Avalanche Resuscitation in the Emergency Department

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Authors: Vivek Abraham, MS4

Medical Student
Uniformed Services University F. Edward Hebert School of Medicine

Ivan Yue, MS4
Medical Student
Uniformed Services University F. Edward Hebert School of Medicine
AAEM/RSA Publications and Social Media Committee

Alexander Li, MS4
Medical Student
Uniformed Services University F. Edward Hebert School of Medicine

Introduction
Avalanches are among the most feared events to occur in mountainous areas. Although the morbidity and mortality statistics are underreported worldwide, in North America and Europe combined there are roughly 140 avalanche-related deaths per year.[1,2] The majority of victims include snowboarders, skiers, mountaineers, and snowmobilers. With more people seeking to participate in snow sports or explore the mountains as part of expeditions, preparing to treat avalanche-related injuries is essential for an emergency physician working or traveling near a mountainous area. This article details the resuscitation guidelines that physicians can implement for those who fall victim to an avalanche as well as recommendations for mitigating avalanche exposure risk.

Resuscitation Guidelines Updates: What You Need to Know

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Author: Kasha Bornstein, MSc Pharm, EMT-P, MSIII
University of Miami Miller School of Medicine MD/MPH Program
AAEM/RSA Modern Resident Blog Copy Editor

Introduction

In late 2019, the International Liaison Committee on Resuscitation (ILCOR) released its updated guidelines for adult and pediatric resuscitation, informing the United States-based American Heart Association (AHA)/Advanced Cardiac Life Support (ACLS) focused protocol update.[1]

Significant changes this year in ILCOR recommendations focus on:

- Vasopressor use
- Advanced airway interventions and extracorporeal cardiopulmonary resuscitation (ECPR) in adult and pediatric cardiac arrest
- Targeted temperature management (TTM) in pediatric cardiac arrest This short article will address the salient details regarding each of these updates. Vasopressor Use Epinephrine, the old standby for the all-cause pulseless patient, has undergone significant review in recent years. Multiple large-scale retrospective and placebo-controlled randomized-controlled prospective studies have probed the efficacy and safety of epinephrine in cardiac arrest.[2,3] The majority of these studies find that while epinephrine may increase return of spontaneous circulation (ROSC), the effect size is small versus placebo and no difference is seen in favorable neurologic outcome. Many aspects surrounding best practices in epinephrine use remain unknown. These include optimal timing for administration in patients with shockable rhythms, efficacious dosing, and dose/effect relationships. However, alternative interventions are limited, overall survival for patients with non-shockable rhythms (asystole, pulseless electrical activity) is low, and no other pharmacologic intervention has demonstrated improved ROSC in these cases.

Does Albumin as Resuscitative Fluid in Sepsis Improve Mortality When Compared to Crystalloid?

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Authors: Laurie Bezjian Wallace, DO
Mike O’Callaghan Military Medical Center

Bottom Line Up Front
Utilizing albumin as resuscitative fluid in patients with sepsis demonstrated no difference in all-cause mortality when compared to crystalloid (System of Record ((SOR)) A: meta-analysis of randomized controlled trials [RCTs]). Administration of 300mL of 20% albumin did not significantly lower mortality rates at 28 days or 90 days post-administration (SOR B: single unblinded RCT).

Introduction
Crystalloid versus colloid fluid resuscitation in septic patients remains a topic of discussion within the critical care community. This article details a meta-analysis and RCT which address the outcomes of utilizing albumin as a resuscitative fluid in patients with sepsis.

Carotid Doppler Ultrasound and Passive Leg Raise to Predict Fluid Responsiveness

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Author: Jake Toy, DO
PGY1 Emergency Medicine, Harbor UCLA Medical Center
Modern Resident Blog Editor-in-Chief

Background
The management of intravascular volume in critically ill patients is a challenge we face daily in the emergency department (ED). Since the beginning of our training, hypotension and shock have often been synonymous with rapid fluid resuscitation. Yet at present, fluid resuscitation remains largely empiric in nature.

Reanimare: View from a Romanian Resuscitation Bay

Author: Wit Davis, DO MS MPH
PGY2 Baystate Medical Center
Board Member of Equal Health

Your three-person resuscitation bay has four boarding intubated patients when the woman that you just stabilized becomes tachypneic to the 70’s with an O2 sat of 65% on non-rebreather. As you get her onto CPAP ventilation, the overhead alert announces that the helicopter has landed with a trauma arrest. That’s when you hear someone yelling from the adjacent CT scanner, “Ajuta! Ajuta-ma!”

At least that’s what you think they said. After all, the cries of a CT tech when a patient codes in their scanner is universally understood, and you’re in Romania.

Electrical Storm: Don’t Just “Push Another Milligram of Epi”

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Author: Khalid M Miri, OMSIV
Western University of Health Sciences, College of Osteopathic Medicine of the Pacific

"Are you ready to call it?" "Not yet, let’s push one more of epi." Sound familiar? Despite doing proper CPR, defibrillating, and pushing all the ACLS meds, you know deep down that after the first few rounds of chest compressions, your cardiac arrest patient has a tiny chance of surviving to discharge in good neurological condition. You have seen too many codes that go on too long and all you know to do is keep pushing epinephrine and hope that your patient is that one rare case that will achieve sustained ROSC. Have you ever wished you had another option, something that might work when epinephrine and amiodarone do not? Well, an additional option may exist. During a specific condition — refractory ventricular fibrillation — research shows that using a beta blocker can have a better chance of bringing that patient out of their dysrhythmia than when using epinephrine and antidysrhythmics alone.

Cardiac electrical storm (ES) is often defined as three or more episodes of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) within 24 hours. It is a dangerous arrhythmia that leads to refractory VF and will kill most of its victims despite treatment with the current ACLS recommendations of epinephrine, antidysrhythmics, CPR, and defibrillation.[1]

Use of Mechanical CPR Devices has Increased 1,511% - What You Need to Know

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Author: Jake Toy, OMS II
Western University of Health Sciences
College of Osteopathic Medicine of the Pacific, Pomona, CA
AAEM/RSA Publications Committee Member

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Introduction
There are an estimated 424,000 out of hospital cardiac arrests (OHCA) among Americans annually.[1] Survival rates for OHCA are low, ranging from 10.6% to 31.4%.[2] External defibrillation and CPR represent the first line treatments for OHCA. The American Heart Association (AHA) defines high-quality CPR as 100-120 compressions per minute (CPM) at a depth of 2 inches on the average adult. Allowance of full recoil, minimization of compression interruptions, and avoidance of excessive ventilation are also important (Figure 1).[3] 

Figure 1. 2015 American Heart Association Adult CPR Guidelines (Source – American Heart Association[2])

Drowning in your own Blood: Managing Massive Hemoptysis

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Author: Jonathan Morgan, MSIV Lake Erie College of Osteopathic Medicine-Bradenton

Case:
EMS calls; they are 5 minutes out
with a 50-year-old female patient in cardiac arrest with massive airway bleeding. She began coughing up blood and collapsed several minutes prior to EMS arrival. She is currently intubated with a 7.0 ETT, 3 doses of epinephrine have been administered, and CPR is ongoing; she has been alternating between

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PEA and asystole. Family reported a recent diagnosis of lung cancer.

What defines massive hemoptysis?
There is no consensus on the definition of “massive.” Many sources use a definition of 600cc of expectorated blood per hour, but proposed cutoffs run between 200 and 1000 mL/hr. [1] However, estimating blood volumes can be difficult and it may only take 100-400mL of blood in the airway to cause impaired gas exchange.[1,2] Because of this, some proposals call for inclusion of other clinical data including evidence of impaired gas exchange or hemodynamic derangements to define “massive.”[3]

What is the likely etiology of this patient’s cardiovascular collapse? 
Asphyxiation rather than exsanguination is the most likely cause of cardiovascular collapse in massive hemoptysis.[4] 90% of cases of massive hemoptysis are caused by bleeding in the bronchial circulation, which is exposed to systemic pressures; bleeding in the low pressure pulmonary circulation accounts for only 5% of cases.[2]