July 25, 2018

Background: In the ED, POCUS has become one of the most important tools in discovering both the diagnosis and in the management of critically ill patients.  cardiac arrest, is ultimately as sick as a person can get in the spectrum of critical illness.  I mean how can someone be deader than dead, right?  There has been a slew of literature evaluating the use of POCUS in cardiac arrest and many providers have started to incorporate its use into their practice.  Newer literature, however indicates that the use of POCUS prolongs CPR pauses which ultimately impacts good neurological survival.  POCUS protocols may help decrease cognitive load, but many are too cumbersome and complicated.  Enter the Cardiac Arrest Sonographic Assessment (CASA) exam.

July 20, 2018

Background: Epinephrine(adrenaline) has been used in advanced life support in cardiac arrest since the early 1960s. Despite the routine recommendation for its use, evidence to support administration is less than ideal.  Although it is clear from multiple observational studies that epinephrine improves return of spontaneous circulation (ROSC) and short-term survival, most evidence suggests an absence of improvements in survival with good neurologic outcomes.  In cardiac arrest we want to take advantage of the alpha effects of epinephrine, including peripheral vasoconstriction, and therefore increasing aortic diastolic pressure, which in turn helps augment coronary and cerebral blood flow.  On the other hand, we want to avoid the potentially detrimental beta effects including dysrhythmias, decreased microcirculation, and increased myocardial oxygen demand all of which increase the chances of recurrent cardiac arrest and decreased neurologic recovery.  The only two interventions in cardiac arrest that have shown improve survival with good neurologic outcomes continue to be high-quality CPR and early defibrillation. The debate over the utility of epinephrine in OHCA has been ongoing for several years now and many providers have been awaiting the results of the PARAMEDIC-2 trial that was just published in the NEJM 2018. 

July 9, 2018

Background: Critically ill patients come to the ED all the time and it is almost reflexive to liberally administer oxygen in these acutely ill patients.  Many providers may consider supplemental oxygen a harmless and potentially beneficial therapy in these patients, irrespective of the presence or absence of hypoxemia (i.e. hyperoxia). There have been several trials (Stroke Oxygen Study, Oxygen in AMI, & Oxygen in the ICU) that have shown harm with hyperoxia in the critically ill. This paper is a systematic review and meta-analysis evaluating the evidence base for liberal versus conservative oxygen therapy in this patient population.

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 13, 2018

Background: The provision of safe and judicious analgesia is an important task for the emergency physician. Recent literature has demonstrated the effectiveness of sub-dissociative ketamine (SDK) in the emergency department (ED) setting (Motov 2015), however concerns regarding increased rates of hemodynamic and psychoperceptual adverse effects have limited application of this analgesic strategy in older populations. As awareness of geriatric oligo-analgesia has risen along with efforts to limit opioid utilization, interest in identifying a data set specific to this population has grown. The authors of this study sought to distinguish the performance and shortcomings of SDK in this unique patient group.