recent articles

practice updates

Roc Rocks and Sux Sucks! Why Rocuronium is the Agent of Choice for RSI

I recently had the pleasure of engaging in a point-counterpoint discussion on the optimal agent for Rapid Sequence Intubation with Billy Mallon at Essentials of Emergency Medicine 2014. I took the pro-rocuronium side. For decades, succinylcholine (suxamethonium) was the paralytic agent of choice (and the only available option) for RSI. The National Emergency Airway Registry (NEAR) found that it was used in 90% of airways. Succinylcholine has a number of perceived advantages that led to this situation:

  • Rapid onset (45-60 seconds)
  • Short half-life (6-8 minutes of paralysis)
Rapidly achieving an optimal intubating environment is critical as prolonged time to paralysis can delay successful intubation, potentially leading to oxygen desaturation. Early data demonstrated that succinylcholine reached optimal intubating parameters more rapidly than rocuronium (Sluga 2005, McCourt 1998, Laurin 2000). However, this difference was shown to be caused by inappropriate dosing of rocuronium (0.6 mg/kg in most studies). When a 1.2 mg/kg dose of rocuronium is given, the time to achieving optimal intubating parameters is virtually equivalent (Herbstritt 2012). Rapid offset has been touted as an advantage because if the airway provider was unable to intubate the patient, the drug would wear off quickly and the patient would resume spontaneous breathing before desaturation occurs. We will see later why this logic is flawed. Over the last 4-5 years, the RSI agent preference has swung away from succinylcholine. swami1 There are likely numerous reasons for this swing including drug shortages but a better understanding of the limitations of succinylcholine are also likely at play. [...]

From @EMSwami

Cardiogenic Shock

Click here to view Tintinalli's chapter on Cardiogenic Shock via Access Emergency Medicine!A 55-year-old man arrives via ambulance in respiratory distress. Paramedics attempted to start an intravenous line but the patient is altered and pulled it out. They were also unable to keep an NRB mask on him. His vital signs are: HR: 132, BP: 71/38, RR: 35, O2Sat: 83% A quick bedside ultrasound reveals numerous B lines in both lung fields and markedly depressed left ventricular function. Based on your quick evaluation, you determine that the patient is suffering from cardiogenic shock. You are familiar with treatment of acute decompensated heart failure (ADHF) but are unclear on the management priorities and appropriate treatments in cardiogenic shock. [...]

From @EMSwami

IV Contrast Myths

"Premedication with corticosteroids has never been shown to reduce the risk of moderate or severe adverse drug reactions"
We're thrilled to present another game-changing writeup from Anand Swaminathan, MD MPH (@EMSwami), this time on the conundrums of shellfish allergies and utility of premedication in patients receiving IV contrast.

From @EMSwami

Myths in DKA Management

"The bolus insulin group had longer lengths of stay and a 6-fold increase in hypoglycemic episodes"

Anand Swaminathan, MD MPH (@EMSwami) addresses urban legends in DKA management, including VBGs vs ABGs, when to replete potassium, bicarb administration, and insulin boluses.

From @EMSwami

Epinephrine in Cardiac Arrest

"It’s time to re-examine this recommendation"
Epinephrine in cardiac arrest: helpful for ROSC, but maybe not so much for good neurological outcomes. Anand Swaminathan, MD MPH takes a thought-provoking look at the historical evidence behind this practice, as well as at newer evidence that calls its benefit into question.

From @EMSwami

Furosemide in the Treatment of Acute Pulmonary Edema

"The continued central role [loop diuretics] play highlights a lack of understanding of the underlying pathophysiology of the disease"

In this excellent article, Anand Swaminathan, MD, MPH dissects the evidence to challenge common perceptions regarding the utility of furosemide in patients with APE.