ACEP Now

JULY 7, 2024

Neurology consultation should be initiated, and the patient should be admitted to the ICU. References Brophy GM, Bell R, Claassen J, et al. Zehtabchi S, Abdel Baki SG, Omurtag A, et al. Towne AR, Waterhouse EJ, Boggs JG, et al. Huff JS, Melnick ER, Tomaszewski CA, et al. Paliwal P, Wakerley BR, Yeo LLL, et al.

Emergency Department 52

Emergency Department Critical Care ALS ED 52

EMS 12-Lead

AUGUST 22, 2022

A 65 y/o Female was admitted to the ICU for septic shock. Beats 9-12 : Continuation of the previously described events, all inducible by the pause (and thus, prolongation of refractoriness) created by the PVC of Beat 8. She was critically ill despite aggressive vasopressor therapy. References Chiale, P. JACC, Vol 23, No 3; 724-32.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

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

The Skeptics' Guide to EM

JUNE 4, 2017

[display_podcast] Date: June 3rd, 2017 Reference: Sierink et al. display_podcast] Date: June 3rd, 2017 Reference: Sierink et al. Huber-Wagner et al ( Lancet 2009 ) showed a mortality reduction in a retrospective database study of patients who have had a pan scan. Reference: Sierink et al. Lancet August 2016.

OR 130

OR ALS CPR ICU 130

REBEL EM

AUGUST 21, 2023

Background Information: Cardiac arrest is a devastating event that imposes considerable human and financial burdens. Paper: Eastwood G, et al. PMID: 37318140 Mckenzie N, et al Arterial carbon dioxide tension has a nonlinear association with survival after out-of-hospital cardiac arrest: A multicentre observational study.

Critical Care 98

Critical Care E-9-1-1 CPR 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. Roy A, Allareddy V, Lee M, Nalliah R, Rampa S, Allareddy V, Rotta A. Critical Care Medicine 41(12):p A191, December 2013. 2020 Feb 12;10(1):2470.

E-9-1-1 75

E-9-1-1 ICU ACS EMS 75

REBEL EM

SEPTEMBER 5, 2022

Paper 1: Schmidt HJ et al. PMID: 360027567 [ Access on Read by QxMD ] Paper 2: Kjaergaard J et al. References: Schmidt HJ et al. PMID: 360027567 [ Access on Read by QxMD ] Kjaergaard J et al. A higher MAP may offer advantages due to improved cerebral perfusion pressure, however data is lacking. Liberal O2: 33.9%

ICU 52

ICU ALS OR CPR 52

AAEM RSA

AUGUST 27, 2020

Nielsen N, Wetterslev J, Cronberg T et al. By the time of the study by Nielsen et al. The authors also investigated harms in both groups and determined no significant difference in adverse events between both groups. Kirkegaard H, Soreide E, de Haas, I et al. Kirkegaard et al. New Engl J Med. 2017;318(4):341–350.

E-9-1-1 52

E-9-1-1 CPR ICU ALS 52

EMDocs

APRIL 10, 2024

While not specifically reviewed in this post, check out the methemoglobinemia tox card for more information about one of the other known events that can occur with local anesthetic administration. Hemodynamics slowly begin to stabilize, and the patient is transferred to the ICU for further post-cardiac arrest care. BMJ Case Rep.

E-9-1-1 93

E-9-1-1 Plasma Epinephrine EMS 93

Emergency Medicine Ireland

JULY 5, 2021

Peak levels occur ~15-120 mins post event and decline predictably (T1/2 ~2hrs). The ALS guidance is all about the IM and this should continue to be the case though there is a caveat for IV adrenaline use by “experts” in quotation marks. Treatment is adrenaline.

Critical Care 40

Critical Care ICU ALS OR 40

REBEL EM

OCTOBER 5, 2023

Paper: Dequin P, Meziani F, Quenot J, et al. ClinicalTrials.gov: NCT02517489 7 Clinical Question: In adult patients with severe community-acquired pneumonia admitted to the ICU, does early hydrocortisone treatment, compared to standard therapy, reduce mortality at 28 days? 70 events in the hydrocortisone group. N Engl J Med.

Critical Care 94

Critical Care ICU E-9-1-1 ALS 94

REBEL EM

FEBRUARY 19, 2024

Paper: Yerke JR et al. 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? No Extravasation Event vs Extravasation Event Age: 63 vs 67 years BMI: 28.3 CHEST 2024. Not met in 15.7%

ICU 137

ICU EMS ALS OR 137

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. He went into cardiogenic shock and is intubated in the cardiac ICU. The main premise of my qualitative approach — is to be suspicious of an acute cardiac event when you see ST-T wave findings that shouldn't be there.

Coronary 52

Coronary Paramedic EMS ICU 52

EMDocs

APRIL 22, 2024

EMS verbalized concern to EPs that an “intracranial bleed” may have precipitated the event. 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., Available from: [link] Meneveau, Nicolas, et al. 10,11 Vid 1.

ED 82

ED NARCAN ALS OR 82

REBEL EM

FEBRUARY 15, 2024

Paper: Freund Y et al. PMID: 38019968 Clinical Question: In patients with suspected acute poisoning and GCS <9, is a conservative airway strategy of withholding intubation associated with a reduction in death, ICU LOS, and hospital LOS compared with routine practice of intubation? References: Freund Y et al.

ICU 141

ICU ALS ED OR 141

REBEL EM

AUGUST 12, 2024

The authors of this study sought to test the hypothesis that intravenous amino acid therapy would lead to a lower occurrence of postoperative AKI when compared to placebo. Paper: Landoni G. Intravenous amino acid therapy for kidney protection in cardiac surgery a protocol for a multi-centre randomized blinded placebo controlled clinical trial.

ICU 80

ICU Critical Care Operating Room ALS 80

Dr. Smith's ECG Blog

MARCH 12, 2018

It is also true that anterior and inferior T-wave inversion could be consistent with reperfusion of a type III wraparound LAD occlusion, despite the fact that Kosuge et al showed that T-wave inversion in lead III is much more likely to be PE than ACS if your differential contains nothing else. Stein et al. Kosuge et al.

ACS 52

ACS Coronary ALS ICU 52

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. And importantly, adverse event rates were both low and equivalent in both groups. However, Kornelson et al.’s For those in the standard therapy arm, escalation of care meant high flow.

E-9-1-1 81

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

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

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 104

ICU ED ALS OR 104

REBEL EM

MAY 29, 2023

Paper: Ibarra-Estrada, M et al. 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 Limited, small studies on its use in septic shock do not make a clear argument for use. Crit Care 2023.

ICU 145

ICU ALS Epinephrine OR 145

REBEL EM

JUNE 8, 2023

Paper: Singer S, et al. From a safety standpoint this is a great thing, but also could be the reason we see such few adverse events Discussion: There is a recent “push” to utilize “Push dose pressors” as the correction of acute hypotension in a variety of clinical scenarios. Am J Emerg Med. 2022 Sep 5.

Epinephrine 98

Epinephrine Emergency Department ALS Critical Care 98

REBEL EM

JUNE 26, 2023

This could potentially help improve thrombin generation, reduce blood product consumption, but also could increase the risk of thromboembolic events. Click here for Direct Download of the Podcast Paper: Bouzat P et al. Additionally, the use of 4F-PCC resulted in a higher rate of thromboembolic events compared to placebo.

FFP 145

FFP Frozen Plasma ALS Plasma 145

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. To confirm VAP, events were defined in a standardized approach using the American Thoracic Society criteria. 4, 8 Paper: Dahyot-Fizelier, C.,

E-9-1-1 124

E-9-1-1 ICU OR ALS 124

The Skeptics' Guide to EM

OCTOBER 3, 2021

Date: September 28th, 2021 Reference: Zampieri et al. Date: September 28th, 2021 Reference: Zampieri et al. In the two large trials, this benefit was seen as a reduction in a composite outcome of major adverse kidney events within 30 days (MAKE-30). Reference: Zampieri et al. Lactated Ringer’s or Plasmalyte 148) over 0.9%

OR 130

OR Critical Care ICU Plasma 130

EMDocs

SEPTEMBER 25, 2023

The trade off to using FI for these challenging airways is the consideration of an aspiration event, the initial indication for RSI. First pass success (FPS) is key as increased attempts correlate to increased desaturation (>10%) events (~10% on first attempt, ~30% on second attempt, ~60% for 4+ attempts) (15).

ED 65

ED Emergency Department ALS OR 65

EMDocs

OCTOBER 7, 2023

6 Prolonged down time from falls, usually in the elderly Incidence is difficult to ascertain due to broad definition and that events that cause crush injuries are rather rare. Oda J, Tanaka H, Yoshioka T, et al. Tanaka H, Oda J, Iwai A, et al. Chen CY, Lin YR, Zhao LL, et al. Wald R, Quinn RR, Luo J, et al.

EMS 73

EMS E-9-1-1 Emergency Department ALS 73

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. Once a sufficiently high level is achieved, modelling of behaviours and episodes of retaliation can perpetuate the behaviours far beyond the initial event. Frich JC, Brewster AL, Cherlin EJ, Bradley EH. British journal of nursing.

E-9-1-1 105

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

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

REBEL EM

SEPTEMBER 26, 2022

Article: Kumar M et al. The TEG group had a shorter ICU length of stay in the first admission. Patients exclusively managed in the ICU which decreases applicability for patients in other locations Very small sample size of 96 patients No definition was provided for exclusion criteria of significant cardiopulmonary disease.

FFP 52

FFP E-9-1-1 ICU ALS 52

Don't Forget the Bubbles

MAY 3, 2023

Forestell B, Battaglia F, Sharif S, et al. Results of this study showed that the use of low-dose insulin infusion led to similar clinical outcomes and fewer adverse events compared to the standard-dose insulin infusion. units/kg/hr ) is as efficacious as standard-dose, with fewer adverse events. O’Connell et al.

CPR 52

CPR Emergency Department ALS ICU 52

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

MARCH 6, 2019

If for some reason the angiogram is delayed, they should receive maximal medical therapy in an ICU setting with continuous 12-lead ST segment monitoring under the close attention of a practitioner with advanced ECG interpretation training. Patel et al., Krucoff et al.) Patel et al. Krucoff et al. Schomig et al.

STEMI 52

STEMI ALS ACS OR 52

Don't Forget the Bubbles

JULY 5, 2023

They should be admitted to hospital in case of clinical deterioration to receive ICU treatment. However, there are documented adverse events such as haemorrhagic cerebrovascular accidents or recurrence of VOC after drug withdrawal, which represent a drawback in its regular use. This treatment is usually done in the ICU setting.

E-9-1-1 126

E-9-1-1 ACS OR ICU 126

Don't Forget the Bubbles

JANUARY 4, 2024

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. Yam JC, Zhang XJ, Zhang Y, Yip BHK, Tang F, Wong ES, Bui CHT, Kam KW, Ng MPH, Ko ST, Yip WWK, Young AL, Tham CC, Chen LJ, Pang CP.

ED 128

ED ICU ALS OR 128

AAEM RSA

SEPTEMBER 17, 2020

Marik P, Khangoora V, Rivera R, et al. All treatments were given for the assigned time frame or until ICU discharge, whichever came first. Keh D, Trips E, Marx G, et al. Questions Does the treatment of sepsis with a combination of vitamin C, thiamine, and hydrocortisone improve outcomes in septic shock? 2017;151(6):1229-38.

ICU 52

ICU E-9-1-1 ALS OR 52

EMDocs

DECEMBER 18, 2023

1 The rationale for the shift away from normal saline in 2021 derived from multiple trials, including the Isotonic Solutions and Major Adverse Renal Events Trial (SMART) and Saline Against Lactated Ringer’s or Plasma-Lyte in the Emergency Department (SALT ED). References Evans L, Rhodes A, Alhazzani W, et al. Intensive Care Med.

E-9-1-1 65

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