Emergent airway management and severe sepsis are both high-risk situations that are commonly encountered by emergency physicians. It is well known that complications can be high in both situations, which in turn can lead to increased morbidity and mortality. For instance, about 1/4 of patients who are hemodynamically stable prior to intubation get post-intubation hypotension (PIH) after rapid sequence intubation. Also septic patients may not be reliably identified by systemic inflammatory response syndrome (SIRS) markers early in their disease course. The Shock Index (SI) may be an adjunct that is easy to calculate and could predict both PIH and severe sepsis.
To provide a resource for evidence-based Emergency Medical education, this list of must-read landmark articles was created to supplement the Emergency Medicine (EM) internship year of training. There are 52 articles so that one article can be read at leisure each week of the year. I searched national databases and polled faculty at the University of Washington to identify articles that faculty would expect any EM resident to be familiar with or that they felt were practice-changing in EM. Articles were selected for the final list based on the quality of study design, sample size, and relevance for EM residents.
Pauses in chest compressions are known to be detrimental to survival in cardiac arrest, so much so that the 2010 American Heart Association (AHA) emphasize high-quality compressions while minimizing interruptions. There have been some studies that now advocate for continuous chest compressions during a defibrillation shock. There have been substantial changes to external defibrillation technology including:
- Biphasic shocks with real-time impedance monitoring to reduce peak voltages
- Paddles being replaced by adhesive pre-gelled electrodes
- Enhancement in ECG filtering permitting rhythm monitoring during chest compressions.
So the mantra of “hard and fast” may be true when it comes to CPR, but the real question now becomes, should we be continuing CPR during defibrillation?
When talking about Out of Hospital Cardiac Arrest (OHCA) there are really only three things that make a true difference on outcomes (i.e. survival and neurologic function):
- High quality, non-interrupted CPR
- Early defibrillation
- Therapeutic hypothermia
The quality of CPR is often under appreciated and performed incorrectly (too slow and/or not hard enough). With mechanical CPR, chest compressions are delivered uninterrupted and at a predefined depth and rate. In my own practice I have seen these devices being used more and more, but my questions is do these devices impact outcomes?
Ischemic stroke is an emergent and devastating neurologic disorder, and is a leading cause of both death and disability in the United States. With each minute of brain ischemia, two million neurons are irreversibly damaged. Total ischemic time is linked to functional outcome, and therefore, the role of the Emergency Department is paramount in the management of these patients. Fibrinolytic therapy has become a mainstay of therapy for acute stroke, but guidelines for the use of tPA are dynamic, and often even controversial. When you identify someone with symptoms of stroke, what is your approach to determining if a patient should receive tPA?
Derangements in acid-base status are commonly discovered on routine emergency department evaluation and often suggest the presence of severe underlying disease. Many acute conditions can disrupt homeostatic mechanisms used to buffer and excrete acid, and these changes may necessitate immediate intervention. When you discover a patient with an abnormal pH, what is your approach to the diagnosis?
The incidence of critical illness in the ED is rising, with greater than 1 million ED patients requiring emergent resuscitation each year. In addition to definitive airway management, hemodynamic support is among the most important life-saving interventions implemented by emergency physicians. When a patient develops persistent hypotension, what is your approach to choosing the right medication for hemodynamic support?