Pediatric cardiogenic shock is an often insidious phenomenon with presentations requiring a broad differential diagnosis. Even after narrowing the diagnosis to cardiogenic shock, the list of possible etiologies is vast and the cause important to determine because the source of the shock will respond differently to different treatments.

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. 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. [...]

A particularly complicated case and tricky diagnosis, along with the need-to-know information for all emergency physicians

The transplant patient is always sicker than they appear. It is important to be aggressive in these patients since they are severely immunocompromised which not only puts them at greater risk of infection but also blunts their normal signs to infection. Always contact the transplant team to help with management as many centers have specific protocols for treatment of rejection and infection. Often it is very difficult to differentiate between rejection and infection. In these cases, treat on the side of infection as it would be the greatest immediate threat to life in the patient. [...]

The HEART score is an invaluable adjunct to emergency physicians when deciding which chest pain patients are appropriate for early discharge.

There have been a number of new publications reviewing our approach to managing sepsis. Both the ProCESS Trial and ARISE trial published in 2014 editions of the New England Journal question whether invasive procedures and rigid protocols are required to have positive patient outcomes. Other studies included in this power review examine the importance of early antibiotic therapy, effects of different mean arterial pressure parameters, and impact of chloride heavy versus chloride restricted solutions.

Update: This AMA will be happening Friday, December 12th from Noon-1:30pm EST.

We're very pleased to announce that our next Ask Me Anything will be with Mike Stone, MD, RDMS. Dr. Stone is the Division Chief of Emergency Ultrasound and the Emergency Ultrasound Fellowship Director at Brigham and Women’s Hospital in Boston, MA, and can be found on Twitter as @bedsidesono.

Locate the best site for needle insertion, demonstrate the appropriate angle of insertion, and measure the distance to reach the subarachnoid space.