March 6, 2019

Take Home Points:

  1. If the patient is a clear traumatic arrest, compressions aren’t indicated and, instead we should focus on the important interventions that need to be done.
  2. Ultrasound can be incredibly helpful in traumatic arrest. If you’ve got a traumatic arrest patient with neither pericardial fluid nor cardiac activity, it may be reasonable to stop resuscitation without the thoracotomy.
  3. When decompressing the chest, it’s better to place you angiocath in the 5th intercostal space in the anterior axillary line. This helps you avoid the great vessels in the as well as the thick anterior chest wall
  4. And last, if you are doing a thoracostomy, you may as well go bilaterally. You are doing invasive things to a dying patient, there is no reason to guess where the problem is. Similarly, if you have to do a thoracotomy, you could consider making it a clamshell as it space to look into and making sure the right side of the chest is accessed.

February 25, 2019

Introduction: The production and release of new antibiotics is rare and should be celebrated by clinicians. As antibiotic resistance continues to mount, our options narrow and, in turn, our patients suffer. Recently, the NEJM published two articles on a new antibiotic that was recently FDA approved - omadacycline. The articles compared omadacycline to moxifloxacin in the treatment of community acquired pneumonia (CAP) and to linezolid in the treatment of skin and soft tissue infections. Both studies yielded promising results for the new drug which should be cause of excitement. However, significant biases, methodological flaws and poor selection of comparator treatments should temper our excitement.

Both studies tested the new antibiotic in a non-inferiority set up. Non-inferiority studies seem to be increasingly prevalent in the literature and because they serve an important purpose, it’s important for us to understand them and also to understand why this approach is used and why it may not be appropriate.

February 20, 2019

Take Home Points:

  1. Hypothermia is neuroprotective and patients can survive prolonged periods of cardiac arrest. Termination of resuscitative efforts in cardiac arrest should not considered until the patient is >32°C or has a K > 12 mEq/L
  2. Active internal rewarming is the keystone of treatment for unstable hypothermic patients. Utilize available resources including ECMO to effectively warm your patient
  3. Consider alternate causes for hypothermia, especially in patients who fail to respond to warming

February 11, 2019

Background: Syncope, defined as a transient loss of consciousness with a complete recovery, is a common ED presentation. There are numerous causes of syncope ranging from the relatively benign (eg vasovagal syncope) to the potentially life-threatening (eg dysrhythmia, ectopic pregnancy, aortic dissection). Among the life-threatening diagnoses is pulmonary embolism (PE). PE is a common cause of sudden, unexpected, non-traumatic death and, syncope in the setting of PE portends poor 30-day outcomes (Roncon 2018). What is not well known is how often ED presentations of syncope are the result of PE. A study in 2016 demonstrated a 17.3% rate of PE in first time syncope presenting to the ED but, had numerous significant biases and limitations (Prandoni 2016). Ultimately, this study is unlikely to reflect the reality of ED syncope cases and lacks external validity. Incorporating the PESIT trial data into clinical assessment would lead to a profound increase in PE evaluation without adding significant benefit. Additional clinical data demonstrating the true prevalence of PE in syncope patients is needed to confirm these suspicions.

February 6, 2019

Take Home Points

  1. Bed Up Head Elevated (BUHE) position is a simple intervention that can reduce the rate of intubation-related complications.
  2. The bougie should be considered standard practice in all intubations and has an NNT = 11 for 1st pass success.
  3. Consider using Suction Assisted Laryngoscopy for Airway Decontamination (SALAD) for all intubations to avoid the failed airway due to contamination.