Emergency Medicine Ireland

MAY 13, 2024

Part 1 will cover a broad overview of pulmonary hypertension and part 2 will focus on management strategies for a PH patient in the ICU. The definition of PH since the 2022 ESC guidelines is a mean PAP of 20mmHg on a right heart catheter. Saying a patient has PH does not really tell you very much. This is by far the commonest.

Critical Care 98

Critical Care ICU OR 98

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? Intensive Care Med.

ICU 80

ICU CAD ALS OR 80

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. 1: Early or Delayed Intubation in Critically Ill Patients? 2023.04.048.

ICU 68

ICU ED OR 68

The Skeptics' Guide to EM

MARCH 18, 2023

Outcome: * Primary Outcome: Hospital length of stay (LOS) * Secondary Outcomes: 7-day hospital readmission, late ICU transfer (on or after hospital day 2 after being admitted to general ward), composite outcome of in-hospital death or ECMO use. . JAMA Pediatr. JAMA Pediatr. JAMA Pediatr.

ICU 101

ICU Emergency Department OR 101

EMDocs

FEBRUARY 20, 2024

2022 Sep 15;387(11):989-1000. Fluids in Pancreatitis #1 : de-Madaria E, Buxbaum JL, Maisonneuve P, et al; ERICA Consortium. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. N Engl J Med. cc/kg/hour of LR Control: LR Bolus of 20 cc/kg (regardless of fluid status) followed by 3.0

E-9-1-1 83

E-9-1-1 ICU ALS OR 83

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

Don't Forget the Bubbles

JUNE 14, 2023

This post, from Ben Symon on XXX, is the first of our 2022 DFTB conference. We store the ability to look after a patient who’s on the edge of death for hours at a time in ICU nurses, and we saw the knowledge of where the hell anything is in the hospital in our wardies. Ben Symon is a pediatric emergency medicine physician.

ICU 135

ICU OR 135

Dr. Smith's ECG Blog

OCTOBER 23, 2023

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. She had an uneventful ICU course and was extubated for ongoing care with the inpatient psychiatric service. 2022 Jul;27(4):e12939.

ICU 124

ICU OR Defibrillator EMS 124

EMDocs

NOVEMBER 29, 2023

2022 Sep 15;387(11):989-1000. EBM Update: Fluids in Pancreatitis, Hypertriglyceridemic Pancreatitis #1: de-Madaria E, Buxbaum JL, Maisonneuve P, et al; ERICA Consortium. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. N Engl J Med. cc/kg/hour of LR Control: LR Bolus of 20 cc/kg (regardless of fluid status) followed by 3.0

E-9-1-1 66

E-9-1-1 ICU ALS OR 66

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

His temperature was brought back to normal over time in the ICU. We've discussed Osborn Waves ( both ischemic and hypothermic ) — on a number of occasions in Dr. Smith's ECG Blog ( Please check out My Comment at the bottom of the page in the February 8, 2022 post ). He was extubated and had normal neurologic function.

ICU 135

ICU OR ALS ED 135

ALiEM

MAY 19, 2023

In our emergency department, the RTs do not spend a lot of time going around measuring cuff pressures and usually save that until the patient reaches the ICU. Updated 2022 Jun 5]. Another minor difference is that the gastric balloon in the Minnesota tube holds 450-500 ccs of air, while the SB gastric balloon holds 250 ccs of air [2].

E-9-1-1 245

E-9-1-1 Emergency Department ICU OR 245

EMDocs

AUGUST 15, 2023

Avoid additional bites to yourself or the patient and move the patient safely away from the snake. Do NOT attempt to capture or kill the snake. Give analgesics for pain control but avoid NSAIDs due to their inhibitory effect on platelets Obtain initial labs including CBC, BMP, PT/INR, and fibrinogen.

Emergency Department 82

Emergency Department OR EMS ED 82

EMDocs

SEPTEMBER 19, 2023

Propofol utilized for sedation; patient admitted to ICU for EEG monitoring. Causes: Inadequately treated convulsive status, acute brain injury or structural lesion, infection, encephalopathy, medications/toxins Underlying cause is the most important factor in morbidity and mortality. CT demonstrated no acute, actionable findings.

STEMI 72

STEMI Coronary Emergency Department EMS 72

REBEL EM

SEPTEMBER 5, 2022

A higher MAP may offer advantages due to improved cerebral perfusion pressure, however data is lacking. Paper 1: Schmidt HJ et al. Oxygen Targets in Comatose Survivors of Cardiac Arrest. PMID: 360027567 [ Access on Read by QxMD ] Paper 2: Kjaergaard J et al. Blood-Pressure Targets in Comatose Survivors of Cardiac Arrest. Liberal O2: 33.9%

ICU 52

ICU ALS OR CPR 52

Handtevy

AUGUST 15, 2022

Study Overview A recent research study titled “Sodium Bicarbonate Use During Pediatric Cardiopulmonary Resuscitation: A Secondary Analysis of the ICU-RESUScitation Project Trial” aimed to evaluate the associations between sodium bicarbonate use and outcomes during p-IHCA.

CPR 52

CPR ICU Overdose Critical Care 52

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. Designed to be a point of reference for hospitals and trauma centers alike, the Trauma Index is the largest de-identified data trauma registry program in the country.

Operating Room 105

Operating Room ICU OR ED 105

Dr. Smith's ECG Blog

JUNE 23, 2024

Given the presentation, the cardiologist stented the vessel and the patient returned to the ICU for ongoing critical care. The above said — it may prove insightful to take another look at the Wellens' Syndrome case instantly recognized by Dr. Smith in the August 12, 2022 post in Dr. Smith’s ECG Blog.

Coronary 112

Coronary CAD CPR Critical Care 112

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 ALS 52

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

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

REBEL EM

AUGUST 7, 2023

Background Information: Delirium is a common and serious condition in patients in the intensive care unit (ICU). It is estimated to affect 30-50% of patients in the ICU and haloperidol is the most frequently used agent in treatment (3). Paper: Andersen-Ranberg NC,et al; AID-ICU Trial Group. 2022 Dec 29. N Engl J Med.

ICU 52

ICU ALS OR EMS 52

REBEL EM

AUGUST 31, 2023

ICU: 42.6% vs 0% ICU length-of-stay: 9 days vs 7 days In-Hospital Mortality: 28.2% ICU Mortality: 56.7% vs 0% ICU length-of-stay: 9 days vs 7 days In-Hospital Mortality: 28.2% ICU Mortality: 56.7% Non-inferiority margin was set at 2.5% later adjusted to INR > 3.0) Non-inferiority margin was set at 2.5%

ICU 57

ICU ALS OR EMS 57

REBEL EM

MARCH 23, 2023

Chronic alcohol use causes changes to preserve homeostasis, and when the stimulus is removed, alcohol withdrawal results due to decreased inhibition via the GABA system and increased excitation via the glutamate system. Tolerance to alcohol can also result in cross-tolerance to benzodiazepines and to a lesser degree barbiturates.

ICU 52

ICU Emergency Department ALS OR 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. 2022 Sep;36(8):1228-1241. Epub 2022 Aug 8. 2022 Sep;36(8):1217-1227. 2022 Sep;36(8):1217-1227. Epub 2022 Aug 3. 2022 Aug 12;23(1):80. 2022 Nov 26;23(1):120.

Emergency Medical Services 52

Emergency Medical Services EMS CPR Paramedic 52

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

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

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

ACEP Now

MAY 9, 2024

After developing encephalopathy and hypoxemic respiratory failure, the patient was transferred to the ICU. Further diagnostic testing in the ICU identified salicylate toxicity. Further diagnostic testing in the ICU identified salicylate toxicity. Rockville (MD): Agency for Healthcare Research and Quality (US); 2022 Dec.

Emergency Department 52

Emergency Department ICU ALS ACS 52

ACEP Now

DECEMBER 10, 2023

You ultimately begin a slow naloxone infusion and admit him to the medical ICU. 2022 Jun;34(3):473-474. His POLST says comfort measure only (CMO) and we should respect his wishes.” You find yourself in a situation which is ethically, emotionally, and legally challenging for all physicians. You order IV potassium and magnesium.

Naloxone 52

Naloxone Life Support ALS Paramedic 52

EMDocs

OCTOBER 21, 2023

More common in the setting of atherosclerotic lesions than emboli, which typically occur with sudden onset of symptoms. Symptoms may range from days to months prior to stroke onset. As many as two-thirds of patients with BAO experience prodromal symptoms, including TIAs, minor strokes, or other symptoms.

EMS 74

EMS ALS OR ACS 74

Dr. Smith's ECG Blog

JUNE 21, 2024

A patient in the ICU with significant underlying cardiac disease [HFrEF 30%, non-ischemic cardiomyopathy, LBBB s/p CRT-D (biventricular pacer), AVNRT s/p ablation a few yrs ago, hx sinus tachycardia while on max tolerated BB therapy] went into a regular wide-complex tachycardia after intubation for severe COPD exacerbation.

ICU 75

ICU OR 75

ACEP Now

MAY 4, 2023

Definitive treatment with surgical stabilization has been gaining favor, with current literature suggesting decreased ICU stays and fewer complications, especially with patients under 60 years old when taken to the operating room within 72 hours of injury. 2022; 22(11):432-439. 2022; 276:221-234. References Mistry RN, Moore JE.

EMS 52

EMS Operating Room ICU Emergency Department 52

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

MAY 30, 2022

Like most things in ICU this is likely physiological wishful thinking rather than good science and it keeps us amused while the disease process resolves on its own. Lose the Na and the water will follow. First on the list of course is furosemide. Furosemide is one of several loop diuretics. A class largely occupied by spironolactone.

Critical Care 52

Critical Care ICU OR 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

Don't Forget the Bubbles

OCTOBER 19, 2023

Secondary outcome analysis showed there was no difference in length of hospital stay, ICU stay, or duration of oxygen therapy. Sure, they had their ups and downs (what couple doesn’t?), but after more than 40 years of courtship, Ken proposed to Barbie. After a gorgeous wedding, they soon announced their wonderful news: Barbie was pregnant.

E-9-1-1 81

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

Core EM

JANUARY 25, 2024

The standard of care of treating DKA is fluid resuscitation, electrolyte management, and intravenous insulin infusion in the intensive care unit (ICU) setting for close glucose and electrolyte monitoring. Recent research aims at investigating the treatment of DKA with subcutaneous insulin in non-ICU settings. Image from cited article.

EMS 246

EMS ICU ED OR 246