January 9, 2020

Background: Rapid sequence intubation (RSI) is the most widely utilized approach for patients requiring emergency tracheal intubation.  RSI typically requires the use of a induction agent followed by the use of a neuromuscular blocking agent (NMBA) to improve the overall intubation conditions and therefore improve first-attempt intubation success rate. Historically, succinylcholine has been the preferred NMBA, due to its fast onset (45 – 60 seconds) and fast offset (6 – 8 minutes of paralysis). Recent studies, however, show that rocuronium is an effective agent (similar timing of onset for ideal intubating conditions) as well.  When used at a dose of 1.2mg/kg, rocuronium has a similar onset time to succinylcholine of about 1 minute. Additionally, succinylcholine has several contraindications (see bottom of the post) while rocuronium has no contraindications (except for hypersensitivity) which has increased the debate about the paralytic agent of choice for RSI.

January 6, 2020

Background: Although the standard positioning for intubation is supine in the sniffing position, there has been recent literature in the past decade that elevating the head of the bed to 25 to 30 degrees may be a preferable setup for direct laryngoscopy due to improved laryngeal view and reduced airway complications. These studies have been conducted in multiple settings and patient populations including the prehospital setting, the emergency department, and the operating room (for elective cases). Additionally, video-assisted laryngoscopy has been a relatively recent innovation in airway management: the first video laryngoscope produced commercially became available in 2001. Similarly, this technology has been studied in multiple settings including in the emergency department and in the operating room. Both head-elevated direct laryngoscopy and video-assisted laryngoscopy have been studied with a variety of outcomes including first-pass success rate, time to intubation, and mortality rates. However, despite video-assisted laryngoscopy becoming increasingly ubiquitous, its limitations include a high cost and the possibility of components becoming damaged. Both of these innovations in intubation—video-assisted laryngoscopy and elevating the head of the bed—remain debated within the field of emergency medicine.

REBEL Review 94: Drugs to Avoid in Myasthenia Gravis

Created January 4, 2020 | Neurology | DOWNLOAD

January 2, 2020

Background: Traditionally, vasopressors have been given through central venous catheters (CVCs) in the critically ill.However, the time it takes to place a CVC is time a patient could potentially remain hypotensive. Early initiation of vasopressors may be associated with reduced mortality by increasing end-organ perfusion. Therefore, there has been a growing trend to use vasopressors through peripheral IVs (PIVs).  Running pressors through a peripheral IV has a couple of important benefits including faster time to pressor initiation and no need for invasive procedures (i.e. CVC). There islittle evidence to support the safety of this practice other than one systematic review which included case reports and small case series. Now we have two more papers that evaluate this very question…are peripheral pressors safe?

December 30, 2019

Background: One of my favorite ED superstitions is that if someone says the word “quiet,” all hell is going to break loose. Many believe this superstition and as the ED inevitably gets busier as the day goes on, the person who said the Q word gets blamed for the volume; classic association being confused with causation.  I have never heard the opposite…“oh it’s busy,” and when it slows down, no one ever gets upset for someone saying the B word.  This is our own bias of work aversion in my humble opinion.  In this day and age of evidence-based medicine, we finally have a tongue-in-cheek study that proves my point.