May 18, 2015

Patients with pulseless electrical activity (PEA) account for almost 1/3 of cardiac arrest and even more troublesome is that the survival rate is significantly worse than patients with shockable rhythms. Both the European and American ACLS guidelines stress the importance of quickly finding and addressing the cause of PEA. This is traditionally done with recalling the 5 to 6 H’s and T’s, but during cardiopulmonary resuscitation it is difficult to recall all 13 causes of PEA by trying to recall this list. In 2014 a review article was published that was developed by several departments from the Carolinas Medical Center in Charlotte, NC that tried to simplify the diagnostic approach to PEA.

April 27, 2015

We’ve had some heated debates on the topic of hands-on defibrillation (HOD) for the past few years. We all know the most important time to avoid a pause during CPR is the perishock pause ([1]). We also know that despite lots of safety data ([2], [3]) and safe experience doing HOD ([4]) there are still concerns over the potential electrical leak using common exam gloves ([5], [6], [7], [8], [9]). For those who don’t enjoy a little electrical spice in your resuscitations, some recent articles have shown ways in which the safety of HOD can be mitigated using inexpensive tools.

March 17, 2015

Since 2002, the surviving sepsis campaign (SSC) has stated that best practice in sepsis care includes: early recognition, source control, appropriate/timely antibiotic therapy, resuscitation with intravenous fluids (IVF) and vasoactive medications. Resuscitation of the septic patient in the emergency department has been largely based off the 2001 Rivers trial [1]. This single center study's focus was to optimize tissue oxygen delivery following several parameters including, central venous pressure (CVP), mean arterial pressure (MAP), and central venous oxygen saturation (SCVO2) to guide IVF, vasoactive medications, and packed red blood cell (PRBC) transfusions. Well today, part 3 of the sepsis trilogy was published in the saga of Early Goal Directed Therapy (EGDT) versus "usual" care. The 3 parts to this saga consist of:
  1. Protocolized Care for Early Septic Shock (ProCESS) [2] - 31 Emergency Departments in the United States
  2. Australasian Resuscitation in Sepsis Evaluation (ARISE) [3] - 51 Emergency Departments in Australia, New Zealand, Finland, Hong Kong, and Ireland
  3. The Protocolised Management in Sepsis (ProMISe) Trial [4] - 56 Emergency Departments in the United Kingdom

March 16, 2015

There are more than 750,000 cases of severe sepsis and septic shock in the US each year.  Most patients who present with sepsis receive their initial care in the emergency department.  In 2001, there was a landmark study by Rivers et al [1] that reported that among patients with severe sepsis or septic shock mortality was significantly lower among those who received a 6 hour protocol of Early Goal-Directed Therapy (EGDT) (i.e. 30.5% vs 46.5%). The premise of EGDT was that "usual care" lacked aggressive, timely assessment and treatment. The EGDT protocol used central venous catheterization (CVC) to monitor central venous pressure (CVP) and central venous oxygen saturation (SCVO2) to guide the use of intravenous fluids (IVFs), vasopressors, packed red blood cell (PRBC) transfusions, and dobutamine in order to achieve pre-specified physiological targets.  Since the publication of this landmark article, physicians have become more aggressive in the management of sepsis which raises the question of whether all elements of the protocol are still necessary. 

March 15, 2015

Recently, I wrote a post on the use of epinephrine in out-of-hospital cardiac arrest (OHCA) and this triggered some interesting discussion on twitter. Are we at a point that we can just stop using epinephrine in OHCA?  Has anyone stopped actually using epinephrine in OHCA and if so, why or why not? The evidence seems to point to no "good" neurologic benefit over basic life support (BLS).  I would love to hear more peoples thoughts on this.