EM Quick Hits 28 Cardiogenic Shock, Radiation Dose in Pregnancy, PoCUS in Airway Management, VIPIT, Angiotensin II, Short-Term Steroid Safety

Topics in this EM Quick Hits podcast Anand Swaminathan on an approach to cardiogenic shock (0:53) Hania Bielawska on myths of radiation dose in pregnant patients (8:55) Hans Rosenberg & Michael Gottlieb on the value of point-of-care ultrasound for airway management (14:46) Menaka Pai on Vaccine-Induced Prothrombotic Immune Thrombocytopenia (VIPIT) following AstraZeneca COVID-19 vaccination (21:31) Brit Long & Michael Gottlieb on angiotensin II vasopressor for distributive shock - is it ready for prime time? (30:45) Michael Schull on safety of short-term steroid use - a critical appraisal (36:11) Podcast production, editing and sound design by Anton Helman Podcast content, written summary & blog post by Brit Long, Raymond Cho & Anton Helman Cite this podcast as: Helman, A. Swaminathan, A. Rosenberg, H. Gottlieb, M. Pai, M. Long, B. Schull, M. EM Quick Hits 28 - Cardiogenic Shock, Radiation Dose in Pregnancy, PoCUS in Airway Management, VIPIT, Angiotensin II, Short-Term Steroid Use. Emergency Medicine Cases. May, 2021. https://emergencymedicinecases.com/em-quick-hits-may-2021/. Accessed [date]. An Approach to Cardiogenic Shock 1.Identify cardiogenic shock * Physical exam findings including altered mental status, cool skin and hypotension are nonspecific * POCUS via RUSH or HI MAP protocol, and ECG can rapidly identify patients in cardiogenic shock 2. Identify the cause of cardiogenic shock to guide management Dysrhythmia (i.e. ventricular tachycardia) Valvulopathy – POCUS may identify acute regurgitation, aortic lesion or blown valve and if identified, cardiothoracic surgery should be consulted emergently Ischemia * Patients in cardiogenic shock secondary to ischemia ultimately require angioplasty or thrombolysis; however, these patients require hemodynamic support while awaiting definitive care in the ED * Patients in cardiogenic shock are acidemic and hypoxic, and require resuscitation before intubation; non-invasive PPV and high flow nasal cannula may be used to improve myocardial oxygen delivery and prevent intubation * Patients with evidence of end-organ hypoperfusion require vasopressor support, with the goal to increase myocardial perfusion while minimizing the increase in myocardial demand; consider norepinephrine and epinephrine as first-line agents at the minimal required dose to restore end-organ perfusion * As blood pressure rises, repeat cardiac POCUS to assess for improvements in contractility; no further intervention is necessary if improved, but consider starting dobutamine if contractility remains inadequate * If available in your facility or nearby transfer, consider speaking with intensivist about ECMO, LVAD or Impella device Expand to view reference list Perera, P., Mailhot, T., Riley, D., & Mandavia, D. (2010). The RUSH exam: Rapid ultrasound in shock in the evaluation of the critically lll. Emergency Medicine Clinics of North America, 28(1), 29-56. Vahdatpour, C., Collins, D., & Goldberg, S. (2019). Cardiogenic shock. Journal of the American Heart Association, 8(8).