March 16, 2020

Traditionally, endotracheal intubation has been the gold standard for airway management in cardiac arrest. However, more recent data suggests that maybe less is more (i.e. supraglottic airways and/or bag valve mask ventilation).  The AHA guidelines have also de-emphasized airway management as the old acronym of ABC's has now been changed to CAB's.  In this talk from Rebellion in EM 2019, Dr. Chris Hicks, MD discusses the optimal airway management in OHCA.

March 12, 2020

Background: Most published clinical guidelines on the management of primary spontaneous pneumothorax (PSP) advocate for a conservative approach of observation for small asymptomatic pneumothoraces (PTX).(1,2) However, procedural re-expansion with a catheter or chest tube is recommended for all large pneumothoraces, regardless of symptomatology or clinical stability.(1) More recently, smaller chest tubes (i.e. pigtail catheters) have been used as this can potentially cause less pain. Typically, patients who get chest tubes or pigtail catheters require hospitalization for management of the tube. But, chest tubes are not without risk: there are multiple reports in the literature describing terrible consequences of chest tubes including bleeding, infections and empyemas, and misplacement into vital organs like the liver, spleen, and heart.(3-5) An alternative approach to this invasive procedure is to do nothing, unless the pneumothorax becomes physiologically significant. In an effort to reduce these risks and discomfort to the patient, the clinical quandary becomes: can a large pneumothorax be managed using a conservative observation-only approach, without placement of catheters or chest tubes? To date there have been no randomized clinical trials comparing these two polar opposite management strategies until now (The PSP Trial).

February 17, 2020

Background: In REBEL Cast Episode 73, Anand Swaminathan and I discussed two recent studies on the safety of peripheral vasopressors from two large trials [1][2]. An email from good friend Rory Spiegel brought my attention to yet another trial on this topic [3]. I think we can all agree that in patients with septic shock, or shock in general, the administration of vasopressor agents early, can help to stabilize patients and reverse end-organ hypoperfusion.  Traditionally, this has been done through central venous catheters (CVCs) due to the hypothetical risk of extravasation injury to extremities.  The flip side of this is, that central venous catheters are not without their own risks and time to place them can delay a therapy that may benefit patients.

February 13, 2020

Background: In critically ill patients needing IV access, ultrasound has helped improve gaining access to a set of peripheral veins, located deeper in the arm.  The time it takes to do this however is not insignificant but even more importantly is that once you achieve success, the line can fail due to a short catheter length. Central venous catheters, often seen as a solution to this latter issue, are not without their own risks and complications.  Therefore, a nice alternative option may be a midline catheter. These catheters are not meant for fast, large volume resuscitations because they also take time to place, but also have a longer catheter length which slows down infusion rates. Midline catheters are really about having safe access that is unlikely to be dislodged. This is a great option when you have medications you want to give but not have extravasation occur (i.e. vasopressors, hypertonic saline, calcium chloride, etc.).

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.