Podcast production, editing and sound design by Anton Helman; voice editing by Danielle Lewis
Podcast content, written summary & blog post by Brit Long, Raymond Cho and Anton Helman
Cite this podcast as: Helman, A. Swaminathan, A. Long, B. Gottlieb, M. Reid, S. Rosenberg, H. Cheskes, L. Morgenstern, J. EM Quick Hits 29 – Vasopressor Failure, Asplenic Considerations, Bronchiolitis Update, ICD Electrical Storm, Night Shift Tips. Emergency Medicine Cases. June, 2021. https://emergencymedicinecases.com/em-quick-hits-june-2021/. Accessed [date].
Occult causes of non-response to vasopressors
Primary therapy for hypotension is to treat the underlying cause, while initiation of vasopressors is a temporary adjunctive therapy
Despite substantial vasopressor doses, some patients may not respond appropriately with improvements in hemodynamic parameters; failure to respond should lead to a cognitive pause and consideration of the occult causes of non-response to vasopressors.
Occult causes of non-response to vasopressors (source: REBEL EM)
Long B, Koyfman A, Gottlieb M. Complications in the adult asplenic patient: A review for the emergency clinician [published online ahead of print, 2020 Mar 26]. Am J Emerg Med. 2020;S0735-6757(20)30191-1.
RSV Bronchiolitis update and evolving patterns in the COVID era
Bronchiolitis evolving patterns
RSV bronchiolitis is the most common reason for a child under 1 year to be admitted to hospital in Canada but was virtually non-existent during the peak of the COVID pandemic
There was a recent warning from Australia about off-season bronchiolitis with very significant resurgence during their summer in 2020
Foley and colleagues published data from Western Australia showing the RSV epidemic curve in 2020 – very low through the weeks where public health measures were in place and then rising rapidly during the summer, which is much higher than usual and with an older mean age of 18 months; the authors suggest that an expanded cohort of RSV naïve patients may be driving this resurgence
Another study published by Baker et. al. in December 2020 models the impact of the COVID-19 nonpharmaceutical interventions on the future dynamics of endemic viruses like influenza and RSV; their results also suggest that a buildup of susceptibility due to public health measures may result in large outbreaks and that RSV may reach its peak in North America in winter 2021-2022
RSV detection in children from metropolitan Western Australian up to week 50 of 2020 (source: Clinical Infectious Diseases)
Bronchiolitis management refresher
Clinical assessment and diagnosis
Bronchiolitis is a clinical diagnosis based on patient age, time of year (may be off-season) and clinical presentation
Typically, a child under 1 year of age who has a URTI prodrome then develops LRTI symptoms with increased work of breathing, crackles and wheezes
Acute symptoms generally last 10 days but cough/congestion can continue for 3-4 weeks
Routine CXR for bronchiolitis is not recommended as this often leads to unnecessary antibiotics
Viral testing is indicated for patients who are being admitted only
COVID does not appears to be a significant cause of bronchiolitis-like symptoms in children
Management – mainstay is supportive care
Supplemental O2 if sats < 90%
Gentle nasal suction if less than 4 months old (obligate nose breather)
PO/NG/IV rehydration as needed
No routine nebulized treatments recommended but consider trial of epinephrine nebulizer if moderate/severe distress
No role for steroids at present
Approach to wheezing child over 12 mos
Trial of asthma therapy (salbutamol) and post assessment
If it helps then treat them as a young asthmatic per asthma guidelines (i.e. salbutamol, ipratropium, steroids)
If no improvement with salbutamol, presume bronchiolitis and manage supportively
Bottom Line: Yearly patterns of wheezing illness in children will likely change over the next year; RSV bronchiolitis may present out-of-season, longer and more difficult to manage.
Baker, R. E., Park, S. W., Yang, W., Vecchi, G. A., Metcalf, C. J., & Grenfell, B. T. (2020). The impact of COVID-19 nonpharmaceutical interventions on the future dynamics of endemic infections. Proceedings of the National Academy of Sciences, 117(48), 30547-30553.
Foley, D. A., Yeoh, D. K., Minney-Smith, C. A., Martin, A. C., Mace, A. O., Sikazwe, C. T., Le, H., Levy, A., Moore, H. C., & Blyth, C. C. (2021). The Interseasonal resurgence of respiratory syncytial virus in Australian children following the reduction of coronavirus disease 2019–Related public health measures. Clinical Infectious Diseases.
Management of electrical storm and recurrent ICD shocks in the ED
Definition: 3 or more episodes of sustained VT over 24-hour period or in patients with an ICD, 3 or more appropriate detections of ventricular dysrhythmia that lead to ICD therapy
Electrical storm is caused by scar-mediated re-entry circuits due to prior myocardial injury
Clinical presentation of electrical storm in patient with ICD
Pain from ICD discharges, palpitations, syncope or cardiac arrest
Patients may present with recurrent ventricular tachycardia that is below the ICD therapy threshold (typically < 170-200 beats/min for primary prevention)
Determine whether ICD therapy is appropriate: appropriate ICD therapy refers to ICD therapy delivered for malignant ventricular dysrhythmia (i.e. VT or VF) while inappropriate ICD therapy is one delivered for non-malignant causes, which accounts for 30% of all ICD therapies
Approach to management of electrical storm in patient with ICD
Approach to assessment and management of recurrent ICD discharges in the ED (source: CJEM)
Cheskes L, Krywenky A, Sadek MM. Just the facts: management of electrical storm and recurrent ICD shocks in the emergency department. CJEM 2021;23: 147-149.
Top 10 evidence-based countermeasures for night shift workers
Schedule for circadian rhythm – sequential shifts should move later in the day, minimize transitions between shifts (i.e. all mornings one week, all afternoons the next), work maximum 2-3 night shifts in a row and cap night shifts at 8 hours
Short (15 minute) nap prior to night shifts (longer naps may lead to increased grogginess)
Take a short nap if you can on shift
Maximize bright light on shift: to keep awake and alert while on shift
Drink caffeinated beverages early in the shift (avoid in the last 4 hours of shift)
Avoid large carbohydrate-heavy meals before and during shift as they may increase fatigue
Minimize light (especially blue light from screens) on commute home and before sleeping
Consider melatonin (studies suggest improvement of daytime sleep by an average of 24 minutes)
Sleep in a dark, cool and quiet room (consider blackout blinds on windows, eye mask, soundproofing walls, white noise machine, silicone ear plugs)
Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.