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

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

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

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 135

ICU OR ALS ED 135

EMDocs

FEBRUARY 12, 2024

In this situation, an ABG should be obtained periodically for correlation, though this is more relevant for the intensive care unit (ICU) setting than in routine ED care (5, 9). How would an ABG even change the initial stabilization of any of these patients? What alternative testing can be done in these circumstances?

Emergency Department 94

Emergency Department E-9-1-1 ED ICU 94

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

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 EMS 93

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

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

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

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 83

E-9-1-1 ICU Emergency Department ED 83

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 104

OR ICU EMS ED 104

ACEP Now

MAY 9, 2024

Unfortunately, at least 13 deaths were subsequently reported in Miami-Dade County from 2019–2022, the three years immediately following the implementation of the subcutaneous injection regulation. Or Helly Larson describing the first week after her Miami BBL as “absolute hell” to a Vox reporter.

Emergency Department 52

Emergency Department Operating Room Critical Care ALS 52

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

JUNE 3, 2023

Answer : Cerebellar Stroke Epidemiology: 1-4% of cerebrovascular accidents occur in the cerebellum. 2 In the United States, approximately 795,000 people suffer from strokes every year. 3 Cerebellar strokes are associated with high morbidity and mortality. 2 Superior cerebellar artery strokes most often present with headache, gait ataxia, dysarthria.

EMS 74

EMS ALS OR ED 74

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 84

Defibrillator CPR Epinephrine Life Support 84

REBEL EM

JULY 25, 2022

In this trial 337 patients were enrolled and although overall fluid bolus did not reduce the risk of cardiovascular collapse, in a subgroup analysis there was a hint of decreased risk of cardiovascular collapse among patients receiving positive pressure ventilation with a bag-mask device (OR 0.61; 95% CI 0.33 to 1.13; p = 0.03). No Bolus: 18.2%

ALS 57

ALS Critical Care ICU OR 57

Emergency Medicine Ireland

OCTOBER 30, 2023

Enrolled 800 fairly typical ICU patients, and found a 35% vs 39% mortality benefit favouring the vaso but of course this was below the somewhat arbitrary statistical significance. Nagendran 2019 in CCM. Intens Care Med 45 , 844–855 (2019). How does it work? Well this is where the fun beings. Jama 316 , 509–518 (2016).

Critical Care 52

Critical Care ALS Coronary ICU 52

AAEM RSA

JUNE 30, 2021

Many triple-certified physicians choose to divide their time between the emergency department (ED) and intensive care unit (ICU) for extra variability in their careers, staying sharp in both the high acuity and physiological management of the most ill and complex patients. Published online August 31, 2019. 2018; 15(3):431.

EMS 52

EMS Critical Care ICU Emergency Department 52

NAEMSP

FEBRUARY 15, 2023

The patient was dying while intubated in the ICU but was awake enough to engage in discussions with providers through writing about her wishes. 2019 Aug;58(2):355-359. Epub 2019 Mar 21. His pulse ox drops from 94% to 87% and his heart rate increased from about 110 beats per minute to approximately 180. J Pain Symptom Manage.

Emergency Medical Services 52

Emergency Medical Services EMS CPR Paramedic 52

EMDocs

APRIL 22, 2024

Time was of the essence, the patient was intubated, ACLS measures were continued, and POCUS was performed. The POCUS findings enabled EPs to confidently recognize findings consistent with hemodynamically unstable (formerly sub-massive or massive) PE. Multiorgan POCUS The diagnostic power of POCUS often resides in combining multiple ultrasound exams.

ED 82

ED NARCAN ALS OR 82

Dr. Smith's ECG Blog

DECEMBER 13, 2019

in the ICU but survived with excellent function. Several hours prior to presentation, while driving his truck, he started experiencing new central chest pain, without radiation, aggravating/alleviating factors, or other associated symptoms. You diagnose pericarditis at your peril! Acute MI is frequently misdiagnosed as pericarditis.

E-9-1-1 52

E-9-1-1 ACS Coronary CAD 52

The Skeptics' Guide to EM

SEPTEMBER 28, 2019

Date: September 11th, 2019 Reference: Putzu et al. Date: September 11th, 2019 Reference: Putzu et al. Case: A 45-year-old female in the emergency department is being admitted to the intensive care unit (ICU) for septic shock secondary to urinary tract infection (UTI). You are ready to call the ICU and get her admitted.

ICU 130

ICU Critical Care ALS Emergency Department 130

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 80

ICU Critical Care Operating Room ALS 80

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 104

ICU ED ALS OR 104

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

FEBRUARY 19, 2024

PMID: 37611862 Clinical Question: In patients treated in the ICU, can a protocol of peripheral IV catheter vasopressors safely reduce the number of days of CVC use and frequency of placement? of patients not requiring CVC insertion. REBEL EM: Peripheral Vasopressors – Safe or Dangerous?

ICU 137

ICU EMS ALS OR 137

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-9-1-1 120

E-9-1-1 ALS ACS ICU 120

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

REBEL EM

OCTOBER 31, 2022

(Fujii 2022, Sevransky 2021) Contrary to the above trial, another RCT investigated patients in the ICU with sepsis and acute respiratory distress syndrome. Fowler 2019) This concept and study design provided the framework for the Lessening Organ Dysfunction with Vitamin C (LOVIT) clinical trial. Article: Lamontagne F et al.

ICU 52

ICU ALS OR EMS 52

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 83

Coronary CPR OR ICU 83

REBEL EM

FEBRUARY 29, 2024

3, 4 It is the most common nosocomial infection in patients on mechanical ventilation, and one of the leading causes of nosocomial infection among all patients in the ICU. 1, 2 Its occurrence often portends worse outcomes in intubated patients, whose projected hospital course was already tenuous. 4, 8 Paper: Dahyot-Fizelier, C.,

E-9-1-1 124

E-9-1-1 ICU OR ALS 124

Dr. Smith's ECG Blog

MARCH 11, 2019

The patient was managed in the ICU and had serial troponins. You do NOT see this in normal variant STE, nor in pericarditis. The only time you see this without ischemia is when there is an abnormal QRS, such as LVH, LBBB, LV aneurysm (old MI with persistent STE) or WPW." It is not yet available, but this is your way to get on the list.

OR 52

OR ACS ICU STEMI 52

REBEL EM

FEBRUARY 8, 2024

PMID: 38215002 Clinical Question: In critically ill adults in the ICU is noninvasive blood pressure (NIBP) monitoring similar (≤10% difference) to invasive arterial blood pressure (IABP) monitoring? which was not statistically significant [2]. The biggest issue with this trial is there was only one blood pressure done per patient.

ICU 125

ICU MICU ALS EMS 125

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 70

Epinephrine ICU ALS OR 70

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