February 27, 2020

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.

February 26, 2020

Take Home Points 
  • No palpable pulse does not equal no perfusion. We aren't great at feeling pulses
  • Patients with moderate to severe signs and symptoms of lithium toxicity should be considered for hemodialysis
  • Always consider serious causes of back pain before simply treating with analgesics
  • Consider trauma as well as other toxic exposures (I.e. CO and CN) in patients with major burns

November 18, 2019

Background Information: Therapeutic hypothermia is the use of targeted temperature management to reduce neurologic sequelae resulting from the severe ischemia-reperfusion injury that occurs during cardiac arrest primarily from shockable rhythms.1 Although a mainstay treatment in the Advanced Cardiac Life Support (ACLS) guidelines, its use has been widely debated as beneficial in improving neurologic outcomes in post-cardiac arrest patients with non-shockable rhythms.2-7 Recent studies have also questioned the exact temperature at which patients should be cooled.8 The authors of this study sought to assess whether moderate therapeutic hypothermia, compared with targeted normothermia would improve neurologic outcomes in post-cardiac arrest patients who had a non-shockable rhythm.

August 5, 2019

Background: Epinephrine (adrenaline) remains a central part of management of OHCA in ACLS guidelines. Recent studies (i.e. PARAMEDIC-2) have raised concerns about the efficacy and possible deleterious effects of epinephrine on both overall survival and long-term neurological outcomes. Other observational trials have suggested that there may be a time dependent effect of epinephrine on survival, with earlier timing of epinephrine improving outcomes, and later timing of epinephrine causing deleterious effects[2]. This trial attempts to analyze the association between timing and dose of epinephrine given on survival and neurologic outcomes of patients with OHCA.

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].
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