October 15, 2020

Background: A resuscitative thoracotomy is a time-critical high acuity, low occurrence (HALO) procedure – as an emergency physician you need to know how to do it, but depending on your practice environment, it may be a once-in-a-career maneuver. All the more reason that, if you have to do it, you want to make sure your effort counts. In a prior post, I advised that if you’re going to be doing a thoracotomy as an EM doc, you should do a clamshell approach. This was based both on some evidence from the surgical literature as well as personal experience – I feel the clamshell gives you the exposure you really need if you are doing this rarely and the time difference compared to an anterolateral approach is negligible. A recent paper from Newberry et al. (published ahead of print in Annals of Emergency Medicine) addresses this very issue – from an EM perspective.

October 12, 2020

Background: The only well-established treatments for sepsis and septic shock are antibiotic therapy and source control.  Septic shock, the most severe form of sepsis, is characterized by circulatory and cellular metabolism abnormalities.  There have been a host of randomized controlled trials evaluating the use of vitamin C, thiamine, and corticosteroids (i.e. metabolic cocktail) to help mitigate dysregulated host responses in the hopes of improving patient-oriented outcomes. Thus far none of the randomized trials have shown improvements in mortality and shown mixed results with shock reversal (see tables below).

September 14, 2020

Background: Though it’s been stated numerous times on this blog, it bears repeating: the pillars of sepsis care remain early identification of sepsis, early appropriate empiric antibiotics, source control, and supportive care. The focus should be on getting the basics right but, it is important to evaluate whether other adjunctive therapies can help decrease mortality in a common and frequently fatal condition. Ascorbic acid and thiamine deficiency have been described in patients with sepsis and are thought to be due to reduced intake and increased metabolic demands.  Corticosteroids have had mixed results but seem to improve shock reversal in patients with septic shock based on best available evidence (Link is HERE). There have been a slew of RCTs evaluating this metabolic cocktail (vitamin C, thiamine, & corticosteroids) in recent months. Though biologically plausible, this treatment approach has not been shown to improve patient-oriented outcomes.

August 24, 2020

Background Information:

It is well documented throughout the literature that critically ill patients admitted to the intensive care unit (ICU) with acute kidney injury have a higher morbidity and mortality.1–4 Acute kidney injury may be complicated by acidosis, hyperkalemia and other major metabolic disorders and thus the initiation of renal replacement therapy (RRT) is generally considered beneficial in these patients.5 In patients without these complications, the timing of when to initiate RRT remains unclear and is frequently debated. There are three trials to know before getting to this one: ELAIN, IDEAL and AKIKI. The ELAIN trial was the only one of the three to show reduced 90-day mortality with early vs delayed initiation of RRT and was the smallest in sample size.6 The IDEAL trial concluded that early planned initiation of dialysis in stage V chronic kidney disease was not associated with improvement in survival or clinical outcomes.7 Lastly, the AKIKI trial found no significant difference with regard to mortality between an early and delayed strategy of RRT and actually saw an appreciable number of patients avert the need for RRT in a delayed strategy.8 The authors of the following study sought to investigate whether an accelerated strategy for RRT would result in lower risk of death from any cause at 90 days when compared to a standard strategy of RRT initiation.

August 3, 2020

 Background Information:

The care and management of patients with acute respiratory distress syndrome (ARDS) is complex and follows an inciting injury to the lungs. This constellation of symptoms is characterized by hypoxemia, diffuse lung inflammation, decreased lung compliance and noncardiogenic pulmonary edema typically seen as bilateral opacities on radiographical imaging.1  Slow progress has been made in developing effective ARDS treatments, among them are low tidal volumes which have been shown to improve mortality.2 Over time the development of guidelines such as the ARDSnet protocol have also helped provide a stepwise framework to treatment. However, there are a subset of patients who continue to remain hypoxic and refractory hypoxemia accounts for 10-15% of deaths in ARDS patients.3   The therapies typically implemented to correct refractory hypoxia include proning, inhaled pulmonary vasodilators, extracorporeal membranous oxygenation (ECMO), paralysis, recruitment maneuvers, unconventional ventilator modes and more.4–8 The following post and included infographics focus on the following therapies: Proning, Paralytics and (lung) Protection. It is important to note that regardless of the therapy, specializing care on an individual basis with a risk-benefit analysis is required to give patients the best possible chance at survival.