A 57-year-old man is watching his son’s baseball game when he suddenly collapses. Witnesses did not appreciate a pulse, so they started CPR. Unfortunately, an AED was not available. EMS was called and when they arrived within minutes the patient was found to be in vfib arrest and was defibrillated. When the patient arrived to the hospital, he was in PEA arrest. Ultrasound of the patient’s heart showed some coordinated cardiac activity. ACLS doesn’t really tell us how to proceed with cardiac activity but not enough to generate a pulse on the monitor.
Background: Critical illness and ICU admission comes with significant consequences – not just from the primary pathology but also from the secondary effects of therapies that may be begun to correct the abnormal physiology. One of these consequences in ventilated patients is the development of stress ulcers in the gastrointestinal tract, leading to bleeding. Over two-thirds of patients admitted to the ICU will be prescribed some form of stress ulcer prophylaxis, often in the form of either a proton pump inhibitor (PPI) or a histamine-2 receptor blocker (H2RB)1. But which one is better? Are there any risks?
The existing evidence of benefit of one over another is limited. Though one systematic review did show a benefit of PPIs, the reviewed data was limited2. Neither drug is without risk either. These include a potential for immunosuppression and increased risk of infections3. More evidence is needed – which is where the Proton Pump Inhibitors vs Histamine-2 Receptor Blockers for Ulcer Prophylaxis Treatment in the Intensive Care Unit (PEPTIC) randomized clinical trial comes in4....Read More
The REBELEM Team is proud to provide you with a Critical Care Education Curriculum that can be used for your residents, medical students, advanced providers as well as many other learners during their rotation. We realize now, more than ever, that providers are under high pressure to perform clinically in high stress environments like the Emergency Department and the Intensive Care Unit and provide high quality education at the same time. Our team would like to provide you with a quality resource to help you deliver a fun, dynamic, multimodal curriculum to your learners....Read More
Background: In REBEL Cast Episode 73, Anand Swaminathan and I discussed two recent studies on the safety of peripheral vasopressors from two large trials . An email from good friend Rory Spiegel brought my attention to yet another trial on this topic . I think we can all agree that in patients with septic shock, or shock in general, the administration of vasopressor agents early, can help to stabilize patients and reverse end-organ hypoperfusion. Traditionally, this has been done through central venous catheters (CVCs) due to the hypothetical risk of extravasation injury to extremities. The flip side of this is, that central venous catheters are not without their own risks and time to place them can delay a therapy that may benefit patients....Read More
Background: In critically ill patients needing IV access, ultrasound has helped improve gaining access to a set of peripheral veins, located deeper in the arm. The time it takes to do this however is not insignificant but even more importantly is that once you achieve success, the line can fail due to a short catheter length. Central venous catheters, often seen as a solution to this latter issue, are not without their own risks and complications. Therefore, a nice alternative option may be a midline catheter. These catheters are not meant for fast, large volume resuscitations because they also take time to place, but also have a longer catheter length which slows down infusion rates. Midline catheters are really about having safe access that is unlikely to be dislodged. This is a great option when you have medications you want to give but not have extravasation occur (i.e. vasopressors, hypertonic saline, calcium chloride, etc.). ...Read More