July 22, 2021

Background Information:

Hypothermia was first introduced in 2002 by two studies, Bernard et al and The Hypothermia After Cardiac Arrest (HACA) trial.1,2 The latter, although a small trial, showed improved neurologic outcomes at six months when patients were cooled to 32-34oC. For a long time, a temperature of 33oC was the widely accepted standard of therapy for out-of-hospital cardiac arrest.1 In recent years, a trial aptly named the Targeted Temperature Management (TTM) Trial challenged this notion,3 finding that a temperature of 33oC did not confer any benefit over 36oC.4 Since then, not only has the overall benefit of the therapy remained in question, but many institutions were also left on their own to decide the most appropriate temperature to target. Fever has been proposed as a risk factor for unfavorable outcomes, but the available data only gives us association, not causation. The authors of the TTM trial have now come out with their subsequent study looking to assess the benefit of avoiding fever versus targeting a specific temperature in critically ill patients following cardiac arrest.

July 19, 2021

In the United States, a patient with chest pain presents to the emergency department (ED) every 5 seconds. By the time you finish reading this post, 60 patients will have sought treatment for chest pain. In 2017, chest pain was the second most common chief complaint in US EDs totaling more than 6.5 million visits,[1] or approximately 2.5x the population of Chicago. There have been dramatic advances in the management of ACS and low-risk chest pain. Prior to the days of observation units, I recall admitting high-risk patients with chest pain to a telemetry floor. However, admissions have changed to observation stays, 6-hour 𝚫 troponins changed to 2-hour 𝚫 troponins, conventional troponins changed to high sensitivity troponins, and much more. Remarkably, up to 40% of patients with chest pain will return to the ED with similar concerns within one year.[2] Yet, there is sparse evidence to address the subset of low-risk patients with recurrent chest pain.

July 15, 2021

Background: Transfusion thresholds for anemia have large variations in clinical practice.  This is especially true in patients with acute myocardial infarction (AMI).  Part of the reason for this is the lack of high-quality data.  There was a large, randomized trial looking at restrictive vs liberal transfusion strategies in non-crashing GI bleeding [2] which found a restrictive transfusion strategy was superior, however patients with AMI were excluded.

July 12, 2021

Background: Hypertensive acute heart failure is a subgroup of acute congestive heart failure (CHF) patients.  Physiologically there is increased afterload and decreased venous capacitance both leading to fluid shifts resulting in pulmonary vascular congestion.  Sympathetic crashing acute pulmonary edema (SCAPE) is a severe form of hypertensive acute CHF.  The rapidity and severity of this illness leaves a very narrow period of time for therapeutic intervention before subsequent deterioration. Therapeutic intervention includes vasodilators such as, high-dose nitroglycerin (NTG) and non-invasive ventilation (NIV). Both therapies can result in reduced work of breathing, decreased preload/afterload, and prevention of endotracheal intubation, and ventilation.  There is a paucity of high level literature on this topic. However, many resuscitation-minded clinicians advocate for this therapy.

July 8, 2021

Background Information:

The Canadian Syncope Risk Score (CSRS) is one of several clinical decision tools used in the emergency department (ED) following a syncopal episode. (Figure 1) It was derived from one of the largest datasets currently available and its ability to predict the probability of adverse events from a score increases its clinical utility with flexibility when applied as a continuous risk assessment.1 One benefit it has over other risk-stratification tools is the score’s ability to address the risk of these serious adverse events over 30 days as opposed to 7-30 days after the syncopal episode. The CSRS is not without its disadvantages, of which one item on the score is the clinical diagnosis. The initial clinical picture may not be clear enough to immediately discern this. Furthermore, there’s difficulty in discerning where arrhythmia falls in the score (ie. adverse event or part of the final diagnosis). While CSRS has been previously validated in a multicenter Canadian study,2 the authors of the following paper wanted to externally validate it and compare it to clinical judgement.