Category: Critical Care
Keywords: Achondroplasia, vertebral arteries, mechanical ventilation (PubMed Search)
Posted: 6/11/2019 by Robert Brown, MD
(Updated: 12/9/2024)
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Little people (patients with achondroplasia or "dwarfism") have little lungs. Even though the trunk may appear to be a normal size with small limbs, the vital capacity is actually about 75% the predicted value based on the patient's sitting height. Macrocephaly and a decreased anterior-posterior depth are the cause for this. When you want to mechanically ventilate a little person, you can estimate their height based on a typical person with the same sitting height, but their actual volume will be about 3/4 the tidal volume predicted.
When intubating, remember these patients also have a high risk of basicranial hypoplasia (the foramen magnum may be small and key-hole shaped). These patients will be predisposed to compress the vertebral arteries when you tilt the head back and this itself can cause ischemia of the medulla and pons leading to central apnea.
Stokes DC, Wohl ME, Wise RA, et al. The lungs and airways in Achondroplasia. Do little people have little lungs? CHEST. 1990; 98(1):145-52
Pauli RM. Achondroplasia: A comprehensive review. Orphanet Journal of Rare Diseases. 2019; 14(1):
Stokes DC, Wohl ME, Wise RA, et al. The lungs and airways in Achondroplasia. Do little people have little lungs? CHEST. 1990; 98(1):145-52
Pauli RM. Achondroplasia: A comprehensive review. Orphanet Journal of Rare Diseases. 2019; 14(1):
Category: Critical Care
Keywords: Pulmonary Hypertension, Home Therapies (PubMed Search)
Posted: 6/4/2019 by Mark Sutherland, MD
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Some patients with severe pulmonary hypertension receive continuous infusions at home of prostacyclins, such as epoprostanol (flolan). These are generally delivered via a pump that the patient wears, which is attached to an indwelling catheter. As with any indwelling device, they are at risk for infection and other complications, including malfunction.
Interruption of delivery of the medication can result in rapid cardiovascular collapse, sometimes within minutes. In this instance, the medication should be resumed as quickly as possible (by a traditional IV if the catheter is not functional), and the patients should be treated as one would approach a patient with decompensated right heart failure.
I once saw a patient in the ED whose listed chief complaint was "medication refill", but was actually there for dislodgement of her prostacyclin catheter (thankfully she was ok). With more patients receiving devices they are dependent upon (insulin pumps, AICDs, prostacyclin catheters), be wary of chief complaints such as "medication refill" or "device malfunction."
Bottom Line: Interruption of continuous prostacyclin therapy for pulmonary hypertension can be rapidly fatal and should be addressed immediately.
Farber HW, Gin-sing W. Practical considerations for therapies targeting the prostacyclin pathway. Eur Respir Rev. 2016;25(142):418-430.
Maron BA, Zamanian R, Waxman AB, eds. Contemporary pharmacotherapies involving nitric oxide, prostacyclin, and endothelin receptor signaling pathways. In: Maron BA, Zamanian R, Waxman AB, eds. Pulmonary Hypertension: Basic Science to Clinical Medicine. Cham, Springer International Publishing, 2016; pp. 257–270
Category: Critical Care
Keywords: Alarm fatigue (PubMed Search)
Posted: 5/21/2019 by Robert Brown, MD
(Updated: 12/9/2024)
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In a study of alarms from 77 monitored ICU beds over the course of a month at the University of California, San Francisco, false alarms were common. Accellerated Ventircular Rhythms (AVRs) made up roughly one third of the alarms, and of the more than 4,361 AVRs, 94.9% were false while the remaining 5.1% did not result in a clinical action.
While this study had a majority of patients in the Med/Surg ICUs, a minority were from the cardiac and neurologic ICUs giving it some broad applicability. This study adds to the literature indicating there are subsets of alarms which may not be necessary or which may require adjustment to increase specificity.
Suba S, Sandoval CS, Zegre-Hemsey J, et al. Contribution of Electrocardiographic Accelerated Ventricular Rhythm Alarms to Alarm Fatigue. American Journal of Critical Care. 2019; 28(3):222-229
Suba S, Sandoval CS, Zegre-Hemsey J, et al. Contribution of Electrocardiographic Accelerated Ventricular Rhythm Alarms to Alarm Fatigue. American Journal of Critical Care. 2019; 28(3):222-229
Category: Critical Care
Keywords: capillary refill, lactate, sepsis (PubMed Search)
Posted: 5/14/2019 by Mark Sutherland, MD
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Bottom Line: Consider using capillary refill as an alternate (or complimentary) endpoint to lactate clearance when resuscitating your septic shock patients.
Hernández G, Ospina-Tascón GA, Damiani LP, et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019;321(7):654–664. doi:10.1001/jama.2019.0071
Andromeda-shock - Capillary Refill Vs. Lactate. Clay Smith - https://journalfeed.org/article-a-day/2019/andromeda-shock-rct-perfusion-vs-lactate
Category: Critical Care
Posted: 5/7/2019 by Mike Winters, MBA, MD
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Management of Coagulopathy in Acute Liver Failure
Trovato FM, et al. Update on the management of acute liver failure. Curr Opin Crit Care. 2019; 25:157-164.
Category: Critical Care
Keywords: Mechanical Ventilation, Paralytics (PubMed Search)
Posted: 4/27/2019 by Mark Sutherland, MD
(Updated: 12/9/2024)
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Many, if not nearly all, of our intubated patients in the ED have altered mental status, a potential to clinically worsen, or a requirement for medications that would alter their respiratory status (e.g. propofol, opioids, paralytics). It is imperative to place these patients on appropriate ventilator modes to avoid apnea when their respiratory status changes.
Category: Critical Care
Keywords: pancreatitis, ultrasound, cholelithiasis (PubMed Search)
Posted: 4/23/2019 by Robert Brown, MD
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Gallstones account for 35-40% of cases of pancreatitis and the risk increases with diminishing stone size. Bile reflux into the pancreatic duct can form stones there, beyond where they can be visualized by ultrasound. Biliary colic may precede the pancreatitis, but not necessarily. The pain typically reaches maximum intensity quickly but can remain for days.
Alanine aminotransferase (ALT) > 3x normal is highly suggestive of biliary pancreatitis.
Abdominal ultrasound is not sensitive to common bile duct stones but may find dilation.
In the absence of cholangitis, endoscopic ultrasound or MRCP are sensitive tests and permit intervention. Patients who recover are much more likely to develop cholangitis, therefore cholecystectomy is indicated in patients after they recover from gallstone pancreatitis.
Bottom Line: a patient presenting with days of abdominal pain but an absence of gallstones or cholangitis may still suffer from gallstone pancreatitis which requires further intervention, including cholecystectomy.
Portincasa P, Molina E, Garruti G, et al. Critical Care Aspects of Gallstone Disease. The Journal of Critical Care Medicine. 2019;5(1):6-18.
Category: Critical Care
Posted: 4/16/2019 by Mike Winters, MBA, MD
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Mechanical Ventilation in the Obese Critically Ill
Schetz M, et al. Obesity in the critically ill: a narrative review. Intensive Care Med. 2019 [epub ahead of print].
Category: Critical Care
Keywords: Resuscitation, cardiac arrest, POCUS, ultrasound, ROSC (PubMed Search)
Posted: 4/9/2019 by Kami Windsor, MD
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Background: Previous systematic reviews1,2,3 have indicated that the absence of cardiac activity on point-of-care ultrasound (POCUS) during cardiac arrest confers a low likelihood of return of spontaneous circulation (ROSC), but included heterogenous populations (both traumatic and atraumatic cardiac arrest, shockable and nonshockable rhythms).
The SHoC investigators4 are the first to publish their review of nontraumatic cardiac arrests with nonshockable rhythms, evaluating POCUS as predictor of ROSC, survival to admission (SHA), and survival to discharge (SHD) in cardiac arrests occurring out-of-hospital or in the ED.
Bottom Line: In nontraumatic cardiac arrest with non-shockable rhythms, the absence of cardiac activity on POCUS may not, on its own, be as strong an indicator of poor outcome as previously thought.
Category: Critical Care
Posted: 4/2/2019 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
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The Lung Transplant Patient in Your ED
Welte T, et al. Ten tips for the intensive care management of transplanted lung patients. Intensive Care Med. 2019; 45:371-3.
Category: Critical Care
Keywords: heart transplant, arrhythmias, critical care (PubMed Search)
Posted: 3/26/2019 by Kami Windsor, MD
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When managing transplant patients it is important to keep in mind the anatomic and physiologic changes that occur with the complete extraction of one person's body part to replace another's.
For cardiac transplant patients with symptomatic bradycardia:
For cardiac transplant patients with tachyarrythmias:
Stecker EC, Strelich KR, Chugh SS, et al. Arrythmias after orthotopic heart transplantation. J Card Fail. 2005;11(6):464-72.
Thajudeen A, Stecker EC, Shehata M, et al. Arrhythmias after heart transplantation: Mechanisms and management. J Am Heart Assoc. 2012;1(2):e001461.
Category: Critical Care
Posted: 3/19/2019 by Mike Winters, MBA, MD
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Hyponatremia in the Brain Injured Patient
Mrozek S, et al. Pharmacotherapy of sodium disorders in neurocritical care. Curr Opin Crit Care. 2019; 25:132-7.
Category: Critical Care
Keywords: Airway management, acute respiratory failure, hypoxia, intubation, preoxygenation (PubMed Search)
Posted: 3/12/2019 by Kami Windsor, MD
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The PROTRACH study recently compared preoxygenation with standard bag valve mask (BVM) at 15 lpm to preoxygenation + apneic oxygenation with high flow nasal cannula 60 lpm/100% FiO2 in patients undergoing rapid sequence intubation.
Guitton C, Ehrmann S, Volteau C, et al. Nasal high-flow preoxygenation for endotracheal intubation in the critically ill patient: a randomized clinical trial. Intensive Care Med. 2019. doi: 10.1007/s00134-019-05529-w. [Epub ahead of print]
Category: Critical Care
Posted: 3/5/2019 by Mike Winters, MBA, MD
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A True Tracheostomy Emergency
Przbylo JA, Wittels K, Wilcox SR. Respiratory distress in a patient with a tracheostomy. J Emerg Med. 2019; 56:97-101.
Category: Critical Care
Keywords: ARDS, respiratory failure, ventilator settings, critical care (PubMed Search)
Posted: 2/26/2019 by Kami Windsor, MD
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Despite ongoing research and efforts to improve our care of patients with ARDS, it remains an entity with high morbidity and mortality. Early recognition of the disease process and appropriate management by emergency physicians can have profound effects on the patient's course, especially in centers where ICU boarding continues to be an issue.
Recognition of ARDS (Berlin criteria)
*An ABG should be obtained in the ED if physicians are unable to wean down FiO2 from high settings, if oxygenation by pulse ox is marginal, or if the patient is in a shock state.
Tenets of ARDS Management:
*IBW Males = 50 + 2.3 x [Height (in) - 60] / IBW Females = 45.5 + 2.3 x [Height (in) - 60]
Strategies for Refractory Hypoxemia in the ED: You can't prone the patient, but what else can you do?
1. Escalate PEEP in stepwise fashion
2. Recruitment maneuvers
3. Appropriate sedation and neuromuscular blockade
4. Inhaled pulmonary vasodilators (inhaled prostaglandins, nitric oxide) if known or suspected right heart failure or pulmonary hypertension
Bottom Line: Emergency physicians are the first line of defense against ARDS. Early recognition of the disease process and appropriate management is important to improve outcomes AND to help ICU physicians triage which patients need to be emergently proned or even who should potentially be referred for ECMO.
Fielding-Singh V, Matthay MA, Calfee CS. Beyond Low Tidal Volume Ventilation: Treatment Adjuncts for Severe Respiratory Failure in Acute Respiratory Distress Syndrome. Crit Care Me.. 2018;46(11):1820-31.
Category: Critical Care
Posted: 2/19/2019 by Mike Winters, MBA, MD
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Does This Patient Have Pericardial Tamponade?
Alerhand S, Carter JM. What echocardiographic findings suggest a pericardial effusion is causing tamponade? Am J Emerg Med. 2019; 37:321-6.
Category: Critical Care
Keywords: neutropenic fever, typhlitis, necrotizing enterocolitis, sepsis, septic shock (PubMed Search)
Posted: 2/12/2019 by Kami Windsor, MD
(Updated: 12/9/2024)
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Neutropenic enterocolitis can occur in immunosuppressed patients, classically those being treated for malignancy (hematologic much more commonly than solid tumor). When involving the cecum specifically, it is known as "typhlitis."
It should be considered in any febrile neutropenic patients with abdominal pain or other symptoms of GI discomfort (diarrhea, vomiting, lower GI bleeding), and can be confirmed with CT imaging.
A recent study found that invasive fungal disease, most often candidemia, occurred in 20% of febrile neutropenic patients with CT-confirmed enteritis, a rate that increased to 30% if the patient was in septic shock.
Take Home:
1. Have a lower threshold for abdominal CT imaging in your patients with febrile neutropenia and abdominal pain/GI symptoms, especially if they are critically ill.
2. Consider addition of IV antifungal therapy if they are hemodynamically unstable with enterocolitis on CT.
Duceau B, Picard M, Pirrachio R, et al. Neutropenic enterocolitis in critically ill patients: Spectrum of the disease and risk of invasive fungal disease. Crit Care Med. 2019. [Epub ahead of print] doi: 10.1097/CCM.0000000000003687.
Category: Critical Care
Posted: 2/5/2019 by Mike Winters, MBA, MD
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Management of Acute Variceal Bleeding
Boregowda U, et al. Update on the management of gastrointestinal varices. World J Gastrointest Pharmacol Ther. 2019; 10:1-21.
Category: Critical Care
Keywords: OHCA, cardiac arrest, resuscitation, maternal cardiac arrest, pregnancy (PubMed Search)
Posted: 1/29/2019 by Kami Windsor, MD
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Historically, there has been very limited data regarding the epidemiology of OHCA in pregnant females. Two recently-published studies tried to shed some light on the issue.
Both Maurin et al.1 and Lipowicz et al.2 looked at all-cause out-of-hospital maternal cardiac arrest (MCA) data in terms of numbers and management, in Paris and Toronto respectively, from 2009/2010 to 2014. Collectively, they found:
A few reminders from the 2015 AHA guidelines for the management of cardiac arrest in pregnancy:
Bottom Line: Although maternal cardiac arrest is relatively rare, survival in OHCA is lower than perhaps previously thought. Areas to improve include public education on the importance of bystander CPR in pregnant females, and appropriate physician adherence to PMCS recommendations, with decreased on-scene time by EMS in order to decrease time to PMCS.
Maurin et al. looked at documented out-of-hospital maternal cardiac arrest (MCA) in pregnant females ≥18 years old, in Paris from 2009 to 2014 and reported on some aspects of prehospital care. Prehospital management there includes activation of both a BLS (which usually arrives first) and ALS team, with a prehospital emergency physician being a member of the ALS team.
Lipowicz et al. similarly looked at MCA from 2010 to 2014 using data from the Toronto Regional RescuNet cardiac arrest database:
Category: Critical Care
Posted: 1/22/2019 by Mike Winters, MBA, MD
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Respiratory Complications of ICIs
Ferreyro BL, Munshi L. Causes of acure respiratory failure in the immunocompromised host. Curr Opin Crit Care. 2019;25:21-8.