May 11, 2020

“You’re in the emergency department, you have a patient who EMS has brought in from a nursing home…who’s excited? Right, nobody is. And they are brought in for a chief complaint of altered mental status. So they’re concerned about sepsis. This is your initial set of vital signs: febrile, tachycardic, hypotensive. And you’re looking at the patient and you’re looking at their Foley and it looks like somebody put oatmeal into it. You know for a fact that the probability is that they have a urinary tract infection is pretty high. So the next question is: do you do what you normally do, but add steroids?”

May 8, 2020

Background: Although Helmet CPAP is not something commonly used in the US, I think its nice to know what other potential options there are to help patients in the midst of a COVID-19 pandemic. Hypoxemic acute respiratory failure (hARF) is a well-known complication that can occur in patients with pneumonia.  This has a high morbidity and mortality associated with it.  An intermediary step prior to intubation is the use of noninvasive positive pressure ventilation (NIPPV) to stave off intubation. A more important question is does NIPPV in patients with pneumonia and hARF improve clinical outcomes? There have been no randomized clinical trials that have evaluated the clinical efficacy of helmet CPAP in patients with pneumonia suffering from hARF to date Helmet CPAP has also gained recent attention as an oxygenation tool for COVID19 pneumonia. The authors of this trial wanted to compare helmet CPAP vs oxygen therapy delivered by Venturi mask to reduce the proportion of patients requiring ETI in hARF due to pneumonia.

May 6, 2020

There continues to be a slew of publications coming out on a near daily basis in regard to COVID-19.  Some publications will deserve their own posts and others can really be summarized in one or two paragraphs.  In this post I will summarize 5 papers published in the past week, that I found interesting and each has a unique, but important message.  None of these papers are very long, but there are some important aspects of each I felt tied into each other from a cardiovascular standpoint.

May 4, 2020

Introduction: Emergency physicians rarely are involved in tube exchanges; I can’t remember the last time I had to do one. However, during the COVID19 surge, we found ourselves boarding intubated patients for days and even weeks as our ICUs were filled to the brim. With our ICU teams so busy, it became increasingly important for us to aid in critical care management where we could. Initially this was simply with lines and hemodynamic monitoring but, tube exchange became important. A number of our boarding patients developed considerable mucous plugging and tube obstruction that could not be cleared by suction. Reintubation with a fresh tube, while well within our scope, creates unnecessary risks - aerosol generation, increased provider exposure and possible harm to patient if intubation proves challenging. Tube exchange over a bougie seems to make a lot of sense.

Note: Due to the lack of experience most EM clinicians have with this procedure and the fact that it is a high-risk one, it may be best to consult anesthesia to help with the procedure if they are available. We acknowledge that this may not be possible if that service is stretched thin due to circumstances.