November 14, 2019

Background: Septic shock is the most severe form of sepsis. It is characterized by vasodilation and increased capillary permeability leading to hypotension and tissue hypoxia.  The initial treatment of septic shock includes early identification, intravenous fluids when necessary, appropriate broad-spectrum antibiotics, source control and organ support. Vasopressor therapy is often required to maintain adequate perfusion to support end organs.  Norepinephrine is the accepted first-line vasopressor for patients in septic shock, but it is not always effective in patients with extreme vasoplegia due to sepsis. Selepressin, a selective vasopressin V1a receptor agonist, is a non-catecholaminergic vasopressor that may assist in these patients.  It works by mitigating vasodilatation, vascular leakage, and tissue edema, but without V1b- or V2-mediated effects seen with vasopressin, which result in increased procoagulant factors, salt/water retention, nitric oxide release, and corticosteroid stimulation.

November 11, 2019

Background: Peri-intubation cardiovascular collapse (shock, cardiac arrest or death) is an all too common complication of airway management in critically ill patients seen in up to 25% of patients (Jaber 2010, Umobong 2018). The causes for collapse are numerous and include acidosis, pulmonary hypertension, vasodilation, iatrogenic (medications used in intubation) and hypovolemia. Administration of fluids may help to mitigate the hemodynamic effects of intubation, particularly if decreased venous return is an issue, but this approach is untested.

November 7, 2019

Background: Despite minimal high-quality supporting evidence (Seymour 2017, Liu 2017, Ferrer 2014, Sterling 2015), regulatory bodies have pushed for benchmark times for administration of antibiotics in patients with sepsis. While most clinicians would agree that in patients with septic shock antibiotics should be given as quickly as possible, the same does not hold true for those patients with less severe infections. In the US, the Centers for Medicare and Medicaid Services (CMS) currently mandates that antibiotics be started in patients within 3 hours of onset of new organ dysfunction in patients with systemic inflammatory response syndrome and documented infection. The Surviving Sepsis Campaign (SSC) has even more extreme recommendations stating that antibiotics should be started within 1 hour from triage in septic patients (Levy 2018). Based on prior experience with arbitrary time to antibiotic administration (see community acquired pneumonia), such draconian recommendations are likely to increase inappropriate use of antibiotics, distract clinicians from more important tasks and have minimal effect on patient outcomes. This is likely why the Infectious Disease Society of America (IDSA) declined endorsement of the SSC guidelines. The ridiculous nature of these recommendations has been discussed elsewhere.

Even if the recommendation had some merit, it’s important to ask whether it’s even possible to implement. None of those on the SSC committee work in emergency departments and their understanding of the logistical challenges of such a policy is limited.

November 5, 2019

APPLY NOW: REBEL EM’s 2020 Infographic Competition for Essentials of Emergency Medicine Education Fellowship Program The Essentials of Emergency Medicine (EEM) conference is in May 2020, but the opportunities to attend start NOW. This conference is one of the largest live EM educational conferences in the world with over 2,000 attendees. The conference organizers, led by Dr. Paul Jhun, are again offering an amazing opportunity for EM residents anywhere in the world to serve as an EEM Fellow for the next EEM conference May 21 - 23, 2020.