Beyond ACLS – POCUS in Cardiac Arrest

20 Aug
August 20, 2015

Beyond ACLS - POCUS in Cardiac ArrestAs we have discussed in previous posts, the care of patients with cardiac arrest is a key skill for Emergency Providers. ACLS provides a foundation for care but is rife with shortcomings including, but not limited to, reliance on outdated data and inability to adapt in the face of improved understanding of cardiac arrest pathophysiology. The incorporation of technological advances and skills is another massive limitation of ACLS. One of these technologies is point of care ultrasound (POCUS).

Over the last two decades, POCUS has become a integral part of Emergency Medicine training and practice. POCUS allows for rapid, bedside diagnosis of a number of conditions including cholecystitis, urinary retention and ectopic pregnancy. Additionally, it is becoming a greater component in the management of the critical patient where it can be used to assess cardiac contractility, wall motion abnormalities, intraperitoneal free fluid and more. Application of POCUS in all patients with cardiac arrest is simply the next step. This diagnostic modality is not highlighted in the current iteration of ACLS but is a practice changer. The bottom line is that application of POCUS in cardiac arrest allows the emergency provider to guide resuscitation with a direct look into the body – we are no longer blind.

For this post, I want to discuss two ways that we can use ultrasound in cardiac arrest patients, specifically in pulseless electrical activity (PEA), in the Emergency Department:

  1. Assessment for the presence or absence of cardiac output and
  2. As an alternate framework to the Hs and Ts.

A quick disclaimer – I am not an ultrasound expert, I did not do a fellowship but I am passionate about it’s application in our sickest patients. Read more →

August 2015 REBELCast

17 Aug
August 17, 2015

August 2015 REBELCastWelcome to the August 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics. First topic: renal colic. Renal colic is a commonly seen condition encountered in emergency departments and the use of medical expulsive therapy (MET) is commonly recommended by our urology colleagues. Proponents of MET in the treatment of ureteric colic advocate for them due to their potential ability to increase stone passage, reduce pain medication use, and reduce urologic interventions. Second topic: pediatric weights. In pediatric resuscitations many of use the Broselow tape to predict weights for dosing of medications.  With the increasing weights in pediatric patients seen in developed countries around the world, does the commonly used Broselow tape accurately predict weights?   So with that introduction today we are going to specifically tackle:

Topic #1: MET for Renal Colic
Topic #2: Use of the Broselow Tape to Estimate Pediatric Weights Read more →

Management of Mild to Moderate Asthma Exacerbations

12 Aug
August 12, 2015

Mild to Moderate AsthmaThis post is meant to accompany the REBEL Cast episode on The Crashing Asthmatic from June 2015. This blog post will also be simultaneously posted on the Core EM site here. Come over and check out our core content offerings. Thanks to the REBEL team for continuing to promote our site!

Definition: An episode of wheezing, chest tightness or coughing resulting from variable airflow obstruction that is reversible. Underlying exacerbations are a chronic inflammatory disorder of the airways. Read more →

Post Intubation Sedation for Pregnant Patients

10 Aug
August 10, 2015

Post Intubation Sedation in Pregnant Patients

You have just intubated a seizing eclamptic woman who is 34 weeks pregnant. As she is being prepped for transfer to the OB unit for an emergent C-section your nurse asks you what medications you would like for post intubation analgesia and sedation.

You have limited recollection of whether Propofol crosses the placenta, and have legitimate concerns about Fentanyl’s chances of producing a ‘floppy baby’ for the OB team on delivery.

The literature on the most appropriate post intubation analgesia / sedation package for late pregnancy patients is limited. The agents we are the most familiar with in the emergency department for post intubation sedation and analgesia are Fentanyl and Propofol. One reliable mantra for post intubation analgesia and sedation is ‘Fentanyl is the sauce, and Propofol is the oregano’, it would be great to be able to apply this mantra to the pregnant population also.

Read more →

Medical Expulsion Therapy in Ureteral Colic: An Update

06 Aug
August 6, 2015

Medical Expulsion Therapy 2Back in August 2014, we posted an in depth review on medical expulsion therapy (MET) with tamsulosin in patients with renal colic. The summary of that post was:

“Clearly, there is disagreement in the literature. None of the studies are ideal. We continue to lack a large, RDCT done on patients presenting to the Emergency Department with renal colic.

The best evidence we have DOES NOT show a significant benefit to the use of tamsulosin in renal colic.”

Since that post, two well done RDCTs were published so we thought a brief review of each of these articles and updated recommendations were warranted. Read more →

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