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"2 Liters bolus at the start for a fluid challenge "

"Fill the tank with whatever fluid you have"

Posting this again after another conversation over crystalloid I recently had with an individual. Also, we have many new followers to the page, so important to return to basics from time to time.

For years, this was gospel in trauma teaching and practice. Unfortunately, the dogma is still evident in dangerous practice patterns.

If you've spent anytime on this platform and our community, you know that I preach the antithesis of this concept.

#1 fluid of choice = WHOLE BLOOD (warm/fresh, fresh-frozen).
#2 is component therapy *see my prior massive transfusion posts.

CRYSTALLOIDS: includes Saline, LR (lactated ringers), Plasmalyte
1. Worsens acidosis (hyperchloremic with large volumes of NS) and worsens metabolic acidosis
2. No oxygen carrying capacity
3. Hemodylution
4. No clotting factors
5. Increases base deficit
6. Increased risk of multiorgan failure
7. Increased risk of wound infection
8. Increased risk of wound dehiscence
9. Risk of hypothermia if at room temp


NOTE: exacerbates "LETHAL DIAMOND"

1. Burn patients NOT BLEEDING need appropriate cyrstaloid resuscitation (Rule of 10s)
2. Non-bleeding patients (head trauma for example) need specific fluids like hypertonic 3%.




Photos from Saint Fisher Church of Evidence Based Medicine's post 21/03/2021
Photos from Paramedicine 101's post 10/03/2021

Repost • TXA use in resuscitation of GI bleeds: for years, many used TXA as an adjunct. Now, there's more transparent/concrete evidence towards such a decision.

HALT-IT : "Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding"

DESIGN: international, multi-center placebo-controlled RCT (164 hospitals 15 countries). "Significant" GI bleeds --> shock, cardiac/vital sign instability determination by physician.

*study looked at death from bleeding at 5 days

DOSE: 1 gram IV over 10 minutes --> infused 125 mg/hr for 24 hours.

ENROLLED:  12,009 patients mean age of 58, 65% male.
- Average onset of bleeding to randomization ~ 22 hr, with only 16% of patients presenting < 3hrs
- 90% upper GI bleeding, and
- 45% suspected variceal bleeds.

NOTE: 60% showed no signs of shock at enrollment. I believe the authors meant hemorrhagic in nature.

death due to bleeding at 5 days = 3.7% of the TXA group & 3.8% of placebo (RR 0·99, 95% CI 0·82–1·18). All cause mortality at 28 days was also unchanged (9.5% with TXA vs 9.2% with placebo, RR 1·03, 95% CI 0·92– 1.16).


THOUGHTS: This is a fairly good study design and EBM. I do wonder about the timing of GI bleed onset (under 3hr to presentation) and critical status of patients included. This study offers insight and evidence that routine TXA use for GI bleeds offer no mortality benefit. But what about early presenting patients that require MTP? What about a different dose?

COMMENT BELOW: with your thoughts, ideas and practice patterns.

Roberts I, Shakur-Still H, Afolabi A, et al. The Lancet. 2020; 395(10241):1927-1936.


When it comes to trauma, new research is showing that hypocalcemia, the loss of calcium due to blood loss, is also a factor in the “lethal triad” of acidosis, coagulopathy, and hypothermia. This condition can be further exacerbated by the citrates found in preserved blood, worsening hypocalcemia in patients. The addition of hypocalcemia to the triad would create the “lethal diamond”. As stated in the attached article, “it is hoped that this increased focus on hypocalcemia in trauma can lead to research regarding early administration of calcium with the hopes of improving trauma patient outcomes.”

Ditzel RM Jr, Anderson JL, Eisenhart WJ, et al. A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond?. J Trauma Acute Care Surg. 2020;88(3):434-439. doi:10.1097/TA.0000000000002570

Timeline photos 23/07/2020

Now that we are hearing more about cases of Kawasaki like Illnesses related to Covid I think it’s time for a refresher.

Timeline photos 22/02/2020

Lidocaine vs Amiodarone for PALS?

Cardiology, Critical Care, Pediatrics, Pharmacy/Pharmacology, Resuscitation
Written by Clay Smith

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There was no difference in any clinical outcome in pediatric patients with shockable rhythm with lidocaine vs amiodarone.

Why does this matter?
Either lidocaine or amiodarone is acceptable in PALS for shock-refractory v-fib or pulseless v-tach. Is one preferred over another?

Pick one…
This was a propensity matching study based on a pediatric in-hospital arrest registry over an 18 year period with shock-refractory v-fib or pulseless v-tach. They matched 90 patients in each group, with the only difference being administration of lidocaine or amiodarone. I won’t put all the risk ratios or 95%CI, as they were almost all near 1. There was no difference in ROSC, 24-hour survival, survival to discharge, or survival with favorable neurological outcome comparing lidocaine to amiodarone. Again, despite this being a large registry with 18 years of data, the total number of patients they were able to include was small. Although propensity matching helps, there is always danger of confounding. However, in this study, it looks like it really doesn’t matter which agent you choose for the next round of PALS if defibrillation fails.

Lidocaine versus Amiodarone for Pediatric In-Hospital Cardiac Arrest: An Observational Study. Resuscitation. 2020 Jan 16. pii: S0300-9572(20)30013-7. doi: 10.1016/j.resuscitation.2019.12.033.

Timeline photos 19/02/2020

Epinephrine for Pediatric OHCA Mirrors PARAMEDIC2
Feb 19, 2020 01:00 am
Written by Clay Smith

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Epinephrine for out-of-hospital cardiac arrest (OHCA) in children improved return of spontaneous circulation (ROSC) but not 1-month survival or survival with good neurological outcome.

Why does this matter?
PARAMEDIC2 found improved ROSC with epinephrine during arrest but not 30-day survival or survival with good neurological outcome in adults with OHCA. A recent meta-analysis in adults found improved ROSC and survival to discharge with epinephrine, but not survival with good neurological outcome. What about children with OHCA? Is epinephrine beneficial?

ROSC ≠ Survival
This was a nationwide Japanese arrest database with 1.2 million total people but only 3,961 pediatric arrests in children 8-17 years old. In this age range, 88% were >12 years old. Of these, they did propensity matching and identified 304 children who received epinephrine during arrest. These were compared with a matched cohort of 304 children who did not receive epinephrine. For the primary endpoint of 1-month survival, there was no difference; epi 10.2% vs. no epi 7.9%; risk ratio, RR: 1.13 (95%CI 0.67 to 1.93). There was also no difference in survival with favorable neurological outcome; epi 3.6% vs. no epi 2.6%; RR: 1.56 (95% CI 0.61 to 3.96). ROSC was greater in the epi group vs. no epi, 11.2% vs. 3.3%; RR: 3.17 (95% CI: 1.54 to 6.54), respectively. These results are strikingly similar to PARAMEDIC2. An interesting finding was significant improvement in 1-month survival and ROSC as well as nonsignificant improvement in favorable neurological outcome if epinephrine was given 15 minutes. Take care with these results - this was still a retrospective study, with the ever present danger of selection bias and confounding. It also doesn’t address younger children, as the majority of children included were >12 years old. At this point, I still intend to use epinephrine for pediatric arrest. If given, it should be early (but not in the first 2 minutes post-arrest).

Pre-Hospital Administration of Epinephrine in Pediatric Patients With Out-of-Hospital Cardiac Arrest.


Rock Star Review of Critical Care Literature - 2018
Jan 23, 2020 01:00 am
Written by Clay Smith

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This is a great reference list of critical care articles with EM relevance from the year 2018.

Why does this matter?
This is a group of authors we respect, and these are the critical care articles they thought were most important from the year 2018. JournalFeed covered ten of these in real time back in 2018. What were their picks?

The Lucky 13 CC from 2018

1. A randomized trial of epinephrine in out-of-hospital cardiac arrest. N Engl J Med. 2018; 379:711–21. Authors’ take: “30-day survival occurred in 3.2% of patients who received epinephrine compared to 2.4% of patients who received placebo. In survivors, severe neurologic impairment occurred in 31% of patients who received epinephrine compared to 17.8% of patients who received placebo.”
JF Summary

2. Effect of bag-mask ventilation vs endotracheal intubation during cardiopulmonary resuscitation on neurological outcome after out-of-hospital cardiopulmonary arrest. A randomized clinical trial. JAMA. 2018; 319:779–87. Authors’ take: “28-day survival with favorable neurologic outcome occurred in 4.3% of patients in the BMV group and in 4.2% of patients in the ETI group. There was no difference in the secondary outcomes of survival to hospital admission and 28-day survival between the two groups.”
JF Summary

3. Effect of a strategy of a supraglottic airway device vs tracheal intubation during out-of-hospital cardiac arrest on functional outcome: The AIRWAYS-2 randomized clinical trial. JAMA. 2018; 320:779–91. Authors’ take: “The primary outcome of neurologic outcome at hospital discharge or 30-days after OHCA occurred in 6.4% of patients randomized to an SGA and 6.8% of patients randomized to ETI. Initial successful insertion rates were greater in the SGA group without any increase in complications.”
JF Summary

4. Association between elevated mean arterial blood pressure and neurologic outcome after resuscitation from cardiac arrest: results from a multicenter prospective cohort study. Crit Care Med. 2018;47(1):93–100. Authors’ take: “Patients in the higher MAP group (MAP greater than 90 mmHg) had a higher incidence of good neurologic outcome when compared patients with a MAP between 70 and 90 mmHg. A MAP greater than 90 mmHg was found to be an independent predictor of good neurologic function at hospital discharge. The benefit of a higher MAP was greater in patients with a history of hypertension compared with those with no history of hypertension.”

5. Association between early hyperoxia exposure after resuscitation from cardiac arrest and neurological disability: a prospective multi-center protocol-directed cohort study. Circulation 2018;137(20):2114–2124. Authors’ take: “Patients exposed to hyperoxia had a higher incidence of poor neurologic outcome at hospital discharge compared to patients not exposed to hyperoxia. Hyperoxia was found to be an independent predictor of poor neurologic outcome at hospital discharge.”
JF Summary

6. Adjunctive glucocorticoid therapy in patients with septic shock. N Engl J Med. 2018;378(9):797–808. Authors’ take: “No significant difference in the primary outcome of 90-day all-cause mortality in patients who received hydrocortisone compared to those who received placebo. Time to shock resolution, time to ICU discharge, and the duration of the initial episode of mechanical ventilation were all shorter in patients who received hydrocortisone.”
JF Summary

7. Hydrocortisone plus fludrocortisone for adults with septic shock. N Engl J Med. 2018;378: 809–18. Authors’ take: “The primary outcome of 90-day all-cause mortality occurred 43% of the hydrocortisone-fludrocortisone group compared with 49.1% in the placebo group. Those in the hydrocortisone-fludrocortisone group had a statistically significant difference in all-cause mortality at ICU discharge. Patients in the hydrocortisone-fludrocortisone group had a shorter time to cessation of mechanical ventilation and cessation of vasopressor therapy.”
JF Summary

8. Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation: A randomized clinical trial. JAMA 2018; 319:2179–2189. Authors’ take: “The primary outcome of first attempt success in those with at least one characteristic of a difficult airway occurred in 96% of patients randomized to the bougie and 82% of patients randomized to the ETT plus stylet.”
JF Summary

9. Cardiac arrest and mortality related to intubation procedure in critically ill adult patients: A multicenter cohort study. Crit Care Med. 2018; 46:532. Authors’ take: “Patients who suffered an intubation-related cardiac arrest had a higher 28-day mortality rate compared with patients who did not have an intubation-related cardiac arrest. A systolic blood pressure 75 years were associated with intubation-- related cardiac arrest.”
JF Summary

10. Effect of a low vs intermediate tidal volume strategy on ventilator-free days in intensive care unit patients without ARDS. The PReVENT Trial. JAMA 2018; 320 (18):1872–1880. Authors’ take: “There was no significant difference in the primary outcome of ventilator free days and alive at day 28 between the low tidal volume ventilation group and the intermediate tidal volume ventilation group.”
JF Summary

11. Practice patterns and outcomes associated with early sedation depth in mechanically ventilated patients: A systematic review and meta-analysis. Crit Care Med 2018; 46 (3):471–479. Authors’ take: “A statistically significant decrease in mortality was found for patients who received an early, lighter level of sedation compared with patients who received early, deep sedation. Lighter sedation was also associated with significantly fewer days of mechanical ventilation and shorter ICU lengths of stay.”

12. Balanced crystalloids versus saline in critically ill adults. N Engl J Med 2018;378(9): 829–39. Authors’ take: “The primary outcome of MAKE at 30 days occurred in 14.3% of the balanced crystalloid group compared with 15.4% of the 0.9% sodium chloride group.”
JF Summary

13. Sodium bicarbonate therapy for patients with severe metabolic acidemia in the intensive care unit (BICAR-ICU): a multicenter, open-label, randomized controlled, phase 3 trial. Lancet. 2018; 392:31–40. Authors’ take: “There was no significant difference in the primary outcome of all-cause 28-day mortality and failure of at least one organ system at seven days after randomization between patients in the intervention group and those in the control group.”

Winters ME, Hu K, Martinez JP, Mallemat H, Brady WJ. The critical care literature 2018. Am J Emerg Med. 2019 Nov 28. pii: S0735-6757(19)30772-7. doi: 10.1016/j.ajem.2019.11.032. [Epub ahead of print]

Timeline photos 18/01/2020

Status Epilepticus - Three Anticonvulsants Head-to-Head - ESETT RCT
Jan 17, 2020 01:00 am
Written by Sam Parnell

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For status epilepticus refractory to benzodiazepines, the anticonvulsant medications levetiracetam, fosphenytoin, and valproate had similar rates of seizure cessation (all roughly half of patients), with similar incidence of serious adverse events.

Why does this matter?
The initial management of status epilepticus focuses on securing the ABCs (airway, breathing, circulation) and prompt administration of benzodiazepines. Early seizure cessation is crucial to reduce the morbidity and mortality associated with status epilepticus. However, up to a third of patients with seizures do not respond to benzodiazepine therapy, and further anticonvulsant medication is needed. Unfortunately, there is limited evidence comparing the efficacy and safety of commonly used anticonvulsant medications for status epilepticus.

Is there an optimal anticonvulsant for status epilepticus?
This was a prospective, randomized, multicenter, double-blind trial of 384 patients with benzodiazepine-refractory convulsive status epilepticus comparing the safety and efficacy of levetiracetam (60 mg/kg over 10 minutes, max dose 4500 mg), fosphenytoin (20 mgPE/kg over 10 minutes, max dose 1500 mgPE), and valproate (40 mg/kg over 10 minutes, max dose 3000 mg).

The primary outcome of cessation of status epilepticus and improvement in level of consciousness at 60 minutes occurred in roughly half of all patients (47% in levetiracetam group, 45% in the fosphenytoin group, and 46% in the valproate group) and results did not differ significantly between the three groups. The study was stopped early due to an interim analysis that found futility in continuing. In addition, there was no statistically significant difference in the incidence of adverse events. There was a trend toward more hypotension, respiratory depression, and intubation in the fosphenytoin group as well as more deaths in the levetiracetam group, but these differences weren’t significant.

It should be noted that approximately 10% of patients in this study had psychogenic nonepileptic seizures, unblinding occurred in a significant number of cases, and clinical criteria instead of EEG were used to determine the primary outcome. However, this study suggests that fosphenytoin, valproate, and levetiracetam have similar efficacy and are all valid options for treatment of benzodiazepine-refractory status epilepticus.

Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019 Nov 28;381(22):2103-211

Timeline photos 11/01/2020

Blunt Aortic Injury - Does Pan-scan Help?
Jan 07, 2020 01:00 am
Written by Clay Smith

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Blunt traumatic aortic injury is extremely rare and often has associated chest injuries. High-energy mechanism + wide mediastinum had poor sensitivity. The NEXUS Chest CT rule was 100% sensitive.

Why does this matter?
Major injury prevalence has remained constant, while CT use for trauma has doubled. Often, the rationale for scanning the chest is to avoid missing aortic injury. Are all these CT scans helping patients?

Can we reduce chest scans?
This was a pre-planned analysis of NEXUS Chest, with 24,010 patients. Of these, 0.17% (just 42 patients) had aortic injury. Of patients with aortic injury, 79% had associated thoracic injury, such as rib fractures, pneumothorax, hemothorax or pulmonary contusion. In fact, isolated aortic injury occurred in only 0.03% (9/24,010). No patients died of their aortic injuries, rather from brain injury. Over half had surgery, all endovascular repair. Patients with aortic injury on CT had similar mortality but longer length of stay. The classic way to screen for aortic injury - high-energy mechanism* + widened mediastinum on CXR - had just 76% sensitivity. However, the NEXUS Chest CT rule was 100% sensitive.

*High-energy mechanism = fall > 20 feet, MVC > 40 miles per hour, or pedestrian struck by motorized vehicle

Blunt Traumatic Aortic Injury in the Pan-scan Era. Acad Emerg Med. 2019 Dec 7. doi: 10.1111/acem.13900.

Timeline photos 07/01/2020

This 47 year old patient was admitted to hospital with a suspected deep venous thrombosis of the right leg. Within 6 hours, the patients leg is dark, discoloured and has an associated surgical emphysema.
A necrotising soft tissue infection is suspected.

What is the most likely causative organism?
a) Staphylococcus aureus
b) Streptococcus viridans
c) Streptococcus pyogenes
d) Clostridium perfinigens.
e) Staphylococcus epidermidis

Ok, let’s break it down!
This is a photograph before right leg amputation (hemipelvectomy) of a patient with gas gangrene. The right thigh is edematous (swollen) and discoloured with necrotic bullae (large blisters). Crepitation is detected on deep palpation. At this juncture, the patient is in shock.

Gas gangrene, a subset of necrotizing myositis, is an infectious disease emergency associated with extremely high morbidity and mortality. Organisms in the spore-forming clostridial species, including Clostridium perfringens, Clostridium septicum, and Clostridium novyi, cause most of the cases.
A nonclostridial form is caused by a mixed infection of aerobic and anaerobic organisms. The hallmarks of this disease are rapid onset of myonecrosis with muscle swelling, severe pain, gas production, and sepsis.
Production of hydrogen sulfide and carbon dioxide gas begins late and dissects along muscle bellies and fascial planes. These local effects create an environment that facilitates rapid spread of the infection.
Systemically, exotoxins may cause severe hemolysis. Hemoglobin levels may drop to very low levels and, when occurring with hypotension, may cause acute tubular necrosis and renal failure. A rapidly progressive infection can quickly result in shock.
The combination of aggressive surgical debridement (fasciotomy for compartment syndrome) and effective antibiotic therapy is the determining factor for successful treatment of gas gangrene.

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