The Skeptics' Guide to EM

JULY 16, 2022

Date: July 16th, 2022 Reference: Lamontagne F et al. Date: July 16th, 2022 Reference: Lamontagne F et al. Case: A 59-year-old woman presents to the emergency department (ED) with fever, tachycardia, and hypotension. She is admitted to the intensive care unit (ICU) for septic shock. Guest Skeptic: Dr. Salim R.

ICU 100

ICU ALS Critical Care Emergency Department 100

Core EM

OCTOBER 16, 2024

In: Marx J, ed. In: Wolfson A, ed. 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%

Allergic Reaction 188

Allergic Reaction Plasma ED Epinephrine 188

EMDocs

DECEMBER 9, 2023

Spoon Feed Advanced statistics emulating clinical trial protocols from an ICU database did not identify consistent differences in 30-day mortality when ICU patients were intubated early (within 8 hours of admission) or late (after 48 hours). 2022-007070. Clay Smith at @spoonfedEM , and sign up for email updates here. #1:

ICU 95

ICU ED OR 95

EMDocs

NOVEMBER 29, 2023

Question: In adult patients admitted to the ICU with severe CAP, does hydrocortisone compared to placebo reduce 28-day all-cause mortality? 2022 Aug;48(8):1009-1023. Question: In adult patients admitted to the ICU with severe CAP, does methylprednisolone compared to placebo reduce 60-day all-cause? N Engl J Med.

ICU 98

ICU CAD ALS OR 98

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

He was intubated on arrival at the ED for mental status and airway protection due to vomiting. His temperature was brought back to normal over time in the ICU. There is also large T wave inversion and long QT. Clinical context: A man in his 50s was found down outside in the cold, unresponsive but with intact vital signs.

ICU 138

ICU OR ALS ED 138

EMDocs

SEPTEMBER 19, 2023

On ED arrival GCS is 3, there are rapid eye movements to the right but no other apparent seizure activity. Propofol utilized for sedation; patient admitted to ICU for EEG monitoring. Official diagnosis requires EEG, which is not something we can typically obtain in the ED. 2022 Nov 15;80(20):1925-1960. J Am Coll Cardiol.

STEMI 100

STEMI Coronary Emergency Department ICU 100

Dr. Smith's ECG Blog

OCTOBER 23, 2023

On arrival to the ED the patient was intubated with normal vital signs. She was admitted to the ICU where subsequent ECGs were performed: ECG at 12 hours QTc prolongation, resolution of T wave alternans ECG at 24 hours Sinus tachycardia with normalized QTc interval. 2022 Jul;27(4):e12939. Epub 2022 Feb 11.

ICU 131

ICU OR Defibrillator EMS 131

EMDocs

AUGUST 15, 2023

He was initially seen at a regional ED and was administered 10 vials of crotalidae equine immune F(ab’) 2 (ANAVIP®) antivenom before transfer to your referral center. Published April 15, 2022. Accessed May 7, 2022. StatPearls Publishing; 2022. Accessed May 17, 2022. Accessed May 7, 2022. Am J Hosp Pharm.

Emergency Department 98

Emergency Department OR EMS ED 98

EMDocs

JUNE 3, 2023

A 53-year-old female with a past medical history significant for hypertension presents to the ED with headache and dizziness. Patients receiving thrombolysis will require ICU admission for neurologic monitoring. Updated 2022 May 8]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Tintinalli JE, ed.).

EMS 98

EMS ALS OR ED 98

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

JUNE 8, 2023

2022 Sep 5. This study chose a relevant topic to analyze that could influence acute management in the ED and has a fairly larger sample size of patients to do so. 2022 2022 Sep 5. The relationship between ICU hypotension and in-hospital mortality and morbidity in septic patients. Paper: Singer S, et al.

Epinephrine 98

Epinephrine Emergency Department ALS Critical Care 98

EMDocs

APRIL 10, 2024

These medications are a vital tool in the care of ED patients, from simple local analgesia for a laceration repair to regional analgesia for painful procedures. Hemodynamics slowly begin to stabilize, and the patient is transferred to the ICU for further post-cardiac arrest care. doi:10.1007/BF03161199 Olson K, Smollin C, eds.

E-9-1-1 111

E-9-1-1 Plasma Epinephrine Overdose 111

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. Saini, A.,

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

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. Over the past few years, there has been an increase in emergency department (ED) volumes and lengths of stay. The typical nursing to patient ratio is 1:3 with a shared respiratory therapist for the entire ED.

Emergency Department 52

Emergency Department ICU Critical Care EMR 52

EMDocs

JANUARY 16, 2024

Louis) // Reviewed by: Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit) Case You are working in the trauma/critical care pod of your emergency department (ED). His blood sugar was normal en route to the ED, and his initial rhythm on the cardiac monitor was asystole. Published 2022 Jan 3. doi: 10.1097/MAT.0000000000001518

Defibrillator 110

Defibrillator CPR Epinephrine Life Support 110

ESO

MARCH 7, 2024

It’s built from ESO-compiled data consisting of 968,538 hospital records from 596 hospital systems that took place between January 1 st to December 31 st of 2022. of patients with open long bone fractures receive antibiotics within the critical first 60 minutes of ED arrival.

Operating Room 105

Operating Room ICU OR ED 105

Core EM

OCTOBER 2, 2024

In: Marx J, ed. In: Wolfson A, ed. 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%

Allergic Reaction 100

Allergic Reaction Plasma ED Epinephrine 100

Dr. Smith's ECG Blog

OCTOBER 8, 2024

A temporary pacemaker was implanted, and she was admitted to the ICU with cardiogenic shock. I interpreted this tracing knowing only that the patient was a woman in her 60s, with a prior history of proximal LAD OMI — who now presented to the ED with a history of new chest discomfort and shortness of breath.

OR 123

OR STEMI ICU Coronary 123

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. This patient presented to the ED “after a couple of days of chest discomfort”. Remember that this patient presented to the ED “after a couple of days of chest discomfort”.

Coronary 119

Coronary ACS ED OR 119

EMDocs

APRIL 22, 2024

4 In an emergency department (ED) presentation of cardiac arrest, the diagnosis of PE is challenging without the use of CT angiography. Case A 25-year-old-female presented to the ED in cardiac arrest. Summary This case exemplifies the value of POCUS in cardiac arrest patients in the ED. 2022 Sep;24(6):579-581.

ED 98

ED NARCAN ALS OR 98

Broome Docs

MARCH 28, 2024

2022 Feb;52:85-91. Although I miss performing the procedure, these days I almost always leave the central line until the patient is stabilized and settled into their ICU bed. Myths and misconceptions about the treatment of acute hyperkalemia Gupta AA, Self M, Mueller M, Wardi G, Tainter C. Am J Emerg Med. doi: 10.1016/j.ajem.2021.11.030.

E-9-1-1 96

E-9-1-1 ICU Emergency Department ALS 96

EMDocs

OCTOBER 21, 2023

Median time from ED arrival to diagnosis was 8 hours 24 min in one study, with only 19% being diagnosed within the 4.5-hour All patients who receive thrombolytics for ischemic stroke should be admitted to a neurosurgical, neurologic, or medical ICU for management and monitoring, as this is shown to decrease mortality and length of stay.

EMS 98

EMS ALS OR ACS 98

Don't Forget the Bubbles

JUNE 17, 2024

The Importance of Civility in Critical Care Resuscitation A 3-year-old patient with diabetic ketoacidosis arrives at your ED. The team sits down for a hot debrief once the patient is stabilised and transferred to the ICU. 2022 May 12;46(3):319-24. Australian Health Review. Edmondson, Amy C. The Fearless Organization.

E-9-1-1 105

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

Don't Forget the Bubbles

JUNE 30, 2023

All you know, back in ED, is that the ETA is 10 minutes, and there is a single stab wound to the chest. The ODP is caught up leaving theatres and has not yet made it down to ED. 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.

E-9-1-1 139

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

REBEL EM

NOVEMBER 3, 2022

Matchett 2022). In this post, we critically appraise the first systematic review and meta-analysis to compare the safety and efficacy of etomidate and ketamine as induction agents for RSI in the ED and prehospital setting. Indian J Crit Care Med 2022. Article: Sharda SC et al.

ALS 52

ALS ICU ED Emergency Department 52

REBEL EM

FEBRUARY 2, 2023

Background Information: Atrial fibrillation with rapid ventricular rate (RVR) is one of the many tachydysrhythmias we encounter in the Emergency Department (ED). 2 Amiodarone is commonly known for its anti-arrhythmic properties and a commonly used agent in the Intensive Care Unit (ICU). Paper: Mason JM, et al. Am J Emerg Med.

Emergency Department 52

Emergency Department ALS Critical Care ED 52

ACEP Now

DECEMBER 10, 2023

A middle-aged male with squamous cell carcinoma and extensive metastases is brought to the emergency department (ED) after being found unresponsive following a believed suicide attempt (SA) by methadone ingestion. You ultimately begin a slow naloxone infusion and admit him to the medical ICU. 2022 Jun;34(3):473-474.

Naloxone 52

Naloxone Life Support Paramedic ALS 52

Don't Forget the Bubbles

OCTOBER 19, 2023

You, however, are working an ED shift, and when you see the name “Barbie Junior” on your computer screen, your heart does a flutter. It can be in started in the ED, and many of us are already using it. Secondary outcome analysis showed there was no difference in length of hospital stay, ICU stay, or duration of oxygen therapy.

E-9-1-1 81

E-9-1-1 ED OR Emergency Department 81

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. 6 Theoretically, ultrasound guidance should decrease this risk, which formed the basis for the 2022 Florida Medical Board regulation.

Emergency Department 52

Emergency Department Operating Room Critical Care ICU 52

ACEP Now

MAY 9, 2024

It has been well over a year since the controversial publication of the Agency for Healthcare Research and Quality (AHRQ) report on diagnostic errors in the emergency department (ED). percent of ED visits resulted in preventable death as result of diagnostic error. Further diagnostic testing in the ICU identified salicylate toxicity.

Emergency Department 52

Emergency Department ICU ALS ACS 52

ACEP Now

MAY 4, 2023

A 58-year-old male with a history of alcohol abuse presented to the emergency department (ED) as a category 2 trauma for a fall with a reported flail chest. 2022; 22(11):432-439. 2022; 276:221-234. Case FIGURE 1: Chest X-ray of multiple rib fractures (arrows). Click to enlarge.) References Mistry RN, Moore JE. BJA Education.

EMS 52

EMS Operating Room ICU Emergency Department 52

REBEL EM

AUGUST 29, 2022

Sharda 2022) Etomidate and ketamine act distinctly from each other. Duration of mechanical ventilation, ICU, and percentage of vasopressor use were not significantly different. All intubations were performed on hospitalized patients, limiting application to the ED population. 2022 Jan;48(1):78-91.Epub Intensive Care Med.

MICU 52

MICU ICU OR Emergency Department 52

REBEL EM

JULY 14, 2022

2022 Mar; 17. An example using a real case I had while on call in the ICU: A 61-year-old female had a post-induction arrest on the wards/hospital telemetry floor after being intubated for airway protection. 2022 Mar; 17. In a PCAC 1 or 2, we may prioritize a cath and tolerate a couple hours without ICU Neuroresuscitation.

ICU 52

ICU ALS OR CPR 52

Dr. Smith's ECG Blog

MAY 5, 2022

Submitted and written by Destiny Folk MD , peer reviewed by Meyers, Smith, Grauer, McLaren A man in his early 30s with no significant past medical history was brought to the ED by EMS after being found unresponsive by a friend. On arrival in the ED, he was hypotensive with a systolic blood pressure in the 70s. Use Lewis Leads!!

E-9-1-1 52

E-9-1-1 OR STEMI ED 52

Dr. Smith's ECG Blog

JANUARY 6, 2023

The patient vomited once and given the more intense pain decided to come to the ED. Clin Cardiol 2022; [link] Labs included: hsTnI 156 ng/L, Hb 12 g/dL, WBC 12x10^9/L, Cr. 2-hour hsTn: 615 ng/L; bedside ED echo (without contrast) did not show a clear wall motion abnormality (WMA). No history of GIB, dysuria, or GU symptoms.

ACS 52

ACS Coronary ICU STEMI 52

EMDocs

FEBRUARY 12, 2024

As the only respiratory therapist in the ED has been paged and is starting BiPAP for this patient, an overhead call for two incoming trauma alerts from a multivehicle collision sounds. Because the RT responsible for drawing arterial blood gases is busy caring for these patients, ABGs will be delayed.

Emergency Department 98

Emergency Department E-9-1-1 ED ICU 98

EMDocs

DECEMBER 18, 2023

On arrival to the ED, her blood pressure is 84/36 mmHg with a heart rate of 110 beats per minute. 3,4 Prompt recognition and management of sepsis and septic shock are paramount for the ED clinician. 8,9 Recently, monocyte distribution width (MDW) has shown promise in a large meta-analysis as a useful screening tool in the ED.

E-9-1-1 93

E-9-1-1 ALS Emergency Department Plasma 93