April 2, 2020

Background: Peripheral intravenous (PIV) access is one of the most commonly performed invasive procedures in unwell patients.  Although, most patients can have PIVs placed by palpation, there is a subset of patients with difficult vascular access that will require ultrasound-guided peripheral IVs. We have covered this topic before with Jacob Avila (The Ultrasound Podcast, 5 Minute Sono) in REBEL Cast Ep 62. One thing we did not cover was catheter dwell rates.  Catheter dwell rate is an important endpoint as it takes time to perform the procedure, but more importantly for the patient, premature IV failure can include complications such as infiltration, phlebitis, ischemia, necrosis, as well as delays in receiving medications. Therefore, an important concept worth covering is the length of the catheter that is in the vein.

Midline catheters, which we have also covered on REBEL EM are catheters with lengths of 6 to 20cm and represent a potential solution.  These catheters have high success rates and longevity, but insertion requires institutional protocols and specialized training.  A nice go between is the peripheral ultralong catheter (ULC), which is 6.35cm. As with anything new in medicine, it is important to review the evidence to ensure we are performing best practices for our patients.

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.).
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