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Introduction: Surrogate decision makers (SDMs) represent critical stakeholders in decision making for comatose survivors of cardiac arrest, yet these individuals are often unprepared for decision making and unfamiliar with the complexity of post-cardiac arrest care. To that end, we created a decision aid for SDMs intended to inform and support evidence-based decision making for comatose survivors of cardiac arrest. Methods: We conducted a pilot trial to measure real world effectiveness of the Tool to EMPOwer (TEMPO) Surrogate Decision Makers, by measuring knowledge and acceptability. Individuals were enrolled who self-identified as the SDM for a comatose survivor of OHCA admitted to an academic tertiary care hospital. Participants completed a pre-intervention survey prior to the provision of TEMPO, and a post-intervention survey approximately 24 hours after exposure to the intervention. Pre-survey questions included SDM demographics and an 8-question knowledge survey. Post-intervention surveys included the same knowledge questions, the Ottawa Acceptability of Decision Aid tool, and questions to measure if SDMs shared TEMPO with others. This study was approved by the Colorado Multiple Institutional Review Board and registered at Clinicaltrials.gov (NCT03908346). Results: Twenty SDMs were enrolled between 9/1/2020 and 6/7/2021. One subject did not complete the post-intervention survey therefore 19 subject responses were analyzed for the purpose of this report. Participants were 85.0% Female, 47.4 +/- 14.8 years, and 45.0% were the spouse of the patient. In the 8-question knowledge survey, results improved from 57.2% correct to 90.8% correct after exposure to TEMPO (p Conclusion: Initial pilot data on the efficacy of the Tool to EMPOwer Surrogate Decision Makers of comatose survivors of cardiac arrest shows significant promise in improving knowledge and supporting decision-making.

Introduction: Tumor lysis syndrome (TLS) and hemophagocytic lymphohistiocytosis (HLH) are two medical emergencies associated with malignancy and treatment thereof. More commonly they are associated with treatment of fast growing and highly chemotherapy-responsive tumors such as lymphomas and small cell lung cancer. However, a growing body of evidence demonstrates they can occur with other malignancies, such as melanoma, and can happen spontaneously prior to treatment initiation. Case Series: We describe two cases of patients with metastatic melanoma who experienced rapid progressive clinical decline prior to initiation of treatment for their metastatic disease. Laboratory findings at the time of presentation in both cases were consistent with TLS. The second case was further complicated by possible HLH, though diagnosis and treatment remained controversial among our team. Conclusion: We hope these reports increase awareness of the risk of spontaneous TLS and HLH in metastatic melanoma, foster discussion of the difficulty of defining HLH, and shed light on their prognostic implications and management.

Therapeutic hypothermia has been shown to improve neurologic outcome in medical cardiac arrest patients, yet little is known about factors that delay target temperature achievement. Our primary aim was to identify factors associated with not achieving our institutional "door-to-cool" (DTC) performance goal (emergency department [ED] arrival to temperature of 34°C) of ≤4 hours. Secondary aims included whether achievement of DTC goal was associated with timing of bolus neuromuscular blockade (NMB), survival, or functional outcome. This was a retrospective cohort study of a medical cardiac arrest quality improvement (QI) database that included patients treated from November 2007 to August 2012. The database was queried for patient demographics, arrest characteristics, specific cooling techniques used, whether patients underwent emergent computed tomography imaging or cardiac catheterization, and patient outcomes. Logistic regression was used to assess the factors associated with DTC goal performance and outcomes. We enrolled 327 patients, median age 58, median return of spontaneous circulation (ROSC) time of 21 minutes (interquartile range [IQR] 14-29 minutes), and shockable initial rhythm in 61%. One hundred forty-four (44%) patients survived to hospital discharge, 133 (41%) with good functional outcome, as defined as cerebral performance category 1-2. Induction with cold IV fluids [OR 0.50 (CI: 0.29-0.85)] and NMB administration within 2 hours of ED arrival [OR 2.95 (CI: 1.17-7.43)] was associated with achieving DTC goal. Logistic regression showed that achievement of DTC goal ≤4 hours [OR 0.59 (0.32-1.09)] was not associated with good functional outcome. In our single-center cohort, initiation of cold intravenous fluids (IVF) and early NMB administration were associated with improved DTC goal performance of 4 hours. However, patients achieving DTC goals were not associated with improved outcomes.

The purpose of this article is to provide a framework for academic clinicians, educators, and mentors to advise the emergency medicine (EM) resident with an interest in the field of critical care medicine. Prior articles have detailed the prerequisites and specific training curricula of the distinct critical care pathways, but an approach for the advising faculty member in this climate of increased interest in critical care training has yet to be disseminated. In this article, we assume a starting point of EM residency and focus on pivotal training and decision points that occur along the path to matriculation into a critical care fellowship program. These decision points are described in stepwise fashion with aligned questions to help the EM resident evaluate individual strengths and desires that may help the decision-making process. We also describe considerations of the postfellowship job market, as this also plays a role in the fellowship decision-making process.

This article reviews the recent literature pertaining to assessment of the adequacy of oxygen delivery in critically ill patients with circulatory shock.The assessment of the adequacy of oxygen delivery has traditionally involved measurement of lactate, central (or mixed) venous oxygen saturation (ScvO2), and global hemodynamic markers such as mean arterial pressure and cardiac index. The search for noninvasive, reliable, and sensitive methods to detect derangements in oxygen delivery and utilization continues. Recent studies focus on near-infrared spectroscopy (NIRS) to assess regional tissue oxygenation, as well as bedside ultrasound techniques to assess the macrovascular hemodynamic factors in oxygen delivery.In this article, we review physiologic principles of global oxygen delivery, and discuss the bedside approach to assessing the adequacy of oxygen delivery in critically ill patients. Although there have been technological advances in the assessment of oxygen delivery, we revisit and emphasize the importance of a 'tried and true' method - the physical examination. Also potentially important in the evaluation of oxygen delivery is the utilization of biomarkers (e.g., lactate, ScvO2, NIRS). In complementary fashion, bedside ultrasound for hemodynamic assessment may augment the physical examination and biomarkers, and represents a potentially important adjunct for assessing the adequacy of oxygen delivery.

Pleomorphic adenomas of the submandibular glands are exceedingly rare tumors in the pediatric practice. Patients usually present with a painless and mobile mass without any other associated symptoms. Radiologic studies are usually unable to differentiate benign from malignant tumors in most cases. Recurrences are rare with complete en bloc excision of the tumor and the submandibular gland. Except for the rare cases of malignant transformation, the prognosis is excellent.