Critical Care Perspectives in Emergency Medicine: Recent Episodes
Critical Care Perspectives in Emergency Medicine
Critical Care Guys: The Minds Behind Critical Care Perspectives in Emergency Medicine. 4 Docs come together to discuss current trends in Emergency Medicine. Check out this podcast to stay up-to-date on the goings ons.
Oxygen is one of the most used, and misused, therapies delivered to critically ill patients. In recent years, a number of trials have compared the use of a conservative oxygen therapy strategy with a liberal oxygen therapy strategy. These trials have produced mixed results and the optimal oxygen strategy for critically ill patients remains unknown. In this podcast, we discuss the latest study, UK-ROX Trial, to investigate a conservative oxygen therapy strategy with usual oxygen therapy in critically ill ICU patients. Which approach is better?
Critically ill patients receiving mechanical ventilation require analgesia and sedation. At present, propofol remains the most widely used sedative for intubated/ventilated patients. Recent trials have suggested that dexmedetomidine may reduce delirium and the duration of mechanical ventilation compared with other sedative medications. In fact, recent SCCM guidelines suggest the use of dexmedetomidine over propofol in intubated patients. In this podcast, we discuss a recent randomized trial that compared the effectiveness and safety of a dexmedetomidine-based sedation strategy with a propofol-based sedation strategy in mechanically ventilated critically ill patients.
Approximately 75% of patients older than 65 years of age are seen in an ED within 6 months of their death. While palliative care teams are now present in many hospitals in the US, they are often not present 24/7 or in resource-limited settings. As such, there may be an opportunity to improve palliative care in the ED by providing palliative care education to ED team members. In this podcast, we review the recently published PRIM-ER trial, which evaluated the impact of a robust primary palliative care intervention on hospital admission rates in 29 EDs across the US.
Sepsis results in more than 250,000 deaths each year in the United States. Resuscitation of the septic patient centers on timely recognition, early antibiotic administration, appropriate fluid administration, source control, and vasopressor administration for those with inadequate mean arterial pressures. At present, norepinephrine is the recommended first-line vasopressor for sepsis. Current guidelines then recommend vasopressin as the second-line vasopressor agent, but the optimal timing of its initiation remains unknown. In this podcast, we discuss a recent article on the use of a machine learning tool for vasopressin administration to optimize short- and long-term outcomes in patients with sepsis.
Nearly 4 million patients sustain out-of-hospital cardiac arrest (OHCA) worldwide each year. International guidelines for the resuscitation of patients with OHCA recommend early administration of epinephrine in those with an initial nonshockable rhythm. Both intravenous (IV) and intraosseous (IO) access are routinely attempted to gain vascular access to administer medications. While IV access is recommended, this is based on very low certainty evidence. In this podcast, we discuss three recently published randomized trials that investigated IO and IV access in patients with OHCA.
Both NIV and HFNC are used to treat patients with acute respiratory failure. Current guidelines recommend NIV for acute respiratory failure caused by COPD and acute cardiogenic pulmonary edema. However, NIV may be hard for some patients to tolerate. When compared to low-flow oxygen therapy, HFNC has been shown to improve oxygenation, improve alveolar recruitment, and enhance clearance of secretions. HFNC may be easier to use and tolerate than NIV, but there remains uncertainty regarding the effectiveness of HFNC compared to NIV for acute hypoxemic respiratory failure. In this podcast, we discuss the RENOVATE trial that sought to compare HFNC with NIV on rates of intubation in patients with acute respiratory failure.
NIPPV is frequently used in the management of critically ill patients presenting with an acute COPD exacerbation, as NIPPV decreases the rates of intubation and is associated with lower in-hospital mortality. Typically, "low" intensity NIPPV, whereby inspiratory positive airway pressures less than 18 cm H2O are used. More recently, the use of "high" intensity NIPPV, with IPAPs between 20-30 cm H2O, has been shown to improve gas exchange, ventilatory function, and improve arterial PCO2 values. In this podcast, we review the HAPPEN Trial, which compared low intensity to high intensity NIPPV on the need for intubation in patients with an acute COPD exacerbation and hypercapnia.
The incidence of opioid-associated out-of-hospital cardiac arrests continues to rise. Current guidelines for the resuscitation of patients with OHCA advise the clinician to consider the administration of naloxone of patients with suspected opioid-associated OHCA. In this podcast, we review a recenlty published study in JAMA that evaluated the association of naloxone with patient outcomes in opioid-associated OHCAs.
Timely administration of broad-spectrum antibiotics is a critical pillar in the resuscitation of patients with sepsis. B-lactam antibiotics are an important class of antibiotics commonly administered to patients with sepsis. Typically, B-lactam antibiotics are administered over 30 minutes, but optimal bactericidal activity requires the concentration of free drug to be above the MIC of the organism for 40-70% of the dosing interval. In this podcast we discuss two recent publications that compare continuous infusions of B-lactam antibiotics with intermittent effusions in patients with sepsis.
Patients with COVID-19 can require supplemental oxygen for acute hypoxemic respiratory failure. While international guidelines recommend a target SpO2 between 90-96%, a safe oxygenation strategy has not been identified. In this podcast, we discuss the recently published HOT-COVID Trial, which compared a lower oxygenation strategy with a higher oxygenation strategy in adult ICU patients with COVID-19.
Over 1 million critically ill patients are intubated each year in the US. Hypoxemia occurs in up to 20% of patients and can lead to peri-intubation cardiovascular collapse and cardiac arrest. As such, adequate and appropriate preoxygenation is critical in increasing the safe apnea time and decreasing the risk of hypoxemia. At present, the majority of patients receive preoxygenation through a non-rebreather mask. In this podcast, we discuss a recent study that evaluated the use of noninvasive ventilation for preoxygenation in critically ill patients.
Timely and appropriate administration of empiric broad-spectrum antibiotics for adult patients with sepsis is critical. Current guidelines recommend an antipseudomonal antibiotic for those at risk of a resistant gram-negative organism. The two most common antipseudomonal antibiotics prescribed in this setting are cefepime and piperacillin-tazobactam. In recent years, observational studies have reported an association with cefepime and neurotoxicity, whereas piperacillin-tazobactam has been associated with AKI especially when given with vancomycin. In this podcast, we discuss the recently published ACORN Trial, a randomized trial that evaluated cefepime and piperacillin-tazobactam for adult patients with suspected infection.
In recent years, there has been intense focus on delivering high-quality compressions during the resuscitation of patients with OHCA. In contrast, ventilation metrics in OHCA resuscitation have not been well studied. In this podcast, we discuss a recent publication from Circulation that evaluated ventilation waveforms during OHCA resuscitation and the association of these metrics on patient outcomes. Can we do better?
Critically ill patients commonly develop a dysregulated inflammatory response. Corticosteroids are hypothesized to be beneficial due to their anti-inflammatory properties. In recent years, several studies have been published on the use of corticosteroids in select critical illnesses. In this podcast, we review a recently published clinical update on the use of corticosteroids in sepsis, ARDS, and community acquired pneumonia.
In this podcast we review a few key articles from the 2023 critical care, emergency medicine, and resuscitation literature that pertain to our care of the critically ill ED patient.
Acute mental status changes after the ingestion of alcohol or other substances are a common presentation to the ED. Those with severe obtundation may require intubation for airway protection while the substance metabolizes. In fact, more than 20,000 patients are intubated each year in the United States for acute poisoning or intoxication. Notwithstanding, intubation and mechanical ventilation are not benign procedures. In this podcast we discuss the recently published NICO Trial, that evaluated a strategy of withholding intubation in patients with coma due to acute poisoning.
REBOA is a relatively new and novel technique that in animal studies has demonstrated benefit in controlling hemorrhage. However, the evidence for the efficacy of REBOA in humans remains scant. In this podcast, we discuss the recently published UK-REBOA Trial, which randomized patients to receive REBOA with standard care compared to those randomized to standard care alone. You may be surprised by these results!
RSI is one of the most common procedures in critically ill patients. Despite its frequency, there remains significant practice variation on numerous aspects of RSI in the critically ill. In this podcast, we review pertinent recommendations from the recently published SCCM Guidelines on RSI in the critically ill patient.
Care of the patient with ROSC following OHCA can be complex and typically includes a protocolized approach to optimizing oxygenation, ventilation, hemodynamics, early cardiac catheterization for patients with STEMI, seizure detection, and possibly TTM. In this podcast, we review two recent articles that focused on the use of mild hypercapnia compared with normocapnia in post arrest patients and the use of a pan-CT protocol to detect critical time sensitive conditions and complications.
Central venous catheter (CVC) placement is common in critically ill patients for a variety of indications. Thrombocytopenia is also quite common in critically ill patients. Unfortunately, literature and guideline recommendations vary on the threshold for prophylactic platelet transfusion in patients undergoing a procedure. In this podcast we discuss a recent trial that evaluated prophylactic platelet transfusion in patients with severe thrombocytopenia undergoing CVC placement.
Over 1 million critically ill patients undergo intubation each year in the United States. Though direct laryngoscopy remains the most common technique worldwide for intubation, the use of video laryngoscopy has significantly increased. Studies evaluating video to direct laryngoscopy have thus far produced mixed results. In this podcast, we review the latest randomized trial, the DEVICE Trial, that assessed video with direct laryngoscopy. Which device won?
Both etomidate and propofol are commonly used sedative agents in critically ill patients. Recent literature has suggested that these agents may result in increased harm and mortality. In this podcast, we discuss the most recent two systematic reviews and meta-analyses that evaluated etomidate and propofol in critically ill patients. Do we need to change our practice?
The use of steroids in patients with sepsis and septic shock has been controversial for decades. At present, the Surviving Sepsis Campaign recommends the administration of corticosteroids to patients with persistent shock despite fluid and vasopressor administration. In recent years, several trials have evaluated the addition of fludrocortisone, a potent mineralocorticoid, to hydrocortisone in septic shock. In this podcast, we review the latest study that evaluated the combination of hydrocortisone and fludrocortisone in patients with septic shock. Should we administer this medication with hydrocortisone for our patients with septic shock?
In recent years, numerous trials have investigated the administration of corticosteroids in patients with pneumonia and have produced mixed results. In this podcast, we discuss the latest randomized trial, the CAPE COD trial, that evaluated whether the administration of hydrocortisone to ICU patients with severe CAP reduced mortality. Is this a therapy we should look to administer in the ED based on the results of this trial? Take a listen and find out...
In recent years, several single center trials have demonstrated positive outcomes in patients with OHCA randomized to receive ECPR compared with patients who received standard resuscitation. Not surprisingly, these single center studies have limitations that impact the generalizability of these results. In the current podcast, we discuss the recently published INCEPTION Trial, which is a multicenter, randomized trial that compared the effect of extracorporeal CPR with conventional CPR in patients with refractory OHCA due to a ventricular arrhythmia.
Intravenous fluid (IVF) administration is a central tenet to the resuscitation of patients with sepsis and sepsis-induced hypotension. At present, the administration of large volumes of IVF is common, though based on low quality of evidence. In this podcast, we review and interpret the recently published CLOVERS Trial, which compared the use of a liberal fluid strategy with a restrictive fluid strategy in patients with sepsis-induced hypotension.
Given the increase in critically ill patients who present to the ED in need of resuscitation, along with the increase in those who board in the ED awaiting an ICU bed, it is imperative that the emergency physician be knowledgeable about recent literature in resuscitation and critical care medicine. In this podcast, we discuss important articles published in 2022 that pertain to care of critically ill ED patients.
More than 350,000 cardiac arrests occur each year in North America. Approximately 100,000 of these arrests are due to shockable rhythms. Unfortunately, many patients have refractory ventricular fibrillation and do not respond to many attempts at standard defibrillation. In this podcast, we discuss a recent study that evaluated double sequential external defibrillation and vector-change defibrillation compared to standard defibrillation in patients with refractory ventricular fibrillation in OHCA.
Approximately 3 million critically ill patients are intubated and initiated on mechanical ventilation each year in the United States. A critical component of mechanical ventilation is the adjustment of FiO2 to maintain adequate arterial oxygen saturation. However, the optimal oxygenation target in critically ill adult patients receiving mechanical ventilation remains uncertain. In this podcast we discuss a recently published study, the PILOT Trial, that evaluated low, intermediate, and high oxygenation targets in critically ill patients.
The emergency department resuscitation of patients with sepsis focuses on early recognition, timely administration of appropriate antibiotics, appropriate fluid resuscitation, early vasopressor initiation for patients with sepsis-induced hypoperfusion, and hemodynamic monitoring. Source control is also an important component in the resuscitation of patients with sepsis. Though current guidelines identify source control as a "best practice" the optimal timing of source control remains uncertain. In this podcast, we discuss a recent study that evaluated the timing of source control with mortality in patients with community-acquired sepsis.
The care of patients with return of spontaneous circulation following cardiac arrest centers on optimizing oxygenation and ventilation, optimizing hemodynamics, identifying patients that require immediate coronary angiography, detecting seizures, and targeted temperature management. In recent years, numerous articles have evaluated various components of this post-arrest bundle of care. In the current podcast, we discuss Part II of the BOX Trial that evaluated a restrictive versus liberal oxygenation target in the post-arrest patient.
The care of patients with return of spontaneous circulation following cardiac arrest centers on optimizing oxygenation and ventilation, optimizing hemodynamics, identifying patients that require immediate coronary angiography, detecting seizures, and targeted temperature management. In recent years, numerous articles have evaluated various components of this post-arrest bundle of care. In the current podcast, we discuss Part I of the BOX Trial that evaluated mean arterial blood pressures in the post-arrest patient.
Approximately 2 million adult patients undergo intubation in the United States each year. Hypotension and cardiovascular collapse may occur in up to 40% of critically ill patients in the ICU who undergo intubation. Guidelines and expert recommendations often suggest the administration of IVFs during RSI to prevent cardiovascular collapse. However, a recent trial found that an IVF bolus during induction did not prevent cardiovascular collapse in a population of critically ill patients. In this podcast, we review and discuss the recently published PREPARE II Trial, which evaluated the administration of IVFs to prevent cardiovascular collapse in critically ill patients undergoing intubation and who were receiving positive pressure ventilation.
Transcatheter aortic valve replacement is now more common than open surgical replacement and may be associated with lower mortality. Given the significant increase in TAVRs it is imperative to be knowledgeable on the complications that may occur following TAVR and result in patients presenting to acute care settings for evaluation and treatment. In this podcast we review an outstanding recent article on TAVR complications and discuss the things we need to know!
IVF administration is central to the management of patients with sepsis. Though the Surviving Sepsis Campaign recently downgraded its recommendation on the amount of initial fluid administration, there are currently no recommendations on a fluid strategy for septic patients who continue to demonstrate hypoperfusion after the initial fluid bolus. In this podcast we discuss the recently published CLASSIC Trial, which compared a restrictive fluid strategy to standard care in adult patients admitted to the ICU with sepsis.
Approximately 2 million patients present each year to EDs in the United States for acute asthma exacerbations. Of these, up to 50,000 may require ICU admission for continued care and resuscitation. The management of critically ill asthmatic patients can be fraught with peril. In this podcast we discuss the assessment and management of patients presenting with a severe asthma exacerbation.
In a recent podcast we reviewed the ARREST Trial, which demonstrated significant improvement in survival among OHCA patients at a single center randomized to ECPR and early coronary angiography upon arrival. In this podcast we discuss the latest trial to investigate whether a bundle of early transport, ECPR, and coronary angiography improves favorable neurologic survival in patients with refractory OHCA.
Though low-tidal volume ventilation has been shown to decreased mortality in patients with ARDS, the use of these settings in mechanically ventilated ED patients has been variable. In this podcast, we discuss a recent systematic review that examined the effect of low-tidal volume ventilation in the ED on clinical outcomes including mortality, length of stay, occurrence of ARDS, and duration of mechanical ventilation.
Though we've discussed the use of balanced solutions in the resuscitation of critically ill patients numerous times on CCPEM, the literature remains controversial with mixed results as to which IVFs are superior. In this podcast, we discuss the latest randomized trial, the PLUS Study, comparing the use of balanced multielectrolyte solution and 0.9% normal saline.
Hyperglycemic hyperosmolar syndrome (HHS) is a potentially life-threatening hyperglycemic emergency that has a mortality that can be 10 times as high compared with patients who have diabetic ketoacidosis. Resuscitation of these complex patients can be fraught with peril and result in patient harm and poor outcomes. In this podcast, we discuss the identification and resuscitation of patients with HHS.
Etomidate and ketamine are frequently used for RSI in critically ill patients. Recent articles have raised concern about an increased incidence of post-intubation hypotension in patients who receive ketamine for RSI. Notwithstanding, is either agent superior for RSI in the critically ill? In this podcast we discuss the recently published EvK trial, which evaluated etomidate and ketamine for RSI in emergency endotracheal intubations.
While COVID continued to be predominant in 2021, a number of important articles that pertained to various aspects of critical care and resuscitation were published. In this podcast, we review a few important trials that were published in 2021 and their impact upon the management of select critical illnesses.
Resuscitating the sick patient and providing ongoing critical care is incredibly challenging in critical access locations and resource limited EDs. In this podcast, we interview Dr. Eric Klotz who has runs a hugely successful mobile critical care team that provides ongoing critical care and resuscitation to patients requiring transfer from resource limited settings.
In this podcast we are joined by EM/CCM superstars Dr. Gabe Wardi and Dr. Kit Tainter, who discuss the physiologic effects of metabolic acidosis, the rationale for sodium bicarbonate administration, and its use in select critical illness states. An awesome podcast to start of 2022!
More than 1.5 million patients are intubated each year in the United States. In up to 20% of patients, the first attempt at intubation is not successful and places patients at risk for peri-intubation cardiovascular collapse and death. In recent years, many providers have used the bougie as either a rescue device for failed attempts or during the initial attempt at intubation. In this podcast, we discuss the BOUGIE Trial, a recently published study that compared the effect of using a bougie to endotracheal tube with stylet on outcomes in patients undergoing tracheal intubation.ReplyReply allForward
The COVID-19 pandemic continues to affect millions of patients worldwide. While the majority of children have milder illness compared with adults, some develop multisystem inflammatory syndrome with a significant increase in morbidity and mortality. In this podcast, we discuss a recent review article on MIS-C as it pertains to the pediatric patient with COVID-19.
Hyperkalemia is a life-threatening electrolyte disorder that is commonly encountered in the ED and ICU. In this podcast we review the latest evidence in the management of hyperkalemia based on a recently published consensus-based panel. https://ccpem.blog/wp-content/uploads/2021/11/CCPEM-Hyperkalemia-in-the-Emergency-Department.pdf
In 2009 and 2013 investigators published studies that demonstrated improved outcomes in patients with IHCA who received vasopressin and steroids in addition to epinephrine. However, both US and European cardiac arrest guidelines have not endorsed these medications due to lack of additional evidence. In this podcast we discuss the recently published VAM-IHCA trial, which evaluated vasopressin and steroids for patients with IHCA. Should we now be administering this combination of medications along with epinephrine for IHCA?
Hemodynamic management of patients with cardiogenic shock centers on vasopressors, inotropes, and mechanical circulatory devices. With respect to inotropic medications, there is little data to guide optimal management and selection of agents. In this podcast we discuss the results of a recent trial that compared milrinone with dobutamine for patients with cardiogenic shock. Which agent was the winner?
The COACT trial demonstrated no improvement in 90-day mortality for post-arrest patients without evidence of an ST-segment elevation MI who were randomized to immediate or delayed coronary angiography. However, the COACT Trial included only OHCA with a shockable rhythm and overall had a very low number of patients that had an acute thrombus at the time of angiography. In this podcast, we discuss the recently published TOMAHAWK study that evaluated OHCA patients due to either a shockable or nonshockable rhythm and had no evidence of a STEMI. Should this study change our post-arrest management of OHCA patients with a non-diagnostic ECG?
The administration of IVFs is nearly universal in critically ill patients. In recent years, several studies have suggested improved outcomes with the use of balanced crystalloids solutions in contrast to 0.9% NS. In this podcast, we discuss the recently published BaSICS Trial that evaluated Plasma-Lyte 148 with 0.9% NS in critically ill patients. Does this study provide practice-changing evidence to make that switch?
Traumatic hemothorax has traditionally been treated with a large bore thoracostomy to prevent retained hemothorax and morbidity. In this podcast we discuss the results of a recent study on the use of small bore thoracostomy (pigtail catheters) for the treatment of traumatic hemothorax.
Ventilated ED patients may be at high risk for awareness with paralysis, thereby increasing the risk of long-term psychological sequelae. In this podcast, we discuss the results of the recently published ED-AWARENESS Study and its implications for managing the ventilated ED patient.
Current international guidelines recommend TTM for adult patients with ROSC from OHCA who remain comatose or unable to follow verbal commands. However, the overall level of evidence for this recommendation remains of low certainty. In this podcast, we discuss the results of the recently published TTM2 Trial and its implications on the management of post-cardiac arrest patients.
More than 3 million patients develop ARDS each year across the globe. Like any therapy, mechanical ventilation can induce further lung injury and cause patient harm if misapplied. In this podcast we bring you up to speed on the latest, evidence-based titration of mechanical ventilation in patients with ARDS.
Over 80% of patients with sepsis receive care in the ED. Despite evidence demonstrating the benefits of ED sepsis resuscitation, there remains significant controversies on many aspects of ED sepsis care. In this podcast, we are joined by EM/CCM extraordinaire Dr. Gabe Wardi, who discuss an upcoming article on ED sepsis resuscitation that will have a significant impact the care we provide to our patients. You cannot afford to miss this episode!
Airway guru Dr. Ken Butler joins us for this podcast to discuss some great pearls and pitfalls in intubating patients with physiologic derangements that place that at high-risk for peri-intubation catastrophes. If you intubate patients in your ED you simply CAN'T miss this episode!
Despite continued advances in resuscitation, favorable outcomes for patients with OHCA who receive standard resuscitation remain dismal. In recent years there has been significant interest in the use of ECMO for OHCA. However, the evidence demonstrating the efficacy of ECMO in OHCA remains limited. In this podcast we review the recent ARREST Trial, which evaluated ECMO-facilitated resuscitation in OHCA. In addition, we also discuss a recent systematic review on VA-ECMO for massive PE.
In recent weeks, there have been several important studies and guidelines published that have served to improve our understanding of treating critically ill patients with COVID-19 infection. In this podcast, we highlight the latest update from the SSC and discuss studies on convalescent plasma and IL-6 antagonists.
Critically ill patients with acute hypoxic respiratory failure receive supplemental oxygen as a component of their treatment. In recent years, exposure to high levels of FiO2 with resultant "hyperoxia" have been associated with increased mortality in critically ill patients. At present, there is no clinical practice guideline on oxygenation targets for adult patients with hypoxic respiratory failure. In this podcast, we discuss the recently published HOT-ICU trial that evaluated a lower versus high oxygenation target in adult patients with acute hypoxic respiratory failure.
Patients with severe aortic stenosis who present with acute decompensated heart failure are among the most challenging patients to resuscitate. In this podcast, we discuss the pearls and pitfalls in managing both the hypertensive and hypotensive patient with severe AS and acute heart failure.
To say that 2020 has been a challenging year would be a gross understatement. The courage and determination that all healthcare providers have shown in confronting the COVID-19 pandemic has been nothing short of inspirational. In addition to the thousands of COVID-19 patients, we have also needed to manage many other critical illness conditions that have presented to our various settings. In this annual podcast, we review key articles published in 2020 on various aspects of select critical conditions.
The period following ROSC from cardiac arrest is a time when lives can be saved...or lost. A systematic and comprehensive approach to post-arrest care is associated with improved survival to discharge with good neurologic function. In this podcast, we discuss the recently published 2020 AHA Updates to Cardiopulmonary Resuscitation and Emergency Cardiovascular Care with attention to Post-Arrest care.
Approximately 350,000 adults in the US experience an out-of-hospital cardiac arrest (OHCA). Despite numerous potential improvements in treatments, survival from OHCA remains essentially unchanged since 2012. The American Heart Association (AHA) just released its 2020 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. In this podcast, we review the key updates and recommendations that impact the acute care provider managing the patient in cardiac arrest.
Although electrical storm is an uncommon presentation, it is important that we readily recognize and treat these patients to prevent rapid progression to cardiac arrest. Effective management can be complex. In this podcast we discuss the management of patients with unstable and stable electrical storm.
Patients with acute liver failure can be incredibly sick and have an exceedingly high mortality. Early identification and prompt, evidence-based management of the patient with acute liver failure may improve patient-centered outcomes. In this podcast, we discuss updated guidelines for the management of adult patients with acute liver failure. Key resuscitation topics include fluid resuscitation, blood pressure targets, vasopressor selection, bleeding and thrombosis risk, and mechanical ventilation.
Ketamine is a well-known anesthetic used commonly in the ED for RSI and procedural sedation. In this podcast, we review the use of ketamine in other critical illness states, such as status asthmaticus, status epilepticus, acute pain management, and acute alcohol withdrawal syndrome.
Emergency department (ED) visits for critically ill patients has nearly doubled over the past decade. Unfortunately, ED boarding of critically ill patients awaiting ICU admission has also risen significantly, and is associated with several adverse patient outcomes. In this podcast, we review a white paper on boarding of the critically ill ED patient just published in Critical Care Medicine by a joint task force from ACEP and SCCM. If you care for the critically ill ED boarder in your ED, you CAN'T afford to miss this discussion!
The use of tranexamic acid (TXA) has markedly increased since the results of the CRASH-II trial were published. In addition to its use in trauma, TXA has been evaluated and used in numerous other conditions, including post-partum hemorrhage and epistaxis. Recently, the HALT-IT Trial was published online in the Lancet, which evaluated the use of TXA in patients with acute gastrointestinal bleeding. In this podcast we discuss the HALT-IT Trial and its implications for clinical practice.
There has been an explosion of literature on the evaluation and management of patients with COVID-19 infection. In this podcast, we discuss updates (as of June 2020) in the care of critically ill patients with COVID-19. We touch on non-invasive ventilation, mechanical ventilation, proning, and medication administration.
Emergency medicine, critical care, and resuscitationists often use the Shock Index to identify patients with increased mortality. The Shock Index is calculated by dividing heart rate by the systolic blood pressure, with a value > 0.8 identifying a potential critically ill patient. In the setting of sepsis, the use of systolic blood pressure to calculate the Shock Index may be less sensitive. In this podcast, we review a recent article that suggests the use of the Diastolic Shock Index may be better in identifying septic patients who require earlier initiation of vasopressor medications.
As we gain more experience managing critically ill patients with COVID-19 infection there has been a shift away from immediate intubation and towards more frequent use of non-invasive ventilatory strategies. Dr. Michael Allison joins CCPEM this podcast to discuss the latest evidence, controversies, and recommendations on the use of HFNC in COVID-19 patients.
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Currently, there is no approved treatment or proven therapy for COVID-19. As such, many have turned to treatments with little to no supporting evidence. In this podcast, we bring back EM Pharmacy extraordinaire Bryan Hayes to discuss information on the toxicities of potential therapies used in the management of patients with COVID-19.
Current guidelines for many critical illnesses recommend targeting a MAP of 65 mm Hg, with consideration of higher MAPs in older patients with chronic HTN. Recent literature, however, suggests increased mortality in older patients who are exposed to larger quantities of vasopressor medications. In this podcast, we do a deep dive into the recently published 65 Trial, which sought to evaluate the effect of permissive hypotension in older patients with vasodilatory hypotension.
Our understanding and management of patients with COVID-19 infection continues to rapidly evolve, almost on a daily basis. In this podcast, we discuss current experience and thoughts on managing the critically ill patient with COVID-19 infection with attention to ventilator management.
In 2017, Paul Marik published a single-center retrospective before-and-after study that demonstrated significant mortality benefit to patients with septic shock who received a cocktail of steroids, vitamin C, and hydrocortisone. Since that time, many providers have adopted this cocktail for the treatment of septic shock, despite the fact that no randomized trial has evaluated this regimen. In this podcast, we welcome EM/CCM superstar Dr. Gabriel Wardi to review the VITAMINS trial, a randomized clinical trial evaluating this cocktail among patients with septic shock.
In December 2019 a novel coronavirus (now named COVID-19) was identified as responsible for a cluster of pneumonia cases in Wuhan, China. As of March 2020, over 50 countries have identified patients who have tested (+) for COVID-19, with over 90,000 identified cases and more than 3000 deaths to date. As the discussion regarding COVID-19 rapidly evolves, it is important for clinicians to prepare locally and to review standards for prevention, diagnosis, and treatment. In this podcast, we review the latest information on identification, diagnosis, and treatment of patients with COVID-19 infection.
The debate on the ideal neuromuscular blocking agent for RSI in emergency intubations rages on. In this podcast, we review the latest randomized trial comparing rocuronium with succinylcholine in out-of-hospital patients needing emergency tracheal intubation - The CURASMUR Trial. Emergency medicine airway guru Dr. Ken Butler takes us through the paper and provides his expert opinion on which NMBA you should be reaching for in your next intubation!
In recent years, the use of e-cigarette and vaping products has sharply risen. Concomitant with the increased use is an increase in patients presenting with severe respiratory disease associated with these products. In this podcast we review the latest information on the clinical presentation, diagnosis, and treatment of patients presenting with e-cigarette associated acute lung injury (EVALI).
The number of critically ill cancer patients presenting to the ED is increasing. Though many of these patients are critically ill with conditions directly related to their cancer, some are sick as a result of toxicities from new therapies used to treat their cancer. Dr. Sarah Dubbs joins the podcast to discuss what we NEED to know about these new classes of cancer therapies and their related toxicities. Simply a TON of pearls in this 25-minute podcast.
A plethora of literature was published during the course of 2019. In this podcast, we review several key articles published in the 2019 critical care literature that pertain to the resuscitation and management of select critically ill patients. Simply a great way to start 2020!
Up to one-third of patients with status epilepticus will not respond to benzodiazepines. Unfortunately, treatment of benzodiazepine-refractory status epilepticus is not well studied. The longer seizures persist, the worse patients do. In this podcast, we discuss the results of the recently completed ESETT trial that evaluated three anticonvulsant medications for status epilepticus.
Amniotic fluid embolism (AFE) is a catastrophic syndrome that occurs very soon after delivery and is a significant cause of morbidity and mortality. Unfortunately, the diagnosis is often missed, or at the very least delayed. In this podcast, we discuss the clinical presentation, diagnosis, and management of this critical illness. Check it out!
Up to 25% of critically ill patients who undergo RSI and endotracheal intubation (ETI) may suffer cardiovascular collapse.? Many clinicians administer IVFs during RSI and ETI in hopes of preventing cardiovascular collapse, though this has never been studied...until now.? In this podcast we discuss the results of the recently published PrePARE Trial, as well as provide some thoughts on maximizing a patient's physiology before performing ETI.
Current guidelines for post-cardiac arrest management recommend TTM (32C to 36C) for all patients with coma after resuscitation from cardiac arrest. The benefit of TTM is primarily seen in patients who present with a shockable rhythm. However, nonshockable rhythms are now the most common presenting rhythm in patients with cardiac arrest. The use of TTM in patients with nonshockable rhythms remains controversial. In this podcast, we discuss the latest randomized article on the use of TTM in patients with cardiac arrest with a nonshockable rhythm. Should these results change YOUR practice?
Given the development of ED-ICUs and the ever increasing boarding of critically ill patients in the ED, extubation in the ED has become a more common practice. Selecting the appropriate patient and following a practical, organized approach is paramount to safely and successfully performing this procedure. In this podcast, we discuss the pearls and pitfalls of ED Extubation. Simply an outstanding discussion that you can't miss!
Over the past decade, the annual hours of critical care delivered in US emergency departments has sharply risen. Undoubtedly, many critically ill patients remain in the ED for numerous hours awaiting an ICU bed. In an attempt to improve the delivery of critical care to boarding ED patients, several hospitals and health care systems have recently implemented ED-based ICUs. In this podcast, we discuss a recent article published in JAMA Open Network evaluating the impact on mortality and resource utilization of an ED-based ICU.
Over 500,000 patients suffer sudden cardiac arrest each year in the United States. Though survival rates are improving, there remains significant variation in outcomes by region. In recent years, numerous advances in post-resuscitation care have been associated with improved outcomes. In this podcast, we discuss the key elements of post-arrest care along with current controversies. Most importantly, we discuss what you NEED to know when caring for the post-arrest patient in order to maximize outcomes!
The World's population is aging. By 2030, 20 percent of the US population will be over the age of 65 years. Older patients have a number of age-related physiologic changes that impact their disease presentation and resuscitation. In this podcast, we review common physiologic changes in the geriatric patient and provide critical resuscitation pearls when confronted with the sick, geriatric patient.
With increasing water temperatures, there is a rise in the incidence of V.vulnificus infections in non-endemic regions. Patients with V.vulnificus infection are often critically ill, can quickly decompensate, and crash within hours. In this podcast, we discuss the clinical characteristics of this serious infection, along with the current treatments of choice. A very hot and timely topic!
ICH accounts for approximately 15 percent of all strokes. Despite improvements in neurocritical care, the mortality for patients with ICH can still reach 50 percent at 1-year, with many left with significant residual deficits. Patients with an ICH who are taking an oral anticoagulant medication tend to have larger ICH volumes, more frequent IVH, and a greater frequency of hematoma expansion. In this podcast, we review the latest recommendations on reversing anticoagulant medications in patients with an ICH. This is information you can't afford to miss!
A critical component to post-arrest care for the patient with ROSC following out-of-hospital cardiac arrest is early coronary angiography. Current guidelines recommend immediate cardiac angiography for patients with evidence of a STEMI on their post-arrest ECG. For the more common scenario of non-diagnostic ECGs, the role of early coronary angiography remains uncertain. In this podcast, superstar Amal Mattu joins us to discuss an article just published in the New England Journal of Medicine on early coronary angiography for patients without evidence of STEMI following ROSC.
Emergency medicine, critical care, and acute care providers evaluate, resuscitate, and manage patients with shock on a daily basis. Despite initial efforts, a select number of patients are refractory to fluid and vasopressor administration. In this podcast, we discuss a rationale approach to vasopressor administration, along with several rescue therapies for the patient with refractory vasodilatory shock.
Bryan Hayes rejoins the podcast to discuss some great pearls and pitfalls with select medications used to resuscitate and treat critically ill patients. This episode contains numerous pearls that you can't afford to miss!
Renal transplants are one of the most common organ transplants worldwide. Renal transplant patients can quickly succumb to illness and present to the ED or be admitted to the ICU in need of urgent resuscitation. In this podcast, we discuss critical pearls and pitfalls in managing the renal transplant patient.
Rory Spiegel (@EMNerd_) joins the podcast this month for an in-depth analysis and discussion of the recently published ANDROMEDA-SHOCK trial. Should capillary refill time replace serial lactate values for guiding the hemodynamic resuscitation of patients with septic shock? What are the limitations of this potential game-changing study? How will you incorporate its results into your clinical practice?
More than 1.5 million patients undergo endotracheal intubation each year in the U.S. Endotracheal intubation can be complicated by hypoxemia, which is a known risk factor for peri-intubation cardiac arrest and death. Rapid sequence intubation typically involves a delay of up to 2 minutes between the administration of sedative/paralytic medications and laryngoscopy. In this podcast, we discuss a recent article in the New England Journal of Medicine that suggests critically ill patients may benefit from bag-mask ventilation during the period between medication administration and laryngoscopy.
Respiratory distress in the patient with a tracheostomy can incite fear in even the most seasoned emergency physician or intensivist. In this episode, we review the initial management of respiratory distress in the trach patient, along with a review of common tracheostomy emergencies that are likely to present to your ED or ICU.
As bitter cold temperatures grip the Northeast, many struggle to stay warm and often resort to nontraditional methods of heating. As a result, there has been an increase in the number of cases of CO toxicity. In this episode, we cover what you NEED to know about diagnosing and managing the critically ill patient with CO exposure.
As EDs across the country strive to meet sepsis benchmark metrics, many have implemented a variety of screening tools. With the publication of Sepsis-3, qSOFA is the latest screening tool recommended for patients outside of the ICU setting. In this podcast we review the derivation of qSOFA and discuss recent literature on whether qSOFA is any better than traditional screening tools.
Extracorporeal life support (ECLS) is being used with increasing frequency in many EDs across the US and across the World. In this podcast, we review the basics of ECLS, as well as discuss the current indications, contraindications, and complications of this critical therapy. In addition, we review some key pearls and pitfalls in the cannulation of patients for ECLS.