Contributor: Aaron Lessen MD

Educational Pearls:

• Induction agent selection during rapid sequence intubation involves accounting for hemodynamic stability in the post-intubation setting

• Many emergency departments use ketamine or etomidate

• A recent study sought to explore the rates of post-induction hypotension of ketamine compared with propofol

  • Single center retrospective cohort study of patients between 2018-2021

• Ketamine and propofol were both significantly associated with post-induction hypotension

  • Ketamine adjusted odds ratio = 4.50

  • Propofol adjusted odds ratio = 4.88

  • 50% of patients became hypotensive after induction with either propofol or ketamine

• These findings suggest post-induction hypotension is mainly due to sympatholysis rather than the choice of agent itself

References

1. Tamsett Z, Douglas N, King C, et al. Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension?. Emerg Med Australas. 2024;36(3):340-347. doi:10.1111/1742-6723.14355

Summarized & Edited by Jorge Chalit, OMS3

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Contributor: Aaron Lessen MD

Educational Pearls:

Can opioids cause cardiac arrest?

• Opioids can cause respiratory suppression and the subsequent low oxygen levels can lead to arrhythmias and eventually cardiac arrest.

• In 2023, 17% of out-of-hospital cardiac arrests (OHCA) were attributable to opioids.

Given that this is a rising cause of cardiac arrest, should we just treat all cardiac arrest with naloxone (Narcan)?

• Naloxone is correlated with an increased chance of return of spontaneous circulation (ROSC)

• Additionally, a wide variety of individuals can be exposed to opioids and therefore opioid overdose should be considered in all cases of OHCA

But does naloxone improve neurologic outcomes?

• Yes, naloxone, especially when given early on in the resuscitation can improve neuro outcomes

What is the dose?

• 2-4 mg IN/IV depending on access.

• High suspicion for opioid overdose consider going with an even higher dose such as 4-8 mg IN/IV

References

1. Orkin, A. M., & Dezfulian, C. (2024). Recognizing the fastest growing cause of out-of-hospital cardiac arrest. Resuscitation, 198, 110206. https://doi.org/10.1016/j.resuscitation.2024.110206

2. Quinn, E., & Du Pont, D. (2024). Naloxone administration in out-of-hospital cardiac arrest: What's next?. Resuscitation, 201, 110307. https://doi.org/10.1016/j.resuscitation.2024.110307

3. Saybolt, M. D., Alter, S. M., Dos Santos, F., Calello, D. P., Rynn, K. O., Nelson, D. A., & Merlin, M. A. (2010). Naloxone in cardiac arrest with suspected opioid overdoses. Resuscitation, 81(1), 42–46. https://doi.org/10.1016/j.resuscitation.2009.09.016

4. Wampler D. A. (2024). Naloxone in Out-of-Hospital Cardiac Arrest-More Than Just Opioid Reversal. JAMA network open, 7(8), e2429131. https://doi.org/10.1001/jamanetworkopen.2024.29131

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce MS1 & Jorge Chalit, OMS3

Donate: https://emergencymedicalminute.org/donate/

Contributor: Aaron Lessen MD

Educational Pearls:

• A study evaluated the patient-care impact and financial costs of holding patients in the ED, a nationwide issue

• • Prospective, observational study of acute stroke management

  • Conducted at a large urban, comprehensive stroke center

• The study evaluated patients in multiple categories:

1. admitted to med/surg

2. admitted to med/surg but held in the ED

3. admitted to the ICU

4. Admitted to ICU but held in the ED

• Examined the amount of time nurses and providers spent with each patient

• • This was analyzed in conjunction with the knowledge of each providers’ salaries and the overhead costs of the med/surg unit, ICU, and ED

• Conclusions:

• • Patients who required med/surg inpatient care but who were held in the ED resulted in a doubled daily cost

  • • $1856 for med/surg inpatient boarding vs $993 for med/surg inpatient care

  • Patients who required ICU care but who were held in the ED also resulted in an increased daily cost, but this difference was not as large

  • • $2267 for ICU inpatient boarding vs $2165 for ICU care

• Holding in the ED negatively impacts patients since they receive less time from providers

• Holding also results in increased financial costs

References

1. Canellas MM, Jewell M, Edwards JL, Olivier D, Jun-O’Connell AH, Reznek MA. Measurement of Cost of Boarding in the Emergency Department Using Time-Driven Activity-Based Costing. Annals of emergency medicine. Published online May 1, 2024. doi:https://doi.org/10.1016/j.annemergmed.2024.04.012

Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3

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