Background: IV access is one the most important interventions that must be performed in effectively managing patients in the Emergency Department. It is part of “Circulation” in the ABCs acronym and is even first in the “IV, O2, Monitor” phrase that we have become accustom to hearing. Although experienced ED nurses can obtain access quickly and without much difficulty in most patients, there remain a handful of patients that will present to the ED where standard peripheral access is unable to be obtained after multiple attempts. What is the next step? Peripheral placement of an IV using ultrasound can be a great next step if timing permits, but this too can be troublesome in patients who are difficult to access, especially if dehydration is present. IOs have become more popular but are painful when medications are given through them, thus making management more difficult in patients who are alert. Also IOs are limited in regards to what lab testing can be performed. Central lines are not worth the risk if IV access does not need to be central or if access is only needed temporarily. External Juglar IV placement can have similar difficulties as traditional peripheral access especially, in patients with a large body habitus or who have had repeated EJ cannulations. What if a peripheral IV was placed into the internal jugular vein (Easy IJ)? It is an easily visualized structure on ultrasound and cannulating it is a skill that is familiar to most Emergency physicians. Is this a safe approach? Read more →
Author Archive for: srrezaie
Background: Just a few months ago the surviving sepsis campaign published their international guidelines for management of sepsis and septic shock . There has been a lot of talk in the FOAM world about sepsis 3.0 and this is the first update since the introduction. This was a 67 page document that made a total of 93 statements on the early management and resuscitation of patients with sepsis or septic shock. 1/3 of the statements were strong recommendations and just over 1/3 were weak recommendations. Instead of going through every component of this document, we thought we would discuss one of the potentially biggest components of sepsis care that would affect clinical practice for those of us on the front lines.
One of the main reasons we have seen a mortality decrease in sepsis overtime is due to the proactive nature health care professionals have taken in sepsis management. The so called ABC’s of sepsis management: Early identification, Early fluids, and Early antibiotics. One of the biggest components of this is early identification of these patients.
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 →
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 →
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 →