More than 600,000 patients in North America sustain sudden cardiac arrest each year.  When return of spontaneous circulation (ROSC) is achieved, there are a number of critical interventions to consider in order to provide the patient with the best chance of being discharged with meaningful neurologic survival.  In this podcast, we discuss an excellent recent review article on the management of patients with ROSC following cardiac arrest.

Emergency physicians intubate critically ill patients daily.  Unfortunately, up to 17% of ED intubations can be complicated by peri-intubation hypoxemia, hypotension, and cardiac arrest. Efforts to optimize patient's physiology prior to rapid sequence intubation are critical in mitigating the risk of potentially disastrous peri-intubation complications.  In this podcast, we discuss a recent Clinical Policy from the American College of Emergency Physicians that addresses critical issues in the management of adult ED patients undergoing endotracheal intubation.  

Critically ill patients receiving mechanical ventilation require analgesia and sedation.  At present, propofol remains the most widely used sedative for intubated/ventilated patients.  Recent trials have suggested that dexmedetomidine may reduce delirium and the duration of mechanical ventilation compared with other sedative medications.  In fact, recent SCCM guidelines suggest the use of dexmedetomidine over propofol in intubated patients.  In this podcast, we discuss a recent randomized trial that compared the effectiveness and safety of a dexmedetomidine-based sedation strategy with a propofol-based sedation strategy in mechanically ventilated critically ill patients.

Approximately 75% of patients older than 65 years of age are seen in an ED within 6 months of their death.  While palliative care teams are now present in many hospitals in the US, they are often not present 24/7 or in resource-limited settings.  As such, there may be an opportunity to improve palliative care in the ED by providing palliative care education to ED team members.  In this podcast, we review the recently published PRIM-ER trial, which evaluated the impact of a robust primary palliative care intervention on hospital admission rates in 29 EDs across the US.

Sepsis results in more than 250,000 deaths each year in the United States. Resuscitation of the septic patient centers on timely recognition, early antibiotic administration, appropriate fluid administration, source control, and vasopressor administration for those with inadequate mean arterial pressures. At present, norepinephrine is the recommended first-line vasopressor for sepsis.  Current guidelines then recommend vasopressin as the second-line vasopressor agent, but the optimal timing of its initiation remains unknown. In this podcast, we discuss a recent article on the use of a machine learning tool for vasopressin administration to optimize short- and long-term outcomes in patients with sepsis.

Nearly 4 million patients sustain out-of-hospital cardiac arrest (OHCA) worldwide each year.  International guidelines for the resuscitation of patients with OHCA recommend early administration of epinephrine in those with an initial nonshockable rhythm.  Both intravenous (IV) and intraosseous (IO) access are routinely attempted to gain vascular access to administer medications.  While IV access is recommended, this is based on very low certainty evidence.  In this podcast, we discuss three recently published randomized trials that investigated IO and IV access in patients with OHCA.

Both NIV and HFNC are used to treat patients with acute respiratory failure.  Current guidelines recommend NIV for acute respiratory failure caused by COPD and acute cardiogenic pulmonary edema.  However, NIV may be hard for some patients to tolerate. When compared to low-flow oxygen therapy, HFNC has been shown to improve oxygenation, improve alveolar recruitment, and enhance clearance of secretions. HFNC may be easier to use and tolerate than NIV, but there remains uncertainty regarding the effectiveness of HFNC compared to NIV for acute hypoxemic respiratory failure. In this podcast, we discuss the RENOVATE trial that sought to compare HFNC with NIV on rates of intubation in patients with acute respiratory failure.

NIPPV is frequently used in the management of critically ill patients presenting with an acute COPD exacerbation, as NIPPV decreases the rates of intubation and is associated with lower in-hospital mortality.  Typically, "low" intensity NIPPV, whereby inspiratory positive airway pressures less than 18 cm H2O are used. More recently, the use of "high" intensity NIPPV, with IPAPs between 20-30 cm H2O, has been shown to improve gas exchange, ventilatory function, and improve arterial PCO2 values.  In this podcast, we review the HAPPEN Trial, which compared low intensity to high intensity NIPPV on the need for intubation in patients with an acute COPD exacerbation and hypercapnia.

The incidence of opioid-associated out-of-hospital cardiac arrests continues to rise.  Current guidelines for the resuscitation of patients with OHCA advise the clinician to consider the administration of naloxone of patients with suspected opioid-associated OHCA.  In this podcast, we review a recenlty published study in JAMA that evaluated the association of naloxone with patient outcomes in opioid-associated OHCAs.

Timely administration of broad-spectrum antibiotics is a critical pillar in the resuscitation of patients with sepsis.  B-lactam antibiotics are an important class of antibiotics commonly administered to patients with sepsis.  Typically, B-lactam antibiotics are administered over 30 minutes, but optimal bactericidal activity requires the concentration of free drug to be above the MIC of the organism for 40-70% of the dosing interval.  In this podcast we discuss two recent publications that compare continuous infusions of B-lactam antibiotics with intermittent effusions in patients with sepsis.