In emergency medicine, we are so heavily trained in resuscitation that any senior resident could recite the ACLS algorithm to you after being woken up at 3 am. However, the real work begins after the pulse return. Up to two-thirds of patients with return of spontaneous circulation (ROSC) will not survive to discharge.1,2 This approach, modeled after the 2015 American Heart Association Guidelines3 and an excellent review article by Dr. Jacob Jentzer et al,4 can help guide you through the chaos to stabilize your next post-ROSC patient.
What is the most commonly fractured carpal bone in adults? It’s the scaphoid bone. As a bonus it has the dreaded complication of avascular necrosis. So how good are the physical exam and imaging modalities in diagnosing a fracture? What is the likelihood ratio (LR) that snuffbox tenderness predicts a fracture? Bottom lines: The exam is highly sensitive but poorly specific, such that one can only confidently state that a NON-tender snuffbox and scaphoid tubercle essentially rule out an acute scaphoid fracture. Also negative x-rays for patients with scaphoid tenderness still yield a fracture post-test probability of 25%. This PV card breaks down all the LRs.1
PV Card: Scaphoid Fracture
Adapted from 1
- Carpenter C, Pines J, Schuur J, Muir M, Calfee R, Raja A. Adult scaphoid fracture. Acad Emerg Med. 2014;21(2):101-121. [PubMed]
First and foremost, international emergency medicine (IEM) is a big tent. We’ve got clinicians with an interest in tropical medicine and trauma, systems experts, inventors, educators, missionary families, public health experts, thrill-seekers, and policymakers. A disaster response specialist who has a “go bag” packed at all times ready for deployment belongs in this tent, as does an epidemiologist based in the U.S. who analyzes data on cholera outbreaks in refugee camps. Because it’s a relatively new specialty there is the occasional squabble about what does and does not constitute IEM, but generally we agree that we are working together to improve the state of health for people in our world. Our specialty allows us to work in a multitude of settings and clinical environments, something that no other specialty can do.
The newest round of the 2015 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC) contains 315 recommendations.1 It is easy to be overwhelmed by this massive (275 pages) document so this post will distill what you need to know in the emergency department. This update marks the end of a 5-year revision cycle for the AHA and the shift to a continuously updated model. Current and future guidelines can now be found at ECCGuidelines.heart.org. This round lacks any of the major foundational changes seen in 2010; however, we do say goodbye to some recommendations (bye bye vasopressin).
The first time I saw the Thumper performing CPR on a patient I thought “well, that makes sense.” Since then we have seen other devices, most notably the Zoll AutoPulse and the Physio-Control LUCAS. It was disappointing to many in 2005 when the AutoPulse trial was halted early due to harm. 1 Although four-hour survival was similar between groups, the hospital discharge survival rate in the manual CPR group was 9.9% compared to 5.8% in the mechanical CPR group. Many hypotheses were proposed to explain the results, which included Hawthorne effect, prolonged device deployment time, and enrollment bias. Last month, the results of the LUCAS in Cardiac Arrest (LINC) trial were published in JAMA, breathing new life into the mechanical vs manual CPR debate. 2
The short answer to this question is NO. Since the landmark post-arrest, therapeutic hypothermia studies published in 2002, 1,2 extensive efforts have been made to ensure our post-arrest patients are cooled… and cooled fast. It only seemed logical to extend this revolutionary treatment into the field and have paramedics begin the cooling in the field. New EMS protocols were developed around the country to incorporate hypothermia into cardiac arrest management and well received by paramedics and EMTs. But a recent JAMA publication calls this now into question. 3