The Skeptics' Guide to EM

SEPTEMBER 2, 2023

The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis): Impacts on ED operational metrics. The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis): Impacts on ED operational metrics. He is wondering, “Hey doc, do I have to go back to the ICU strapped to an IV pole?” He is otherwise healthy.

ICU 201

ICU ED Critical Care ALS 201

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 141

ICU ED OR Critical Care 141

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 98

ED ICU Emergency Department Overdose 98

Core EM

JANUARY 25, 2024

Background: The immediate post intubation period in the ED is a critical time for continued patient stabilization. The reality of ever increasing ED volumes and longer boarding times to the ICU makes it imperative for emergency physicians to learn how to manage these critical patients.

ICU 246

ICU Emergency Department Critical Care ALS 246

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 136

ICU Emergency Department ALS ED 136

REBEL EM

FEBRUARY 15, 2024

Background: Patients with decreased level of consciousness due to alcohol, drugs, or medications commonly present to the ED. These patients can be at risk of vomiting and aspiration and often prompts clinicians to pursue definitive airway management to avoid pneumonia and other complications. References: Freund Y et al.

ICU 141

ICU ALS ED OR 141

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 105

ICU ED ALS OR 105

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 187

ICU ALS Ambulance OR 187

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 100

ICU ED 100

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 189

ICU Defibrillator CPR Paramedic 189

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

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

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

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

EMDocs

FEBRUARY 26, 2024

The ED clinician should inquire about a relevant history of HIV infection, malignancy, high-dose corticosteroid use, chemotherapy, organ transplant, or use of immunosuppressive drugs for other indications. She reports occasional central chest pain exacerbated by coughing. Int J STD AIDS. 2019;30(2):188-193. Am J Emerg Med. 2013;31(2):401-405.

E-9-1-1 87

E-9-1-1 ED ALS OR 87

EMDocs

SEPTEMBER 25, 2023

However, RSI has never been shown to reduce the risk of aspiration in the ED (13) or during emergent OR cases (14). While RSI should remain the gold standard in the vast majority of patients in the ED, FI presents an additional technique to mitigate anatomic or physiologic risk. To date, ketamine has been the agent of choice (12).

ED 65

ED Emergency Department ALS Paramedic 65

Core EM

JANUARY 25, 2024

More than 1/3 of geriatric trauma patients presenting to the ED after a fall return to the ED or die within one year of initial evaluation. 4 Elderly patients, who comprise only 8-12% of total ED major trauma cases, represent a disproportionate 15-30% of trauma mortalities and costs. of those report a fall-related injury.

ALS 246

ALS ED ICU OR 246

The Bottom Line

JANUARY 10, 2024

In acutely ill adults (ED / ICU) does the administration of cefipime or piperacillin-tazobactam (pip-taz) result in an increased incidence of AKI or death by day 14?

ICU 62

ICU ED OR 62

The Skeptics' Guide to EM

APRIL 22, 2023

Case: A 14-month-old boy presents to the emergency department (ED) with two days of upper respiratory symptoms and respiratory distress. 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]. He has a cough, fever of 38.5°C,

ICU 130

ICU Emergency Department ALS ED 130

The Skeptics' Guide to EM

JUNE 22, 2024

Dr. Anireddy Reddy Case: A 3-year-old girl presents to the emergency department (ED) with fever and respiratory distress. Your ED team quickly intubates her and places her on a ventilator. Her parents tell you that she has been sick for almost a week and her symptoms seem to be getting worse. Her oxygen saturation is 78% on room air.

Critical Care 133

Critical Care ICU ALS Emergency Department 133

EMDocs

OCTOBER 29, 2024

A 43-year-old male with a history of mitral valve regurgitation s/p valvular replacement, hypertension, hyperlipidemia was evaluated in the ED for septic shock secondary to a pyelonephritis with a renal abscess. Left ventricular outflow tract obstruction in ICU patients. He has clinically deteriorated and required intubation.

E-9-1-1 87

E-9-1-1 ICU Epinephrine EMS 87

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? Question: In adult patients admitted to the ICU with severe CAP, does methylprednisolone compared to placebo reduce 60-day all-cause? Reyes LF, Garcia E, Ibáñez-Prada ED, et al.

ICU 80

ICU CAD ALS OR 80

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

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 75

ICU Emergency Department ED OR 75

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 246

ICU ED OR 246

Critical Care Scenarios

NOVEMBER 15, 2020

Takeaway lessons Many decisions in the ED are less about what to do, and more about when to do it. Takeaway lessons * Many decisions in the ED are less about what to do, and more about when to do it. Goals of care starts in the ED, and not with lip service. ICU time and ED time are different.

ICU 100

ICU Life Support Emergency Department ED 100

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

The Skeptics' Guide to EM

JULY 16, 2022

Case: A 59-year-old woman presents to the emergency department (ED) with fever, tachycardia, and hypotension. She is admitted to the intensive care unit (ICU) for septic shock. The ICU team is considering using Vitamin C therapy for this patient. She is found to have a urinary tract infection. Reference: Lamontagne F et al.

ICU 100

ICU ALS Critical Care Emergency Department 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

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 104

ICU ALS ED Emergency Department 104

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 68

ICU ED OR 68

The Skeptics' Guide to EM

OCTOBER 3, 2021

Some bench work, observational studies, and now two large, unblinded, cluster-randomized single-center trials ( SMART and SALT-ED ) suggested a benefit to using balanced crystalloids (i.e. The SALT-ED trial was also a single-centre unblinded trial, but the primary outcome was hospital free days. Reference: Zampieri et al.

OR 130

OR Critical Care ICU Plasma 130

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 145

Allergic Reaction Plasma ED Epinephrine 145

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

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 Emergency Department ED 100

REBEL EM

JUNE 29, 2023

REBEL Cast Ep119: A Discussion with Scott Weingart on the CT FIRST Trial Click here for Direct Download of the Podcast Timing Is 6hrs reasonable because most pts excluded because of this Right before heading up to ICU seems good 1st couple hours after ROSC…pts are high risk for re-coding Where Not single coverage or stand-alone EDs Optimize and transfer…scans (..)

CPR 145

CPR ICU EMS ALS 145

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-9-1-1 109

E-9-1-1 Emergency Department ICU ALS 109