September 16, 2019

Background: Rapid sequence intubation (RSI) involves the use of an induction agent followed by a neuromuscular blocking (NMB) agent to obtain optimal intubating conditions.  Administration of a NMB results in apnea which, in turn, can lead to oxygen desaturation.  Oxygen desaturation during rapid sequence intubation may lead to serious adverse events including dysrhythmias, hypotension, and cardiac arrest.  Preoxygenation helps extend the duration of safe apnea and has 2 major goals:
  1. Attempt to achieve an O2 saturation of 100%
  2. Maximize oxygen storage in the lungs by denitrogenation of the residual capacity of the lungs (Approximately 95% of oxygen reservoir)
Preoxygenation is assessed in the ED but usually through pulse oximetry which is inadequate.  In the operating room, anesthesiolgists use gas analyzers to quantify and optimize preoxygenation with ETO2.  In critically ill patients, preoxygenation should be performed to achieve an ETO2 ≥85% based on the response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society [2].

September 12, 2019

Background:

  • Tramadol is a centrally acting synthetic opioid analgesic approved for use in the United States in 1995 by the Food and Drug Administration.
  • In 2014, the Drug Enforcement Agency classified tramadol as a Schedule IV controlled substance.
  • ~41 million prescriptions for tramadol were dispensed in the United States in 2017.

September 9, 2019

Background: Epinephrine (adrenaline) has been used in advanced life support in cardiac arrest since the early 1960s. Despite the routine recommendation for its use, evidence to support administration is less than ideal.  Although it is clear from multiple observational studies that epinephrine improves return of spontaneous circulation (ROSC) and short-term survival, most evidence suggests an absence of improvements in survival with good neurologic outcomes.  In cardiac arrest we want to take advantage of the alpha effects of epinephrine, including peripheral vasoconstriction, and therefore increasing aortic diastolic pressure, which in turn helps augment coronary and cerebral blood flow.  On the other hand, we want to avoid the potentially detrimental beta effects including dysrhythmias, decreased microcirculation, and increased myocardial oxygen demand all of which increase the chances of recurrent cardiac arrest and decreased neurologic recovery.  The only two interventions in cardiac arrest that have shown improve survival with good neurologic outcomes continue to be high-quality CPR and early defibrillation. The debate over the utility of epinephrine in OHCA has been ongoing for several years now and many providers are left with the ultimate question of what to do with epinephrine in OHCA.

September 2, 2019

Background: Convulsive status epilepticus is the most common pediatric neurological emergency worldwide.  Currently, phenytoin (UK & Europe) or fosphenytoin (USA) is the recommended second-line IV anticonvulsant for the treatment of pediatric status epilepticus.  Some evidence and providers however suggest that levetiracetam could be an effective and safer alternative. Recently not one, but two RCTs were published trying to figure out whether levetiracetam or phenytoin should be second-line treatment of pediatric status epilepticus.

August 26, 2019

Normal saline started being used based on work done in the 1830s with cholera.  We are still doing the same thing the same way and it’s not until recently we have begun to ask the hard questions about why we are doing things the same way 150 years later.  In this debate, titled "What the Fluid," from Rebellion in EM 2019, Scott Wieters, MD and Rob J. Bryant, MD debate the pros and cons of balanced and unbalanced crystalloids.

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