June 4, 2020

Traditionally, vasopressor infusions have been done through central venous catheters (CVCs) due to the hypothetical risk of extravasation injury to extremities when given through peripheral IVs.  The documented risk of extravasation from peripheral pressors is 3 – 6% [1][3][4][5]. Hypothetically, the extravasation rate can be further reduced.  At Essentials of EM 2020 I gave a short 10-minute talk on 6 pearls I have implemented.  This post will serve as a summary of that talk.

June 2, 2020

Background: We have covered the two previous RCTs on remdesivir on REBEL EM (RCT #1 and RCT #2). In the first trial by Wang et al [2], there was no statically significant improvement in clinical outcomes, but, there were trends toward shorter duration of illness. In the ACTT-1 preliminary report [3], despite all the methodological issues, there was a 4 day decrease in clinical improvement (although not in patients requiring HFNC/NIV/IMV/ECMO).  Neither trial was perfect, however in the middle of pandemic, a several day decrease in recovery time may be beneficial in reducing hospital crowding if the difference holds true in subsequent studies and if the correct target population is known.  We now have our 3rd RCT on remdesivir [1], just published in the NEJM comparing 5 days vs 10 days of remdesivir in patients with severe COVID-19.

June 1, 2020

Background: Humeral shaft fractures are commonly seen in the Emergency Department and emergency management is relatively straightforward: assess for other trauma, assess for radial nerve injury, analgesia, sling or functional bracing and follow up with orthopedics. However, there are debates in management specifically around operative vs non-operative management. The non-operative approach has been the standard but, the rate of surgery has markedly risen in the last decade (Schoch 2017). Operative management appears to reduce the risk of nonunion significantly but, comes with other risks including infections and iatrogenic radial nerve injuries. In the absence of high-quality evidence, marked practice variation persists.

May 31, 2020

I am fortunate to work in a hospital system that is very forward thinking.  We have a phenomenal relationship with our intensivists, and I have been fortunate enough to have several discussions with them about how we are managing COVID-19 in our ICUs.  For full transparency, I don’t work up in the ICU, but had the opportunity to discuss what we are doing in our ICUs with one of our intensivists (ECMO, steroids, Remdesivir, etc...).  We are doing something different in San Antonio that I thought was worth discussing on this podcast that may be a feasible option for some institutions and some patients, but not all. If there is one thing this disease has taught me, that is one size does not fit all.

May 30, 2020

Background: One of the hot topics in COVID-19 care is the mortality rate associated with invasive mechanical ventilation (IMV). There have been early reports of IMV having mortality rates ranging from 50 to 90%.  These high rates are concerning but, context is important; many of the reports emerged from areas with large surges where hospital systems were overwhelmed. Additional data looking at outcomes of critical patients is important particularly within systems that were able to maintain baseline critical care provisions despite surges.