May 13, 2019

Background: Post-ROSC care is a multifaceted endeavor that includes targeted temperature management (TTM), vital-organ support, and treatment of the underlying cause of arrest. One of the most common causes of cardiac arrest is acute coronary syndrome.  Current European and American guidelines recommend immediate coronary angiography with PCI in patients who present with cardiac arrest due to STEMI. However, in patients with cardiac arrest who do not have STEMI, the role of immediate coronary angiography is still up for debate.  The ACC/AHA published a statement in July of 2015 (Covered on REBEL EM) that proposed an algorithm to stratify cardiac arrest patients who are comatose on presentation for emergent coronary angiography and possible PCI. 

May 3, 2019

Despite decades of experience with endotracheal intubation, we continue to find approaches to improving the process of how we intubate.  In today’s post we are not only going to talk about how to avoid post intubation cardiac arrest, but we are also going to cover 5 rather controversial topics in airway management including: Apneic oxygenation (ApOx), use of video laryngoscopy (VL) compared to direct laryngoscopy (DL), bougie 1st intubation, back up head elevated (BUHE) intubation, and finally bag valve mask ventilation (BVM) prior to intubation.

April 29, 2019

Background: The two biggest keys to successful survival with good neurological outcome in out-of-hospital cardiac arrest (OHCA) are high-quality CPR and early defibrillation. Dispatcher-assisted (DA) CPR is a novel concept to not only improve the rate of CPR being performed, but also the quality of CPR.  In DA-CPR, rescuers perform CPR under telephone guidance from trained dispatchers. In this study, the authors sought to see if DA-CPR improved the quality of chest compressions (Compression depth, compression rate, no-flow time, complete release of pressure between compressions, and hand location).

April 25, 2019

Background: Although the debate over balanced (i.e. lactated ringers, PlasmaLyte) vs unbalanced (i.e. 0.9% saline) crystalloids has not been settled, fluid resuscitation continues to be a fundamental therapy given to critically ill patients.  0.9% saline is one of the most common fluids given in resuscitation of patients but the high chloride content may contribute to the development of acute kidney injury (AKI) [1]. Alternatives to 0.9% saline include crystalloids with electrolyte compositions that are more balanced and resemble that of plasma (i.e. Lactated Ringer’s Plasma-Lyte, etc). Theoretically use of more balanced crystalloids would result in less potential side effects when compared to 0.9% saline. The crux of the matter is does fluid choice affect any patient-oriented outcomes?

April 15, 2019

Background:Tracheal intubation is a common procedure performed on critically ill patients. In these patients, there is a high risk of life-threatening complications associated with the procedure, with severe hypoxemia being one of the more common. Development of severe hypoxemia, in turn, increases the risk of post-intubation cardiac arrest. Therefore, optimal preoxygenation is an essential part of tracheal intubation to help stave off subsequent complications.

Both NIV and HFNC can provide a higher fraction of inspired oxygen than standard oxygen therapies.  HFNC can provide continuous oxygen up to 70L/min via nasal prongs with the potential advantage of remaining in place for apneic oxygenation. NIV can also provide high flow oxygen but must be removed during the apneic phase of intubation.  To date there has not been a study comparing NIV vs HFNC to reduce the incidence of severe hypoxemia during intubation until now; the FLORALI-2 trial.

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