The Skeptics' Guide to EM

JUNE 12, 2022

He is board certified […] The post SGEM#368: Just A Normal Saline Day in the ICU – The PLUS Study first appeared on The Skeptics Guide to Emergency Medicine. Then, the BaSICS trial (a multicentred RCT done in 75 Brazilian ICUs) came along and compared saline to Plasma-Lyte at what the authors deemed slow and fast infusion rates. .

ICU 132

ICU Plasma Critical Care ALS 132

The Skeptics' Guide to EM

JULY 27, 2024

They were randomized to ceftriaxone 2gm intravenous (IV) in the ambulance or usual cares (fluids and supplementary oxygen) until arrive to the ED. The primary outcome reported was no statistical difference in mortality at 28 days (8% in both groups) despite giving antibiotics 96 minutes earlier [2].

ICU 246

ICU ALS Ambulance OR 246

The Skeptics' Guide to EM

APRIL 27, 2024

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. When emergency department (ED) staff roll her to remove her clothing her humeral intraosseous (IO) is dislodged. Prehospital Emergency Care. February 2024.

ICU 231

ICU Defibrillator Paramedic CPR 231

EMOttawa

JANUARY 25, 2024

Mechanical ventilation has a lot of nuance associated with it, but a lot of reference guides focus on care in the ICU. There is certainly a need for more practical application for the ED doc or initial setup of patients on the vent.

ICU 143

ICU ED OR Critical Care 143

ALiEM

JUNE 1, 2023

Are you using phenobarbital instead of benzodiazepines as the first-line monotherapy for patients in alcohol withdrawal in the Emergency Department (ED)? Is phenobarbital safe for the treatment of EtOH withdrawal in the ED? If not, you probably should be. Another old drug for a new indication, right? Well not exactly. In short, yes.

Emergency Department 246

Emergency Department ICU ED OR 246

Core EM

JANUARY 25, 2024

A narrow pulse pressure has been shown to predict the need for hemorrhage control in the ED setting but has not been assessed as a predictor in the prehospital setting. A narrow pulse pressure occurs due to compensatory increased systemic vascular resistance in the setting of decreased cardiac output.

Operating Room 246

Operating Room EMS ED ICU 246

ALiEM

OCTOBER 30, 2024

Our experience: Traditionally, ED physicians do not like ordering urine drug screens (UDS). We have certainly seen patients who have pain which is controlled and still have psychomotor agitation and sympathetic activation, leading some to require ICU admission for dexmedetomidine and/or ketamine infusion. JAMA Network Open.

E-9-1-1 161

E-9-1-1 Naloxone Emergency Department ALS 161

REBEL EM

JULY 17, 2023

REBEL Cast Ep120: Etomidate vs Ketamine for RSI in the ED? PMID: Clinical Question: Does a single dose of ketamine or etomidate used for rapid sequence intubation (RSI) of critically adults in the ED impact the SOFA score within 3 days of hospitalization? Click here for Direct Download of the Podcast Paper: Knack SKS et al.

ED 97

ED ICU Emergency Department Overdose 97

The Skeptics' Guide to EM

SEPTEMBER 14, 2024

Case: It’s another day, another dollar in the emergency department (ED). You wonder if she could have an allergy challenge dose of ceftriaxone in the ED. Emergency Physicians frequently encounter ED patients with self-reported penicillin allergies. AEM August 2024. The next patient is a 63-year-old woman with a cough and fever.

ICU 141

ICU Emergency Department ALS ED 141

EMCrit Project

AUGUST 26, 2022

It is unacceptable to have the rates of Awareness during Paralysis seen in a recent ED sedation study--We are better than this. EMCrit Project by Scott Weingart, MD FCCM.

ICU 101

ICU ED 101

Broome Docs

JANUARY 27, 2025

European Journal of Internal Medicine , [link] You can listen to my 27-minute rant on Youtube here: [link] This multinational trial looked at a three-pronged diagnostic protocol in the ED for adults with suspected acute aortic syndromes. The protocol used the ADD score, a POCUS echo protocol and D-dimer to try and exclude AAS in the ED.

ED 101

ED OR ACS Critical Care 101

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. The SQuID Protocol (Subcutaneous Insulin in /diabetic Ketoacidosis): Impacts on ED Operational Metrics. Paper: Griffey RT et al. Acad Emerg Med 2023.

ICU 102

ICU ED ALS OR 102

The Skeptics' Guide to EM

FEBRUARY 25, 2023

Sodium bicarbonate use during pediatric cardiopulmonary resuscitation: a secondary analysis of the icu-resuscitation project trial. 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. Pediatric Crit Care Med.

CPR 130

CPR ICU Critical Care Defibrillator 130

Core Ultrasound

MARCH 25, 2024

For example a pt in the ED with sepsis, and a collapsible IVC, dry lungs and no peripheral edema is more likely to benefit from fluid than be harmed Take that same pt, with the same US and physical exam findings and make it 72-hrs later in the ICU after 6-10 L. For this we use clinical judgement, US findings, PE findings.

ICU 189

ICU ED OR 189

EMergucate

MAY 1, 2020

40 year old healthy ICU nurse, works with COVID-19 patients. She was brought to ED by ambulance after collapsing in a shower. Her pulse rate was 120 and blood pressure was 120/80. Her blood gases (…

ICU 100

ICU Ambulance ED 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

JUNE 15, 2024

. #1: PREOXI RCT – Preoxygenation with Noninvasive Ventilation vs. Non-rebreather Mask Spoon Feed Noninvasive ventilation (NIV) was superior to a standard non-rebreather (NRB) oxygen mask for preoxygenation of critically ill ED or ICU patients requiring intubation, with a NNT of 11 to prevent 1 episode of hypoxemia <85%.

ICU 98

ICU Emergency Department ED OR 98

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). Clay Smith at @spoonfedEM , and sign up for email updates here. #1: Neurology vol.

ICU 96

ICU ED OR 96

Critical Care Scenarios

NOVEMBER 29, 2020

Looking at the workflow of a fresh post-op open heart surgery patient, as well as what to do when it devolves into cardiac tamponade, with (returning) guest Brendan Riordan, cardiothoracic ICU PA (@concernecus) at the University of Washington, and his NP colleague Kris Ramilo (@krsrml0). Audio quality was a bit dodgy in this one; sorry all!–eds.]

ICU 100

ICU Epinephrine OR ED 100

ACEP Now

JANUARY 4, 2025

I was about two months into a family practice internship when I went to visit my uncle whose neighbor happened to be an ED resident, Dr. Clarke said. ED attendings Dr. Gerald Whelan and Dr. Shumary Chow supervising a full arrest in C booththe main trauma roomwith an ED tech administering CPR. Click to enlarge.) Click to enlarge.)

ED 52

ED Emergency Department Ambulance CPR 52

The Skeptics' Guide to EM

JUNE 6, 2020

Max is then going to Georgetown to be an attending in both EM and ICU. Case: It’s another day in your emergency department (ED). The triage nurse places a 61 year-old-man with fever, hypotension, cough into the smallest room in the ED. You scan through the EMR and see the blood pressure is 60/40.

EMR 130

EMR ALS ICU Emergency Department 130

The Skeptics' Guide to EM

MARCH 27, 2021

2020 Case: A 74-year-old woman who suffered a fall earlier today presents to the emergency department (ED) and is found to have five rib fractures to her right thorax, but no other injury. His team found grip strength was weakly correlated with frailty in older ED patients [6]. J Trauma Acute Care Surg. Reference: Schuster et al.

ICU 100

ICU ALS ED Emergency Department 100

Critical Care Scenarios

JULY 11, 2021

Our guest is trauma surgeon Dr. Dennis Kim ( @traumaicurounds ), associate professor of Clinical Surgery at UCLA and medical director of the Harbor-UCLA Medical Center SICU, as well as host of the Trauma ICU Rounds podcast. Traction splinting is usually not done in the ED.

Operating Room 100

Operating Room ICU ED OR 100

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. JAMA Netw Open. 2022;5(4):e226417.

ICU 80

ICU ALS ED Emergency Department 80

EMDocs

JULY 8, 2023

. #1: DEVICE RCT – VL vs DL for Critically Ill Adults Spoon Feed Video laryngoscopy (VL) was associated with higher rates of first attempt intubation success compared to direct laryngoscopy (DL) for critically ill patients in the ICU and ED.

ICU 95

ICU ED OR 95

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

The Skeptics' Guide to EM

NOVEMBER 16, 2019

Case: A 59-year-old woman comes is brought into your emergency department (ED) by EMS in cardiac arrest. The patient achieved return of spontaneous circulation (ROSC) on arrival to the ED. She had a witnessed arrest, and CPR was initiated by bystanders.

ALS 100

ALS CPR ICU EMS 100

University of Maryland Department of Emergency Med

JULY 17, 2023

Central Venous Catheter (CVC; aka central line) placement is a common procedure in both the ED and ICU, and while overall quite safe, does ca. Click to view the rest

ICU 58

ICU ED 58

CanadiEM

JUNE 4, 2024

You are on-call – covering medicine and ICU admissions – while overseeing 20 admitted patients. You receive 3 new admissions from the ED, but you still have to move 2 sick patients to the ICU. Your wards are at capacity. You also have to prepare 3 discharges for the next morning.

ICU 52

ICU ED 52

Broome Docs

SEPTEMBER 3, 2024

PMID: 38592662 Bottom line: Would you be happy if you kid follow-ed your footsteps into emergency medicine? For the most part, central lines can be left to the ICU team during day time hours (and a good percentage of patients will never need one). Maybe ED is not the best place for all patients! 2024 Jun;26(6):381-385.

E-9-1-1 95

E-9-1-1 Emergency Department ICU ALS 95

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. Surawicz, B.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

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. They administer two doses of 10 mg midazolam IM.

STEMI 102

STEMI Coronary Emergency Department ICU 102

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 137

ICU OR ALS ED 137

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 Life Support 111

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

The Skeptics' Guide to EM

DECEMBER 25, 2017

Everyone on the team from the pre-hospital setting, to the ED, in-patient, ICU and primary care providers. I can’t tell you how much it means to have an audience of people committed to providing patients with great care in their time of need. Take a moment to recognize what an important role you play in so many lives.

ICU 100

ICU ED 100

EMDocs

APRIL 2, 2024

Check the pulse RSI= Resuscitation Sequence Intubation Hypoxia, Hypotension, and Acidosis are the reason patients code during/post intubation These patients are super high risk for all 4 Optimize first pass success – Induction agent + paralytic Unconscious patients will still have muscle tone Induction Ketamine or Etomidate at half doses (i.e.,

CPR 116

CPR STEMI Epinephrine ICU 116