Background: Patients with shock frequently present with hypotension.  Many of these patients are started on vasopressor and inopressor medications to assist in efforts to normalize blood pressure to help improve organ perfusion. In shocky patients, arterial lines are often used to monitor hemodynamic parameters and inform treatment decisions.  However, there is limited data on the benefit of invasive blood pressure monitoring over non-invasive blood pressure monitoring. The largest trial comparing invasive arterial blood pressure (IABP) to noninvasive blood pressure (NIBP) monitorin ..read more

Background: Community-acquired pneumonia (CAP) can lead to pulmonary and systemic inflammation, resulting in impaired gas exchange, sepsis, organ failure, and an increased risk of death. Corticosteroids have excellent anti-inflammatory and immunomodulatory effects that could mitigate some of the inflammation caused by pneumonia. There have been several randomized trials that have shown glucocorticoids have positive effects in patients with CAP. However, except for one trial, none showed a between-group difference regarding mortality.1-6We now have the Community-Acquired Pneumonia: Evaluation ..read more

Background Information: Acute Hypotension is associated with increased morbidity and mortality. Continuous vasopressor infusions have previously been the mainstay of treatment. However, peripherally dosed push dose pressors, (PDPs), are beginning to be administered more frequently for management of acute hypotension.1-4 The PDPs, phenylephrine and epinephrine, result in vasoconstriction and increased cardiac contractility. They can be associated with side effects such as reflex bradycardia, decreased stroke volume in phenylephrine, tachycardia and hypertension associated with epinephrine. The ..read more

Background Information: Obtaining definitive control of the airway, when indicated, is the responsibility of the emergency medicine physician. Traditionally patients were managed on the ventilator with lung volumes of 10 – 15 ml/kg. However, that practice is long-outdated and patients managed on lower tidal volumes (6 ml/kg) were found to have decreased mortality.1 This practice of lower tidal volumes has been termed “lung protective ventilation” (LPV) and is now the standard of care for patients receiving mechanical ventilation. Ventilator-associated lung injury and inflammation can occur eve ..read more

Background: Outside of early defibrillation and high-quality CPR, little has been shown to improve outcomes in out-of-hospital cardiac arrest (OHCA). In theory, rapid identification of the underlying cause of arrest can be beneficial. Many emergency clinicians have adopted Point-of-care ultrasound (POCUS) into cardiac arrest care by for this reason. Ultrasound is a rapid bedside tool that may help identify reversible causes, provide procedural guidance and assess cardiac activity. (Gaspari 2016, Littmann 2014) Despite all these potential benefits, recent studies have expressed concern th ..read more

Background Information:  Diabetic Ketoacidosis (DKA) is a life-threatening complication of diabetes that we frequently encounter in both the emergency department (ED) and intensive care unit (ICU). While intravenous fluid replacement remains one of several cornerstones of therapies, much debate exists on exactly which IV fluid results in faster DKA resolution with less adverse events. While international guidelines recommend 0.9% sodium chloride as the fluid of choice, it has been associated with hyperchloremia and prolonged ICU length of stays.1 Plasmalyte on the other hand has less chlo ..read more

Background Information: The management of patients in cardiogenic shock is often multifactorial, consisting of mechanical circulatory support, vasopressors and inotropes. While the latter two are the foundation of therapy, the literature is scarce on whether milrinone or dobutamine will be more effective. Prior comparisons are limited to a single randomized trial of patients awaiting heart transplant and two observational studies that showed no difference in in-hospital mortality.1 The lack of data to answer this question often results in clinician preference driving the decision on drug ..read more

In this 15-minute talk from Rebellion in EM 2021, Dr. Sara Gray, MD uses a case-based discussion to look at ED care from the intensivists perspective and includes quick pearls that make patient care better in the ICU. Sara Gray, MDEmergency Medicine/Critical Care Associate Professor at the University of Toronto St. Michael’s Hospital Twitter: @EmICUcanada Presentation Objectives  We will review simple strategies for delivering better clinical care in the ED to critically ill patients We will discuss communication strategies: what does your intensivist really want to know? Delivering ..read more

I have started to split my time between the ED and ICU.  Obviously these two areas of clinical care have their similarities, but also have their differences. So I decided to create this post to put things that I have found useful and recurrently coming back to when on my critical care time.  This is not meant to be an EBM based post, but rather a clinical post of useful critical care/ICU information.  I will continue to add to this post as I spend more time in the ICU and hopefully this becomes a nice repository of information for others. Vaso/InoPressors Milrinone 0.375-0.75 ..read more

Background Information: Hypothermia was first introduced in 2002 by two studies, Bernard et al and The Hypothermia After Cardiac Arrest (HACA) trial.1,2 The latter, although a small trial, showed improved neurologic outcomes at six months when patients were cooled to 32-34oC. For a long time, a temperature of 33oC was the widely accepted standard of therapy for out-of-hospital cardiac arrest.1 In recent years, a trial aptly named the Targeted Temperature Management (TTM) Trial challenged this notion,3 finding that a temperature of 33oC did not confer any benefit over 36oC.4 Since then, not onl ..read more