The Skeptics' Guide to EM

AUGUST 14, 2021

Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Circulation 2020 Guest Skeptic: Missy Carter is a PA practicing in emergency medicine in the Seattle area and an adjunct faculty member with the Tacoma Community College paramedic program.

Shock 52

Shock CPR Hyperthermia / Hypothermia EMS 52

Taming the SRU

MAY 5, 2023

doi:10.1056/NEJMoa2212663 BACKGROUND Sepsis, including severe sepsis and septic shock, is a frequently encountered condition in the emergency department and carries a high mortality rate. Each subsequent one-hour delay in antimicrobial administration increases mortality by 35% in patients with septic shock (Im, Kang et al.

Sepsis 52

Sepsis Shock Administration Resuscitation 52

PulmCCM

NOVEMBER 27, 2023

Beta-blockers for septic shock (STRESS-L trial) Septic shock deranges multiple complex signaling systems in the body. A meta-analysis of 7 randomized trials (n=503) previously suggested that co-administration of esmolol to blunt vasopressor-induced tachycardia and arrhythmias could reduce mortality in septic shock by one-third.

Sepsis 52

Sepsis Shock Administration Outcomes 52

The Skeptics' Guide to EM

DECEMBER 11, 2021

. * Fujii et al ( VITAMINS RCT) JAMA 2020: n=216 patients with septic shock. No statistical difference in their primary outcome for duration of time alive and free of vasopressor administration up to day 7 or the secondary outcome of 90-day mortality. It was Dr. Paul Marik who has been a big advocate for Vitamin C sepsis.

Sepsis 40

Sepsis Shock Outcomes Research 40

Northwestern EM Blog

FEBRUARY 14, 2022

The ATHOS-3 trial in 2017 explored the efficacy of angiotensin II as a vasopressor for severe vasodilatory shock. Severe shock is defined as persistent hypotension requiring vasopressors to maintain a mean arterial pressure of 65mmHg and serum lactate <2 despite adequate volume resuscitation.

Shock 52

Shock Resuscitation Outcomes Fluid Resuscitation 52

EMDocs

FEBRUARY 12, 2024

First, there can be a poor correlation between venous and arterial gases in states of shock, hemodynamic instability, or extremes of acid-base disturbances, due to poor cardiac output/circulatory failure impairing venous and arterial flow, with associated poor gas exchange as well as hypercapnia and acidemia at the tissue level (8).

Emergency Department 94

Emergency Department Resuscitation COPD Shock 94

ACEP Now

MAY 9, 2024

These questionable practices led to a rash of bad outcomes. This should be suspected in patients with intraoperative cardiac arrest or shock. While both conditions rely on supportive care as the mainstay of treatment, plastic surgery literature suggests better outcomes with microscopic fat embolism. Accessed March 6, 2024.

Emergency Department 52

Emergency Department Operations Ultrasounds Hospitals 52

PulmCCM

OCTOBER 30, 2023

Professional Medical Societies Call for Elimination of SEP-1 The Infectious Diseases Society of America (IDSA), along with societies for emergency medicine physicians and hospitalists, are again speaking up about the ongoing policy experiment known as the Centers for Medicare and Medicaid Severe Sepsis/Septic Shock Management Bundle (SEP-1).

Sepsis 52

Sepsis Shock Hospitals Outcomes 52

Ken Grauer, MD

FEBRUARY 28, 2023

These 2 settings are: i ) In patients with severe , often longstanding pulmonary disease ; and / or , ii ) In acutely ill patients with multi-system disease ( ie, sepsis, shock, electrolyte and/or acid-base disorders ). These cases provide insight to assessment for MAT: The January 5, 2020 post in Dr. Smith’s ECG Blog — for an example of MAT.

EKG/ECG 195

EKG/ECG Documentation/Coding Sepsis COPD 195

PulmCCM

JULY 10, 2023

In the MERCY trial, 607 critically ill patients with sepsis (most with septic shock) at 26 hospitals in Croatia, Italy, Kazakhstan, and Russia were randomized to receive meropenem by either continuous (3 g / 24 hours) or intermittent administration (1 g every 8 hours). A sequel to that trial, BLING III, is underway. access, etc.,

Stroke 52

Stroke Sepsis Infectious Diseases Outcomes 52

Thinking Critical Care

MAY 18, 2023

In 1983 I was an Englishman abroad, the London anaesthetist who was appointed to be the English anaesthetist on the Shock Team only because the outstanding candidate from Oxford had preferred to take up a job doing muscle relaxant research with Kitz and Katz in the USA. 4] The research agenda at the time was broad.

Shock 40

Shock Research Sepsis Resuscitation 40

The Skeptics' Guide to EM

FEBRUARY 25, 2023

He is found to be in hypoxic respiratory failure and septic shock. Case: A 6-month-old boy presents to the emergency department (ED) with three days of worsening cough, cold symptoms, and fever. Parents note that he has been progressively more tired and difficult to arouse. Intravenous (IV) access is obtained. He is quickly intubated.

Pediatrics 52

Pediatrics Hospitals CPR Resuscitation 52

RebelEM

APRIL 29, 2024

Given AHA guidelines recommend early epinephrine administration in cardiac arrest, obtaining access is imperative for resuscitative efforts ( 9) When evaluating over 300,000 out-of-hospital cardiac arrests, a meta-analysis found no significant change in primary outcomes when IV and IO access were compared ( 10 ). Resuscitation. Resusc Plus.

Resuscitation 102

Resuscitation Administration Emergency Department Hospitals 102

Don't Forget the Bubbles

JANUARY 10, 2024

Some wonder if giving blood to children with a haemoglobin <6g/dl will improve outcomes. Outcomes Primary outcome Mortality at 28 days after randomisation. The authors chose a patient-centred, primary outcome in keeping with their pragmatic design. What were the research questions? The study asked TWO questions: 1.

Blood Transfusions 78

Blood Transfusions Outcomes Research Hospitals 78

Taming the SRU

OCTOBER 1, 2023

As these patients are typically already at a high risk for poor health outcomes, secondary spontaneous PTX is often more serious in presentation and management more complex [11]. J Emerg Trauma Shock. Published 2020 Jul 23. Published 2020 Jan 21. doi:10.1183/13993003.03375-2020 Light RW. Ann Emerg Med. Respir Med.

Fractures 94

Fractures COPD Hospitals Emergency Department 94

EMDocs

JUNE 27, 2024

2020 Feb 12;10(1):2470. Intravenous fluid therapy and hospital outcomes for vaso-occlusive episodes in children, adolescents, and young adults with sickle cell disease. Factors associated with adverse outcome among children with sickle cell disease admitted to the pediatric intensive care unit: an observational cohort.

Pediatrics 75

Pediatrics EMS Dehydration Hospitals 75

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

The notes now refer to the patient being in cardiogenic shock, on pressors. hours from presentation, where he was found to have an acute thrombotic LAD occlusion which was stented with resulting TIMI 3 flow, but still the patient was in severe cardiogenic shock. Academic Emergency Medicine 27(S1): S220; May 2020.

EKG/ECG 87

EKG/ECG Shock Documentation/Coding Academics 87

RebelEM

MAY 25, 2023

I recently gave a talk on the initial management of trauma patients with hemorrhagic shock. Clinical Take Home Point: In patients with TBI and hypovolemic shock, target a SBP or MAP ≥90mmHg, but know this is based on limited evidence. vs SBP target <90mmHg which resulted in a mortality of 33.4% NEJM 1994. [2]

Resuscitation 145

Resuscitation Fluid Resuscitation Head Injuries Shock 145

Pediatric EM Morsels

JULY 21, 2023

Motor Fingernail bed pressure with a pencil first If flexion outcome, then apply painful stimulus to neck or head (trapezius or supraorbital notch) to look for localization Spinal reflex can result in a falsely elevated score if lower extremity pain induced Verbal Orientated- Able to answer all questions. Fun fact for animal lovers!

Head Injuries 246

Head Injuries Pediatrics Outcomes Shock 246

ALiEM

JULY 17, 2023

Match Data The unprecedented numbers of unfilled PGY-1 EM residency training positions in the NRMP Match results shocked the specialty these last two years. In fact, the average number of applicants between 2015-2020 and 2022-2023 were relatively similar, with the latter demonstrating 122 more applicants (2,801 vs 2,923).

EMS 52

EMS Burns Emergency Department Shock 52

Taming the SRU

MAY 3, 2023

During the admission, she completed a course of broad-spectrum antibiotics and as the underlying shock state improved, she was also weaned off all vasopressor support. For a complete discussion of cardiogenic shock and right ventricular failure, please see this other Air Care Series post on the subject. StatPearls Publishing; 2020.

Wellness 52

Wellness Hospitals Shock Outcomes 52

PulmCCM

JANUARY 2, 2022

What they did Between August 2020 and May 2021, patients were screened in over two-dozen hospitals in India, Denmark, Sweden and Switzerland. Thoughts After reading the COVID STEROID 2 trial, I was immediately reminded of the ANDROMEDA-SHOCK investigation from a few years ago. supplemental oxygen flowing at least at 10 L/min or 2.]

Outcomes 40

Outcomes Hospitals Shock Wellness 40

PulmCCM

DECEMBER 11, 2023

Sepsis, infectious disease Managing septic shock with a restrictive-fluids approach (preferentially using vasopressors after a single liter crystalloid bolus) led to similar outcomes as the usual practice of bolusing large volumes of fluids first. Either approach in severe sepsis with shock seems reasonable.

Sepsis 94

Sepsis Stroke Shock Infectious Diseases 94

Dr. Smith's ECG Blog

APRIL 8, 2022

Her long term outcome (with very large LAD MI and EF of 30%) is unknown. Otherwise it results in a terrible outcome, as in this case, with devastating permanent loss of myocardium). 21, 2020 post — Optimal Use of Lead aVL for predicting the "culprit" artery ).

EKG/ECG 52

EKG/ECG Outcomes Wellness Shock 52

RebelEM

NOVEMBER 30, 2023

Current SSC guidelines recommend fluid resuscitation with at least 30mL/kg IV crystalloid in patients with sepsis induced hypoperfusion or septic shock within the first three hours of resuscitation, regardless of comorbidities. Outcomes: Primary Outcome: In-hospital mortality. 2.89, p = 0.01. times more intubations and 2.15

Sepsis 113

Sepsis Fluid Resuscitation Resuscitation Administration 113

Don't Forget the Bubbles

JUNE 26, 2023

But, they may present postnatally with cyanosis/hypoxaemia due to insufficient pulmonary blood flow, cardiogenic shock due to insufficient systemic blood flow, or both. These cases illustrate some of the common issues associated with each shunt type, but what does the evidence say about outcomes? 2014;129(20):2013-2020.

Operations 128

Operations Research Hyperthermia / Hypothermia Hospitals 128

Dr. Smith's ECG Blog

AUGUST 28, 2020

Now appears to be in cardiogenic shock." However, cardiogenic shock usually takes some time to develop, so it is probably subacute." A fixed stenosis in that other artery, especially in the context of hypotension from the occlusion of the first coronary artery, can lead to ischemia and very poor LV function and worsening shock.

Shock 52

Shock EKG/ECG Wellness Outcomes 52

ACEP Now

JULY 7, 2023

2,3 In general, patients who develop cardiac arrest with an initial rhythm of VT or VF tend to have favorable outcomes compared to patients who develop cardiac arrest from either asystole or pulseless electrical activity. Initial guidelines defined “refractory” as VT or VF occurring despite three shocks from a cardiac defibrillator.

Resuscitation 98

Resuscitation Shock Stroke Hospitals 98

RebelEM

AUGUST 12, 2024

What They Did: Double-blind, randomized, placebo controlled trial that ran from October 2019 through January 2024 Multinational study conducted at 22 centers in three European countries 3512 patients were enrolled and before surgery eligible patients were randomly assigned to one of the following two groups Amino Acid Group: 10% Isopuramin at a dose (..)

Outcomes 74

Outcomes Hospitals Operations Shock 74

Taming the SRU

JANUARY 10, 2024

Phenobarbital has been proven to be equivalent to benzodiazepines with regard to clinical, pharmacologic and utilization outcomes. Physicians believe the biggest factors contributing to ED violence are a lack of adequate punitive consequences toward the attacker and the absence of adequate protective mechanisms for staff.

EKG/ECG 91

EKG/ECG Shock Fractures Emergency Department 91

ACEP Now

SEPTEMBER 3, 2024

These stakeholders are similarly shielded in court when adverse patient outcomes, such as negligent deaths, occur under their management or when the bought-out companies are challenged for anticompetitive business practices overseen by the PE firm. Published March 15, 2020. Published April 20, 2020. Accessed August 25, 2024.

Hospitals 69

Hospitals Radiology Radiology Administration 69

RebelEM

DECEMBER 19, 2022

This procedure involves applying another set of pads attached to a second defibrillator to a patient and shocking them in hopes of terminating the rhythm. That write up was for the DOSE-VF pilot trial done in March 2020 and can be found here. Now that same group has published the results of their full randomized control trial.

EMS 52

EMS CPR Shock Resuscitation 52

RebelEM

MARCH 30, 2023

Background: Previous observational studies published in 2015 (Geri 2015)(Vyas 2015) indicated that early cardiac catheterization in patients with out-of-hospital cardiac arrest (OHCA) might improve mortality and result in more favorable neurological outcomes. Article: How-Berlemont C, Lamhaut L, Diehl J, et al. 1.15; P= 0.32 1.15; P= 0.31

Hospitals 63

Hospitals Outcomes EKG/ECG Resuscitation 63

ACEP Now

APRIL 3, 2024

1,2 However, the European TTM1 trial in 2013 showed similar outcomes for those cooled to 33 degrees Celsius compared to 36 degrees Celsius, leading to a 2015 AHA class I recommendation of “cooling between 32 degrees Celsius-36 degrees Celsius.” degrees Celsius. 5,6 In 2021, the TTM2 trial was published. degrees Celsius for 72 hours.

Hyperthermia / Hypothermia 40

Hyperthermia / Hypothermia Resuscitation Outcomes Hospitals 40

RebelEM

FEBRUARY 8, 2024

Background: Patients with shock frequently present with hypotension. patients with more discrepant readings had NIBP checked more frequently) Some patients were on multiple vasopressors, but for an unclear reason the authors decided to only evaluate the dose of norepinephrine MAP discrepancy is not a patient oriented outcome (i.e.

Resuscitation 116

Resuscitation Outcomes EMS Sepsis 116

EMDocs

JANUARY 4, 2024

In 2020, bupropion was the 18 th most-prescribed medication in the USA. Cardiogenic shock and hypotension can occur (systolic heart failure with reduced ejection fraction.) 10,12 Refractory shock or malignant arrhythmias occur in < 5% of patients. References: The Top 200 Drugs of 2020. Accessed 12/18/2022.

Seizures 66

Seizures EKG/ECG Poisoning Shock 66

The Skeptics' Guide to EM

JANUARY 9, 2021

JAMA 2020 Guest Skeptic: Mike Carter is a former paramedic and current PA practicing in pulmonary and critical care as well as an adjunct professor of emergency medical services […] The post SGEM#314: OHCA – Should you Take ‘em on the Run Baby if you Don’t get ROSC? CPR is currently in progress with a single shock having been delivered.

EMS 52

EMS Resuscitation CPR Hyperthermia / Hypothermia 52