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].

February 20, 2019

Take Home Points:

  1. Hypothermia is neuroprotective and patients can survive prolonged periods of cardiac arrest. Termination of resuscitative efforts in cardiac arrest should not considered until the patient is >32°C or has a K > 12 mEq/L
  2. Active internal rewarming is the keystone of treatment for unstable hypothermic patients. Utilize available resources including ECMO to effectively warm your patient
  3. Consider alternate causes for hypothermia, especially in patients who fail to respond to warming

November 8, 2018

Background: In the United States 424,000 out of hospital cardiac arrests occur per year with a 10.4% overall survival rate.1 Refractory Ventricular Fibrillation (RVF) is a complication of cardiac arrest and has varying definitions in the literature but is commonly defined as ventricular fibrillation that does not respond to, or resists, three or more defibrillation attempts.2,3Although the estimated incidence of refractory ventricular fibrillation is 0.5-0.6 per 100,000 of the population, some authors report that 10-25% of cardiac arrest cases could develop RVF or recurrent VF.3-5 Patients who experience RVF during their cardiac arrest have a mortality of up to 97%.6,7 Several case reports have shown success with excellent neurologic outcomes in terminating RVF using dual defibrillation after failure of traditional Advance Cardiac Life Support (ACLS) measures.8-12 It is important to note and distinguish that dual defibrillation can either be simultaneous or sequential depending on the duration of the defibrillation potential as well as the intershock interval between the two defibrillator shocks.9-13 The terms “sequential” and “simultaneous” are often used interchangably due to the lack of accurately measuring pulse intervals when performing dual defibrillation in the actual clinical environment. The authors of this review utilize the term dual sequential defibrillation (DSD). They present a case of RVF in a patient with cardiac arrest, on whom DSD was successful in reversion to sinus rhythm and provide a thorough review of similar cases in the literature.

October 1, 2018

Background: POCUS has become a powerful tool in the evaluation of critically ill patients in the ED.  However, in patients with cardiac arrest, the use of POCUS has been shown to significantly increase the duration of pauses.  This is concerning as high quality CPR with minimal interruptions is one of the keys to maximizing ROSC and survival with good neurologic outcomes. Recently, I had the chance to interview the lead author of the Cardiac Arrest Sonographic Assessment (CASA Exam) on REBEL Cast Ep 57 and on that episode we discussed a follow up study, which has finally been published in Resuscitation 2018.

September 27, 2018

Background:There is a lack of high quality RCTs  investigating optimal airway management in patients with out-of-hospital cardiac arrest (OHCA).  The majority of evidence comes from observational studies and expert opinion. The observational trials have consistently favored basic airway management (i.e. BVM) over tracheal intubation [3]. Supraglottic airway(SGA) devices offer an alternative advanced airway management technique to endotracheal intubation (ETI) during OHCA. SGA devices may offer an advantage over ETI as they are simpler and faster to placeAdditionally, proficiency  with SGAs requires less training and ongoing practice. Although there have been several recent studies published on airway management in OHCA, this post/podcast will focus on the recently published AIRWAYS-2 trial.