When is Enough, Enough?

Another great question for the blog this week:

"If you are caring for a patient in cardiac arrest, do you have to wait until they are in asystole to pronounce the patient dead and terminate efforts at resuscitation? Are there any other rhythms in which you can pronounce a patient dead and stop the resuscitation if multiple rounds of ACLS aren't working?"

Get in the blog and let us know your thoughts on this!

What does this IVC ultrasound suggest?

A 52 year-old male presents to the ED with acute onset of shortness of breath and chest pain.  He has a history of hypertension, hypercholesterolemia, and diabetes.  His initial vital signs show a HR of 126, RR 34, BP 110/76, O2 sats of 93% on RA, and temp of 37.6.  During his assessment, a bedside ultrasound of his IVC is performed. 

What do you think of the IVC?

What is in your differential?

What else do you want to scan on this patient?

IVC US.jpg

Etomidate or Ketamine for RSI?

Thanks to one of our followers for the next question:

I am have been hearing many of my colleagues concerned about the potential harm created by adrenal suppression secondary to Etomidate use, especially in septic patients. A recent meta-analysis [Chan, C. et al Etomidate is associated with mortality and adrenal insufficiency in sepsis: A meta-analysis. Critical Care Medicine 2012 Nov;40(11):2945-53] found an association between Etomidate and increased mortality. I have two questions to ask:
1. Should I stop using Etomidate during RSI and switch to Ketamine? 
2. Is there literature to support the use of Ketamine during RSI  in patients with suspected increased intra-cranial pressure or intra-occular pressure?

So, what do you all think?

How do you treat a GI bleed without endoscopy?

The following question comes from an overseas EMCast listener who asks:

"...speaking of UGI bleeds, it's a diagnosis with which we are essentially helpless (i.e., definitive therapy) because we have no Gastroenterologist. I was just curious what you considered effective modalities and drugs for GI bleed without endoscopy."

What are your thoughts on the non-endoscopic management of GI bleeds?