despite this, corticosteroids are standard care for patients with these disorders. Second, current regulations permit storage of PRBCs for up to 42 days, but maybe fresh PRBCs may improve outcomes in the critically ill by enhancing oxygen delivery while minimizing toxic effects from cellular changes and accumulation of bioactive materials in blood components during prolonged storage. So with that introduction today we are going to specifically tackle:

  • Topic #1: Corticosteroids in Allergic Reactions & Anaphylaxis
  • Topic #2: Age of Packed Red Blood Cells (PRBCs) in Critically Ill Adults

Read more →

In Criticism Of Praise

11 May
May 11, 2015

In Criticism of PraiseSometimes the most profound academic concepts haven’t come from the wonderful medical conferences or hundreds of academic articles I’ve read, but they come from arenas completely tangential to the medical field.  The topic of this article is a great example of this phenomenon.  It came from of all places, a Southwest Airlines magazine.  It’s titled “In Criticism of Praise” by Heidi Stevens.  Being an optimist with four children and many medical students under my wing, (yes I view them as my children) I was initially offended by the title and it of course, it drew me in. Read more →

REBELCast: Sepsis Care in 2015

04 May
May 4, 2015

Sepsis Care in 2015So I was recently invited to the Texas College of Emergency Physicians meeting in Austin, TX (April 23rd – 26th, 2015) and was asked to give a lecture on sepsis, titled “Optimizing ED Management of Sepsis.” I was able to record my audio from that lecture and will summarize it on this blogpost and attach the audio to the lecture as well. Now usually on REBELCast I do a mini-critical appraisal of recent literature with Swami and Matt, but in this episode I am going to try and give you a succinct summary of the recent sepsis trials that have been released over the past 6 – 12 months. Read more →

Is it Time to Start Using the HEART Pathway in the Emergency Department?

30 Apr
April 30, 2015

The HEART PathwayThere are approximately 8 to 10 million patients complaining of chest pain coming to Emergency Departments (EDs) in the United States annually. In the US, we use a very liberal testing strategy in order to avoid acute coronary syndrome (ACS) in patients presenting with chest pain. This results in over 50% of ED patients with acute chest pain receiving serial cardiac biomarkers, stress testing, and cardiac angiography at an estimated cost of $10 to $13 billion annually and yet fewer than 10% of these patients are diagnosed with ACS.

Despite these numbers the American College of Cardiology/American Heart Association (ACC/AHA) recommends that low-risk chest pain patients receive serial cardiac markers followed by some sort of provocative/objective cardiac testing. Using this strategy amongst low-risk chest pain patients unnecessarily uses resources on those least likely to benefit. Low-risk chest pain patients have ACS rates of <2% and provocative/objective cardiac testing is associated with a significant amount of “downstream” testing (i.e. cardiac catheterization) due to false positive tests.

To date, the HEART score has been examined in >6000 patients and demonstrated a high NPV for MACE at 6 weeks exceeding 98%, but until now there has been no randomized trial. Read more →

Hands-On Defibrillation: If the Glove Fits…You Must Acquit!

27 Apr
April 27, 2015

Hands-On DefibrillationWe’ve had some heated debates on the topic of hands-on defibrillation (HOD) for the past few years. We all know the most important time to avoid a pause during CPR is the perishock pause ((21690495)). We also know that despite lots of safety data ((2302275)(19211180)) and safe experience doing HOD ((18458166), Johnson) there are still concerns over the potential electrical leak using common exam gloves ((22925991), (23507464)(23507465), (23266533)(24992873)). For those who don’t enjoy a little electrical spice in your resuscitations, some recent articles have shown ways in which the safety of HOD can be mitigated using inexpensive tools.

Read more →

Bibliography

Skin Anesthesia: Lidocaine vs Bupivacaine +/- Epinephrine

23 Apr
April 23, 2015

 

Skin AnesthesiaWhen selecting a local anesthetic agent for skin wounds I have historically been taught to use lidocaine to provide a faster onset, and to use bupivacaine for a longer duration of action.

It can be time consuming to find 0.5% Bupivacaine with epinephrine and 2% Lidocaine with Epinephrine to produce a final mixture of 1% Lidocaine and 0.25% Bupivacaine with Epinephrine.

  • If there is no difference in effect between these agents time could be saved when drawing up local anesthetics.

Read more →

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