Background: 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 →
Author Archive for: srrezaie
Patients 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 →
Welcome 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
So 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 →
There 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 →