March 26, 2020

Background Information: Refractory ventricular fibrillation (RVF) is a complication of cardiac arrest defined as ventricular fibrillation (VF) that does not respond to three or more standard defibrillation attempts.1,2 Patients with RVF during their cardiac arrest have a mortality of up to 97%.3,4 Double external defibrillation (DED) involves the use of a second defibrillator providing an additional shock in a sequential or simultaneous manner. The left ventricle (LV), being the most posterior part of the heart and the furthest away from the anterolateral electrode pads, have led some to hypothesize that utilizing an anterior-posterior pad placement (ie. Changing the vector) is what accounts for DED’s success. Some theorize that the increase in amount of energy from two defibrillations as opposed to one is what’s needed to reach the LV. There are also theories suggesting that the sequential administration of the shocks, more effectively lowers the defibrillation threshold of the cardiac myocytes and thus leads to a more successful conversion of VF. In spite of these many theories, the intervention of DED has been studied for decades in the electrophysiology lab and widely discussed in the literature through case reports and meta-reviews. These case reports have shown success and a recent meta-review of 39 patients who received DED showed that 25% of them were discharged neurologically intact with Cerebral Performance Category (CPC) scores of 2 or less indicating normal recovery/mild disability or moderate disability but able to independently perform activities of daily living.5-10 While this literature is promising, DED is a highly variable intervention and there are still many unknown factors which continue to cause debate and controversy. The role of vector direction via pad placement, the role of a pulse interval in energy deliverance and the efficacy in method of delivering DED sequentially vs simultaneously continues to remain unclear. 6-11 The authors of this pilot RCT (DOSE VF) wished to answer some of these questions by first determining the feasibility and safety of performing a full RCT.  In doing so, they used alternate defibrillation strategies such as vector changes and double external sequential defibrillation (DSED) in treating RVF.12

February 6, 2020

Background Information: The administration of alteplase (tPA) in acute ischemic stroke (AIS) continues to remain a highly debated topic. As hospital systems continue to undergo major changes to facilitate this controversial drug’s administration, more studies are coming out focusing on neuroimaging and how it plays a role in the time window of AIS. The WAKE-UP trial was one of the first studies to identify MRI patterns suggestive of a stroke in patient whose onset time was unknown.1,2 Over the past 10+ years, other studies have also attempted to identify the role of advanced neuroimaging guiding tPA administration for improved functional outcomes. The authors conducted a meta-analysis to test the hypothesis that tPA improves functional outcomes compared with placebo 4.5 - 9 hours after onset in AIS patients who received advanced neuroimaging. Before getting into the study, we need to better understand the terminology and different types of neuroimaging modalities available and how they play a role in strokes.

November 18, 2019

Background Information: Therapeutic hypothermia is the use of targeted temperature management to reduce neurologic sequelae resulting from the severe ischemia-reperfusion injury that occurs during cardiac arrest primarily from shockable rhythms.1 Although a mainstay treatment in the Advanced Cardiac Life Support (ACLS) guidelines, its use has been widely debated as beneficial in improving neurologic outcomes in post-cardiac arrest patients with non-shockable rhythms.2-7 Recent studies have also questioned the exact temperature at which patients should be cooled.8 The authors of this study sought to assess whether moderate therapeutic hypothermia, compared with targeted normothermia would improve neurologic outcomes in post-cardiac arrest patients who had a non-shockable rhythm.

October 21, 2019

Background Information: Atrial fibrillation is the most commonly encountered dysrhythmia in the emergency department (ED) and is associated with an increased long-term risk of stroke, heart-failure and all-cause mortality.1,2 In fact, the overall mortality rate for patients with atrial fibrillation is approximately double that of patients in normal sinus.3,4 The decision to rate vs. rhythm control patients while in the emergency department remains controversial in the literature and the method of doing so using chemical vs. electrical cardioversion also stirs up debate. Prior studies have shown the success rate of electrical cardioversion alone to be 90%.1,5 other studies have demonstrated that emergency physicians use each strategy roughly half the time.1 The authors of this study sought to determine if one of the two strategies resulted in achievement of normal sinus rhythm and discharge more quickly.

September 26, 2019

Background Information: Critical care and emergency medicine are frequently intertwined as the resuscitation of critically ill patients occurs in both environments. While the majority of these patients come through the emergency department (ED), the resuscitation of critically ill patients is not defined by a geographic location, but rather a set of principles designed to deliver appropriate care in a timely fashion.1,2 Increased numbers of critically ill patients in combination with decreased availability of intensive care unit (ICU) beds and a shortage of intensivists has led to a shift in critical care being delivered in the ED.3 Furthermore the lack of ICU beds, among many other factors, have contributed to a prolonged length of stay (LOS) of already admitted patients known as “ED Boarding”. Another factor to consider, is that providing prolonged critical care in a traditional ED setting is challenging as it requires more staff and is often associated with increased mortality. Multiple studies have demonstrated an association of worsened outcomes when patient’s ED LOS is greater than 6 hours and, in the United States, 33% of all ICU admissions from the ED have an ED LOS greater than 6 hours.1,4 A proposed solution has been the development of ICUs housed within the ED known as ED-ICUs. While only a handful exist, this new method of care delivery aims to reduce the time it takes for patients to receive critical care and offset the strain on current ICUs (Table 1)4. The authors of this study sought to determine the association of ED-ICUs on 30-day mortality and inpatient ICU admission.