Author Archive for: srrezaie

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 →

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 →

Low-Dose Ketamine for Acute Pain in the ED: IV Push vs Short Infusion?

10 Apr
April 10, 2017

Background: Ketamine’s role in the ED has expanded in recent years.  The clinical reasons for this make it easy to understand why, and include analgesia, amnesia, and anesthesia. Amazingly, ketamine does not only reduce acute pain, but it also decreases persistent chronic and neuropathic pain as well. More importantly, use of low-dose ketamine (0.1 – 0.3 mg/kg IV) has been demonstrated to be opioid sparing.  Some of the major issues with IV push low-dose ketamine include its adverse effects, such as feelings of unreality, nausea/vomiting, and dizziness. Many emergency medical providers have anecdotally noticed a decrease in adverse effects when ketamine is given slowly. In the paper we are reviewing today, the authors tried to see if increasing the duration of the ketamine from IV push (3 – 5 min) to a slow infusion (10 – 15 min) could mitigate some of these effects, while maintaining analgesic efficacy. Read more →

The Marik Protocol: Have We Found a “Cure” for Severe Sepsis and Septic Shock?

07 Apr
April 7, 2017

Background: The overall mortality in sepsis has decreased quite a bit in the last decade or so, however for a subset of patients, like those with Septic Shock, the mortality still remains high (as high as 50%).  There have been hundreds of studies trying to identify the holy grail to decrease mortality further, but one has not been found thus far.  Marik PE et al [1] published a study in Chest 2016 that has found a potential front runner.  In addition, the authors go on to say, in order to have an impact on a global scale, treatments would not only need to be effective, but also cheap, safe, and readily available; the authors of the following paper may have found just that..
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