Claim OwnershipCritical Care Perspectives in Emergency Medicine
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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.
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Emergency physicians intubate critically ill patients daily. Unfortunately, up to 17% of ED intubations can be complicated by peri-intubation hypoxemia, hypotension, and cardiac arrest. Efforts to optimize patient's physiology prior to rapid sequence intubation are critical in mitigating the risk of potentially disastrous peri-intubation complications. In this podcast, we discuss a recent Clinical Policy from the American College of Emergency Physicians that addresses critical issues in the management of adult ED patients undergoing endotracheal intubation.
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.
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.
1In 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.
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?
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