Diastolic Shock Index: A clinically relevant predictor of poor outcome in septic shock?

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Diastolic Shock Index: A clinically relevant predictor of poor outcome in septic shock?

Early recognition and resuscitation of patients in septic shock are critical skills for an emergency medicine physician. Many clinical decision-making tools have been developed and validated in their use to identify and define those who are in sepsis or septic shock, as well as predict a patient’s overall risk of morbidity and mortality, including tools like the SIRS criteria and SOFA score. The diastolic blood pressure is determined by vascular tone, and thus it can be assumed that a decrease in the diastolic blood pressure should correlate with the pathologic vasodilation in septic shock. As a result, the authors of this study hypothesized that the relationship between heart rate and the diastolic blood pressure (i.e. the diastolic shock index) could provide providers a tool to quickly identify patients that are at risk for unfavorable outcomes.

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CTs for SAH - Does Time Even Matter?

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CTs for SAH - Does Time Even Matter?

Spontaneous subarachnoid hemorrhage (SAH) is a can’t miss diagnosis for patients presenting to the emergency department with a headache. The diagnosis is associated with a 30% mortality at 30 days, and approximately 30% of survivors may have long-term neurocognitive deficits (Rincon et al., 2013). The majority of spontaneous SAH are secondary to a ruptured arterial aneurysm (80%) while non-aneurysmal SAH are often due to low pressure venous bleeds, arteriovenous malformations, and other more rare causes. This post will recap the existing literature on the diagnosis of aSAH and will focus on breaking down a recently published paper by Vincent, et al which may inform our future practice.

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What Drip to Use After the Drop - Post-Cardiac Arrest Hypotension

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What Drip to Use After the Drop - Post-Cardiac Arrest Hypotension

During a cardiac arrest resuscitation, finally palpating a pulsatile flow beneath your gloved fingertips brings a sense of satisfaction like no other. But just as you go to finally breathe a sigh of relief and wipe the beading sweat off your brow, your now widening pupils focus on the patient’s steadily plummeting blood pressure. As you begin to sense your own heart palpitating, you think about medications to utilize in hopes of staving off another round of chest compressions. Since you’ve already given four doses of code-dose epinephrine, maybe an epinephrine infusion is best? You also recall that norepinephrine seems to be a popular choice in patients with shock, so maybe you should start that instead?

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Family Presence in Cardiac Arrest Resuscitations

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Family Presence in Cardiac Arrest Resuscitations

Cardiac arrests are an inevitable reality for emergency medicine providers. There is often a debate on whether family members presence during CPR will lead to more emotional burdens on the family members who witnessed these resuscitations. This study aimed to determine if there are increased rates of PTSD-related symptoms of close relatives who witnessed CPR of a family member.

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Tube Thoracostomy for Hemothorax - Is a Tiny Tube Just Fine?

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Tube Thoracostomy for Hemothorax - Is a Tiny Tube Just Fine?

In this Journal Club podcast, PGY-3 Tony Fabiano breaks down a paper from the Journal of Trauma comparing the effectiveness and patient perception of pigtail catheters versus standard chest tubes for hemothorax in the setting of trauma. Is a tiny tube effective at all in draining blood from the chest?

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EKG to Activation - A Quality, Quality Metric?

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EKG to Activation - A Quality, Quality Metric?

Time is myocardium, and minimizing door-to-activation time improves outcomes in patients with acute coronary occlusion. There are a number of existing quality metrics used to help drive improvements in the time-based care of STEMI patients. Could a new quality metric help the decision making time of Emergency Physicians?

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Is a STEMI a STEMI in Post-ROSC Patients?

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Is a STEMI a STEMI in Post-ROSC Patients?

One of the first tests ordered for a patient with ROSC following cardiac arrest is an EKG. Many of these EKGs are profoundly abnormal. Current practice is to evaluate for STEMI and to activate the cardiac cath lab if one is found. But, the test characteristics (sensitivity and specificity) of post-ROSC EKGs are likely different than the test characteristics for patients presenting to the ED with complaints of chest pain/symptoms concerning for ACS. This meta-analysis looked to pull together the existing literature and determine those test characteristics for this critically ill patient population. Read the summary after the link and listen to the podcast to hear a breakdown of this study.

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Droperidol for Agitation in the ED - No Danger to the Dangerous?

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Droperidol for Agitation in the ED - No Danger to the Dangerous?

Droperidol is a versatile medication with a number of potential uses for patients in the Emergency Department. It is also a medication surrounded in some degree of mystique because of the decision by the FDA in 2001 to issue a black box warning for its use in response to reports of QT prolongation and torsades de pointes. Many at the time (and since) have argued that, despite these case reports, droperidol is a safe and effective medication that can be used for the treatment of agitation, nausea and vomiting, and migraine. We have previously covered much of this background in a previous blog post. In our most recent journal club, we discussed 3 articles that looked at the safety and efficacy of droperidol for treating acutely agitated patients. Take a read and listen below for an in depth look at each of these papers.

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Old News and New News for Cardiac Arrest

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Old News and New News for Cardiac Arrest

Anyone who’s faced a patient with refractory V fib or V Tac, knows the certain pang of hopelessness that strikes when round and round of epi, CPR, and shocks fails to deliver a return to organized rhythm. ECMO is an option. Baring the availability of perhaps one of the most resource-intensive procedures in medicine, what option does one have? If nothing is working what do you change? Beta blockers? Change up the shocks? Is that bicarb you’re giving doing any good? This post and the affiliated podcast will cover 3 articles looking at the evidence for these new and old treatments for cardiac arrest.

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Trio of Trauma - Journal Club Recap

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Trio of Trauma - Journal Club Recap

The care of trauma patients is constantly evolving. From the time of injury to OR or ICU, there are dozens of management decisions that can improve the care and outcome for your patients. In our most recent journal club we took a look at 3 articles that looked at the management of trauma patients in the ED and ICU. Should we be adding vasopressin to our massive transfusion protocols? Is DL dead for trauma patients? Should we move to use IO’s early in traumatic arrests?

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Ketamine Potpourri

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Ketamine Potpourri

In our most recent journal club, we took a look at 3 articles focused on the use of ketamine in the Emergency Department. When treating pain with ketamine, does a rapid administration of ketamine result in more dysphoria? When used for RSI, is ketamine more hemodynamically stable than etomidate? When using ketamine for procedural sedation in adult patients, does pre-treatment with versed or haldol decrease clinically significant emergence agitation?

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