Managing Refractory Shock with Dr. Matthew Roginski

Recorded at ACEP26 Scientific Assembly in Chicago, Dr. Ryan Stanton talks with Dr. Matthew Roginski, an emergency physician and intensivist at Dartmouth Hitchcock Medical Center, about the underused and controversial medications that come into play when septic or distributive shock stops responding to the basics. Dr. Roginski lays out a tiered approach, starting with fluids, norepinephrine, and vasopressin, then adding steroids, epinephrine, bicarbonate, and calcium, and finally turning to last-resort options such as methylene blue, angiotensin II, and hydroxocobalamin. He is candid about how thin the evidence gets at each step, including the serotonin syndrome risk with methylene blue. Just as important is his emphasis on a resuscitation checkpoint, a built-in pause to ask whether the data are right and the diagnosis is correct. He also encourages community physicians to build relationships with intensivists and pharmacists before the 3 AM crisis.