UMEM Educational Pearls - By Mike Winters

Category: Critical Care

Title: Things to Consider for Persistent or Worsening Shock

Posted: 3/21/2023 by Mike Winters, MD (Updated: 3/22/2023)
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Things to Consider for Persistent or Worsening Septic Shock

Septic shock is one of the most common critical illnesses in emergency medicine and critical care.
Norepinephrine is recommended as the initial vasopressor of choice for patients with septic shock, with vasopressin or epinephrine commonly added as a second vasopressor for patients with refractory shock.
While vasopressors are being added and titrated, it is important to consider additional diagnoses in patients with worsening or persistent septic shock. Some of these diagnoses include:
- Undetected infection that requires emergent source control
- Concomitant causes of shock: cardiogenic, PE, abdominal compartment syndrome, tamponade, adrenal insufficiency
- Severe acidosis
- MAP underestimation by a radial arterial line

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Category: Critical Care

Title: Uncommon Causes of Shock

Posted: 1/24/2023 by Mike Winters, MD (Updated: 3/22/2023)
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An Uncommon Cause of Shock

Sepsis is the most common cause of distributive shock encountered in the emergency department and intensive care unit.
Notwithstanding, it is important to consider other etiologies of shock, especially when the patient is not responding to resuscitation.
Adrenal crisis is one uncommon etiology of distributive shock whereby the diagnosis is often delayed.
Risk factors for adrenal crisis can include recent GI illness, thyrotoxicosis, recent surgery, and physical or psychological stress.
Patients often have nonspecific symptoms of generalized weakness, abdominal pain, vomiting, fever, and altered mental status.
Current guidelines recommend the administration of 100 mg of hydrocortisone in adults suspected of having adrenal crisis.

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Category: Critical Care

Title: Pacer Pad Placement for TCP

Posted: 11/29/2022 by Mike Winters, MD (Updated: 3/22/2023)
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Transcutaneous Cardiac Pacing

Transcutaneous cardiac pacing (TCP) is often attempted while preparing for transvenous cardiac pacing in critically ill patients with symptomatic bradycardia unresponsive to medical therapy.
For TCP, pacer pads can be placed in either the anterolateral (AL) or anteroposterior (AP) positions.
Current resuscitation guidelines from the American Heart Association and the European Resuscitation Council do not identify a preferred pacer pad placement for TCP.
In a recent study of patients who received TCP following cardioversion from atrial fibrillation or flutter, Moayedi and colleagues found that pacer pads placed in the AP position required less mA to capture and chest wall contractions were less severe when compared to the AL position.
In fact, capture was approximately 80% more likely with pacer pads placed in the AP position compared to the AL position.
Take Home Point: Consider placing the pacer pads in the AP position the next time you need to initiate TCP.

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Category: Critical Care

Title: Timing of Source Control in Sepsis

Posted: 10/4/2022 by Mike Winters, MD (Updated: 3/22/2023)
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Optimal Timing of Source Control in Sepsis

Sepsis is the most common critical illness encountered in the emergency department.
Much of the resuscitation of patients with sepsis is focused on early and appropriate antibiotic administration, appropriate fluid resuscitation, vasopressor support, and continued hemodynamic monitoring.
Another critical pillar in sepsis resuscitation is source control. To date, there is varying literature on the optimal timing of source control in sepsis.
In a recent cohort study of approximately 5,000 patients with community-acquired sepsis, Reitz and colleagues report a 29% reduction in risk-adjusted odds of 90-day mortality for patients who had early source control (< 6 hours) compared to those with late source control (6-36 hours).
The greatest reduction in risk-adjusted 90-day mortality with early source control occurred in patients with gastrointestinal/abdominal and soft-tissue sources of infection.
Take Home Pearl: Early source control matters in sepsis resuscitation, especially in sicker patients with a GI or soft-tissue source of infection.

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Category: Critical Care

Title: Pay Attention to the Diastolic Blood Pressure

Posted: 8/9/2022 by Mike Winters, MD (Updated: 3/22/2023)
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Diastolic Blood Pressure

The diastolic blood pressure (DBP) is determined by vascular tone and remains relativley constant throughout the arterial system.
A low DBP (< 50 mm Hg) suggests vasodilation and may be associated with an increased risk of myocardial ischemia and left ventricular dysfunction.
In a recent trial, Ospina-Tascon and colleagues described the diastolic shock index (heart rate/DBP) and found that a DSI > 2.2 was associated with higher mortality in patients with septic shock.
Take Home Point: pay attention to the DBP and, when low, consider initiation of vasopressors concomitant with fluid resuscitation.

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Category: Critical Care

Title: Vasopressors in the Critically Ill

Posted: 6/14/2022 by Mike Winters, MD
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Vasopressor Tips in the Critically Ill

Critically ill patients often require the administration of vasopressors to maintain adequate organ perfusion.
A few tips to consider when administering vasopressors include:
- Titrate to mean arterial blood pressure (MAP) or diastolic blood pressure goals. Systolic blood pressure (SBP) is not a key driver of perfusion pressure.
- As vasopressors also result in venoconstriction and can increase venous return, early initation may limit the need for overly aggressive fluid resuscitation.
- Vasopressors can be safely administered through an appropriately placed peripheral venous catheter.
- There is no maximal dose of vasopressors.
- Consider vasopressors with a different mechanism of action in patients with persistent shock refractory to the initial vasopressor agent.

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Category: Critical Care

Title: Low-Tidal Volume Ventilation in the ED - Does it Make a Difference?

Posted: 4/19/2022 by Mike Winters, MD (Updated: 3/22/2023)
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ED Low-Tidal Volume Ventilation

Low-tidal volume ventilation (LTVV) reduces mortality in patients with ARDS and may reduce mortality in patients without ARDS.
Recent literature has highlighted the importance of initial ED ventilator settings, as these often persist for many hours after ICU admission.
But..does the use of LTVV in the ED really make a difference?
A recent systematic review and meta-analysis sought to evaluate the use of LTVV in the ED and the impact upon clinical outcomes.
In short, the use of LTVV in the ED was associated with an increase in the use of LTVV in the ICU, decreased occurrence of ARDS after admission, shorter ICU and hospital lengths of stay, decreased duration of mechanical ventilation, and decreased mortality.
Take Home Point: The use of LTVV in the ED makes a difference!

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Category: Critical Care

Title: Hyperglycemic Hyperosmolar State

Posted: 2/22/2022 by Mike Winters, MD (Updated: 3/22/2023)
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Hyperglycemic Hyperosmolar State (HHS)

Though less common, HHS has a mortality rate that is 10x greater than DKA.
The hallmark features of HHS include severe hyperglycemia (> 600 mg/dL), hyperosmolality (> 320 mOsm/kg), minimal to no ketosis, and severe dehydration.
Though the management of HHS is similar to DKA and includes fluid resuscitation, correction of hyperglycemia, and correction of electrolyte abnormalities, it is important to also monitor serum osmolality.
Too rapid correction of serum osmolality can cause cerebral edema and worsen patient outcomes.
Current recommendations are to monitor serum osmolality every 1-2 hours with a correction of no more than 3 mOsm/kg/hr.

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Category: Critical Care

Title: Bougie or Endotracheal Tube with Stylet for First Attempt?

Posted: 12/28/2021 by Mike Winters, MD
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The BOUGIE Trial

More than 1 million patients undergo endotracheal intubation each year in the US.
Up to 20% of intubations fail on the first attempt, thereby increasing the risk of adverse outcome.
Over the past several years, many have become comfortable using the bougie as a rescue device when the first attempt at intubation fails with an endotracheal tube with stylet.
In contrast to its use as a rescue device, should the bougie be used during the first attempt rather than an endotracheal tube with a malleable stylet?
The BOUGIE Trial compared the effect of using the bougie to an endotracheal tube with stylet on first attempt success in critically ill patients.
The trial enrolled 1106 patients in 7 EDs and 8 ICUs at 11 hospitals.
The primary outcome of first pass success was not statistically different between those randomized to bougie and those randomized to endotracheal tube with stylet for the first attempt at intubation..
Though the trial did not find a statistical difference in first pass success rates, the bougie remains an important device in our management of the critically ill airway.

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Category: Critical Care

Title: The Critically Ill Asthmatic Patient

Posted: 11/2/2021 by Mike Winters, MD (Updated: 3/22/2023)
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Initial Mechanical Ventilation Settings for the Intubated Asthmatic

Approximately 2% of adult patients who present with an acute asthma exacerbation will require intubation and mechanical ventilation.
It is critical to provide the intubated asthmatic with sufficient time for exhalation.
Initial recommended settings for mechanical ventilation include:
- Tidal volume: 6-8 ml/kg ideal body weight
- Respiratory rate: 6-10 breaths per minute
- PEEP: 0-5 cm H2O
- Inspiratory flow rate: 80-120 L/min
Permissive hypercapnea is tolerated to a pH of approximately 7.15

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Category: Critical Care

Title: Intermediate-High Risk PE Patients

Posted: 9/7/2021 by Mike Winters, MD
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Management of Intermediate-High Risk PE Patients

Though there are varying definitions, intermediate-high risk patients with a PE are generally defined as those who are hemodynamically stable, have radiographic or laboratory evidence of right heart strain, and an elevated PE risk score.
A few key management pearls include:
- Be judicious with IVFs to avoid worsening septal shift and fruther decreases in LV cardiac output.
- Consider dobutamine for severe RV dysfunction.
- Administer norepinephrine, if needed, to achieve a MAP of 65 mm Hg.
- Avoid initiation of positive pressure ventilation, if possible.
- If intubation is needed for clinical deterioriation avoid propofol for RSI. Propofol has been associated with increased mortality in this patient population.

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Category: Critical Care

Title: HLH in the ED

Posted: 7/20/2021 by Mike Winters, MD (Updated: 3/22/2023)
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Hemophagocytic Lymphohistiocytosis (HLH)

HLH is a hematologic disorder that results from overactivation of the immune response (macrophages and cytotoxic T cells).
HLH is often underrecognized and has a mortality that can be as high as 75%.
Secondary HLH is most commonly associated with infection (sepsis), malignancy (lymphoma), and autoimmune disorders (SLE, RA).
Hallmark features of HLH include fever, splenomegaly, hepatomegaly, cytopenias, coagulopathy, elevated ferritin, elevated triglycerides, and decreased fibrinogen levels.
ED resuscitation of patients with suspected HLH includes Hematology consultation, treatment of the underlying disorder (infection), and potentially corticosteroids and chemotherapeutic agents.

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Category: Critical Care

Title: Refractory Anaphylaxis

Posted: 5/25/2021 by Mike Winters, MD
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Refractory Anaphylaxis

Refractory anaphylaxis is defined as anaphylaxis that does not respond to at least 2 doses of 300 mcg of epinephrine given IM into the anterolateral thigh.
Refractory anaphylaxis can be due to several factors including patient comorbidities, delayed diagnosis, delayed epinephrine administration, or concomitant beta-blocker or ACE-inhibitor medication use.
Consider the following treatments in patients with refractory anaphylaxis, persistent hypotension, and shock:
- Aggressive IVF resuscitation - patients may need up to 7L of IVFs
- Epinephrine infusion (1-10 mcg/min) to target a MAP of 65 mm Hg
- Glucagon (1-5 mg via slow IV push) for those taking a beta-blocker and who fail to respond to epinephrine
- Norepinephrine, vasopressin, angiotensin II, methylene blue, or dobutamine can be administered with epinephrine for persistent hypotension.
- VA-ECMO - though there is no prospective evidence on the use of ECMO in anaphylaxis.

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Category: Critical Care

Title: Simple Interventions to Improve LPV Compliance

Posted: 3/30/2021 by Mike Winters, MD
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Improving Compliance with Lung-Protective Ventilation

Approximately 250,000 ED patients are intubated and receive mechanical ventilation each year in the United States.
While emergency physicians understand the importance of providing lung-protective ventilation, current studies demonstrate that more than 40% of ED patients are placed on initial tidal volumes > 8 ml/kg of predicted body weight (PBW).
In many cases, this may be due to the inaccurate estimation of patient height when determining PBW.
In a recent single-center study, Tallman and colleagues evaluated a quality improvement intiative, whereby respiratory therapists were provided with a tape measure and an EHR BPA that reminded them to measure the patient's height for PBW.
In this study, these simple, low-cost interventions significantly increased compliance with lung-protective ventilation.
Take Home Pearl: Be sure to measure your intubated patient to accurately determine PBW and set the correct tidal volume.

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Category: Critical Care

Title: Mechanical Ventilation for the Critically Ill COPD Patient

Posted: 2/2/2021 by Mike Winters, MD (Updated: 3/22/2023)
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Mechanical Ventilation in COPD

Mechanical ventilation of the patient with obstructive lung disease can be challenging, primarily due to the presence of dynamic hyperinflation.
In the initial phase of ventilation, it is important to prevent complications of hyperinflation and not to target normalization of blood gas values.
Recommended initial ventilator settings include:
- Mode: Volume assist-control
- Inspiratory flow waveform: square
- Tidal volume: 6-8 ml/kg PBW
- RR: 12 bpm
- Inspiratory flow: 60-90 L/min
The effect of PEEP is variable with each patient. When titrating PEEP, be sure to frequently measure plateau pressure and discontinue titration should Pplat increase.

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Category: Critical Care

Title: PEEP in the Intubated Obese Patient

Posted: 12/8/2020 by Mike Winters, MD
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PEEP in the Intubated Obese Patient

Obesity has numerous adverse effects on the respiratory system, most notably a reduction in lung volumes.
The reduction in lung volumes (i.e., FRC) often result in airway closure and atelectasis.
The application of PEEP in the mechanically ventilated patient helps maintain alveolar patency by preventing derecruitment.
Importantly, the typical initial PEEP setting of 5 cm H2O is insufficient for many ventilated obese patients.
Pearl: In the ventilated obese patient start with an initial PEEP of 10-15 cm H2O.

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Category: Critical Care

Title: Blood Pressure in Acute Ischemic Stroke

Posted: 10/13/2020 by Mike Winters, MD (Updated: 3/22/2023)
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Blood Pressure Management in Acute Ischemic Stroke

Blood pressure (BP) is elevated in many patients who present to the ED with an acute ischemic stroke (AIS).
Severe elevations in BP are associated with hemorrhagic transformation, as well as cardiac and renal complications.
As such, it is important to know the various BP goals for patients with an AIS.
- Permissive hypertension with a BP less than or equal 220/120 mm Hg is recommended for patients not receiving IV-tPA or endovascular therapy.
- BP should be lowered to less than or equal to 180/105 mm Hg for patients who have received IV-tPA.
- BP goals for patients who have received endovascular therapy remain controversial and should be individualized based on the degree of recanalization.

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Category: Critical Care

Title: Ketamine in the Critically Ill

Posted: 8/25/2020 by Mike Winters, MD (Updated: 3/22/2023)
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Ketamine In the Critically Ill Patient

Ketamine has become a popular agent in the ED for both RSI and procedural sedation.
Given the sedative, analgesic, dissociative, antidepressant, and anti-inflammatory properties, ketamine has also been used in a number of other critical illness conditions including:
- Acute pain management
- Status asthmaticus
- Alcohol withdrawal syndrome
- Status epilepticus
- Acute agitated delirium
The authors of a recent review in Critical Care Medicine found that the evidence supporting the use of ketamine in the critically ill is most robust for adjunctive analgesia in the intubated patient. Surprisingly, the data is very limited to support the use of ketamine in these other conditions.
Pearl: ketamine does have a myocardial depressant effect, which can be unmasked in states of catecholamine depletion and result in hypotension and bradycadia.

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Category: Critical Care

Title: Analgesic & Sedative Dosing in the Critically Ill Obese Patient

Posted: 6/16/2020 by Mike Winters, MD (Updated: 3/22/2023)
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Analgesics & Sedatives in the Critically Ill Obese Patient

Analgesic and sedative medications are frequently administered to critically ill patients.
Weight-based dosing regimens for these medications can lead to significant over-, or under-, dosing in the critically ill obese patient (BMI > 40 kg/m²).
In order to avoid harm, it is important to know when to use actual body weight (ABW), ideal body weight (IBW), or adjusted body weight in weight-based dosing regimens.
Recommendations for weight-based dosing regimens for commonly used analgesic and sedative medications include:
- Opioids: use IBW or adjusted body weight
- Ketamine: use IBW or adjusted body weight
- Propofol: use IBW or adjusted body weight
- Etomidate: use adjusted body weight or ABW
- Midazolam: use IBW or adjusted body weight

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Category: Critical Care

Title: Vitamin C for Septic Shock?

Posted: 4/28/2020 by Mike Winters, MD
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Vitamin C for Septic Shock?

In 2017, a single center before-and-after study demonstrated benefit for patients with sepsis who received vitamin C, hydrocortisone, and high-dose thiamine.
At present, there are more than 30 trials evaluating the use of vitamin C in sepsis.
The VITAMINS Trial was recently published and evaluated shock resolution in patients with septic shock who received vitamin C, hydrocortisone, and high-dose thiamine compared to those that received only hydrocortisone.
In this randomized controlled trial of 211 ICU patients, the authors found no difference in the primary outcome of time alive and free of vasopressors at 7 days between the two groups.
There was also no difference in the secondary outcomes of hospital, 28-day, and 90-day all-cause mortality.
Though we still await the results of ongoing trials, the VITAMINS Trial and the recent CITRIS-ALI Trial have not demonstrated benefit of vitamin C for select patient populations with sepsis.