The PESIT Trial: Do All Patients with 1st Time Syncope Need a Pulmonary Embolism Workup?

24 Oct
October 24, 2016

the-pesit-trialBackground: Syncope is a very frustrating chief complaint for many in the medical field.  There is no gold standard test and no validated decision instrument. It represents about 3 – 5% of ED visits, 1 – 6% of hospital admissions, and in patients over the age of 65 years it is the 6th most common cause of hospitalization [2][3]. Additionally, both ED and inpatient work ups are notoriously low yield for finding significant pathology. Pulmonary embolism is one of the myriad of diagnoses included in the differential diagnosis of syncope, but there is little information looking at its prevalence amongst hospitalized patients. Fast forward to Oct. 20th, 2016 and there is now some evidence just published in the NEJM: The PESIT Trial. Read more →

American College of Emergency Physicians (ACEP) Conference 2016

20 Oct
October 20, 2016

acep-2016This years ACEP 2016 conference took place in Las Vegas, NV from Oct 16th – 19th.  There was greater than 350 courses, labs, and workshops given throughout the week.  It was impossible to make all of these great lectures, but I was able to take away some very important clinical pearls that I wanted to share with our readers.  Read more →

Hyperthermia Syndromes

17 Oct
October 17, 2016

hyperthermia-syndromesDefinition: A life-threatening emergency in which there is a failure of the body’s thermoregulatory mechanisms to handle extrinsic and intrinsic heat. The failure of thermoregulation leads to multi-system organ dysfunction characterized by alteration of neurologic function. Unlike in fever, hyperthermia is not caused by endogenous pyrogens that change the thermoregulation set point in the brain. Hyperthermia results from excessive heat production and/or inadequate heat dissipation Read more →

Das SMACC: Registration and Ticket Releases

15 Oct
October 15, 2016

das-smaccFor those of us who have been lucky enough to attend one of the first four SMACC conferences, I think we would agree that this is one of the highest quality, academic meetings in the world. One of the main reasons for this is the enormous and inspiring energy of the critical care community itself. A community that crosses traditional hierarchies, professional barriers and international borders. This is a community dedicated to innovation, teaching and learning. A community based around the pursuit of excellence in patient care, and a passion for sharing this as widely as possible.  Well, the Social Media and Critical Care Conference (SMACC) is back with its 5th iteration of the conference in Berlin, June 26th – 29th, 2017.

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October 2016 REBEL Cast: IDSA Pneumonia Update

10 Oct
October 10, 2016

pneumoniaEvery few years we get updates in the guidelines based on new evidence. Guidelines give us a framework to work with in the treatment of disease processes, such as pneumonia. The last Infectious Disease Society of America (IDSA) guidelines update on the treatment of pneumonia came from 2005, but recently, the new 2016 guidelines were just published. This was a massive 51 page summary that starts off by saying:

“It is important to realize that guidelines cannot always account for individual variation among patients.  They are not intended to supplant physician judgment with respect to particular patients or special clinical situations.  IDSA considers adherence to these guidelines to be VOLUNTARY, with the ultimate determination regarding their application to be made by the physician in the light of each patient’s individual circumstances.” Read more →

Critical Care Updates: Resuscitation Sequence Intubation – pH Kills (Part 3 of 3)

03 Oct
October 3, 2016

Resuscitation Sequence Intubation - pH Kills

This blog post is the third part of a series of 3, on a recent lecture I was asked to give  on Critical Care Updates: Resuscitation Sequence Intubation. This talk was mostly derived from a podcast by Scott Weingart (Twitter: @EMCrit) where he talked about the physiologic killers during preintubation and perintubation. In this podcast, Scott mentions the HOp killers: Hypotension, Hypoxemia, and Metabolic Acidosis (pH) as the physiologic causes of pre-intubation/peri-intubation morbidity and mortality. Taking care of these critically ill patients that require intubation can be a high stress situation, with little room for error.  In part three of this series we will discuss some useful strategies at the bedside to help us not worsen pre-intubation/peri-intubation metabolic acidosis.
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Critical Care Updates: Resuscitation Sequence Intubation – Hypoxemia Kills (Part 2 of 3)

29 Sep
September 29, 2016

Resuscitation Sequence Intubation - Hypoxemia Kills

This blog post is the second part of a series of 3, on a recent lecture I was asked to give  on Critical Care Updates: Resuscitation Sequence Intubation. This talk was mostly derived from a podcast by Scott Weingart (Twitter: @EMCrit) where he talked about the physiologic killers during preintubation and perintubation. In this podcast, Scott mentions the HOp killers: Hypotension, Hypoxemia, and Metabolic Acidosis (pH) as the physiologic causes of pre-intubation/peri-intubation morbidity and mortality. Taking care of these critically ill patients that require intubation can be a high stress situation, with little room for error.  In part two of this series we will discuss some useful strategies at the bedside to help us reduce pre-intubation/peri-intubation hypoxemia.
Read more →

Critical Care Updates: Resuscitation Sequence Intubation – Hypotension Kills (Part 1 of 3)

26 Sep
September 26, 2016

Resuscitation Sequence Intubation - Hypotension Kills

This blog post is the first part of a series of 3, on a recent lecture I was asked to give  on Critical Care Updates: Resuscitation Sequence Intubation. This talk was mostly derived from a podcast by Scott Weingart (Twitter: @EMCrit) where he talked about the physiologic killers during preintubation and perintubation. In this podcast, Scott mentions the HOp killers: Hypotension, Hypoxemia, and Metabolic Acidosis (pH) as the physiologic causes of pre-intubation/peri-intubation morbidity and mortality. Taking care of these critically ill patients that require intubation can be a high stress situation, with little room for error.  In part one of this series we will discuss some useful strategies at the bedside to help us reduce pre-intubation/peri-intubation hypotension.
Read more →

Beyond ACLS: Cognitively Offloading During a Cardiac Arrest

22 Sep
September 22, 2016

Beyond ACLSToday I am giving a talk at the 25th National Emergency Medicine Symposium by Kaiser Permanente in Maui, HI.  The focus of this talk was on how to cognitively offload our minds as we are running a resuscitation. ACLS provides us with a framework in treating adult victims of Cardiac Arrest (CA) or other cardiopulmonary emergencies. This helps get providers who don’t commonly deal with CA, to improve things, such as the quality of CPR, minimizing interruptions during CPR for pulse checks, and the timing/dosing of epinephrine. Emergency Medicine (EM) and the prehospital world are different than many environments in medicine. We get minimal information at the time of patient arrival while at the same time the disease process that is taking place has not quite defined itself.  We are constantly expected to acutely manage and resuscitate anyone who comes in our doors 24-7-365, many times without crucial information. Our job therefore should be to ensure coronary and cerebral perfusion are at their highest quality, but also simultaneously putting the pieces of the puzzle together to figure out why our patient is in CA. It can be very difficult to do both and many times we sacrifice one for the other. It is therefore important to cognitively offload ourselves during the resuscitation of our patients in CA and focus our attention on why they are in CA. As a disclosure for this lecture I did state that some of the recommendations made have evidence to support them and others are more theoretical and certainly up for discussion. Read more →

September 2016 REBEL Cast: Refractory Ventricular Fibrillation

05 Sep
September 5, 2016

Refractory Ventricular FibrillationBackground: Welcome back to the September 2016 REBEL Cast. We are back with another episode and I am super excited about this episode because we are going to talk about two papers just published in the Resuscitation Journal on management of refractory ventricular fibrillation. It is a well known fact that the cornerstones for survival from Out-Of-Hospital Cardiac Arrest (OHCA) have always been early, high quality CPR and early defibrillation in patients with shockable rhythms (i.e. Ventricular Fibrillation/Ventricular Tachycardia). Some patients with shockable rhythms may be refractory to standard defibrillation therapy (i.e. refractory VF). Even more frustrating, there is truly a dearth of data on what to do with these patients. One strategy that has been reported more and more in the literature is double sequential defibrillation (DSD).

Another issue in cardiac arrest patients is we frequently give boluses of 1mg epinephrine every 3 – 5 minutes as is outlined in the ACLS guidelines.  When patients have minimal cardiac output, the buildup of catecholamines may potentially cause refractory ventricular fibrillation (RVF).  This could be due to an increase myocardial oxygen consumption causing an increase in myocardial ischemia, and ultimately more difficulty in successful defibrillation.  But maybe by blocking the beta-adrenergic receptors in the myocardium, we can block the beta effects of the catecholamines and potentially increase the chances of successful sustained ROSC.

Read more →

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