June 27, 2018

Background: Pulseless electrical activity (PEA) is an organized electrical activity without a palpable pulse.  1/3 of cardiac arrest cases will be pulseless electrical activity and the overall prognosis of these patients is worse than patients who have shockable rhythms (ventricular fibrillation or pulseless ventricular tachycardia).  It can be a challenge to decide when to terminate or continue resuscitation efforts in PEA arrest.  Palpating pulses is difficult in the setting of a code situation, neither sensitive nor specific based on current literature.  The use of POCUS could help split PEA patients into Pseudo-PEA (cardiac activity on US = profound shock) vs True-PEA (no cardiac activity on US) in determining the potential for ROSC.

June 15, 2018

Background: As with all medications in cardiac arrest (i.e. epinephrine, amiodarone) the benefits of sodium bicarbonate administration have been discussed and debated for decades. While it is clear that sodium bicarbonate can play a role in resuscitation of arrest due to hyperkalemia, it’s role in patients with acidemia resulting from or causing arrest is unclear. In theory, raising the pH may be beneficial but the use of bicarbonate increases serum CO2 which may be deleterious as it creates a respiratory acidosis. Despite the absence of good evidence, sodium bicarbonate continues to be used in non-hyperkalemic cardiac arrest management.

June 8, 2018

Background: Administration of a neuromuscular blocker (NMB) is an essential part of Emergency Department  (ED) airway management for facilitating ideal airway conditions and is most commonly performed with either succinylcholine or rocuronium. Despite extensive debates between providers, one agent has not been shown to be superior to other. Limited anesthesia literature has shown that succinylcholine may provider better intubating conditions but it has a number of contraindications (which may not be initially apparent)(Shoenberger 2018). Rocuronium at high doses has a similar onset of action to succinylcholine and may provider longer safe apneic times (Swaminathan 2018). This study seeks to add more information to the clinical discussion.

May 10, 2018

Background:Intubation is a commonly performed procedure in the ED and ICU. We have discussed the physiologically difficult intubation before on REBEL EM.  One of the tenants in managing these patients is “resuscitate before you intubate.”  Two publications in the past [1][2] discussed the incidence and risk factors associated with cardiac arrest complicating RSI.  In the first study [1], 542 patient underwent emergency intubation, 4.2% had a cardiac arrest, meaning nearly 1 in 25 intubations were associated with cardiac arrest.  In the second study [2], 2,403 patients underwent emergency tracheal intubation, and 1.7% had a cardiac arrest, meaning nearly 1 in 60 intubations were associated with cardiac arrest.  A new study in Critical Care Medicine was just published looking at the prevalence and risk factors associated with intubation (RSI) in 64 ICUs in France.

REBEL Review 86: Flow Rates in IV/IO Access

Created May 7, 2018 | Resuscitation | DOWNLOAD

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