The Skeptics' Guide to EM

FEBRUARY 11, 2023

NEJM 2022 Guest Skeptic: Dr. Sean Moore is an emergency physician working in Kenora Ontario, where he is Chief of Staff at Lake of the Woods District Hospital, Northern Medical Director for the Ornge air medical transport program and associate medical director with CritiCall Ontario. Date: February 7, 2023 Reference: Cheskes et al.

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REBEL EM

JUNE 8, 2023

1-4 The PDPs, phenylephrine and epinephrine, result in vasoconstriction and increased cardiac contractility. They can be associated with side effects such as reflex bradycardia, decreased stroke volume in phenylephrine, tachycardia and hypertension associated with epinephrine. 2022 Sep 5. Paper: Singer S, et al. Am J Emerg Med.

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The Skeptics' Guide to EM

FEBRUARY 25, 2023

2022 Date: February 15, 2023 Guest Skeptic: Dr. Carlie Myers is Pediatric Critical Care Attending at Cincinnati Children’s Hospital Medical Center. 2022 Date: February 15, 2023 Guest Skeptic: Dr. Carlie Myers is Pediatric Critical Care Attending at Cincinnati Children’s Hospital Medical Center. Pediatric Crit Care Med.

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CPR ICU Critical Care Defibrillator 130

REBEL EM

APRIL 29, 2024

In cardiac arrest, a delay in IV access subsequently results in a delay in epinephrine administration. 2022 PMID: 35206981 2. Healthcare 2022 PMID: 35206981 Post Peer Reviewed By: Frank Lodeserto, MD & Salim R. Labs can be drawn from an IO to help with rapid diagnosis in emergencies. References: 1 Astasio-Picado Á et al.

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ALS Epinephrine Critical Care Emergency Department 105

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

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ACEP Now

JULY 7, 2023

2 Standard management for VT and VF involves the use of electrical defibrillation, high-quality chest compressions, and epinephrine. 5 More recent literature defines “refractory” as VT or VF that is persistent or recurrent despite three shocks from a defibrillator, three rounds of epinephrine, and use of an antiarrhythmic (i.e.,

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EMDocs

APRIL 10, 2024

1,2] Consider using a physiological marker to help identify inadvertent vascular injection, such as epinephrine. [3] If epinephrine is used, small initial doses ( <1 ug/kg) are preferred. McGraw Hill; 2022. Epidemiology Most common cause: inadvertent intravascular injection. per 10,000 cases of peripheral nerve blocks. [3]

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E-9-1-1 Plasma Epinephrine Life Support 111

REBEL EM

SEPTEMBER 1, 2022

Resus 2022. Resus 2022. It is unknown whether these harms are present at long-term follow up. Paper: Vallentin MF et al. Effect of Calcium vs. Placebo on Long-Term Outcomes in Patients with Out-of-Hospital Cardiac Arrest. Placebo: 9.1% RR 0.51; 95% CI 0.24 Survival with Good Neurological Outcome at 1 Year: Calcium: 3.6% Placebo: 8.6%

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EM Literature of Note

OCTOBER 20, 2022

Thin Evidence Supporting Thrombolysis of Those on Blood Thinners Epinephrine Norepinephrine, That Is the Question Ill PREPAREd-II Intubate the Critically Ill Enjoy! How FAST Can You Spot a Pneumothorax?

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Epinephrine 40

REBEL EM

NOVEMBER 6, 2023

to 1mg/kg/hr) Information regarding the vasopressors used in the study is as follows: Norepinephrine equivalents = norepinephrine mcg/kg/min + (phenylephrine mcg/kg/min/10) + epinephrine mcg/kg/min + (vasopressin units/min x2.5) 2022 Aug 22. Ann Thorac Surg. Epub 2017 May 24. PMID: 28551045 Bak MA, et al.

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ICU Epinephrine ALS OR 71

Broome Docs

APRIL 6, 2023

2022 Dec 16:emermed-2021-211946. Epub 2022 Nov 21. 2022 Jul 2;400(10345):39-47. 2022 Oct;51(10):595-604. 2022 Dec 20;328(23):2296. Epinephrine metered-dose inhaler for pediatric croup. Epub 2022 Dec 7. Emerg Med J. doi: 10.1136/emermed-2021-211946. Epub ahead of print. Am J Emerg Med. 2023 Feb;64:206.e1-206.e3.

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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

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Allergic Reaction Plasma ED Epinephrine 100

NAEMSP

APRIL 19, 2023

After several cycles of defibrillation, epinephrine, and amiodarone, the patient remains in cardiac arrest. Vallentin, Povlsen, Granfeldt, Terkelsen, & Andersen, 2022). CPR is taken over by responding crews, and he is placed on a cardiac monitor/defibrillator. He is found to be in ventricular fibrillation (VF).

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E-9-1-1 Advanced Life Support Overdose CPR 52

Handtevy

DECEMBER 3, 2021

January 2022 will be 12 years since the founding of Handtevy, inspired after a 10-fold medication error I had made, yet wasn’t aware of at the time. From there, I listed the few medications that I’d potentially use in a code; Epinephrine (1 mg/mL and 1 mg/10mL), Atropine (yes I’m old), Bicarb (repeat the old comment), D25 and Normal Saline.

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Epinephrine EMS ED OR 52

REBEL EM

SEPTEMBER 19, 2022

Some look promising (ie eCPR and application of US) while others have been considerably less effective or inconsistent (ie epinephrine and targeted temperature management). Resuscitation 2022; 179: 9-17. Resuscitation 2022; 179: 9-17. However, human data is sorely lacking. Article: Moore JC et al. References: Moore JC et al.

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CPR Defibrillator EMS Epinephrine 52

REBEL EM

DECEMBER 19, 2022

2022 Nov 6 PMID: 36342151 Clinical Question: How does double defibrillation and vector change defibrillation compare to standard therapy in OHCA patients with refractory ventricular fibrillation? 2022 Nov 6 PMID: 36342151 Cheskes S, et al. Defibrillation Strategies for Refractory Ventricular Fibrillation. N Engl J Med. N Engl J Med.

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Defibrillator Paramedic CPR EMS 52

EMS 12-Lead

MARCH 30, 2024

After administering 1mg of epinephrine ROSC is noted with a bradycardic rhythm ( Figure 2 ). The University of Maryland found that capture occurred in only 42-78% of patients, dependent on pad positioning (Moayedi et al, 2022). Junctional Rhythm, occasional PAC's, and artifact.

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FOAMfrat

DECEMBER 26, 2024

Children who develop stridor may be treated with racemic epinephrine (0.25- 0.75ml of 2.25% racemic epinephrine to 2.5 As (Narayan & Petersen, 2022)explains, SulfHb is a stable, green-pigmented molecule, which constitutes less than 1% of normal hemoglobin invivo. This may take up to 24 hours. 2018, 05 21).

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ALiEM

NOVEMBER 29, 2023

Xylazine is an alpha-2 agonist similar to clonidine that inhibits the release of norepinephrine and epinephrine resulting in decreased vascular tone and heart rate [4]. Journal of Addiction Medicine 16(5):p 595-598, 9/10 2022. Published 2022 Aug 19. Published 2022 Apr 20. How does xylazine toxicity present?

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Naloxone Overdose Epinephrine ALS 169

The Skeptics' Guide to EM

MARCH 5, 2022

Date: February 24th, 2022 Reference: Parish et al. Date: February 24th, 2022 Reference: Parish et al. An umbrella review of effect size, bias, and power across meta-analyses in emergency medicine. An umbrella review of effect size, bias, and power across meta-analyses in emergency medicine.

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REBEL EM

JUNE 12, 2024

According to the 2022 Annual Report of the National Poison Data System from America’s Poison Center, CCBs and BBs account for the sixth and seventh largest number of fatalities from overdose. 2022 Annual Report of the National Poison Data System ® (NPDS) from America’s Poison Centers ® : 40th Annual Report. Clin Toxicol (Phila).

Epinephrine 101

Epinephrine Overdose OR ALS 101

EMDocs

JANUARY 16, 2024

The patient received 1 mg of epinephrine IV x2 with conversion of his rhythm to ventricular fibrillation (VF) for which he was defibrillated twice in the field. He requires low-dose epinephrine to maintain his mean arterial pressure (MAP) in the 60s mmHg and is transported to the cardiothoracic (CT) ICU. Published 2022 Jan 3.

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EMDocs

JANUARY 4, 2024

Other Norepinephrine or epinephrine are preferred vasopressors when needed. Accessed 12/18/2022. Accessed 12/18/2022. 2022; 55:232.e3-232.e4 Consider lidocaine for associated dysrhythmias. 8 Consider intravenous lipid emulsion (ILE) for cardiotoxicity not responsive to other treatments. Clin Toxicol (Phila). Eds (2017).

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Overdose E-9-1-1 ALS Emergency Department 91

REBEL EM

MAY 29, 2023

What They Did: Single-center, parallel, double blind, randomized controlled trial performed in a medical-surgical ICU (Mexico) Both groups received: Adjunctive vasopressin initiated at a dose of 0.03 NaCl over 6hrs once daily x3 doses Placebo: 500mL of 0.9% 95% CI 15.4 NaCl over 6hrs once daily x3 doses Placebo: 500mL of 0.9% 95% CI 15.4

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EMDocs

DECEMBER 18, 2023

Multiple studies published in 2022 have indicated that, despite disagreement surrounding prognostic accuracy, no such screening tool so far exists. 34 If a MAP of 65 mmHg is still not achieved, epinephrine should be added as a third agent (Figure 1). 32,33 Once the dose of norepinephrine is between 0.25-0.5 units/minute.

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E-9-1-1 ALS Emergency Department Plasma 90

Dr. Smith's ECG Blog

JULY 21, 2024

Epinephrine infusion was begun. Meyers and Smith illustrate 20 example cases vs "look-alikes" of Swirl ( with my synthesis of "Swirl" ECG findings in My Comment on that post ) from October 15, 2022. You can see Left Main and Proximal LAD obstruction, but with some flow, which is saving this patient's life.

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Defibrillator Coronary ALS STEMI 131

Dr. Smith's ECG Blog

OCTOBER 10, 2022

On epinephrine and norepinephrine drips." If you use quantitative end-tidal CO2 monitoring, there is never any need to waste time making sure that the endotracheal tube is correctly placed. == MY Comment, by K EN G RAUER, MD ( 10/10/2022 ): == Today’s case is a “Save”! CT angiogram showed extensive saddle pulmonary embolism.

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ACS CPR CAD Heart Attack 52

Don't Forget the Bubbles

DECEMBER 5, 2023

doi.org/10.1136/emermed-2022-212667 What’s it all about? Epinephrine was initially given to both groups after 5 minutes of chest compressions, this delay was based on a previous simulation study looking at length of time to site an UVC. Nizami T, Beaudoin F, Suner S, et al. Emergency Medicine Journal 2023;40:564-568.

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Coronary Epinephrine CPR Emergency Department 111

FOAMfrat

SEPTEMBER 19, 2024

These side effects do not contraindicate antivenom administration and can be treated with antihistamines and epinephrine. Hypotension and anaphylaxis should be treated with epinephrine following your local guidelines. 2022, www.ncbi.nlm.nih.gov/books/NBK557565/. Wilderness & Environmental Medicine , vol. Meyers, Stephen E.,

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Emergency Department Epinephrine OR Plasma 95

EMDocs

JANUARY 20, 2024

2022 May 17;145(20):e1053]. Answer: Takotsubo Cardiomyopathy 1-18 Background: Also known as transient apical ballooning syndrome, apical ballooning cardiomyopathy, stress-induced cardiomyopathy, stress cardiomyopathy, Gebrochenes-Herz syndrome, and broken-heart syndrome. Journal of Clinical Medicine. 2021;10(15):3235. Circulation.

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E-9-1-1 EMS Coronary ACS 100

This Podcast Will Kill You

JANUARY 14, 2025

Our allergy treatment toolkit includes an impressive suite of tools, and in the second episode of our two-part series on allergies, we focus on three in particular: antihistamine medications, allergy shots, and the epinephrine auto-injector (aka the EpiPen). “Epinephrine: a short history.” Then this is the episode for you.

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Allergic Reaction E-9-1-1 Epinephrine ALS 52

FOAMfrat

DECEMBER 4, 2024

Low-dose epinephrine is a strong beta-1 drug with minimal alpha-1 effects if you stay below ~0.08 Dobutamine is a synthetic catecholamine, similar to epinephrine, but without the alpha-1 effects. If you only carry one inotrope, the choice is easy. mcg/kg/min. This will aid in contractility and bring your cardiac output up.

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Coronary STEMI Epinephrine Critical Care 64

EMDocs

JANUARY 22, 2025

Profound increase in epinephrine concentration in plasma and cardiovascular stimulation after mu-opioid receptor blockade in opioid-addicted patients during barbiturate-induced anesthesia for acute detoxification. References Spencer MR, Minio AM, Warner M. Drug overdose deaths in the United States, 20012021. NCHS Data Brief, no 457.

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Naloxone E-9-1-1 Overdose NARCAN 96

ACEP Now

OCTOBER 29, 2024

He was defibrillated twice and received two doses of epinephrine, with return of spontaneous circulation. 2022; 8(3):386-405. There was no family history of syncope or sudden death. EMS found the patient pulseless and apneic, with an initial rhythm showing ventricular fibrillation (see figure 1). Figure 1: The EMS rhythm strip.

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E-9-1-1 Defibrillator ALS Epinephrine 52