A Cardiac Arrest Story: Patient Interview

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This episode is a departure from the typical FOAMcast clinical content, we will be back with strictly clinical content soon.

In May 2022, I came across a fellow passenger and stranger in cardiac arrest at the Charlotte airport. A small team of strangers, including an emergency medicine resident, Dr. Jason Tanner, and an emergency department technician, Angel, assembled to treat this passenger. Billy Frolick, a writer and our patient that day shares his perspective on his case with us. This story is a reminder of the importance of continuous chest compressions, early defibrillation, and that what we do in emergency and prehospital medicine matters. For more on why we should, in accordance with guidelines, abandon routine pulse checks, see this podcast: https://foamcast.org/2022/09/04/pulse-checks-during-cardiopulmonary-resuscitation/ or this article: https://www.acepnow.com/article/stop-performing-routine-pulse-checks-during-cpr/

ACEP Clinical Policy on Heart Failure Syndromes & High Dose Nitrates

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This episode covers the 2022 American College of Emergency Physicians (ACEP) clinical policy on acute heart failure syndromes with a special focus on high-dose nitrates The 2007 ACEP clinical policy can be found here.

References:

  1. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Acute Heart Failure Syndromes. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Heart Failure Syndromes: Approved by ACEP Board of Directors, June 23, 2022. Ann Emerg Med. 2022 Oct;80(4):e31-e59. doi: 10.1016/j.annemergmed.2022.05.027. PMID: 36153055.
  2. Silvers SM, Howell JM, Kosowsky JM, Rokos IC, Jagoda AS; American College of Emergency Physicians. Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with acute heart failure syndromes. Ann Emerg Med. 2007 May;49(5):627-69. doi: 10.1016/j.annemergmed.2006.10.024. Epub 2007 Apr 3. Erratum in: Ann Emerg Med. 2010 Jan;55(1):16. PMID: 17408803.
  3. Levy P, Compton S, Welch R, Delgado G, Jennett A, Penugonda N, Dunne R, Zalenski R. Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis. Ann Emerg Med. 2007 Aug;50(2):144-52. doi: 10.1016/j.annemergmed.2007.02.022. Epub 2007 May 23. PMID: 17509731.
  4. Cotter G, Metzkor E, Kaluski E, Faigenberg Z, Miller R, Simovitz A, Shaham O, Marghitay D, Koren M, Blatt A, Moshkovitz Y, Zaidenstein R, Golik A. Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Lancet. 1998 Feb 7;351(9100):389-93. doi: 10.1016/S0140-6736(97)08417-1. PMID: 9482291.
  5. Wilson SS, Kwiatkowski GM, Millis SR, Purakal JD, Mahajan AP, Levy PD. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017 Jan;35(1):126-131. doi: 10.1016/j.ajem.2016.10.038. Epub 2016 Oct 18. PMID: 27825693.
  6. Wang K, Samai K. Role of high-dose intravenous nitrates in hypertensive acute heart failure. Am J Emerg Med. 2020 Jan;38(1):132-137. doi: 10.1016/j.ajem.2019.06.046. Epub 2019 Jun 25. PMID: 31327485.
  7. Perlmutter MC, Cohen MW, Stratton NS, Conterato M. Prehospital Treatment of Acute Pulmonary Edema with Intravenous Bolus and Infusion Nitroglycerin. Prehosp Disaster Med. 2020 Dec;35(6):663-668. doi: 10.1017/S1049023X20001193. Epub 2020 Oct 7. PMID: 33023684.

STEMI Equivalent Update – 2022 ACC Consensus Statement

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The American College of Cardiology released a new consensus statement, “Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee“. This document has several algorithms for managing chest pain – from high-sensitivity troponin algorithms to chest pain risk disposition pathways. However, one major update is the incorporation of several “STEMI” equivalents.

It has become increasingly publicized, primarily due to Stephen Smith and Pendell Meyers, that the STEMI vs NSTEMI dichotomy neglects many patients who may benefit from reperfusion due to Occlusion Myocardial Infarctions. This update incorporates some other signs as “STEMI Equivalents” and recommends these patients be treated just as those with STEMI.

Pulse Checks During Cardiopulmonary Resuscitation

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Since 2010, the American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) have recommended against routine pulse checks during CPR. More than a decade has elapsed since this time, yet many people are continuing to perform pulse checks every couple of minutes during CPR. In this episode, and in this ACEPnow article, we discuss the literature around this.

Neumar RW et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;122(18 Suppl 3):S729-67. doi: 10.1161/CIRCULATIONAHA.110.970988. PMID: 20956224.
Dick WF, Eberle B, Wisser G, Schneider T. The carotid pulse check revisited: What if there is no pulse? Crit Care Med. 2000;28(11 Suppl):N183–5.
Tibballs J, Russell P. Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Resuscitation. 2009 Jan;80(1):61-4. doi: 10.1016/j.resuscitation.2008.10.002. Epub 2008 Nov 6. PMID: 18992985.

Cummins RO, Hazinski MF. Cardiopulmonary resuscitation techniques and instruction: When does evidence justify revision? Ann Emerg Med. 1999;34(6):780–784.

Monkeypox

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Updated July 29, 2022

In a three-part series, we review the current status of the monkeypox outbreak.

Episode 1: Virology, Transmission, Epidemiology

Episode 2: Clinical Manifestations, Treatment, Vaccination

Episode 3: The TLDR Quick Summary

Patel A et al. Clinical features and novel presentations of human monkeypox in a central London centre during the 2022 outbreak: descriptive case series. BMJ. 2022 Jul 28;378:e072410. PMID: 35902115.

Thornhill JP et al. Monkeypox Virus Infection in Humans across 16 Countries – April-June 2022. N Engl J Med. 2022 Jul 21. doi: 10.1056/NEJMoa2207323. PMID: 35866746.

References: https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html
Reference: https://www.cdc.gov/poxvirus/monkeypox/clinicians/smallpox-vaccine.html#pre-exposure

Hemorrhoids

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There are practice-changing updates in the guidelines from the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST), found here. In this podcast, we review hemorrhoids and management.

Perera N, Liolitsa D, Iype S, Croxford A, Yassin M, Lang P, Ukaegbu O, van Issum C. Phlebotonics for haemorrhoids. Cochrane Database Syst Rev. 2012 Aug 15;(8):CD004322. doi: 10.1002/14651858.CD004322.pub3. PMID: 22895941.
Cavcić J, Turcić J, Martinac P, Mestrović T, Mladina R, Pezerović-Panijan R. Comparison of topically applied 0.2% glyceryl trinitrate ointment, incision and excision in the treatment of perianal thrombosis. Dig Liver Dis. 2001 May;33(4):335-40. doi: 10.1016/s1590-8658(01)80088-8. PMID: 11432512
Cavcić J, Turcić J, Martinac P, Mestrović T, Mladina R, Pezerović-Panijan R. Comparison of topically applied 0.2% glyceryl trinitrate ointment, incision and excision in the treatment of perianal thrombosis. Dig Liver Dis. 2001 May;33(4):335-40. doi: 10.1016/s1590-8658(01)80088-8. PMID: 11432512.

The End of Diphenhydramine

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Diphenhydramine and other first-generation antihistamines are ubiquitous in medicine cabinets across the globe. Clinicians commonly recommend or administer diphenhydramine (Benadryl) for a variety of diseases – anaphylaxis, allergic reactions, urticaria, benign headaches/migraines, and as a sleep aid. However, professional societies have recommended against many of these indications for decades and, in other cases, there are safer alternatives. For more reading and references, see this article in ACEPnow.

For more in-depth reviews: Podcast on anaphylaxis and podcast on urticaria

Urticaria

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In this podcast, we review acute urticaria (<6 weeks in duration). We review the recent international EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis, and management of urticaria (Zuberbier et al) In addition, we review some of the controversy regarding the administration of steroids for acute urticaria.

algorithm for treatment of urticaria based on: the recent international EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis, and management of urticaria (Zuberbier et al)
Emergency medicine relevant recommendations from the recent international EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis, and management of urticaria (Zuberbier et al)
Palungwachira et al. A randomized controlled trial of adding intravenous corticosteroids to H1 antihistamines in patients with acute urticaria. Am J Emerg Med. 2021 Apr;42:192-197.  PMID: 32139204.

Intramuscular Sedation for Severe Agitation

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Intramuscular chemical sedation is commonly used in the emergency department (ED) for severe agitation and physical assault when other attempts at de-escalation and agitation control (verbal de-escalation, space, etc) are unsuccessful. The “cocktails” people use are often institution-based. In this podcast, we review commonly used intramuscular agents along with recent papers including ketamine, droperidol, and choice of benzodiazepines.

Droperidol has been cited as working very quickly, however, several studies show that the onset is in the ballpark of 15-20 minutes (even at 10 mg IM).

  1. Cole et al. A Prospective Study of Intramuscular Droperidol or Olanzapine for Acute Agitation in the Emergency Department: A Natural Experiment Owing to Drug Shortages. Ann Emerg Med. 2021 Aug;78(2):274-286. PMID: 33846015.
  2. Isbister GK et al. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. Ann Emerg Med. 2010 Oct;56(4):392-401.e1. doi: 10.1016/j.annemergmed.2010.05.037. PMID: 20868907.
  3. Calver L et al. The Safety and Effectiveness of Droperidol for Sedation of Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med. 2015 Sep;66(3):230-238.e1. PMID: 25890395.

A recent randomized controlled trial of ketamine versus haloperidol + midazolam by Barbic et al demonstrates impressive time to agitation control for ketamine.