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 195

ICU Defibrillator CPR Paramedic 195

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

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 132

Critical Care ICU ALS Emergency Department 132

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

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 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

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 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. Perdue &al. Am J Emerg Med. Liu &al.

ALS 246

ALS ED ICU OR 246

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. That is a holy grail that we have to stop chasing.

ICU 246

ICU ED OR 246

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

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

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). Originally published at JournalFeed , a site that provides daily or weekly literature updates.

ICU 68

ICU ED OR 68

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

EMDocs

JUNE 22, 2024

A 37-year-old G5P4 at 33 weeks presents to the ED after being brought in by ambulance. We’ll keep it short, while you keep that EM brain sharp. She had a precipitous delivery while the ambulance was pulling in. The newborn is doing well, but the mother is complaining of shortness of breath and chest pain.

EMS 96

EMS Ambulance FFP ICU 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

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

ACEP Now

JULY 7, 2024

1 History and physical examination have been the cornerstone of seizure diagnosis in the emergency department (ED). 1 History and physical examination have been the cornerstone of seizure diagnosis in the emergency department (ED). Should emergency physicians rely on standard textbooks for diagnostic and treatment regimens?

Emergency Department 52

Emergency Department Critical Care ALS ED 52

Critical Care Scenarios

JULY 11, 2021

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. Likewise, many penetrating injury patients with palpable pulses can wait for further resuscitation (whether blood or anything else) until surgery.

Operating Room 100

Operating Room ICU ED OR 100

EMDocs

JUNE 27, 2024

An 8-year old male with a history of sickle cell anemia presents to the ED for evaluation of fever for 2 days and “feeling like I can’t get a full breath”. This series provides evidence-based updates to previous posts so you can stay current with what you need to know. Other lung fields unremarkable. C or 100.4 mg/kg, max 0.4 C or 100.4

E-9-1-1 75

E-9-1-1 ICU ACS EMS 75

Dr. Smith's ECG Blog

OCTOBER 19, 2022

A patient had 3rd degree AV block in the ED. and the 2021 YouTube Review by ICU Advantage on "Temporary Pacemakers: Modes and Basic Settings". A transvenous pacer was placed in the Emergency Department by the emergency physicians. Capture was obtained and a 12-lead ECG was recorded: What do you see here and what complication can occur?

ED 52

ED ICU OR Emergency Department 52

EMDocs

FEBRUARY 12, 2024

As the only respiratory therapist in the ED has been paged and is starting BiPAP for this patient, an overhead call for two incoming trauma alerts from a multivehicle collision sounds. Because the RT responsible for drawing arterial blood gases is busy caring for these patients, ABGs will be delayed.

Emergency Department 94

Emergency Department E-9-1-1 ED ICU 94

EMDocs

SEPTEMBER 7, 2024

A 70-year-old female with a past medical history of hypertension, coronary artery disease s/p 2x drug eluting stent placement one month ago, atrial fibrillation on apixaban presents to the ED with weakness and lightheadedness. A 25-year-old man presents to the ED via EMS after he sustained a gunshot wound to the left flank.

EMS 73

EMS E-9-1-1 Operating Room OR 73

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. Originally published at JournalFeed , a site that provides daily or weekly literature updates.

ICU 67

ICU ED OR 67

EMS 12-Lead

MAY 8, 2022

This is critical for the EMS provider, or ED clinician, as identification of Grade I ischemia (aka, HATW’s) addresses the culprit lesion at the earliest opportunity with excellent downstream prognosis for the patient. [2] The following ECG was captured upon arrival at the receiving ED. The ED resulted an 8.7 An ECG is recorded.

STEMI 130

STEMI ED EMS Firefighter 130

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. The majority of local anesthetics have a common structure of a lipophilic aromatic ring, a hydrophilic amine group, and a linking group. [2] lidocaine) or an ester (e.g., mL/kg/min.

E-9-1-1 93

E-9-1-1 Plasma Epinephrine Life Support 93

Don't Forget the Bubbles

AUGUST 23, 2023

Very rarely are the ED team allowed to stand, in silence, with a purpose. 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. Or exhausted from it.

Emergency Department 98

Emergency Department ICU ALS Critical Care 98

ACEP Now

MARCH 13, 2024

Emergency departments (EDs) provide the essential service of evaluating patients with unscheduled, acute, undifferentiated, and decompensated conditions. ED crowding impairs this mission. The Emergency Medical Treatment and Labor Act (EMTALA) mandates examination, treatment, and stabilization of anyone who comes to the ED.

Emergency Department 52

Emergency Department ED ALS OR 52

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. After second dose the tonic clonic movement stop; GCS is 3, and she’s unresponsive. Concern for nonconvulsive status epilepticus (NCSE).

STEMI 72

STEMI Coronary Emergency Department EMS 72

EMDocs

NOVEMBER 1, 2023

A 39-year-old male with history of achalasia with recent endoscopic dilation 24 hours prior presents to the ED for progressively worsening chest pain with radiation to his left shoulder. This series provides evidence-based updates to previous posts so you can stay current with what you need to know.

Critical Care 67

Critical Care ED EMS OR 67

ESO

MARCH 7, 2024

of patients with open long bone fractures receive antibiotics within the critical first 60 minutes of ED arrival. Antibiotics and Open Long Bone Fractures: The 2023 Index points out that 67.3% ISS: Nearly 50% of patients with trauma-related injuries received treatment at a Level I trauma center, with an almost 95% survival rate.

Operating Room 105

Operating Room ICU OR ED 105

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

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 134

ICU OR ALS ED 134

Dr. Smith's ECG Blog

OCTOBER 23, 2023

On arrival to the ED the patient was intubated with normal vital signs. 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. No ischemic ST changes.

ICU 123

ICU OR Defibrillator EMS 123

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 92

CPR STEMI Epinephrine ICU 92

EMDocs

JUNE 7, 2023

F, HR 48, RR 28, BP 104/62, SPO2 88% on non-rebreather mask The patient’s friend who brought her to the ED tells you the patient made suicidal statements earlier in the day and was found in her yard shed. These are send-out labs with turn-around times that make them unlikely to affect the ED course or guide treatment.

E-9-1-1 83

E-9-1-1 ICU Emergency Department ED 83

Don't Forget the Bubbles

JUNE 12, 2023

It wasn’t until over 20 minutes later that they managed to secure an airway and transfer her to the ICU, where she died 13 days later. Having just completed my Paediatric ED placement, I donned the navy flight suit and spent two weeks learning how to deal with every conceivable le in-flight emergency.

ICU 145

ICU ED OR 145

Emergency Medicine Ireland

FEBRUARY 21, 2022

I don’t think I’ve ever looked after a true myasthenic crisis in the ICU. I don’t think I’ve ever looked after a true myasthenic crisis in the ICU. I have made the diagnosis twice de novo in the ED (or at least admitted them with that as the leadning diagosis) so it is out there. Likely because.

Critical Care 40

Critical Care ICU ED OR 40