Association of hyperosmolar therapy with cerebral oxygen extraction after cardiac arrest.

Background: Elevated jugular bulb venous oxygen saturation (SjvO2) after cardiac arrest may be due to diffusion-limited oxygen extraction secondary to perivascular edema. Treatment with hyperosmolar solution (HTS) may decrease this edema and thus the barrier to oxygen diffusion. Alternatively, SjvO2 may rise when cerebral metabolic rate declines due to irreversible cellular injury, which would not be affected by HTS.

Severe hyperlactatemia in the emergency department: clinical characteristics, etiology and mortality.

Background: Severe hyperlactatemia (lactate level ≥ 10 mmol/L) is associated with high mortality rates in critically ill patients. However, there is limited data on emergency department (ED) patients. We aimed to investigate the clinical characteristics, etiology and outcomes of patients with severe hyperlactatemia in the ED setting.

Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) and ultrasound-guided left stellate ganglion block to rescue out of hospital cardiac arrest due to refractory ventricular fibrillation: A case report.

Out of hospital cardiac arrest from shockable rhythms that is refractory to standard treatment is a unique challenge. Such patients can achieve neurological recovery even with long low-flow times if perfusion can somehow be restored to the heart and brain. Extracorporeal cardiopulmonary resuscitation is an effective treatment for refractory cardiac arrest if applied early and accurately, but often cannot be directly implemented by frontline providers and has strict inclusion/exclusion criteria.

Duration of cardiopulmonary resuscitation and phenotype of post-cardiac arrest brain injury.

Background: Patients resuscitated from cardiac arrest have variable severity of primary hypoxic ischemic brain injury (HIBI). Signatures of primary HIBI on brain imaging and electroencephalography (EEG) include diffuse cerebral edema and burst suppression with identical bursts (BSIB). We hypothesize distinct phenotypes of primary HIBI are associated with increasing cardiopulmonary resuscitation (CPR) duration.

Comparison of the NIO and EZIO for Resuscitative Vascular Access in the Emergency Department: A Quasi-Experimental, Before-and-After Study.

Introduction: Intraosseous (IO) needle insertion is a key adjunctive procedure in the care of critically ill and injured patients in a variety of settings, including the battlefield. The NIO is a new, fully disposable, single-piece, IO device with potential practical advantages under austere conditions. We sought to compare the efficacy and safety of the NIO to an established, well-studied device, the EZIO, when used for resuscitative vascular access in the emergency department (ED).

Severe bradycardia from severe hyperkalemia: Patient characteristics, outcomes and factors associated with hemodynamic support.

Objective: Bradycardia is an under-studied manifestation of hyperkalemia potentially associated with adverse outcomes. We sought to systematically describe emergency department (ED) patients that present with severe bradycardia (heart rate < 50) associated with severe hyperkalemia (potassium ≥6.0 mEQ/L) and identify factors associated with the receipt of hemodynamic support.

Goal-directed cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest in the emergency Department: A feasibility study.

Aim: To describe the feasibility of prospective measurement of intra-arrest diastolic blood pressure (DBP) and goal-directed treatment of refractory out-of-hospital cardiac arrest (OHCA) in the emergency department (ED).

Methods: Retrospective case series performed at an urban, tertiary-care hospital from 12/1/2018 - 12/31/2019. We studied consecutive adults presenting with refractory, non-traumatic OHCA treated with haemodynamic-targeted resuscitation that entailed placement of a femoral arterial catheter, transduction of continuous BP during CPR, and administration of vasopressors (1 mg noradrenaline) and, if applicable, Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), to achieve DBP ≥ 40 mmHg.

Hemodynamic Instability and Abnormal Vasopressor Responsiveness in the Setting of Severe Metabolic Acidosis Treated With Adapted Alkalinization and Continuous Renal Replacement Therapy in the Emergency Department.

Background: Whereas laboratory data and clinical experience suggest that metabolic acidosis deleteriously affects certain cardiovascular functions and may contribute to hemodynamic compromise, treatment of acidemia itself with alkalinization therapy, predominantly in the form of bolus dosing of intravenous sodium bicarbonate, has not been shown to improve hemodynamics or patient-oriented outcomes in clinical trials. Detailed examination of the biochemical effects of standard sodium bicarbonate administration reveals a possible explanation: ionized serum hypocalcemia, serum hypercarbia, and a paradoxical decrease in intracellular pH occur when bicarbonate is given alone and rapidly, without adjustment in minute ventilation or calcium supplementation. "Adapted alkalinization" treatment countering these side effects through hyperventilation, calcium supplementation, and slower sodium bicarbonate infusion has been studied in animals, but not yet described in humans.

Design and implementation of a temporary emergency department-intensive care unit patient care model during the COVID-19 pandemic surge.

The ongoing pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in rapid surges of critically ill patients infected with coronavirus disease 2019 (COVID-19) pneumonia presenting to the emergency department (ED) and requiring ICU admission nationwide. Despite adaptations in critical care personnel staffing, bed availability and supply provision, many inpatient ICUs have become acutely crowded, leading to boarding of critically ill patients with COVID-19 and other diseases in the ED. To address this scenario at our urban, safety net, tertiary care institution in the spring of 2020, we designed and implemented a temporary "emergency department-intensive care unit" (ED-ICU) patient care service.

Sex Differences in In-hospital Complications Among Older Adults After Traumatic Brain Injury.

Background: Older adults have the highest rates of hospitalization and mortality after traumatic brain injury (TBI) and suffer poorer outcomes compared with younger adults with similar injuries. Non-neurological complications can significantly impact outcomes. Evidence suggests that women may have better outcomes after TBI.

Thromboelastography and rotational thromboelastometry for the surgical intensivist: A narrative review.

Background: Viscoelastic tests (VETs), specifically thromboelastography (TEG) and rotational thromboelastometry (ROTEM), are gaining popularity in the management of critically ill surgical patients with hemorrhage or thrombosis due to their comprehensive characterization of the coagulation process and point-of-care availability in comparison to conventional coagulation tests (CCTs). We review current evidence for VET use in patients in the surgical intensive care unit (SICU).

Methods: We searched PUBMED, EMBASE and the Cochrane Library through May 30, 2018 for articles that evaluated the use of VETs in patient populations and clinical scenarios germane to the surgical intensivist.

Comparison of a novel, endoscopic chest tube insertion technique versus the standard, open technique performed by novice users in a human cadaver model: a randomized, crossover, assessor-blinded study.

Background: The technique of tube thoracostomy has been standardized for years without significant updates. Alternative procedural methods may be beneficial in certain prehospital and inpatient environments with limited resources. We sought to compare the efficacy of chest tube insertion using a novel, endoscopic device (The Reactor™) to standard, open tube thoracostomy.

Use of an intravascular temperature control catheter for rewarming of hypothermic trauma patients with ongoing hemorrhagic shock after combined damage control thoracotomy and laparotomy: A case series.

Background: Correction of hypothermia is a key component of the resuscitation of critically injured patients with hemorrhagic shock who require damage control surgery. External rewarming methods may not be sufficient in this population, while extracorporeal techniques lack widespread feasibility. Intravascular catheter-based temperature modulation is increasingly being employed in different critically ill patient populations but has not been described as part of a damage control resuscitation strategy in trauma patients.

Risk factors for mortality despite early protocolized resuscitation for severe sepsis and septic shock in the emergency department.

Purpose: The purpose was to identify risk factors associated with in-hospital mortality among emergency department (ED) patients with severe sepsis and septic shock managed with early protocolized resuscitation.

Methods: This was a retrospective, observational cohort study in an academic, tertiary care ED. We enrolled 411 adult patients with severe sepsis and lactate ≥4.

Purple Glove Syndrome after Phenytoin or Fosphenytoin Administration: Review of Reported Cases and Recommendations for Prevention.

The aim of our study was to identify all previously reported cases of phenytoin- or fosphenytoin-associated purple glove syndrome (PGS) and summarize the most current understanding of the pathophysiology, clinical presentation, diagnosis, and treatment of the disease. We searched the English language references from MEDLINE, EMBASE, CINAHL, TOXNET, and gray literature that featured one or more case descriptions of phenytoin- or fosphenytoin-associated PGS after administration and provided information on the clinical setting of the event and associated outcome(s). Descriptive statistics were employed to summarize relevant facts about the cases.

Accuracy of Handheld Point-of-Care Fingertip Lactate Measurement in the Emergency Department.

Introduction: Early recognition of elevated lactate levels in sepsis may hasten the detection of those patients eligible for aggressive resuscitation. Point-of-care (POC) testing is now increasingly available for use in the emergency department (ED). We examined the accuracy and time-saving effect of a handheld POC device for the measurement of fingertip and whole blood lactate as compared with reference laboratory testing in critically ill ED patients.

Point-of-care urine albumin:creatinine ratio is associated with outcome in emergency department patients with sepsis: a pilot study.

Objectives: Sepsis is characterized by an initial systemic proinflammatory response leading to endothelial damage and increased capillary permeability. The authors conducted a pilot study to determine if microalbuminuria, measured by the urine albumin:creatinine ratio (ACR), was associated with outcome in emergency department (ED) sepsis patients.

Methods: This was an observational cohort study of a convenience sample of adult patients presenting to two EDs over 10 months with sepsis (two or more systemic inflammatory response syndrome [SIRS] criteria and suspected infection).

Economic impact of additional radiographic studies after registered diagnostic medical sonographer (RDMS)-certified emergency physician-performed identification of cholecystitis by ultrasound.

Background: The standard evaluation of patients with right upper quadrant (RUQ) abdominal pain consists of a history and physical examination, laboratory analysis, and radiological investigation. Given the increasing availability of bedside ultrasound in the Emergency Department (ED), a growing proportion of Emergency Physicians are now performing their own ultrasound examinations in patients with RUQ abdominal pain to circumvent diagnostic delays and improve patient care.

Objective: To determine the economic "opportunity" costs of additional radiographic testing after identification of acute cholecystitis by focused ED ultrasound performed by registered diagnostic medical sonographer (RDMS)-certified personnel.

Point-of-care testing at triage decreases time to lactate level in septic patients.

Early recognition of elevated lactate levels may hasten the detection of time-sensitive illness. We studied a method to measure lactate levels in septic patients using a point-of-care (POC) device at Emergency Department triage. A convenience sample of adult patients with sepsis was enrolled.

Evaluation of extraction techniques for the forensic analysis of human scalp hair using gas chromatography/mass spectrometry (GC/MS).

Preliminary research using on-line supercritical fluid extraction/gas chromatography-mass spectrometry (SFE/GC-MS) has shown that the natural and artificial surface components of human scalp hair are reproducible and differentiable. Therefore, these components may be useful for individualization or determining demographic characteristics or both. However, it is not known how the efficiency and selectivity of on-line SFE/GC-MS compares to other extraction methods.