The Skeptics' Guide to EM

JANUARY 15, 2022

Intensive Care Med 2021 Guest Skeptic: Missy Carter, former City of Bremerton Firefighter/Paramedic, currently a professor of Emergency Medical Services at Tacoma Community College’s paramedic program. Date: January 16th, 2022 Reference: Matchett, G. Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial.

Emergency Medical Services 107

Emergency Medical Services Firefighter Critical Care Paramedic 107

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. Paper: Griffey RT et al. However, it is unclear if all degrees (mild, moderate, severe) of DKA require the same intensive treatment. tests/hr (0.8

ICU 105

ICU ED ALS OR 105

Pediatric EM Morsels

MARCH 17, 2023

In the US, the venomous snakes include rattlesnakes , copperheads, cottonmouths/water moccasins , and coral snakes [ CDC, 2021 ] Rattlesnakes live all across the United State s Copperheads inhabit the eastern U.S. If you are managing a snake bite from a snake that does not typically reside in the U.S.,

Frozen Plasma 130

Frozen Plasma Plasma First Aid OR 130

The Skeptics' Guide to EM

SEPTEMBER 25, 2021

Date: September 20th, 2021 Reference: Litell et al. Date: September 20th, 2021 Reference: Litell et al. It is the leading cause of death in the intensive care unit (ICU) in the US and the most expensive diagnosis. Most emergency department patients meeting sepsis criteria are not diagnosed with sepsis at discharge.

EMR 100

EMR Emergency Department ICU ALS 100

The Skeptics' Guide to EM

MARCH 27, 2021

Date: March 17th, 2021 Guest Skeptic: Dr. Emil Ejersbo Iversen is an emergency medicine resident at the University Hospital of Zealand, Denmark. Date: March 17th, 2021 Guest Skeptic: Dr. Emil Ejersbo Iversen is an emergency medicine resident at the University Hospital of Zealand, Denmark. Reference: Schuster et al.

ICU 100

ICU ALS Emergency Department ED 100

Broome Docs

OCTOBER 31, 2022

Ketamine vs etomidate in ICU intubation ? Epub 2021 Dec 14. The PEACH trial: No body had a fit, so… we have no clue Peter-Derex L, Philippeau F, Garnier P, et al. PMID: 30206143 Less is more when it comes to intravenous fluids de-Madaria E, Buxbaum JL, Maisonneuve P, et al. 2022 Jul 26:emermed-2021-211540.

E-9-1-1 52

E-9-1-1 Defibrillator ICU Critical Care 52

REBEL EM

NOVEMBER 6, 2023

Paper: Hiruy A, et al. So with yet another confounding variable added (sicker patients at baseline in methylene blue group), the comparison of these two medications is yet again even more difficult There was no difference in ICU and hospital length of stays or hospital mortality between the two groups. REFERENCES: Hiruy A, et al.

Epinephrine 72

Epinephrine ICU ALS OR 72

REBEL EM

MARCH 23, 2023

Treatment options for alcohol withdrawal include benzodiazepines such as lorazepam, diazepam, or chlordiazepoxide, gabapentin, and phenobarbital (Buell et al.). Phenobarbital can be used as a monotherapy or in combination with benzodiazepines to treat alcohol withdrawal (Hawa et al.). Paper : Hawa F et al.

ICU 52

ICU Emergency Department ALS OR 52

REBEL EM

AUGUST 21, 2023

This trial aimed to assess whether targeted therapeutic mild hypercapnia (TTMH) applied during the initial 24 hours of mechanical ventilation in the ICU can enhance neurological outcomes at the 6-month mark, as compared to standard care, which involves targeted normocapnia (TN). Paper: Eastwood G, et al. Epub 2021 Feb 8.

Critical Care 98

Critical Care E-9-1-1 CPR ALS 98

REBEL EM

AUGUST 14, 2023

Article: Liu S, Yao C, Xie J, et al. 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.”

ICU 98

ICU EMS OR ALS 98

EMDocs

JUNE 27, 2024

Alkindi S, Al-Busaidi I, Al-Salami B, Raniga S, Pathare A, Ballas SK. Alghamdi FA, Al-Kasim F, Alshhada F, Ghareeb E, Azmet FR, Almudaibigh A, Baitalmal L, Alnawfal B, Alluqmani R. 2021 Sep;194(5):899-907. Epub 2021 Jul 15. Roy A, Allareddy V, Lee M, Nalliah R, Rampa S, Allareddy V, Rotta A. 2020 Feb 12;10(1):2470.

E-9-1-1 75

E-9-1-1 ICU ACS EMS 75

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. Carsten L, et al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Monika BM, Martin D, Balthasar E, et al. 2009;338:b2085. Resuscitation.

Defibrillator 84

Defibrillator CPR Epinephrine Life Support 84

ECG & Echo Learning

OCTOBER 2, 2022

Below follows a drug manual for use in the CCU (coronary care unit), ICU (intensive care unit) or ER (emergency room). References Overgaard, Dzavik et al. Jentzer et al. Müllner M, Urbanek B, Havel C, et al. J Intensive Care Med 2021; 36:101. Lherm T, Troché G, Rossignol M, et al. Circulation 2011.

E-9-1-1 52

E-9-1-1 ALS Coronary Epinephrine 52

REBEL EM

SEPTEMBER 29, 2022

Article: de-Madaria E et al. For More on This Topic Checkout: CorePendium: Pancreatic Disease Internet Book of Critical Care: Acute Pancreatitis EMCrit: Ep333 – The State of Fluids Show with the EMCrit Core Team The Bottom Line: Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis References: de-Madaria E et al.

ICU 52

ICU ALS Critical Care Emergency Department 52

EMS 12-Lead

MAY 8, 2022

Thankfully, the patient experienced an uncomplicated ICU stay and subsequently made a full recovery. The serum K returned 8.7, along with a pH 6.94, and an HCO3 of 5. Unfortunately, no ECG was captured after resuscitation. Do not miss this fantastic tutorial from Dr. Jesse McLaren! link] References [1] Strauss, D. & Schocken, D.

STEMI 130

STEMI ED EMS Firefighter 130

ACEP Now

APRIL 3, 2024

5,6 In 2021, the TTM2 trial was published. Several recent studies yield insights into this hypothesis: In a single site retrospective cohort study, Callaway et al demonstrated that TTM efficacy may be impacted by arrest severity.10 In a multisite retrospective cohort study, a study by Nishikimi, et al., Group W, Nolan JP, et al.

Advanced Life Support 40

Advanced Life Support ALS Life Support CPR 40

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. Article: How-Berlemont C, Lamhaut L, Diehl J, et al. JAMA Cardiol. Published online June 08, 2022.

Coronary 83

Coronary CPR OR ICU 83

ACEP Now

MAY 9, 2024

The procedure has soared in popularity as beauty standards have shifted and cosmetic surgery has become increasingly transparent on social media platforms, with reported cases in the United States increasing from 614 in 2002 to 61,387 by 2021, a nearly 10,000 percent increase. Al Jazeera. Mofid MM, Teitelbaum S, Suissa D, et al.

Emergency Department 52

Emergency Department Operating Room Critical Care ALS 52

EMDocs

SEPTEMBER 25, 2023

Despite the risk of hypotension and bradycardia, propofol has been shown in the ICU setting to be a safe and effective monotherapy intubation agent for hemodynamically unstable patients (19). References: Heffner AC et al. PMID: 23911630 Kim WY et al. PMID: 23911630 Kim WY et al. PMID: 25402500 Forsythe SM et al.

ED 65

ED Emergency Department ALS OR 65

REBEL EM

NOVEMBER 3, 2022

Article: Sharda SC et al. What They Did: Performed a search of the following databases: Pubmed, Embase, Cochrane, and ClinicalTrials.gov up to and including June 1, 2021. Included studies assessed patients in the emergency department and prehospital setting, which limits the external validity to other treatment areas such as the ICU.

ALS 52

ALS ICU ED Emergency Department 52

REBEL EM

SEPTEMBER 15, 2022

Paper: Mullens W et al. diuresis NOT natriuresis) A common clinical practice in the ICU is to use a loop diuretic as monotherapy or a loop diuretic in combination with a thiazide diuretic.This can commonly lead to hypernatremia, hypochloremia, and a metabolic alkalosis. References: Mullens W et al. PMID: 21366472 Bart BA et al.

ALS 52

ALS ICU OR EMS 52

Don't Forget the Bubbles

JUNE 30, 2023

In 2021, Evans and colleagues (1) compared adolescent mortality rates in adult, children’s and mixed major trauma centres across the UK. In 2021, Kulvatunyou, Bauman and colleagues compared the insertion of traditional 28-32Fr chest tubes with 14Fr pigtail catheters for drainage of traumatic haemothorax. 2021 Jul;38(7):488-494.

E-9-1-1 139

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

ACEP Now

MARCH 13, 2024

References Morley, Claire, et al. Kelen GD, Wolfe R, D’Onofrio G, et al. Published online 2021:26. Conclusion/Recommendation ED crowding is a national patient safety issue driven by hospitals routinely operating over capacity. Emergency department crowding: a systematic review of causes, consequences and solutions. PloS one 13.8

Emergency Department 52

Emergency Department ED ALS OR 52

REBEL EM

MAY 8, 2023

2021 Dec 1;91(6):1025-1040. However, this data was driven by a single small trial (Enderson et al.), 2021 Dec 1;91(6):1025-1040. Paper: Smith JA, Secombe P, Aromataris E. Conservative management of occult pneumothorax in mechanically ventilated patients: A systematic review and meta-analysis. J Trauma Acute Care Surg.

E-9-1-1 59

E-9-1-1 Critical Care ICU OR 59

EMDocs

APRIL 22, 2024

Alerhand et al described ten individual echocardiographic findings of RV strain that suggest PE. Marino’s the ICU book, Wolters Kluwer Health, pgs 105-109, 4th ed., VUMC Emergency Medicine, “RV Strain & TAPSE” YouTube Video [link] Farcy et al. 2021 Apr;40(2):100852. Epub 2021 Mar 26.

ED 81

ED NARCAN ALS OR 81

AAEM RSA

APRIL 1, 2021

Holcomb JB, Tilley BC, Baraniuk S, et al. There was no difference in the secondary outcomes of time to hemostasis, ventilator-free days, ICU-free days, disposition at 30 days, incidence of primary surgical procedures, and functional status at hospital discharge (measured as Glasgow Outcome Scale-Extended Score). 2015;313(5):471-82.

E-9-1-1 52

E-9-1-1 Plasma ACS ALS 52

Dr. Smith's ECG Blog

OCTOBER 28, 2022

Learn about the Smith-Modified Sgarbossa Criteria for Diagnosis of OMI Paced Rhythm: Dodd, Meyers, Smith, et al. Annals of Emergency Medicine 2021. He went into cardiogenic shock and is intubated in the cardiac ICU. The location of the infarct is clear, but that does not necessarily tell you what artery it is.

Coronary 52

Coronary Paramedic EMS ICU 52

REBEL EM

AUGUST 29, 2022

Article: Matchett G et al; EvK Clinical Trial Collaborators. Duration of mechanical ventilation, ICU, and percentage of vasopressor use were not significantly different. Epub 2021 Dec 14. Etomidate works on the GABA receptor, while ketamine works as an NMDA antagonist. Yet, both agents provide the same outcome, sedation.

MICU 52

MICU ICU OR Emergency Department 52

Dr. Smith's ECG Blog

MAY 26, 2023

He was admitted to the ICU and was unstable, in shock, overnight. Details of management extend beyond the scope of this ECG Blog — with reviews by Atemnkeng at al ( J Med Cases 12[9]:373-376, 2021 ) and Chakraborty & Hamilton ( StatPearls, 2023 ) available for interested readers. 3 hours later, this was recorded at a K of 2.8

Overdose 88

Overdose E-9-1-1 Coronary OR 88

ALiEM

OCTOBER 30, 2024

We have certainly seen patients who have pain which is controlled and still have psychomotor agitation and sympathetic activation, leading some to require ICU admission for dexmedetomidine and/or ketamine infusion. Multimodal medication options for fentanyl-xylazine withdrawal management in London et al. 2021 Aug 1;94:103086.

E-9-1-1 161

E-9-1-1 Naloxone Emergency Department ALS 161

EMDocs

DECEMBER 18, 2023

The most recent surviving sepsis campaign (SSC) guidelines were released in 2021, which provided 93 recommendations for evidence-based sepsis management. 1 Since 2021, attempts to identify a single screening tool with optimal sensitivity and specificity to predict which patients will develop sepsis or septic shock have been ongoing.

E-9-1-1 65

E-9-1-1 ALS Emergency Department Plasma 65

Dr. Smith's ECG Blog

MAY 5, 2022

He was admitted to the ICU and transferred emergently to a facility where he could undergo emergent dialysis as a part of further evaluation and management. For an excellent State-of-the-Art Review on Brugada Syndrome — Please SEE this article by Brugada et al in JACC — Vol. The November 27, 2021 post ( LA-RA reversal ).

E-9-1-1 52

E-9-1-1 OR STEMI ED 52

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. Clinical Question: Does high-dose vitamin C improve survival and/or persistent organ dysfunction rates in septic patients in the ICU on vasopressors? N Engl J Med 2022.

ICU 52

ICU ALS OR EMS 52

Don't Forget the Bubbles

JANUARY 4, 2024

This retrospective, observational study used data from the UK Trauma Audit & Research Network (TARN) between 2012 and 2021. Records of all children (defined age 0-16) on the TARN database who fulfilled the TARN criteria (had been admitted for longer than 72 hours, admitted to an ICU, or died in hospital) were included. 2022.24162.

ED 129

ED ICU ALS OR 129

EMDocs

AUGUST 15, 2023

link] Kanaan NC, Ray J, Stewart M, et al. Published online April 2021. If you are concerned for elevated compartment pressures, the patient needs to be treated with antivenom. Accessed May 7, 2022. link] Buchanan JT, Thurman J. Crotalidae Envenomation. In: StatPearls. StatPearls Publishing; 2022. Accessed May 17, 2022. doi:10.1212/CPJ.0000000000000180

Emergency Department 81

Emergency Department OR EMS ED 81

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). References/Further Reading (1) Byrne AL, Bennett M, Chatterji R, Symons R, Pace NL, Thomas PS. 2021 Aug 1;133(2):374-378. 2021 Apr;47(2):365-372.

Emergency Department 94

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

REBEL EM

NOVEMBER 11, 2024

In 2021, Buckley et. Article: Chanderraj R, Admon AJ, He Y, et al. Imbalances Between Treatment Groups : ICU Admissions : Higher in piperacillin-tazobactam (33% vs. 30%). For example, in this analysis, 33% of patients receiving piperacillin-tazobactam were admitted to the ICU, compared to 30% of those receiving cefepime.

E-9-1-1 84

E-9-1-1 ALS ICU Critical Care 84