November 4, 2019

Background: Despite decades of experience with endotracheal intubation, we continue to find approaches to improving the process of how we intubate. In this talk at Rebellion in EM 2019, Rob J. Bryant, MD gave a 14 minute 12 second talk on 3 things that have changed the way he intubates (Back Up Head Elevated - BUHE, Bougie 1st Intubation, & Team Management).  

October 15, 2019

Background: Evidence from the CRASH-2 trial showed an absolute reduction in mortality of 1.5% (NNT = 67) in patients with extracranial bleeding treated with tranexamic acid  (TXA) within 3 hours of injury. However, CRASH-2 did not answer the question of effect on mortality in patients with intracranial hemorrhage (ICH), as these patients were excluded from the trial.  It makes biologic sense that administration of TXA in patients with traumatic brain injury (TBI) might prevent or reduce ICH expansion and thus avert brain herniation and death.  There were two smaller RCTs [2] that showed a reduction in death with TXA in patients with ICH. However, both of these trials were small and considered to be hypothesis generating only. TICH-2 [3] was an international, randomized, double-blind, placebo-controlled phase 3 trial in adults with ICH from acute stroke with ≈2300 patients and showed no difference between groups in functional status at day 90. TICH-2 did show a small improvement in hematoma expansion at day 2 and death by day 7.  Due to the fact that these  findings were secondary outcomes they were also hypothesis generating. All of the above positive findings therefore required confirmation in a larger randomized trial, which has finally arrived…CRASH-3.

October 14, 2019

Shock is defined as circulatory failure leading to decreased organ perfusion.  In a shock state there is an inadequate delivery of oxygenated blood to tissues that results in end-organ dysfunction.  Effective resuscitation includes rapid identification and correction of inadequate circulation.  the finding of normal hemodynamic parameters (i.e. normal blood pressure) doe not exclude shock itself.  In this 17 minute and 26 second video, I will review the management shock - part 2b (Dobutamine, Milrinone, Vasopressin, Angiotensin II, & Selepressin).

October 7, 2019

Shock is defined as circulatory failure leading to decreased organ perfusion.  In a shock state there is an inadequate delivery of oxygenated blood to tissues that results in end-organ dysfunction.  Effective resuscitation includes rapid identification and correction of inadequate circulation.  the finding of normal hemodynamic parameters (i.e. normal blood pressure) doe not exclude shock itself.  In this 15 minute and 46 second video, I will review the management shock - part 2a (Norepinephrine, Epinephrine, Dopamine, Phenylephrine, and Push-Dose Pressors).

September 26, 2019

Background Information: Critical care and emergency medicine are frequently intertwined as the resuscitation of critically ill patients occurs in both environments. While the majority of these patients come through the emergency department (ED), the resuscitation of critically ill patients is not defined by a geographic location, but rather a set of principles designed to deliver appropriate care in a timely fashion.1,2 Increased numbers of critically ill patients in combination with decreased availability of intensive care unit (ICU) beds and a shortage of intensivists has led to a shift in critical care being delivered in the ED.3 Furthermore the lack of ICU beds, among many other factors, have contributed to a prolonged length of stay (LOS) of already admitted patients known as “ED Boarding”. Another factor to consider, is that providing prolonged critical care in a traditional ED setting is challenging as it requires more staff and is often associated with increased mortality. Multiple studies have demonstrated an association of worsened outcomes when patient’s ED LOS is greater than 6 hours and, in the United States, 33% of all ICU admissions from the ED have an ED LOS greater than 6 hours.1,4 A proposed solution has been the development of ICUs housed within the ED known as ED-ICUs. While only a handful exist, this new method of care delivery aims to reduce the time it takes for patients to receive critical care and offset the strain on current ICUs (Table 1)4. The authors of this study sought to determine the association of ED-ICUs on 30-day mortality and inpatient ICU admission.