EM Quick Hits 29 Vasopressor Failure, Asplenic Considerations, Bronchiolitis Update, ICD Electrical Storm, Night Shift Tips

Topics in this EM Quick Hits podcast Anand Swaminathan on occult causes of non-response to vasopressors (0:54) Brit Long & Michael Gottlieb on overwhelming post-splenectomy infection (OPSI) (7:45) Sarah Reid on a bronchiolitis update and evolving patterns in the COVID era (12:30) Hans Rosenberg & Lindsay Cheskes on the management of electrical storm and recurrent ICD shocks in the ED (20:43) Justin Morgenstern on the top 10 evidence-based countermeasures for night shift workers (27:45) 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) Expand to view reference list * Anand Swaminathan, "Occult Causes of Non-Response to Vasopressors", REBEL EM blog, July 13, 2017. Available at: https://rebelem.com/occult-causes-of-non-response-to-vasopressors/. Overwhelming Post-Splenectomy Infection (OPSI) Background * The spleen is integral to normal immune function and overwhelming post splenectomy infection (OPSI) is a potentially deadly infection, which can appear like severe sepsis in a patient with asplenia * The annual rate of OPSI among asplenic patients is ~0.5% * Risk factors include young, old and splenectomies performed for hematologic disease * The most common infections are pneumonia, urinary tract infection, bacteremia, spontaneous bacterial peritonitis, and meningitis * S. pneumoniae is the most common microbe causing OPSI, accounting for 40-80% of infections Clinical assessment * Fever should be considered a medical emergency in asplenic patients * Most patients initially present with non-specific symptoms such as fever, chills, myalgias, vomiting, and diarrhea for the first 1-2 days * They can rapidly decompensate after this with hypotension, septic shock, and multiorgan failure * Assess for vaccination status, reason for asplenia and source of infection * Look for a surgical scar and Howell Jolly bodies on peripheral blood smear if their splenic status has not been confirmed Initial Management * While evaluating the patient, initiate broad-spectrum antibiotics * If in shock, administer fluids and vasopressors * Stress dose steroids may be needed if no response to vasopressors