November 14, 2019

Background: Septic shock is the most severe form of sepsis. It is characterized by vasodilation and increased capillary permeability leading to hypotension and tissue hypoxia.  The initial treatment of septic shock includes early identification, intravenous fluids when necessary, appropriate broad-spectrum antibiotics, source control and organ support. Vasopressor therapy is often required to maintain adequate perfusion to support end organs.  Norepinephrine is the accepted first-line vasopressor for patients in septic shock, but it is not always effective in patients with extreme vasoplegia due to sepsis. Selepressin, a selective vasopressin V1a receptor agonist, is a non-catecholaminergic vasopressor that may assist in these patients.  It works by mitigating vasodilatation, vascular leakage, and tissue edema, but without V1b- or V2-mediated effects seen with vasopressin, which result in increased procoagulant factors, salt/water retention, nitric oxide release, and corticosteroid stimulation.

November 7, 2019

Background: Despite minimal high-quality supporting evidence (Seymour 2017, Liu 2017, Ferrer 2014, Sterling 2015), regulatory bodies have pushed for benchmark times for administration of antibiotics in patients with sepsis. While most clinicians would agree that in patients with septic shock antibiotics should be given as quickly as possible, the same does not hold true for those patients with less severe infections. In the US, the Centers for Medicare and Medicaid Services (CMS) currently mandates that antibiotics be started in patients within 3 hours of onset of new organ dysfunction in patients with systemic inflammatory response syndrome and documented infection. The Surviving Sepsis Campaign (SSC) has even more extreme recommendations stating that antibiotics should be started within 1 hour from triage in septic patients (Levy 2018). Based on prior experience with arbitrary time to antibiotic administration (see community acquired pneumonia), such draconian recommendations are likely to increase inappropriate use of antibiotics, distract clinicians from more important tasks and have minimal effect on patient outcomes. This is likely why the Infectious Disease Society of America (IDSA) declined endorsement of the SSC guidelines. The ridiculous nature of these recommendations has been discussed elsewhere.

Even if the recommendation had some merit, it’s important to ask whether it’s even possible to implement. None of those on the SSC committee work in emergency departments and their understanding of the logistical challenges of such a policy is limited.

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).