September 19, 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 11 minute and 40 second video, I will review the management shock - part 1 (The goals of shock management, signs of adequate organ perfusion, the etiology of shock, and some basic terminology).

September 16, 2019

Background: Rapid sequence intubation (RSI) involves the use of an induction agent followed by a neuromuscular blocking (NMB) agent to obtain optimal intubating conditions.  Administration of a NMB results in apnea which, in turn, can lead to oxygen desaturation.  Oxygen desaturation during rapid sequence intubation may lead to serious adverse events including dysrhythmias, hypotension, and cardiac arrest.  Preoxygenation helps extend the duration of safe apnea and has 2 major goals:
  1. Attempt to achieve an O2 saturation of 100%
  2. Maximize oxygen storage in the lungs by denitrogenation of the residual capacity of the lungs (Approximately 95% of oxygen reservoir)
Preoxygenation is assessed in the ED but usually through pulse oximetry which is inadequate.  In the operating room, anesthesiolgists use gas analyzers to quantify and optimize preoxygenation with ETO2.  In critically ill patients, preoxygenation should be performed to achieve an ETO2 ≥85% based on the response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society [2].

September 9, 2019

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 are left with the ultimate question of what to do with epinephrine in OHCA.

August 12, 2019

Background:  In patients with ICH, antiplatelet therapy is withheld due to the perceived risk of hematoma expansion.  Often, these medications are either not restarted or there is prolonged delays until they are restarted, but the risk of occlusive vascular events might be higher without resumption of antithrombotic therapy. A meta-analysis of observational studies found no difference in the risk of hemorrhagic events and a lower risk of occlusive vascular events associated with antiplatelet therapy resumption after any type of intracranial hemorrhage (ICH); however, randomized trials for antiplatelet efficacy in occlusive vascular disease have excluded patients with a history of intracerebral hemorrhage. Due to the paucity of evidence, no guidelines have strong recommendations about long-term anti-platelet therapy after ICH. The RESTART Trial [1] aimed to address the question of whether or not to start antiplatelet therapy following an intracerebral hemorrhagic stroke.

August 5, 2019

Background: Epinephrine (adrenaline) remains a central part of management of OHCA in ACLS guidelines. Recent studies (i.e. PARAMEDIC-2) have raised concerns about the efficacy and possible deleterious effects of epinephrine on both overall survival and long-term neurological outcomes. Other observational trials have suggested that there may be a time dependent effect of epinephrine on survival, with earlier timing of epinephrine improving outcomes, and later timing of epinephrine causing deleterious effects[2]. This trial attempts to analyze the association between timing and dose of epinephrine given on survival and neurologic outcomes of patients with OHCA.