Organophosphate Toxicity

Acute Organophosphate Toxicity

emDOCS / ToxCard - June 7, 2023 - By Daniel Escobar; Ann-Jeannette Geib

Reviewed by: James Dazhe Cao; Alex Koyfman; Brit Long

Clinical Pearls:

1. Exposure can occur via ingestion, dermal absorption, or inhalation from spraying.
2. There are two clinical syndromes with acute toxicity, Acute Poisoning and Intermediate Syndrome, that lead to cholinergic crisis, muscle weakness, respiratory failure, and neurologic complications.
3. Diagnosis is made clinically. Do not delay therapy in lieu of pending lab results.
4. Treatment mainstay is antidote therapy with Atropine (for control of pulmonary secretions and cardiopulmonary stability) and Pralidoxime (to prevent Aging process) and should be administered immediately. Otherwise, provide supportive care.
5. Titrate atropine therapy to pulmonary secretions/bronchospasm, not to the other cholinergic findings.

Etomidate for RSI induction

Etomidate for RSI induction?

St Emlyn´s - By Simon Carley - June 7, 2023

The bottom line

Firstly, head over to the SGEM and read a more in depth review from Ken.

Secondly, having read the paper and the review it is my view that there is very little to support a move away from ketamine as an induction agent. If we run out of the SwissKet, then we may have to explore other countries until the situation resolves (I hear around November is likely).

Sindrome platipnea-ortodeossia

Quando la dispnea è… “piatta”

empills -  diCarlo D'Apuzzo - 5 Giugno 2023

Sindrome platipnea-ortodeossia

La platipnea è la comparsa di difficoltà respiratoria in posizione eretta o seduta che migliora con la posizione distesa

L’ ortodeossia è invece il riscontro clinico di una bassa saturazione arteriosa di ossigeno in posizione eretta che si innalza una volta che il paziente si pone supino.

Ma allora non è stato il mezzo di contrasto a salvarla ma la barella!

Cerebellar Stroke

Cerebellar Stroke

emDOCs / EM@3AM - June 3, 2023 - By Ramya Kondaveeti; Thaer Ahmad

Reviewed by: Sophia Görgens; Cassandra Mackey; Brit Long

Pearls:

• Cerebellar strokes can present as dizziness, nausea and vomiting, ataxia, and/or dysarthria.
• Edema from infarction in the posterior fossa can result in severe brainstem injury, herniation, and death.
• Treat hemorrhagic cerebellar strokes medically with anticoagulant reversal therapy as indicated, prophylactic anti-epileptic treatment, blood pressure management, and hypertonic saline or mannitol for cerebellar edema.
• Ischemic cerebellar strokes should be treated with aspirin and can be considered for thrombolytic therapy if within the correct timeframe.

Contrast Nephropathy

Contrast Induced Nephropathy – sense at last

St. Emlyn´s - By Simon Carley - June 2, 

There is now a significant body of evidence supporting the use of iodinated contrast agent for CT scans in the emergency setting even if baseline renal function is abnormal or the patient isntaking metformin.

The evidence for the routine use of fluid therapy prior to intravenous contrast in the emergency setting is weak. In the emergency setting the balance of risk of CI-AKI is highly likely to be offset by the risk of delay in diagnosis (delayed scan waiting for blood results) and in some cases (especially the elderly and those with known heart failure) the requirement for pre-hydration.

See the joint statement and recommendations here

Hypothermia for TBI

POLAR trial – Hypothermia for Severe TBI

emDOCs / 52 in 52 – #37 - June 1, 2023 - By Christian Van Nispen

Take Aways:

• The data do not suggest that targeted hypothermia improves neurological function, reduces death, or reduces hospital length of stay as compared to normothermia.
• Several secondary outcomes suggest a signal toward harm with hypothermia, including incidence of pneumonia, bradycardia, and more days ventilated.
• Multiple centers, strong follow-up, and rapid induction of hypothermia are strengths of the trial.
• That 19% of patients were withdrawn from the study decreases generalizability.

My take:

• This trial is consistent with other recent data which demonstrate lack of support for prophylactic hypothermia as a standard of care in traumatic brain injury.

Packers, Pushers and Stuffers

Packers, Pushers and Stuffers – Drug Concealment in the ED

St Emlyn´s - By Molly Bowman - June 1, 2023

The take home messages:

• Be vigilant! Not all patients with internally concealed drugs will present with the police or border force, not all of them will be forthcoming with information and not all of them will be symptomatic. 
• Scan with consent. The mainstay of imaging currently is a low dose CT, however this requires consent. Without consent, the general guidance is to observe then discharge to the police. 
• ToxBase is key. Current RCEM guidance focuses around using ToxBase for investigation, treatment and observation guidelines. This relies on patient candour, however in symptomatic patients the generic toxidrome can give direction as to which drug has been concealed, 
• Early surgical input should be sought in cases where there is a suspicion of obstruction, perforation or cocaine toxicity.
• Communicate with, but don’t be directed by, the police. You are not obliged to perform intimate examinations or additional imaging if requested by the police. Provide a safe handover of information with safety netting advice.

Phenobarbital for Alcohol Withdrawal

Phenobarbital as First-Line Medication for Alcohol Withdrawal: 

Have You Switched From Benzodiazepines Yet?

ALiEM - Jun 1, 2023 - By: T. Alex Rogers and J.D. Cambron

Conclusion

Phenobarbital has gained significant popularity for use in EtOH withdrawal in the last few years. Several factors make it ideal for use in EtOH withdrawal, primarily its long half-life allowing for a multi-day, self-tapering effect. The most commonly recommended dosing regimen starts with a 10 mg/IBW kg bolus followed by titration every 30 minutes afterwards. Patients in the ED often can be safely phenobarbital-loaded and discharged, assuming hemodynamic stability, normal alertness, and resolution of withdrawal symptoms. More rigorous studies are needed determine dose thresholds that warrant hospital admission.

ESR and CRP

Erythrocyte Sedimentation Rate and C-Reactive Protein in the ED

emDOCs - May 29TH, 2023 - By Rachel Kelly and Robert Nocito

Reviewed by: Jessica Pelletier; Marina Boushra; Brit Long

Pearls and Pitfalls

• ESR and CRP are neither sensitive or specific for infection, and cut-off values for meaningful elevations are based on the disease process in question. Inflammatory markers can be falsely elevated or decreased based on concomitant conditions.
• Do not routinely order ESR and CRP, as elevations are common in a spectrum of diseases, and false positives may be distracting. Results of these tests should not replace clinical judgment. 
• There can be utility when ordering ESR and CRP for back pain in the ED, but normal values should not dissuade the clinician from ordering an MRI if suspicion is high for an infectious process.
• There is some utility in ordering ESR and CRP for skin/soft tissue/bone and joint conditions, although the levels may be more useful for long-term management as opposed to ED clinical decision making.

Universal Health Coverage

Seventy-sixth World Health Assembly

Daily update: 26 May 2023

Gearing up for a historic UN High-Level Meeting on Universal Health Coverage

…Stronger national plans needed for emergency care to respond to all hazards

In a new resolution agreed today, the World Health Assembly called for timely additional global efforts to strengthen the planning and provision of quality emergency, critical and operative care (ECO) services. Robust ECO services are at the foundation of national health systems, and the need to be able to respond effectively to emergency events, including all hazards. 

Concerned that the COVID-19 pandemic revealed pervasive gaps in the capacity, preparedness of delivery of ECO worldwide, the Assembly urges Member States to, among other actions, create national policies for sustainable funding, effective governance and universal access to needs-based ECO care for all; and promote more coherent, inclusive and accessible approaches to safeguard effective ECO care in disasters, fragile settings and conflict-affected areas.

The Assembly requests the Secretariat to provide progress reports on implementation of this resolution in 2025, 2027 and 2029. 

➜ Related documents EB152(3) 

Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies

• Related linksClinical services and systems: Emergency and critical care

ARDS ??

PulmCrit (EMCrit)

“ARDS” is not a real thing

PulmCrit (EMCrit) - May 27, 2023 - By Josh Farkas

My dear pulmonologists, I have some bad news. Santa Claus isn't real. Neither is “ARDS.”

“ARDS” has traditionally been conflated with a specific histopathological form of lung injury: diffuse alveolar damage (DAD). Lectures, chapters, and articles typically juxtapose these two entities, promoting the concept that they're one and the same.

But they aren't…

Entrapped Metal Zipper

Trick of Trade: Removal of Entrapped Metal Zipper

ALiEM - By Meraj Fatima & Shahan Waheed - May 24, 2023

Background

The 4 most common types of zippers are nylon coil zip, plastic mold zip, metal zip, and invisible zip. Most of the techniques describing solutions on zipper entrapment in the medical literature are derived from case reports and case series. All revolve around understanding zipper anatomy and obtaining adequate exposure to assess how the skin is entrapped. The penile skin often is entrapped either in the sliding mechanism (also known as the endplate) or between the teeth of the zipper…

Topical NSAIDs

Topical NSAIDs for Acute Pain Management

EMOttawa - By Chirag Bhat & Max Zworth - May 25, 2023

Conclusions

In conclusion, while oral NSAIDs are effective for managing pain and inflammation, they are associated with significant risks of adverse events, particularly gastrointestinal and cardiovascular events. Topical NSAIDs provide an effective alternative for managing pain without the systemic side effects associated with oral NSAIDs. Several studies have demonstrated the effectiveness of topical NSAIDs for different types of pain, with a favorable safety profile. As healthcare providers, we should consider the use of topical NSAIDs as a first-line option for managing pain, particularly in patients at high risk for adverse events from oral NSAIDs.

Trauma Updates

Trauma Resuscitation Updates

REBEL EM - By Salim Rezaie - May 25, 2023

I recently gave a talk on the initial management of trauma patients with hemorrhagic shock. In the initial management of trauma resuscitation there are 4 key principles that should be followed:

In this blog post I will summarize the lecture and the evidence for each of these principles…

NICE Head Injury

NICE Head Injury Guidelines 2023: Now who do we scan?

St. Emlyn´s - By Thomas Shanahan - May 22, 2023

What is the bottom line?

Professor Fiona Lecky, topic advisor for the NICE committee provided a useful summary of what as clinicians we need to know:

• An IV TXA bolus within 2 hours of injury can be considered life-saving in people with suspected moderate or severe traumatic brain injury – even when no extracranial bleeding event is evident. 
• Shared decision-making can now inform a decision not to conduct a CT head scan in people taking anticoagulant or antiplatelet medication (not aspirin monotherapy) if there are no signs or symptoms of traumatic brain injury. 
• Evidence suggests that even apparently mild head injury can lead to significant long-term consequences such as hypopituitarism.

Aneurysmal SAH

Neurocritical Care Society Aneurysmal SAH Guidelines

emDOCs - May 22, 2023 - By Brit Long

Reviewed by: Alex Koyfman and Manpreet Singh

Aneurysmal subarachnoid hemorrhage (aSAH) can be deadly. Several recent studies on the management of aSAH have been published, requiring an update of current guidelines. This post will look at the Neurocritical Care Society guidelines for the management of aSAH.

Summary

Burnout

EMCrit RACC

Burnout with Liz Crowe

EMCrit RACC - May 17, 2023 - By Scott Weingart

On this special episode, I am joined with Dr. Liz Crowe to discuss all things burnout and staff well-being. This is a companion episode to the one I recently recorded on the EMCrit Burnout Model.

Fluids in Sepsis

The CLOVERS Trial 

Restrictive vs Liberal Fluids in Sepsis-Induced Hypotension

REBEL Cast Ep116 - May 18, 2023 - By Salim Rezaie

Author Conclusion: “Among patients with sepsis-induced hypotension, the restrictive fluid strategy that was used in this trial did not result in significantly lower (or higher) mortality before discharge home by day 90 than the liberal fluid strategy.”

Clinical Take Home Point: In a group of patients with septic shock (sepsis-induced hypotension), receiving initial treatment with 1 to 3 liters of IV fluids, a restrictive fluid strategy (with early vasopressor use) did not result in a significantly lower (or higher) mortality before discharge home by day 90 compared to a liberal fluid strategy. Basically, in a heterogenous disease process like sepsis, use your clinical judgement to determine how much fluid any particular patient needs.

Beers criteria

Beers criteria for potentially inappropriate medication use in older adults

Fist10 EM - By Justin Morgensten - May 15, 2023

References

By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023 May 4. doi: 10.1111/jgs.18372. Epub ahead of print. PMID: 37139824

The Beers criteria (named after Dr. Beers and not your Friday night escapades) is a guideline to help guide safe prescribing practices in the geriatric population. Polypharmacy and medication side effects are a common, and generally under-recognized, reason for patients to present to the emergency department. Adverse events and drug interactions should almost always be on our differential diagnosis with elderly patients. Additionally, we don’t want to cause harm with our own prescriptions. Thus, the Beers criteria is a document that emergency physicians should be familiar with.

Pediatric Syncope (ECG)

A review of the utility of the ECG in Pediatric Syncope

PEMBLOG - May 15, 2023 - By Stephen Rineer

Syncope is described as a brief loss of consciousness and postural tone caused by transient global cerebral hypoperfusion. It is followed by a complete recovery. An estimated 80% of pediatric syncope is due to autonomic (vasovagal or neurocardiogenic) syncope. Our role as providers is to identify the patients who have a life-threatening etiology to their syncope. The majority of these are cardiac and so today we will review what to look for in your screening ECG. 

A review of red-flag symptoms can be found in the linked PEMBlog post

Cardiac Syncope

Most life-threatening etiologies are related to cardiac syncope and are estimated to be 1.5%-6% of pediatric syncope. This is why ECG is recommended for all initial episodes of syncope with a reported sensitivity as high as 96%. Therefore, what are we looking for with our ECG?

Concerning ECG findingsLong QT syndrome: 

• QTc longer than 480 msec. 
• Brugada syndrome: ST elevation in V1-V3 with a negative T wave (slide or saddleback morphology).
• Wolf-Parkinson-White syndrome: Short PR interval of <120 ms with associated slurred. upstroke and wide QRS complex (delta wave).
• Hypertrophic Obstructive Cardiomyopathy: Precordial high voltages with deep Q waves.

Discharge Communicatios

Discharge Communications (2023)

iEM - May 15, 2023 - By Dominique Gelmann, Bret Nicks

Conclusion

Discharge instructions are a very important part of the emergency department care process and record. It is essential to ensure each patient has a complete understanding of their instructions in order to promote care compliance and improve transitions in care. Verbal instructions remain more effective than written instructions, but both are needed and a multimodal approach to relaying information is preferable to a single modality. Be explicit, keep it simple, and have the patients repeat back instructions to ensure understanding. These simple steps will improve patient outcomes and compliance, and help clinicians avoid medical and legal pitfalls.

Human Factors in the ED

LEARNING ABOUT HUMAN FACTORS 

IN THE EMERGENCY DEPARTMENT

Don’t Forget The Bubbles - By Joe Mullally, Holly Wakefield, Dani Hall - May 11, 2023 

(Last updated 12/05/2023)

• The Zero Point Survey and the acute stress response
• Crowd control
• Closed loop communication
• Situational awareness
• Ten for ten
• Hot debriefs

Dizziness and Vertigo

Acute Dizziness and Vertigo in the Emergency Department

Grace-3 2023 / Society of Academic Emergency Medicine

Acute dizziness or vertigo is a common emergency department (ED) presentation, accounting for 2.1%–3.6% of visits per year, with an estimated annual cost approximating $10 billion in the United States, a large proportion of which is related to imaging.
The traditional diagnostic approach for these patients was developed 50 years ago and is based on symptom reports (asking patients “What do you mean by dizzy?”). Newer evidence suggests that a diagnostic paradigm based on the timing and triggers of dizziness rather than symptom quality is more useful. The GRACE-3 clinical practice guideline has been developed to address the critical need for evidence-based recommendations for the care of patients presenting in the emergency department with acute dizziness and vertigo…

• GRACE-3 Infographic
• Read the Guideline in AEM  (Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. Edlow J te Al. Acad Emerg Med 2023; 30:442-486)

TNK vs TPA

Tenecteplase versus Alteplase before Thrombectomy

for Ischemic Stroke (EXTEND-IA TNK)

emDOCs / 52 in 52 – #34 - May 11, 2023 - By Brannon Inman

Reviewed by: Alex Koyfman; Brit Long

Source Article: Campbell BCV, Mitchell PJ, Churilov L, et al; EXTEND-IA TNK Investigators. Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. N Engl J Med. 2018 Apr 26;378(17):1573-1582. doi: 10.1056/NEJMoa1716405. PMID: 29694815.

Take Aways:

• TNK is non-inferior to TPA for vessel re-cannulation and thrombus/embolus obliteration during index intervention.
• This was an open label study, and thus physicians and other staff were not blinded to randomization.
• As these patients were required to have arterial puncture within 6 hours of stroke onset, these data may not apply to patients who are not presenting to a stroke center. For example, a patient with an LVO stroke presenting to a hospital and needing transfer for endovascular thrombectomy, or a patient getting endovascular thrombectomy within 24 hours.
• Prespecified superiority analysis suggests TNK may result in better functional outcomes. However, ultimately this study was powered and conducted as a non-inferiority study, so this is only hypothesis-generating.
• This study did change its enrollment criteria after 80 patients were already enrolled.
• There existed a substantively larger proportion of patients with MCA occlusion in the TNK arm. Given the smaller infarct territory, this could reasonably be expected to have consequential impacts on long term outcomes.

Atrioventricular nodal reentrant tachycardia

AVNRT

REBEL EM / Core Cast 98.0 - March 22, 2023 - By Anand Swaminathan

Take Home Points

1. AVNRT is a common tachydysrhythmia that results from a reentrant loop within the AV node.
2. Unstable patients with AVNRT should be considered for immediate synchronized electrical cardioversion.
3. Stable patients with AVNRT can have a trial of vagal maneuvers followed by chemical cardioversion with adenosine or verapamil and synchronized electrical cardioversion if that fails.
4. Serum troponins should not routinely be obtained.

Acute Pancreatitis

Rethinking Acute Pancreatitis in the ED

EMOttawa - By Kevin Guo - May 11, 2023

Acute pancreatitis is one of the most common gastroenterology conditions we see in the emergency department with a prevalence of 110-140 cases per 100,000 population. (1) At The Ottawa Hospital alone, we saw over an average of 1 case per day over the last year. Unfortunately, a lot of what we do in the emergency department is still following the dogma of traditional teaching. New evidence has been arising in the recent years about how we could be improving the ED management of acute pancreatitis.

Recall the diagnostic criteria for acute pancreatitis (>2/3):

• Abdominal pain consistent with acute pancreatitis
• Elevated amylase or lipase more than 3 times upper limit of normal
• Characteristic findings of acute pancreatitis on imaging

 

US for PTA

How Good is Ultrasound at Diagnosing PTA?

REBEL EM - April 17, 2023 - by Alanna Dompkowski

Author’s Conclusion: 

“Ultrasound is an acceptable alternative to computed tomography and incision and drainage for establishing diagnosis of peritonsillar abscess. It has high sensitivity for ruling out PTA but it demonstrates only moderate specificity for ruling in the diagnosis.”

Clinical Bottom Line:

This systematic review and meta-analysis adds to the growing body of evidence in favor of utilizing US for diagnosing PTA. However, there simply is not enough high-quality evidence to provide a definite conclusion. Many questions remain, but in our opinion, the benefits provided by US outweigh any drawbacks. We recommend US as an adjunct diagnostic tool for managing patients with suspected PTA. If inconclusive, order a CT scan.

Syphilis

Syphilis: A rapid review

First 10EM - By Justin Morgenstern - May 8, 2023

Syphilis is on the rise. Across North America, we are seeing syphilis rates unheard of since we abandoned the lambskin condom. (OK, I have no idea if that is factually accurate, but I always imagined syphilis and lambskin going hand in hand.) In Canada, there were 96 cases of congenital syphilis in 2021, as compared to 7 in 2017, a 1271% increase! (CCDR 2022) Numbers are similar in the United States, with 2677 cases of congenital syphilis reported in 2021 as compared to 332 in 2012. (Dyer 2022) Among adults in Canada, there were 11,268 cases of syphilis diagnosed in 2021, and there are definitely more cases than diagnoses. (CCDR 2022) Although I am sure there are some emergency departments with significant expertise in the topic, this is not a diagnosis I have seen regularly in my career, and so I figured it was time for a brief review.

The CLOVERS 🍀 Trial

TAMING THE SRU

The CLOVERS 🍀 Trial

TAMING THE SRU - May 05, 2023 - By Lausen Gillespie

Ref: National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury Clinical Trials Network, Shapiro NI, Douglas IS, et al. Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension. N Engl J Med. 2023;388(6):499-510. doi:10.1056/NEJMoa2212663

...Overall, both restrictive and liberal fluid strategies in the initial resuscitation of patients with septic shock, when applied to the appropriate patient populations, are viable strategies for care based on the provided endpoints and subgroup and post-hoc analyses. This study raised some interesting potential questions and hypotheses for future studies based on the subgroup analyses, and demonstrated excellent safety for the administration of peripheral vasopressors.

AAA

Abdominal Aortic Aneurysm

emDOCs / EM@3AM - May, 2023 By Dave Ediger, Rachel Bridwell

Reviewed by: Sophia Görgens; Cassandra Mackey; Brit Long

Pearls

• Consider ruptured AAA in all patients over 50 with truncal pain, syncope / presyncope, or hypotension
• AAA is a local manifestation of systemic vascular disease
• A ruptured AAA is a surgical emergency regardless of hemodynamic stability
• Ultrasound is sensitive for rapid bedside AAA screening, but it cannot exclude rupture, which is typically retroperitoneal
• Don’t let hematuria anchor you to renal pathology or lumbago (muscular back pain)
• Magic ultrasound numbers: 3×5 (>3cm defines an aneurysm; >5.5cm at high risk for rupture)

Edema cerebral

Edema cerebral y manejo de la presión intracraneal

AnestesiaR - 17 de octubre, 2022 - By Andrea Piano

Conclusión

Conocer las bases fisiopatológicas del edema cerebral y de los mecanismos de aumento de la presión intracraneal es importante para cualquier profesional sanitario que trabaje con pacientes neurocríticos dado que son entidades que se asocian a pronósticos a menudo infaustos. Por eso es fundamental reconocer las manifestaciones clínicas de la hipertensión craneal y actuar de forma muy rápida en caso de sospecha o confirmación de aumento de la presión intracraneal, emprendiendo medidas básicas o específicas. Aunque el tratamiento definitivo en muchas ocasiones es quirúrgico, no hay que subestimar la importancia del manejo de los cuidados intensivos disponibles en la actualidad: a pesar de que sean medidas inespecíficas y a veces limitadas que se basan en los principios fisiológicos, pueden tener un papel relevante en la disminución de la presión intracraneal.

El objetivo en los próximos años será intentar individualizar cada vez más la monitorización de la presión intracraneal para personalizar el tratamiento a las características de los pacientes, quizás añadiendo nuevos fármacos más específicos para cada entidad patológica.

Epoprostenol in Right-sided HF

TAMING THE SRU

Air Care Series: Epoprostenol/VELETRI: a Skybridge to Somewhere? 

YAMING THE SRU - By Josh Ferreri - May 03, 2023

SUMMARY: 

The management of ARDS and right-sided heart failure can be daunting. Fortunately, we have multiple tools to combat refractory hypoxia, elevated pulmonary arterial pressures, and right ventricular failure. Of these, epoprostenol and other prostacyclin analogs have been utilized despite limited data on their actual efficacy. Though promising data has been published endorsing the use of prostacyclin analogs in the treatment of acute right sided heart failure, specifically in the setting of ARDS, there are very few randomized controlled trials providing evidence of its benefit on actual meaningful patient outcomes. Though there may be a cost benefit associated with its use, there is an urgent need for further randomized studies evaluating the use of these aerosolized pulmonary vasodilators and their impact on morbidity &mortality. Though further outcome data is certainly needed, inhaled epoprostenol is just another tool in our arsenal to help stabilize critically-ill patients several thousand feet in the sky, while transferring them to a definite center of care. 

Drowning Part 2

A Dive into Drowning – Part Two

EM Ottawa - By James Gilbertson, Amanda Mattice - May 04, 2023

Summary

Overall, the key take-home points for management of a fatal or non-fatal drowning patient in the emergency department includes the following:

• Management in the resuscitation bay: 
• Anticipate a difficult and soiled airway, use a SALAD approach
• Employ ARDS ventilation settings
• Prompt OG or NG tube decompression
• Obtain a core temperature and initiate hypothermia rewarming early
• C-spine injuries are rare (0.5%), collar only if obvious signs and mechanism
• No antibiotics are indicated unless drowned in sewage
• Submersion duration is the only factor with reliable evidence for prognostication.
• Safely discharge the well appearing drowning patient home 6-hours post event if meets all three of:

1. Normal mentation. 
2. Normal age adjusted vitals. 
3. Never required O2.

Drowning Part 1

A Dive into Drowning – Part One

EM Ottawa - By James Gilbertson, Amanda Mattice - April 27, 2023

Summary

Briefly, the take-home points for Part 1 are as follows:

• Drowning as defined by the WHO in 2004 is the process of experiencing respiratory impairment from submersion or immersion in liquid.
• Avoid outdated and irrelevant drowning terms such as secondary, near, dry, wet, freshwater and saltwater drowning.
• The pathophysiology involves washout of pulmonary surfactant, alveolitis, non-cardiogenic pulmonary edema, and hypoxia contributing to bradycardia into PEA arrest.
• In the pre-hospital setting: Ventilate (2-5 breaths) before compressions
• Call for an AED early but know that shockable rhythms are uncommon (2-14%)
• Consider PEEP and recruitment maneuvers for difficulty oxygenating

Metoprolol vs Diltiazem for A fib

TAMING THE SRU

IV Metoprolol vs Diltiazem for A fib with RVR 

and Concomitant Heart Failure

TAMING THE SRU - April 22, 2023 - By Bronwyn Finney

DISCUSSION

The researchers concluded that there was no difference in rate control at 30 minutes when utilizing diltiazem vs metoprolol based on this study. Other interesting notes included that those who received metoprolol were more likely to crossover to diltiazem after 30 minutes and additionally received more doses of medication overall. The study is unfortunately limited due to retrospective nature, probable selection bias due to small sample size and has limited generalizability due to exclusion of concurrent heart failure exacerbation on presentation. Additionally, average EF very high overall with predominantly HFpEF patients. Regarding diltiazem, it is worth noting that it has potential to be unsafe, as more hypotension developed overall, but very few patients required pressors. Additionally, many of the patients in the study ended up on diltiazem drips whether it be for ease of use, titratability or other factors. A wonderful next step would be to see a randomized control trial investigating this same clinical question…