April 29, 2019

Background: The two biggest keys to successful survival with good neurological outcome in out-of-hospital cardiac arrest (OHCA) are high-quality CPR and early defibrillation. Dispatcher-assisted (DA) CPR is a novel concept to not only improve the rate of CPR being performed, but also the quality of CPR.  In DA-CPR, rescuers perform CPR under telephone guidance from trained dispatchers. In this study, the authors sought to see if DA-CPR improved the quality of chest compressions (Compression depth, compression rate, no-flow time, complete release of pressure between compressions, and hand location).

April 25, 2019

Background: Although the debate over balanced (i.e. lactated ringers, PlasmaLyte) vs unbalanced (i.e. 0.9% saline) crystalloids has not been settled, fluid resuscitation continues to be a fundamental therapy given to critically ill patients.  0.9% saline is one of the most common fluids given in resuscitation of patients but the high chloride content may contribute to the development of acute kidney injury (AKI) [1]. Alternatives to 0.9% saline include crystalloids with electrolyte compositions that are more balanced and resemble that of plasma (i.e. Lactated Ringer’s Plasma-Lyte, etc). Theoretically use of more balanced crystalloids would result in less potential side effects when compared to 0.9% saline. The crux of the matter is does fluid choice affect any patient-oriented outcomes?

April 18, 2019

Every now and again someone raises the issue on social media about resuscitative thoracotomy.  What are the indications (we have the EAST guidelines for that), what are the risks (highlighted in this important recent paper), and of course, whether EM or surgery should be doing it in the trauma bay (guess what – it’s in the curriculum for both specialties). That’s not the point of this post.  This post is about how I think you, as the emergency medicine physician (EP), working in a system where your surgeon is not in-house, but is available in a reasonable amount of time, should proceed when faced with the patient who meets the indications.  You’ve gone through your HOTTT(T) algorithm and are now at that final “T” – you have to open the chest.

April 15, 2019

Background:Tracheal intubation is a common procedure performed on critically ill patients. In these patients, there is a high risk of life-threatening complications associated with the procedure, with severe hypoxemia being one of the more common. Development of severe hypoxemia, in turn, increases the risk of post-intubation cardiac arrest. Therefore, optimal preoxygenation is an essential part of tracheal intubation to help stave off subsequent complications.

Both NIV and HFNC can provide a higher fraction of inspired oxygen than standard oxygen therapies.  HFNC can provide continuous oxygen up to 70L/min via nasal prongs with the potential advantage of remaining in place for apneic oxygenation. NIV can also provide high flow oxygen but must be removed during the apneic phase of intubation.  To date there has not been a study comparing NIV vs HFNC to reduce the incidence of severe hypoxemia during intubation until now; the FLORALI-2 trial.

March 28, 2019

Pulse Checks Background: In an older study published in Resuscitation 1998 [1], ED physicians, ICU physicians, and nurses tried to identify a carotid pulse in a healthy male volunteer with normal blood pressure. 43.1% of the health professionals required >5 seconds to detect the carotid pulse and another 4.3% required >10 seconds.  Something I have advocated for in cardiac arrest is the death of pulse checks, as our fingers are poorly sensitive for detecting which patients have a pulse in a shock state.  A visible rhythm on the monitor, along with the absence of a pulse with digital palpation, does not always indicate the presence of true pulseless electrical activity (PEA).  Our reflexive action when we don’t feel a pulse is to begin CPR and give 1mg epinephrine which may not be beneficial in these patients.  Patients in profound shock don’t necessarily need cpr and 1mg of epinephrine, they need augmentation of cardiac output with either push dose pressors or hemodynamically driven epinephrine drips.  Now another study published in Resuscitation looked to compare the efficiency of cardiac ultrasonography (CUSG), doppler ultrasonography (DUSG) and manual pulse palpation to check the pulse in cardiac arrest patients [2].