Core EM

OCTOBER 16, 2024

Author: Natalie Bertrand, MD Editor: Naillid Felipe, MD Background: Definition: adverse reaction to blood product administration Incidence: more common in children than adults, except for delayed hemolytic transfusion reactions Allergic (non-anaphylaxis) – Platelets 1-3%; RBCs 0.1-0.3% mg IF requiring IM Epi >3x, switch to IV Epi, 0.05-0.1

Allergic Reaction 188

Allergic Reaction Plasma ED Epinephrine 188

REBEL EM

OCTOBER 2, 2023

Mild to moderate DKA represents a subgroup of patients that often require admission to the ICU due to hospital policies not allowing insulin infusions outside of this clinical setting. to 19.3hrs); Reduction by 3.6hrs ED LOS was shorter for the SQuID cohort ICU Admissions: SQuID & Traditional (Post Intervention): 42.9%

ICU 105

ICU ED ALS OR 105

The Skeptics' Guide to EM

NOVEMBER 16, 2019

Date: November 6th, 2019 Reference: Lascarrou et al. NEJM Oct 2019 Guest Skeptic: Dr. Laura Melville (@lmelville535) is an emergency physician in Brooklyn, New York, is a part of the New York ACEP Research Committee, ALL NYC EM, and is the NYP-Brooklyn Methodist Resident Research Director. What do you say? Reference: Lascarrou et al.

ALS 100

ALS CPR ICU EMS 100

Critical Care Scenarios

NOVEMBER 1, 2020

A look at oncology-related emergencies in the ICU, with Leon Chen (@CCMNP), NYC nurse practitioner specializing in oncology critical care. 2019 Mar;20(2):316-322. Epub 2019 Feb 14. Takeaway lessons Extremely elevated leukocyte count should always raise suspicion for a “liquid tumor” such as leukemia. West J Emerg Med.

Critical Care 100

Critical Care ICU OR 100

Pediatric EM Morsels

MARCH 17, 2023

Since we all inhabit the same beautiful world , and sometimes we humans overtake previous habitats of animals, we inevitably will cross paths with an animal that bites us. Usually, animals bite from fear or defense of their offspring ( ex, Brown Recluse ). Sometimes it’s a beloved pet who gets surprised or has an “off” day ( Dog Bites and PTSD ).

Frozen Plasma 130

Frozen Plasma Plasma First Aid OR 130

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

His temperature was brought back to normal over time in the ICU. Osborn waves have been reported with hypercalcemia, brain injury, subarachnoid hemorrhage, Brugada syndrome, cardiac arrest from VFib — and — severe, acute ischemia resulting in acute MI ( See My Comment in the November 22, 2019 post on Dr. Smith’s Blog ).

ICU 138

ICU OR ALS ED 138

REBEL EM

AUGUST 14, 2023

They consecutively enrolled 1,817 ICU patients from 45 sites across China. Population: Inclusion Criteria: Age 18-75 years old SOFA score 2-13 Admitted to the ICU with a diagnosis of sepsis 3.0, “ Life-threatening organ dysfunction caused by a dysregulated host response to infection.” 002) ICU-free days: Placebo 12.4%

ICU 98

ICU EMS OR ALS 98

REBEL EM

NOVEMBER 30, 2023

Secondary Outcomes: Delayed hypotension, increased ICU stay, and other relevant outcomes. Kuttab et al’s findings, constituting 45% of the review’s weight, suggest that administering <30cc/kg IVF is associated with increased odds of mortality, delayed hypotension, and increased ICU utilization. 2.89, p = 0.01.

E-9-1-1 121

E-9-1-1 ALS ACS ICU 121

REBEL EM

APRIL 22, 2024

Population: Adult patients ( > 18 years of age) admitted to the ICU with COVID-19 and severe hypoxemia (defined as receiving supplemental O2 with a flow rate of at least 10L/min or receiving mechanical ventilation or non-invasive ventilation. Outcomes (secondary): 90-day all-cause mortality. Unclear how this bias affects outcomes.

Life Support 74

Life Support ICU EMS OR 74

EMS 12-Lead

AUGUST 22, 2022

A 65 y/o Female was admitted to the ICU for septic shock. The combination of prolonged QT and deep T wave inversion throughout the precordium is typical of Takotsubo syndrome, or Stress Cardiomyopathy – which can occur in the context of a physiologically distressed ICU patient, further compromising their hemodynamics.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

REBEL EM

JUNE 26, 2023

Severe acute traumatic coagulopathy = PT >1.5 to 3.33; P = 0.72 NOT STATISTICALLY SIGNIFICANT Also no difference in individual components given Thromboembolic Events: 4F-PCC: 35% Placebo: 24% Absolute Diff: 11%; 95% CI 1 to 21% Relative Risk 1.48; 95% CI 1.04 to 2.10; P = 0.03 Severe acute traumatic coagulopathy = PT >1.5 to 3.33; P = 0.72

FFP 145

FFP Frozen Plasma ALS Plasma 145

REBEL EM

JANUARY 9, 2024

This finding persists when looking at a number of other infections including skin and soft tissue infections (SSTI) ( First10EM ), pyelonephritis ( Strohmeier 2014 ) and even bone and joint infections ( Li 2019 ). This feels intuitive as the IV route seems like it would be stronger, faster, and fix the patient better than the oral route.

ALS 99

ALS ICU ED OR 99

EMDocs

JUNE 22, 2024

A) Amniotic fluid embolism B) Eclampsia C) Placental abruption D) Pulmonary embolism Answer: A Amniotic fluid embolism (AFE) is a rare but potentially fatal complication of pregnancy. AFE should be considered in a patient who experiences cardiorespiratory collapse during labor or shortly thereafter.

EMS 96

EMS Ambulance FFP ICU 96

REBEL EM

AUGUST 12, 2024

PMID: 36038001 Clinical Question: In patients undergoing cardiac surgery with cardiopulmonary bypass, does the administration of intravenous amino acid therapy lead to lower occurrence of postoperative AKI when compared to placebo?

ICU 81

ICU Critical Care Operating Room ALS 81

Don't Forget the Bubbles

AUGUST 23, 2023

2018) “Sacred Pause Imitative in the ICU: A survey of ICU physicians and nurses”. 2019) “The presence of psychological trauma symptoms in resuscitation providers and an exploration of debriefing practices.” Oppressive quietness heavy with professionals’ suppressed emotions mixed with raw parental grief. Or exhausted from it.

Emergency Department 98

Emergency Department ICU ALS Critical Care 98

REBEL EM

NOVEMBER 6, 2023

Background Information: Vasoplegic shock is defined as hypotension with normal or increased cardiac output and can commonly occur in post-cardiac surgery patients having received cardiopulmonary bypass. This dysregulation of vasodilation is associated with a mortality of close to 25%.

Epinephrine 71

Epinephrine ICU ALS OR 71

REBEL EM

MARCH 30, 2023

The TOMAHAWK (Desch 2021), COACT (Abella 2019), and PEARL (Lemkes 2019) trials examined patients with OHCA without ST elevation with a shockable rhythm, and investigators found no difference in delayed versus emergency angiogram. Comparator: Delayed CAG: Patients were admitted to the ICU, and CAG was performed after 48-96 hours.

Coronary 81

Coronary CPR OR ICU 81

REBEL EM

JUNE 8, 2023

Epinephrine – 10ug/mL, 10mL syringe Phenylephrine – 100ug/mL, 10mL syringe Phenylephrine bolus doses from 100-200ug and epinephrine 10-20ug administered every 2-5 minutes pursuant to provider order Inclusion Criteria: Adults age >18 years old Received at least one bolus dose of phenylephrine or epinephrine pre-filled syringes Exclusion (..)

Epinephrine 98

Epinephrine Emergency Department ALS Critical Care 98

Don't Forget the Bubbles

JUNE 17, 2024

The team sits down for a hot debrief once the patient is stabilised and transferred to the ICU. 2019 May 31:bmjqs-2019. 2019 May;27(4):758-64. While you are leading the resuscitation, one of your senior colleagues belittles a junior staff member for struggling to site an IV line. How do you manage this situation?

E-9-1-1 105

E-9-1-1 Critical Care CPR ICU 105

EMDocs

APRIL 10, 2024

The majority of local anesthetics have a common structure of a lipophilic aromatic ring, a hydrophilic amine group, and a linking group. [2] 2] This linking group can be either an amide (e.g., lidocaine) or an ester (e.g., 6] Action of local anesthetics is dependent upon the molecule crossing the plasma membrane in a unionized form. [2] mL/kg/min.

E-9-1-1 93

E-9-1-1 Plasma Epinephrine Life Support 93

EMS 12-Lead

MAY 8, 2022

Thankfully, the patient experienced an uncomplicated ICU stay and subsequently made a full recovery. This grading system is the time sensitive prelude to Q-wave (irreversible transmural scar) formation, as demonstrated in the image below. [1] 2] But there is also Sinus Tachycardia! Such a finding is most dramatic in Lead I, reproduced here.

STEMI 130

STEMI ED EMS Firefighter 130

Emergency Medicine Ireland

DECEMBER 3, 2020

With my deepest apologies to all the great ICU dieticians I have worked with, I just struggle to get excited over this stuff. I would highly recommend attending an excellent lecture given by your ICU dietician which is just possibly where this entire summary came from. As with all ICU nutrition EN is preferred over PN.

Critical Care 52

Critical Care ICU EMS OR 52

Core EM

OCTOBER 2, 2024

Author: Natalie Bertrand, MD Editor: Naillid Felipe, MD Background: Definition: adverse reaction to blood product administration Incidence: more common in children than adults, except for delayed hemolytic transfusion reactions Allergic (non-anaphylaxis) – Platelets 1-3%; RBCs 0.1-0.3% mg IF requiring IM Epi >3x, switch to IV Epi, 0.05-0.1

Allergic Reaction 100

Allergic Reaction Plasma ED Epinephrine 100

REBEL EM

MARCH 27, 2023

2 Finally the settings initiated early in a patient’s care are often carried forward unchanged into their hospital and ICU stay. 2019 Aug; PMID: 30954692 Clinical Question: What is the impact of system factors in the implementation of standard-of-care LPV in critically ill ED patients admitted to the ICU? J Crit Care.

Emergency Department 52

Emergency Department ICU Critical Care EMR 52

EMDocs

JUNE 27, 2024

Left lower lung field end demonstrates expiratory wheezing on auscultation. Other lung fields unremarkable. smoke, high ozone levels, smog) Asthma/reactive airway disease (RAD) Diagnostic criteria 7,8 Respiratory symptoms +/- fever (at least 38.0 C or 100.4 mg/kg, max 4 mg per dose q20-30min) or hydromorphone (0.01-0.02 mg/kg, max 0.4 C or 100.4

E-9-1-1 75

E-9-1-1 ICU ACS EMS 75

Dr. Smith's ECG Blog

OCTOBER 25, 2023

The patient was admitted to the ICU for close monitoring and electrolyte repletion and had an uneventful hospital course. QTc/QUc is in the range of 630 msec. What is the most likely cause of the patient’s ECG findings, and what would be your first step in management? See these other relevant cases: What are these bizarre bigeminal PVCs??

Overdose 120

Overdose OR ACS ICU 120

REBEL EM

MAY 18, 2023

REBEL Cast Ep116: The CLOVERS Trial – Restrictive vs Liberal Fluids in Sepsis-Induced Hypotension Click here for Direct Download of the Podcast Paper: The National Heart, Lung and Blood Institute Prevention and Early Treatment of Acute Lung Injury Clinical Trials Network. Liberal: 14.9% Estimated Difference: -0.9%; 95% CI 04.4 Liberal: 14.9%

OR 105

OR ICU EMS ED 105

Dr. Smith's ECG Blog

JANUARY 9, 2024

The pacing rate was increased without clinical improvement and the patient was transferred to the ICU for closer monitoring/treatment. However , this patient is having chest discomfort, and by definition then she should be considered not to be stable. Is this: 1. In either case, prompt cardioversion is indicated.

Coronary 107

Coronary ACS ED OR 107

Don't Forget the Bubbles

JULY 5, 2023

This process of sickling and unsickling goes on and off until the erythrocyte membrane is no longer flexible. Irreversible sickle cells undergo either intravascular haemolysis or extravascular removal by the reticulo-endothelial system resulting in anaemia and splenic sequestration. Blood culture is pending. How would you evaluate this child’s pain?

E-9-1-1 126

E-9-1-1 ACS OR ICU 126

EMDocs

JUNE 7, 2023

Disposition is often admission to an intensive care unit (ICU) setting. Questions: What is the most likely causative xenobiotic that led to these findings? Influenza vaccine Methanol Organophosphate Paraquat Are her symptoms reversible? Yes No What therapy or therapies are critical for this patient? 7 May lead to respiratory failure.

E-9-1-1 84

E-9-1-1 ICU Emergency Department ED 84

Emergency Medicine Ireland

OCTOBER 14, 2024

The major barrier to implementation in the ICU setting is the almost complete absence of ICU patients from these trial cohorts. And as we all know if there is a complication possible it’s almost definitely going to happen with greater frequency in the ICU cohort. 2019, (2019). LDH>1000 Sugar <2.2

Critical Care 52

Critical Care ICU ALS OR 52

REBEL EM

SEPTEMBER 26, 2022

The TEG group had a shorter ICU length of stay in the first admission. Patients exclusively managed in the ICU which decreases applicability for patients in other locations Very small sample size of 96 patients No definition was provided for exclusion criteria of significant cardiopulmonary disease.

FFP 52

FFP E-9-1-1 ICU ALS 52

Emergency Medicine Ireland

NOVEMBER 26, 2020

Diagnosis can be tricky and from an ICU perspective they’re probably sick enough to justify empiric treatment based on context without waiting for all the results. If they’re in ICU then the cotrimoxazole should be given with a chaser of steroids as this has a mortality altering effect. 2019 Sep;33(9):e13587.

Critical Care 40

Critical Care ICU OR 40

EMDocs

MAY 25, 2023

Design: Multi-centered, double-blinded, randomized trial PICO: Population: Inclusion Criteria: Age 2 years and older Must have been treated with a specified minimum dose of certain benzodiazepines for generalized convulsive seizures: Intravenous or rectal diazepam 0.3 mg/kg or 10 mg Intravenous lorazepam 0.1 mg/kg or 4 mg Intravenous midazolam 0.2

Emergency Department 64

Emergency Department ICU OR ALS 64

Don't Forget the Bubbles

JUNE 30, 2023

They found NO difference in drain failure rates ( 11% pigtail vs 13% chest tube P=0.74), total daily volume drained or length of ICU stay between groups. You ask your anaesthetist to get ready to sedate or intubate depending on their status – Significant risk to the department – you make sure security is aware And your patient arrives.

E-9-1-1 139

E-9-1-1 FFP Plasma Emergency Department 139

Emergency Medicine Ireland

JULY 3, 2023

It is important to realise that a referral to ICU for refractory cardiorenal syndrome may simply be a sign that the patient is reaching end of life. Circulation 139, e840–e878 (2019). Type 4 is again renocardiac with the kidneys causing the heart failure but on a chronic basis. With me so far? – Mullens, W., Verbrugge, F.

Critical Care 96

Critical Care ACS OR ALS 96

EMDocs

JANUARY 16, 2024

He requires low-dose epinephrine to maintain his mean arterial pressure (MAP) in the 60s mmHg and is transported to the cardiothoracic (CT) ICU. Cardiac surgery is immediately paged for consideration of veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) for active rewarming. His point-of-care labs return with a potassium of 3.4

Defibrillator 85

Defibrillator CPR Epinephrine Life Support 85