The Skeptics' Guide to EM

SEPTEMBER 14, 2024

Date: September 12, 2024 Reference: Anderson et al. A pivotal study by Raja et al. The use of direct oral challenges has been tried in the intensive care unit (ICU) setting to de-label patients. Koo et al showed that offering amoxicillin oral challenges to ICU patients with low-risk penicillin allergies.

ICU 136

ICU Emergency Department ALS ED 136

The Skeptics' Guide to EM

APRIL 27, 2024

Reference: Tanner et al, A retrospective comparison of upper and lower extremity intraosseous access during out-of-hospital cardiac arrest resuscitation. Date: April 25, 2024 Guest Skeptic: Missy Carter is a PA working in an ICU in the Tacoma area and an adjunct faculty member with the Tacoma Community College paramedic program.

ICU 189

ICU Defibrillator CPR Paramedic 189

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?

ICU 141

ICU ALS ED OR 141

REBEL EM

MAY 29, 2024

The idea behind abx is to prevent things like AOM and TSS but neither should be much of an issue with short term placement ICU Admission? Traditional teaching is that these patients are at risk for life-threatening bradydysrhythmias and should go to the ICU Literature here is non-existent. PMID: 5569677 Zeyyan E et al.

ICU 105

ICU ALS ACS EMS 105

Emergency Medicine Ireland

MAY 27, 2024

Vasopressin has some animal data suggesting it causes less rise in PVR than our beloved noradrenaline but take that with an appropriately loosely defined portion of salt given that animal data is not ICU patients. Atrial fibrillation is something of a right of passage in the ICU. In terms of monitoring should we be reaching for a PAC?

Critical Care 52

Critical Care ICU OR ALS 52

Core EM

JANUARY 25, 2024

11 Geriatric trauma patients require increased immediate and delayed ICU resources compared to younger counterparts with the same injuries. Perdue &al. Caterino &al. Sterling &al. Liu &al. Gill &al. Demetriades D &al. Goode &al. Hasegawa &al. Li &al.

ALS 246

ALS ED ICU OR 246

The Skeptics' Guide to EM

JANUARY 20, 2024

Reference: Zaoutis T, et al. Reference: Zaoutis T, et al. Reference: Zaoutis T, et al. Short-course Therapy for Urinary Tract Infections in Children: the SCOUT randomized clinical trial. JAMA Pediatr. Short-course Therapy for Urinary Tract Infections in Children: the SCOUT randomized clinical trial. JAMA Pediatr. JAMA Pediatr.

Emergency Department 179

Emergency Department ALS ICU OR 179

Core EM

JANUARY 25, 2024

Disposition to ICU. References: Yuan TH, Kerns WP, Tomaszewski CA, et al. von Lewinski D, Bruns S, Walther S, et al. Cole JB, Corcoran JN, Engebretsen KM, et al. Holger JS, Engebretsen KM, Fritzlar SJ, et al. Kerns W, Schroeder D, Williams C, et al. Kline JA, Tomaszewski CA, Schroeder JD, et al.

Overdose 246

Overdose ALS Epinephrine Critical Care 246

The Skeptics' Guide to EM

APRIL 22, 2023

Date: April 20, 2023 Reference: Franklin D, et al. Date: April 20, 2023 Reference: Franklin D, et al. Previous research has shown that HFNC can lower the rate of escalation of care but showed no impact on admission to the intensive care unit (ICU) or length of stay [1]. Reference: Franklin D, et al.

ICU 130

ICU Emergency Department ALS ED 130

EMDocs

NOVEMBER 29, 2023

EBM Update: Steroids in Severe CAP and CT in Post ROSC OHCA #1: Dequin PF, Meziani F, Quenot JP, et al; CRICS-TriGGERSep Network. Question: In adult patients admitted to the ICU with severe CAP, does hydrocortisone compared to placebo reduce 28-day all-cause mortality? Reyes LF, Garcia E, Ibáñez-Prada ED, et al. N Engl J Med.

ICU 80

ICU CAD ALS OR 80

The Skeptics' Guide to EM

JUNE 22, 2024

Reference: Peters MJ, et al. Reference: Peters MJ, et al. Conservative versus liberal oxygenation targets in critically ill children (Oxy-picu): a UK multicentre, open, parallel-group, randomised clinical trial. But like many interventions, there are potential harms and benefits. While the term “benefits” implies a positive outcome.

Critical Care 133

Critical Care ICU ALS Emergency Department 133

EMDocs

OCTOBER 29, 2024

He was started appropriately on vancomycin and cefepime and accepted for ICU admission but remains in the ED due to boarding and bed lock. Left ventricular outflow tract obstruction in ICU patients. He has clinically deteriorated and required intubation. m/s)—problematic and elevated > 50 mm Hg (2.5 Curr Opin Crit Care.

E-9-1-1 87

E-9-1-1 ICU Epinephrine EMS 87

The Skeptics' Guide to EM

FEBRUARY 25, 2023

Reference: Cashen K, Reeder RW, Ahmed T, et al. Sodium bicarbonate use during pediatric cardiopulmonary resuscitation: a secondary analysis of the icu-resuscitation project trial. Reference: Cashen K, Reeder RW, Ahmed T, et al. Background: We often manage patients in cardiac arrest in the ED or the intensive care unit (ICU).

CPR 130

CPR ICU Critical Care Defibrillator 130

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

FEBRUARY 8, 2024

Paper: Haber, EN et al. PMID: 38215002 Clinical Question: In critically ill adults in the ICU is noninvasive blood pressure (NIBP) monitoring similar (≤10% difference) to invasive arterial blood pressure (IABP) monitoring? Accuracy of Noninvasive Blood Pressure Monitoring in Critically Ill Adults. J Intensive Care Med 2024.

MICU 126

MICU ICU ALS EMS 126

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 81

ICU Operating Room Critical Care ALS 81

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. 1, 2 Its occurrence often portends worse outcomes in intubated patients, whose projected hospital course was already tenuous. 4, 8 Paper: Dahyot-Fizelier, C.,

E-9-1-1 126

E-9-1-1 ICU OR ALS 126

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

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? References: Yerke JR et al. PMID: 37611862 Evans L et al. CHEST 2024. CHEST 2024. Crit Care Med 2021.

ICU 137

ICU EMS ALS OR 137

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? Hydrocortisone in severe community-acquired pneumonia.

Critical Care 94

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

The Skeptics' Guide to EM

SEPTEMBER 28, 2019

Date: September 11th, 2019 Reference: Putzu et al. Date: September 11th, 2019 Reference: Putzu et al. Case: A 45-year-old female in the emergency department is being admitted to the intensive care unit (ICU) for septic shock secondary to urinary tract infection (UTI). You are ready to call the ICU and get her admitted.

ICU 130

ICU Critical Care ALS Emergency Department 130

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

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. She is admitted to the intensive care unit (ICU) for septic shock. The ICU team is considering using Vitamin C therapy for this patient. Reference: Lamontagne F et al. Guest Skeptic: Dr. Salim R.

ICU 100

ICU ALS Critical Care Emergency Department 100

ALiEM

JUNE 1, 2023

References Rosenson J, Clements C, Simon B, et al. Several studies have indicated that dosing with phenobarbital (PO or IV) is safe and effective at decreasing the need for escalating doses of benzodiazepines for EtOH withdrawal [1-6]. barbiturates or benzodiazepines). The Journal of Emergency Medicine. 2013;44(3):592-598.e2. 2012.07.056.

Emergency Department 246

Emergency Department ICU ED OR 246

ACEP Now

OCTOBER 15, 2023

Intravenous insulin infusions typically require treatment in highly monitored settings, such as an intensive care unit (ICU) or step-down unit for safety and due to the frequency and intensity of monitoring. ICU and step-down beds are a limited resource and generate higher hospital charges. ElSayed NA, Aleppo G, Aroda VR, et al.

ICU 104

ICU ALS ED Emergency Department 104

EMDocs

FEBRUARY 20, 2024

Fluids in Pancreatitis #1 : de-Madaria E, Buxbaum JL, Maisonneuve P, et al; ERICA Consortium. 2: Li XW, Wang CH, Dai JW, et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. N Engl J Med. 2022 Sep 15;387(11):989-1000. 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

REBEL EM

APRIL 22, 2024

Paper: Nielsen FM et al. Population: Adult patients ( > 18 years of age) admitted to the ICU with COVID-19 and severe hypoxemia (defined as receiving supplemental O2 with a flow rate of at least 10L/min or receiving mechanical ventilation or non-invasive ventilation. The HOT-COVID Randomized Controlled Trial.

Life Support 75

Life Support ICU EMS OR 75

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. Paper: Owyang CG, et al. 2019 Aug; PMID: 30954692 Clinical Question: What is the impact of system factors in the implementation of standard-of-care LPV in critically ill ED patients admitted to the ICU?

Emergency Department 52

Emergency Department ICU Critical Care EMR 52

REBEL EM

NOVEMBER 30, 2023

Secondary Outcomes: Delayed hypotension, increased ICU stay, and other relevant outcomes. Kuttab et al’s findings, constituting 45% of the review’s weight, suggest that administering <30cc/kg IVF is associated with increased odds of mortality, delayed hypotension, and increased ICU utilization. 2.89, p = 0.01.

E-9-1-1 122

E-9-1-1 ALS ACS ICU 122

EMDocs

NOVEMBER 29, 2023

EBM Update: Fluids in Pancreatitis, Hypertriglyceridemic Pancreatitis #1: de-Madaria E, Buxbaum JL, Maisonneuve P, et al; ERICA Consortium. 2: Li XW, Wang CH, Dai JW, et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. N Engl J Med. 2022 Sep 15;387(11):989-1000. to 9.8L) Moderate: 5.5L (Range 4.0

E-9-1-1 66

E-9-1-1 ICU ALS OR 66

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 22, 2024

A) Amniotic fluid embolism B) Eclampsia C) Placental abruption D) Pulmonary embolism Answer: A Amniotic fluid embolism (AFE) is a rare but potentially fatal complication of pregnancy. AFE should be considered in a patient who experiences cardiorespiratory collapse during labor or shortly thereafter.

EMS 96

EMS Ambulance FFP ICU 96

ACEP Now

JULY 7, 2024

Should emergency physicians rely on standard textbooks for diagnostic and treatment regimens? Or should recent literature guide diagnosis and management? Status epilepticus has previously been defined as seizure(s) greater than or equal to 30 minutes in which the patient does not regain normal mental status between seizures.

Emergency Department 52

Emergency Department Critical Care ALS ICU 52

Emergency Medicine Ireland

OCTOBER 14, 2024

The major barrier to implementation in the ICU setting is the almost complete absence of ICU patients from these trial cohorts. And as we all know if there is a complication possible it’s almost definitely going to happen with greater frequency in the ICU cohort. LDH>1000 Sugar <2.2 What are your options?

Critical Care 52

Critical Care ICU ALS OR 52

Don't Forget the Bubbles

AUGUST 23, 2023

Kapoor et al. 2018) “Sacred Pause Imitative in the ICU: A survey of ICU physicians and nurses”. Oppressive quietness heavy with professionals’ suppressed emotions mixed with raw parental grief. That piercing parental cry rips through the room. Our bodies primed for the fight. Or exhausted from it. Some feel a nothingness.

Emergency Department 98

Emergency Department ICU ALS Critical Care 98

REBEL EM

JANUARY 9, 2024

This feels intuitive as the IV route seems like it would be stronger, faster, and fix the patient better than the oral route. Except for patients with poor gut absorption or those with critical infectious processes such as septic shock or necrotizing fasciitis, this belief appears to be unfounded.

ALS 100

ALS ICU ED OR 100

The Skeptics' Guide to EM

JANUARY 15, 2022

0.3mg/kg IV * Outcome: * Primary Outcome: 7-day survival * Secondary Outcomes: 28-day survival, duration of mechanical ventilation, ICU length of stay, need for vasopressor use, SOFA scores and an assessment of a new diagnosis of adrenal insufficiency by the treating critical care teams. Date: January 16th, 2022 Reference: Matchett, G.

Emergency Medical Services 107

Emergency Medical Services Firefighter Critical Care Paramedic 107