Accidental hypothermia is a life threatening condition that can lead to a challenging resuscitation. The very young, old, and intoxicated patient are at high risk to developing hypothermia, even in temperate climates. The pathophysiologic changes from hypothermia make the standard ACLS approach insufficient to care for the hypothermic patient. This article will discuss the physiology of hypothermia and how you should alter your approach in the hypothermic patient, including early consideration of extracorporeal membrane oxygenation (ECMO).
Drowning cases peak this time of year and represent a leading cause of mortality in children. For example, drowning represents the leading cause of death in boys ages 5-14 years old, and worldwide, there are 500,000 annual deaths from drowning.1 Hypoxic injury and subsequent respiratory failure represent the primary causes of morbidity and mortality. Although providers are typically taught to be aware of possible trauma (e.g. cervical spine fracture) when evaluating a drowning case, less than 0.5% of drownings are traumatic.2 The duration of immersion, volume of aspirated fluid, and water temperature dictate clinical outcomes.1 We review the presentation, pathophysiology, and management of drowning to raise awareness about this important public health issue.
Tumor lysis syndrome (TLS) is an oncologic emergency characterized by life-threatening metabolic disturbances. Although it is most frequently associated with the treatment of hematological malignancies, its frequency may be increasing among patients with solid tumors. Emergency providers should be familiar with the presentation and treatment of these electrolyte abnormalities, which can lead to renal failure, seizures, and cardiac dysrhythmias. ALiEM Cards: Tumor Lysis Syndrome, written by Drs. Christopher Nash and Derek Monette, reviews TLS and the latest updates in its management.
Acute respiratory distress syndrome (ARDS) is a complex, life-threatening form of respiratory failure. It is responsible for almost 75,000 annual deaths in the United States.1Management remains lung-protective mechanical ventilation, an intervention that can begin in the ED. The Berlin Definition of ARDS has better predictive validity for mortality in comparison to previous definitions of ARDS.2 ALiEM Cards: ARDS, written by Dr. Michelle Lin, reviews the Berlin Definition and provides EPs with an on-shift resource to help manage critically-ill patients.
Most protocols for managing pediatric patients with diabetic ketoacidosis (DKA) are based on a theoretical association between fluid resuscitation and subsequent neurological decline. Although the evidence for an association between IV fluids and cerebral edema comes from retrospective reviews, for over 20 years, it is an accepted teaching principle of pediatric DKA.
Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis, published just days ago in the New England Journal of Medicine, challenges this teaching with the first randomized controlled trial designed to investigate the relationship between IV fluids and cerebral edema. We review this publication and present a behind-the-scenes podcast interview with lead authors Dr. Nathan Kuppermann and Dr. Nicole Glaser from the Pediatric Emergency Care Applied Research Network (PECARN). (more…)
Despite the widespread clinical use, and their well-documented life-saving properties, vasopressors are often maligned, accused of causing ischemia to fingers, toes, mesentery, kidneys, and so forth. Not only is the evidence that this happens poor, but, a fear of this dreaded complication can unwarrantedly lead good clinicians to limit or withhold potentially life- and organ-saving medications. This article showcases the importance of end-organ perfusion and explains how vasopressors may in fact be one of the most important therapies in an emergency physician’s armamentarium.
The role of extracorporeal membrane oxygenation (ECMO) in the management of acute respiratory distress syndrome (ARDS) has been a source of debate within the critical care community.1 The use of ECMO has steadily increased over the past decade;2 however, evidence to support the widespread adoption of this expensive and invasive technology is limited. As advances in ECMO technology have rapidly outpaced evidence, clinicians have been left to speculate as to ECMO’s true value. Is ECMO a promising tool to advance the care of patients with respiratory failure3 or an expensive distraction that has inappropriately supplanted evidence-based strategies?4
All who care for patients with ARDS have been eagerly awaiting the results of the Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome (EOLIA) trial which were recently published in May 2018’s New England Journal of Medicine.5