Resuscitation Strategies for Maximizing Survival.

There is no single resuscitation strategy that will uniformly improve cardiac arrest outcomes. Traditional vital signs cannot be relied on in cardiac arrest, and the use of continuous capnography, regional cerebral tissue oxygenation, and continuous arterial monitoring are options for use early defibrillation are critical elements of resuscitation. Cardio-cerebral perfusion may be improved with the use of active compression-decompression CPR, an impedance threshold device, and head-up CPR. In refractory shockable arrest, if ECPR is not an option, consider changing defibrillator pad placement and/or double defibrillation, additional medication options, and possibly stellate ganglion block.

Emergency Airway Management in a Patient with a T-Tube Tracheal Stent.

BACKGROUND: Abnormal anatomy complicates emergency airway management. In this case, we describe definitive airway management in a critically injured emergency department (ED) patient with a history of partial tracheal resection who had a Montgomery T-tube, a type of T-shaped tracheal stent, in place at the time of the motor vehicle collision. The Montgomery T-tube is not a useful artificial airway during resuscitation, as it lacks a cuff or the necessary adapter for positive pressure ventilation. CASE REPORT: We describe a case of a 51-year-old man who required emergency airway management after a motor vehicle collision. The patient had a Montgomery T-tube in place, which was removed with facilitation by ketamine sedation and topical anesthesia. The patient was successfully intubated through the tracheal stoma after removal of the T-tube. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians must recognize the Montgomery T-tube, which resembles a standard tracheostomy tube externally, and have some understanding of how to manage a critically ill patient with this rare device in place. When a patient with a Montgomery T-tube in place requires positive pressure ventilation, the device may require emergent removal and replacement with a cuffed tracheostomy or endotracheal tube.

The utility of laboratory testing for suspected hyperthyroidism in the emergency department.

BACKGROUND: Given signs and symptoms of hyperthyroidism are non-specific, thyroid studies may be completed to evaluate patients with vague complaints such as tachycardia in the emergency department (ED). We sought to determine how often a new diagnosis of hyperthyroidism was made in patients who underwent thyroid laboratory testing in the ED. OBJECTIVES: The primary outcome of this study was a new diagnosis in the ED, or in the following 30 days, of hyperthyroidism or thyrotoxicosis following ED thyroid laboratory testing. METHODS: This was a retrospective chart review study in a single ED of all patients who had a TSH or free T4 ordered from 2007 to 2018, or a TSH value below, or a free T4 higher than the local reference ranges. Patients with a diagnosis of hypothyroidism were excluded. RESULTS: 12,366 patients underwent thyroid laboratory testing, and 12,244 patients were included. Of included patients, 655(5.4%) had abnormal thyroid studies, and 95(0.8%) patients received a new diagnosis of hyperthyroidism or thyrotoxicosis. The sensitivity and specificity of tachycardia for the diagnosis of hyperthyroidism was 70%(95% CI 62% to 77%) and 62%(95% CI 61% to 63%), respectively; and the positive and negative likelihood ratios were 1.8(95% CI 1.7 to 2.0) and 0.5(95% CI 0.4 to 0.6), respectively. CONCLUSION: This study suggests that thyroid laboratory studies may be best used for a focused assessment for thyroid disorders rather than a screening tool for patients with one symptom of hyperthyroidism.