Resuscitation myths (CAEP 2018)

Busting myths to simplify resuscitation

I was asked to speak at CAEP 2018 about myths in resuscitation. Most people, by now, know that I love a good myth, but the one time that I don’t want to be debating the medical literature is when there is a critically ill patient in front of me. Those are times for action, not debate or doubt. I would care if the myth put my patient at risk, but in emergency medicine we are really good at life and death. Myths generally don’t survive if we are talking about a mortality benefit. So why would anyone want to sit through a talk about resuscitation myths? Was I about to plant seeds of doubt that would grow into critical inaction?

However, as I reflected on the various myths that I could speak about, it dawned on me that myths themselves are frequently the cause of inaction. Picture the resuscitation of a sick anaphylactic patient: there are nurses rushing to start IVs and collect medications such as benedryl, ranitidine, and steroids. There is a lot of action, but it is mostly tangential – the stuff of myths. All the patient needs is epinephrine. Everything else just gets in the way; complicates resuscitation.

I value simplicity in the resuscitation room. I want my resuscitations to be smooth; to be easy. All too often, resuscitation is complicated by myths and misunderstandings. Therefore, I decided to pick myths that I thought could simplify resuscitation. These are the myths I discussed:

Peripheral vasopressors

The bottom line is that harms are incredibly rare when running vasopressors through a peripheral IV. There are certainly times when peripheral vasopressors can and should be used in resuscitation. However, very significant adverse events have been occasionally reported, so care must be taken. A write up of this evidence can be found here.

Contrast induced nephropathy

The bottom line is that based on the current literature, it is not clear that contrast has any effect on renal function. If it does, bad outcomes like dialysis are rare. However, the current literature is based entirely on observational data, and we would need RCT data to be sure. What we can be sure of is that if you have a sick patient in front of you that requires contrast to make an urgent diagnosis, the benefit of the contrast will almost certainly outweigh the (potentially mythical) risk. A full write up of this evidence can be found here.

PPIs for GI bleeds

The bottom line is that in 6 RCTs of emergency department patients with upper GI bleeds, PPIs do not decrease any patient oriented outcome (mortality, rebleeding, need for transfusion, or surgery). There were a couple secondary outcomes changed, but they have problems and were not consistent between trials. A full write up of this evidence can be found here.

Preoxygenation

The bottom line is that the classic method of preoxygenation, using a nonrebreather at 15 L/min, is inadequate for emergency department patients. Flush rate oxygen (turning the flow up as high as it will go) will result in better pre-oxygenation, and positive pressure ventilation should be considered as a preoxygenation technique in hypoxic patients (anyone with a saturation less than 95%). These issues are discussed in the airway series.

Fasting for procedural sedation

The bottom line is that across many thousand patients in observational trials, there is no association between NPO status and adverse outcomes. The primary reason for keeping patients NPO is to prevent aspiration, which in these studies occurs in about 1 in every 10,000 patients. Therefore, even the theoretical benefit is tiny, and must be considered in the context of the harms of requiring patients to remain NPO (delayed procedures, prolonged pain, more difficult procedures, and simply the harm of being denied food and drink). A full summary of this evidence can be found here.

Author: Justin Morgenstern

Community emerg doc, FOAM enthusiast, evidence junkie “One special advantage of the skeptical attitude of mind is that a man is never vexed to find that after all he has been in the wrong.” - William Osler

2 thoughts on “Resuscitation myths (CAEP 2018)”

  1. Hey Justin.
    Re: myths. Anaphylaxis

    Im all for simplification. Much of what we do remains unproven and often is of limited utility. 25 years in to emerge and I have, however, twice been witness to serious myocardial injury from overly liberal use of epinephrine. One of those two died – age 56. Just a caution about throwing out all the alternatives to epi. And a good reminder to all of us teacher/professor types to caution our students and residents to weigh all of the possibilities – including the rare outcomes

    Dave Pledger, MD, FRCPC, ABEM

    1. Thanks for the comment Dave
      It is an excellent reminder of the harm inherent in medicine.
      The most important teaching in medicine is that absolutely everything we do can cause harm. (The whole concept of “first, do no harm” is ridiculous and misleading, in my opinion.) That is why it is so important to pick medications that have real benefit: to outweigh the harms.
      Anaphylaxis is a tricky area, because there isn’t strong evidence for anything. But at this point, the best evidence that we have is that the only medication that is going to save a patient’s life is epinephrine. I think it is a bad idea to waste time with any of the other medications when you are seeing true anaphylaxis. There reasonable evidence that epineprhine is safe to use, even in older patients. (PMID 28069483) The only problem that I see is when the definition of anaphylaxis is expanded to include patients who clearly are not sick. If the patient isn’t sick, I think it is appropriate to focus on anti-histamines. But if the patient is sick, they need epinephrine.

Leave a Reply