This is perhaps a silly question but would cocaine help in an arrest? It's a coronary artery vasoconstrictor if given in high enough doses. I think ultimately it would be detrimental as it has been shown to decrease myocardial blood flow, but in the very short term to increase coronary artery perfusion pressure might it contribute to ROSC without brain impact?

Does anyone use TXA to reverse the newer anticoagulants (direct thrombin inhibitor or factor XA)? 

I just saw some data on our ED screening for sepsis which is essentially "suspected infection" + 2 SIRS at triage. Those with a positive screen were NOT diagnosed with sepsis about 80% of the time. Further, about 20% of patients diagnosed with sepsis were screen negative.

How does this compare to others?

One issue may be that we screen everyone, including those going to fast-track.
The other is that I suspect the inter-observer variability to the question "suspected infection" is high among the triage nurses.

We are looking to improve our screening sensitivity and specificity. Any suggestions?

Hi, I enjoyed Josh Farkas' articles regarding Olanzapine. I'm researching the drug. Is there anyone on this site who I could speak with regarding IM or IV injected Olanzapine? Please send me an email at Thanks.

Instead of Epi+Esmolol for cardiac arrest, why don't we use NorEpi via IO instead?

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How do you handle stroke patients who are eligible for TPA except they are on a NOAC? 

Flight nurse here and have had some discussions about bradycardia especially in the presence of hypotension in trauma. It seems so many people are against vasopressors in trauma, but this is how I see it so far. I would like opinions please if I am on track or off base:

1) Must consider non traumatic causes (medication related, MI, etc.)
2) Herniation syndrome. Hypotension may be concomitant hemorrhage and/or impending arrest. Treat with volume but may need epinephrine. 3% saline.
3) Spinal cord injury. Neurogenic shock and again with possible hemorrhage also needs volume replacement but epi/levo may be indicated in the presence of bradycardia.
4) Impending arrest: Could be the result of any of the above or isolated hemorrhage. Declining etco2 is huge red flag. Again treatment as above-volume/pressors.

Am I off base here with moving to vasopressors when inadequate response to volume or impending arrest? Would anyone ever attempt atropine in this scenario. It seems it should improve heart rate in all but brain stem herniation but don't see it really helping hemodynamics. 

Question for the brain trust

Adult patient brought in for cardiac arrest into an ED without ECMO/ECLS. Shortly after arrival ROSC is obtained. Let's say that you already have IV access or at least an IO. What is your next priority regarding access- central venous line or an a-line?

My argument here is for an a-line. These patients are at very high risk to re-arrest and while end-tidal CO2 will give you some warning, an a-line seems like a much better way to monitor this. It should also help monitoring for downtrending BPs and allow you to act on it quickly.

However, I see a lot of focus on getting this crash central line (often while the patient is still in arrest). I give anything I want through a good peripheral line or an IO including high doses of pressors so I don't think a CVL is needed as quickly. Finally, it can be very difficult to obtain a-line access during arrest so I think obtaining it while the patient has a pulse should be a priority.


Im trying to get a nasal endoscope for our department. which one do you recommend? 
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