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