You are working an ED shift with an experienced EM resident. As the resident prepares to intubate a 100kg patient with pneumonia you suggest that the head of the bed be elevated to aid in first pass success and avoidance of peri-intubation hypoxia. The resident thanks you for your kind suggestion and states ‘I just read an article in Annals of EM suggesting there was no benefit to non-supine position in ED patients.’ This is news to you. You give the resident the benefit of the doubt and ask them to send you a copy of their evidence.
You have just intubated a 4 year old with sepsis from a bad pneumonia. Post intubation BP is 70 systolic, while waiting for the epinephrine (adrenaline) infusion to come up from pharmacy you watch the BP decline into the 60 systolic range and start to use fluids to resuscitate. You are an accomplished adult resuscitationist, and are comfortable mixing, and pushing push dose epi in your adult patients.
The following questions arise as you consider mixing a batch of push dose epi:
How much push dose epinephrine should you give this septic 4 year old?
Do pediatric patients need more or less epi when given in push dose format?
How do some pediatric intensivists and pediatric emergency physicians manage this problem?
During a busy resuscitation it behooves the ED resuscitationist to avoid ordering therapies that have no clear benefit to their patients. Our nurses are overburdened, and adding interventions ‘just to be safe’ or ‘because we always do it’ is a great way to overwhelm our nursing colleagues. Bicarb administration is a contentious issue and many clinicians consider its use to fall firmly into the no-benefit camp, even when used in the management of severe metabolic acidosis. There have been no studies to date evaluating clinical outcomes with the use of sodium bicarbonate infusion therapy for severe metabolic acidemia, until now. This post is a review of the recently published BICAR-ICU trial...Read More
Abscess management has evolved somewhat in the 14 years since my residency graduation. The point at which antibiotics are likely to be more helpful than harmful is not always easy to assess, and evidence based expert opinion has flip flopped impressively.
Based on current evidence, I would like to answer 3 big questions that every clinician may have when confronted with an abscess:
Background: Peri-operative anaphylaxis is an unexpected complication of intubation. The major life threat in anaphylaxis is typically loss of airway, however profound hypotension and circulatory collapse are still possible life threats even in the setting of a protected airway. Peri-operative anaphylaxis is considered an important enough issue to be the subject of the NAP 6 (National Audit Project) audit this year in Great Britain. (Reporting period November 2015 – November 2016)....Read More