February 3, 2020

The perimortem cesarean section, or better named the resuscitative hysterotomy, is a procedure that is performed at or near death of a pregnant patient.  Most experts agree that this procedure should be performed in a maternal arrest with a pregnancy ≥24 weeks of gestation.  Although there is no real data regarding the optimal time to delivery post-arrest, survival drastically decreases when the time from maternal death to delivery reaches 5 minutes (ie. Therefore a 4 minute rule has become standard). In this talk from Rebellion in EM 2019, Dr. Jaime Hope, MD walks us through the steps of performing this stressful procedure.

January 30, 2020

The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) has been a hot topic on the cutting edge of trauma resuscitation for several years now. But who should be doing this procedure, on whom, and when? Tissue ischemia results from REBOA followed by reperfusion injury, organ dysfunction and potential cardiovascular collapse. Although appropriate patient selection is paramount, the system of care that surrounds this procedure is vital to minimizing delays to definitive hemorrhage control as well as the ischemic insult of aortic occlusion. In 2018, the American College of Surgeons Committee on Trauma (ACS COT) and the American College of Emergency Physicians (ACEP) published a joint statement on the clinical use of REBOA2. This statement was met with much criticism from the emergency medicine/critical care world. Due to this, a revised statement has been published with different recommendations1. So, what does this statement say and how is it different from the 2018 statement?

January 27, 2020

Background: The combination of vitamin C, hydrocortisone and thiamine in sepsis has been a topic of hot debate in the past couple years.  There is a hypothetical pathophysiological basis to make an argument for the use of this combination of medications, but as with anything it is important to ensure there are no untoward effects either. In Dr. Marik’s before and after study [1] we saw some pretty amazing results showing that treatment reduced hospital mortality  by 31.9% (Treatment Group 8.5% vs Control Group 40.4%). Too good to be true?  Well in short, YES…the major issues with this study were it was not a randomized controlled trial, had a small sample size, was a single center study, and had significant selection bias.  Well we finally have our first randomized controlled trial evaluating the “metabolic cocktail” in a general population of septic shock adult patients.

January 13, 2020

Therapeutic Hypothermia (also called targeted temperature management (TTM)) is a deliberate reduction of the core body temperature to 32 - 34°C, in patients who suffer cardiac arrest with return of spontaneous circulation, but also don't regain consciousness.  In REBEL Crit Cast episode 1, I will go through the evidence for cooling adults and children, potential adverse effects, and what temperature to shoot for.

January 9, 2020

Background: Rapid sequence intubation (RSI) is the most widely utilized approach for patients requiring emergency tracheal intubation.  RSI typically requires the use of a induction agent followed by the use of a neuromuscular blocking agent (NMBA) to improve the overall intubation conditions and therefore improve first-attempt intubation success rate. Historically, succinylcholine has been the preferred NMBA, due to its fast onset (45 – 60 seconds) and fast offset (6 – 8 minutes of paralysis). Recent studies, however, show that rocuronium is an effective agent (similar timing of onset for ideal intubating conditions) as well.  When used at a dose of 1.2mg/kg, rocuronium has a similar onset time to succinylcholine of about 1 minute. Additionally, succinylcholine has several contraindications (see bottom of the post) while rocuronium has no contraindications (except for hypersensitivity) which has increased the debate about the paralytic agent of choice for RSI.