Shock Differently - Out of Hospital Cardiac Arrest

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Shock Differently - Out of Hospital Cardiac Arrest

Out of hospital cardiac arrest (OOHCA) represents a great cause of morbidity and mortality. Approximately 350,000 cardiac arrests occur in North America annually and 20% can be attributed to Ventricular tachydysrhythmias (i.e. ventricular tachycardia [v fib] and ventricular tachycardia [v tach]without a pulse). In this journal club recap, Dr Kelly Tillotson recaps an article comparing different ways of defibrillation and their effect on outcomes in OOHCA

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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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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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Grand Rounds Recap 01.20.2021

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Grand Rounds Recap 01.20.2021

This week’s edition of grand rounds featured some amazing lectures! We practiced pitching ideas in our leadership curriculum then the newest QI/KT pathway was revealed by Drs. Chuko and Goff. Dr Gawron taught us about medical causes of trauma and Dr. Kein gave us an amazing lecture on cyanotic congenital heart diseases. We finished off with Dr. Shewakramani giving an amazing wellness lecture about his BAYLEAF method for dealing with stress in the ED.

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Air Care Series: Ideal Resuscitation Pressure in Polytrauma with TBI

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Air Care Series: Ideal Resuscitation Pressure in Polytrauma with TBI

Damage Control Resuscitation, Permissive Hypotension, Fluid Restrictive Resuscitation… Regardless of name, with all the enthusiasm surrounding permissive hypotension in the actively bleeding trauma patient, what do we do when they have a TBI? Take a dive into the literature surrounding ideal perfusion pressures of patients suffering from TBIs and traumatic injury to find out if we know what pressure is really the best.

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Grand Rounds Recap 10/14

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Grand Rounds Recap 10/14

Simulation with Dr. Hill

Case 1: 45 yo male comes to the ED after being found down at the mall s/p defib x2 for a V fib arrest per EMS with a King Airway in place and undergoing active CPR. In the ED you achieve ROSC after defib x1 for Vfib and then PEA with multiple arounds of epinephrine. EKG shows inferior STEMI.  

Case 2: EMS calls with advanced noticed for GI bleed presents tachycardic and hypotensive, actively bleeding with melanotic stool and hematemesis. 

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The Little Things that Matter

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The Little Things that Matter

We were fortunate, a couple weeks back, to have Dr. Brian Burns of Sydney HEMS come and speak to us.  In his lecture, “When the 1% Makes All the Difference” which you can find here, Dr. Burns hit on a number of excellent points.  We sat down and talked with Dr. Burns a bit more extensively over a couple of the themes of his lecture.

In this podcast, we cover some of the plus/minuses of checklists, the importance of high fidelity continuous training practices (simulation, routine case debriefing, intensive induction training), and the role of cognitive factors in running resuscitations.

Should resuscitations run like a jazz quartet or a Formula 1 pit crew?  Are checklists simply in the way or do they cognitively unload the team members to improve performance?  How do you train cognitive factors in resuscitation?

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Liquid Plasma aka "Never Frozen Plasma"

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Liquid Plasma aka "Never Frozen Plasma"

I recently had the pleasure of sitting down with my co-EMS fellow, Dr. Ryan Gerecht, to discuss his experience with the implementation of a new blood product on our HEMS service: Liquid Plasma. Ryan was responsible for this implementation while serving as a Resident Assistant Medical Director during his last year of EM training at UC (2013-2014).

Here is what Ryan has to say…

In the Emergency Department, ICU, or operating room what do you resuscitate the hemodynamically unstable, bleeding trauma patient with? What about the patient with a massive GI bleed or ruptured AAA? How do you manage the patient with an intracerebral hemorrhage on Coumadin? (assuming you don’t have PCC’s readily available)

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Water Cooler Breakdown: The ProCESS Trial

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Water Cooler Breakdown: The ProCESS Trial

In March of 2014, Derek Angus and colleagues published the ProCESS trail in the NEJM (1)(N Engl J Med 2014;370:1683-93. DOI: 10.1056/NEJMoa1401602). In ProCESS, they explore the time-honored theory in EM-resuscitation that EGDT as described by Rivers (NEJM 2001) is the dominant strategy to improve survival in severe sepsis and septic shock. Despite the marked reduction in mortality that is reported in Rivers’ study, the study itself has not been successfully reproduced in a multicenter trial.

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Resuscitation of Penetrating Trauma Patients

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Resuscitation of Penetrating Trauma Patients

In our last podcast we covered the basics of the evaluation of the patient with blunt trauma.  We switch gears a little bit this week and focus a little more on penetrating trauma.  In this podcast, Dr. Hinckley and Dr. Chris Miller discuss several facets of the care of penetrating trauma patients including the initial approach and evaluation, detection of subtle presentations of shock, and triggers to initiate transfusion of blood products.  In this accompanying blog post, I’d like to focus primarily on why we might want to withhold fluids on penetrating trauma patients.

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