Category: Critical Care
Keywords: Transfusion, Lung, Injury (PubMed Search)
Posted: 7/14/2007 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
Click here to contact Mike Winters, MBA, MD
Category: Critical Care
Keywords: HIV, Lactic, Acidosis (PubMed Search)
Posted: 7/14/2007 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
Click here to contact Mike Winters, MBA, MD
Category: Critical Care
Keywords: Lactate, Sepsis, Infection (PubMed Search)
Posted: 7/14/2007 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
Click here to contact Mike Winters, MBA, MD
Obtain serial lactate levels in ED patients with infection * Elevated serum lactate is associated with an increased risk of death in critically ill patients with infection * An initial lactate level > 4.0 mmol/l is significant and, in some series, is associated with a mortality of approximately 40% * Obtain serial venous lactate measurements every 3-4 hours * If serial levels remain > 4 mmol/l, or rise, be more aggressive with resuscitation Reference: Trzeciak S, et al. Serum lactate as a predictor of mortality in patients with infection. Inten Care Med 2007;33:970-7.
Category: Critical Care
Keywords: Antiobiotics, Sepsis (PubMed Search)
Posted: 7/14/2007 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
Click here to contact Mike Winters, MBA, MD
Category: Critical Care
Keywords: Intubation, ventilation, VAP, bed (PubMed Search)
Posted: 7/14/2007 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
Click here to contact Mike Winters, MBA, MD
Category: Critical Care
Keywords: Escharotomy, burn, ischemia (PubMed Search)
Posted: 7/14/2007 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
Click here to contact Mike Winters, MBA, MD
Category: Critical Care
Keywords: Venous, catheter, subclavian (PubMed Search)
Posted: 7/14/2007 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
Click here to contact Mike Winters, MBA, MD
Category: Critical Care
Keywords: Pacer, Cordis, transvenous (PubMed Search)
Posted: 7/14/2007 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
Click here to contact Mike Winters, MBA, MD
Category: Critical Care
Keywords: Ultrasound, Trauma, Pneumothorax (PubMed Search)
Posted: 8/11/2020 by David Gordon, MD
Click here to contact David Gordon, MD
While chest X ray (CXR) is routinely obtained in the setting of traumatic injury, ultrasound (US) is a fast and reliable way to evaluate for life-threatening traumatic injuries requiring emergent intervention, and is supported by the Eastern Association for the Surgery of Trauma (EAST) guidelines. A recent Cochrane Review compared the test characteristics of chest US vs CXR for detection of traumatic pneumothorax when using Chest CT or thoracostomy as the gold standard.
There possible weaknesses of this study, including blinding in the original studies, and several studies may or may not have been at risk for bias as their risk of bias was ‘unclear’. However, the results were consistent across the studies analyzed and remained similar after sensitivity analysis.
Several anatomical as well as patient care issues may confound US findings for pneumothorax such as the presence of bleb, prior thoracic surgery or pathology, as well as main stem intubation.
1. Chan KK, Joo DA, McRae AD, et al. Chest ultrasonography versus supine chest radiography for diagnosis of pneumothorax in trauma patients in the emergency department. The Cochrane Database of Systematic Reviews. 2018;2018(5):CD013031.
2. Mowery NT, Gunter OL, Collier BR, et al. Practice Management Guidelines for Management of Hemothorax and Occult Pneumothorax. Journal of Trauma and Acute Care Surgery. 2011;70(2):510-518.
Category: Critical Care
Keywords: Right Ventricle, RV Size (PubMed Search)
Posted: 11/5/2019 by Kim Boswell, MD
Click here to contact Kim Boswell, MD
Rapid Assessment of the RV on Bedside Echo
There are several causes of acute RV dysfunction resulting in a patient presenting to the ER with unstable hemodynamics. Some of these include acute cor pulmonale, acute right sided myocardial infarction and acute submassive or massive pulmonary embolism. While bedside assessment of the LV function is often performed by the ED physician, simultaneous evaluation of the RV can provide crucial information that can help guide therapeutic decisions to prevent worsening of the patient’s clinical condition. A rough guideline to determine RV size and function is below using the apical 4 chamber view.
Normal RV size : <2/3 the size of the LV
Mildly enlarged RV : >2/3 the size of the LV, but not equal in size
Moderately enlarged RV: RV size = LV size
Severely enlarged RV: RV size > LV size
Patients who are found to have RV dilation should be given fluids in a judicious fashion as the RV is not tolerant of fluid overload. Early diagnosis of the cause of acute RV failure should be sought to guide definitive therapy, but early institution of inotropic support should be considered. Frequent reassessments of biventricular function during resuscitation should be performed.
Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography Endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography, J Am Soc Echocardiogr 2010;23:685-713
Category: Critical Care
Keywords: amikacin, Torsades de pointes, QT prolongation (PubMed Search)
Posted: 8/20/2019 by Quincy Tran, MD, PhD
Click here to contact Quincy Tran, MD, PhD
Torsades de pointes and QT prolongation Associated with Antibiotics
Methods
The authors queried the United States FDA Adverse Event Reporting System (FAERS) from 01/01/2015 to 12/31/2017 for reports of Torsade de points/QT prolongation (TdP/QT).
Reporting Odd Ratio (ROR) was calculated as the ratio of the odds of reporting TdP/QTP versus all other ADRs for a given drug, compared with these reporting odds for all other drugs present in FAERS
Results
FAERS contained 2,042,801 reports from January 1, 2015 to December 31, 2017. There were 3,960 TdP/QTP reports from the study period (0.19%).
Macrolides ROR 14 (95% CI 11.8-17.38)
Linezolid ROR 12 (95% CI 8.5-18)
Amikacin ROR 11.8 (5.57-24.97)
Imipenem-cilastatin ROR 6.6 (3.13-13.9)
Fluoroquinolones ROR 5.68 (95% CI 4.78-6.76)
Limitations:
These adverse events are voluntary reports
There might be other confounded by concomitant drugs such as ondansetron, azole anti-fungals, antipsychotics.
Bottom Line:
This study confimed the previously-known antibiotics to be associated with Torsades de pointes and QT prolongation (Macrolides, Linezolid, Imipenem and Fluoroquinolones). However, this study found new association between amikacin and Torsades de pointes/QT prolongation.
Teng C, Walter EA, Gaspar DKS, Obodozie-Ofoegbu OO, Frei CR. Torsades de pointes and QT prolongation Associations with Antibiotics: A Pharmacovigilance Study of the FDA Adverse Event Reporting System. Int J Med Sci. 2019 Jun 10;16(7):1018-1022.
Category: Critical Care
Keywords: Botulism, IVDA (PubMed Search)
Posted: 7/2/2019 by Robert Brown, MD
Click here to contact Robert Brown, MD
Don’t miss the injecting drug users with botulism!
Wound botulism presents as descending paralysis when Clostridium botulinum spores germinate in anaerobic necrotic tissue. There have been hundreds of cases in the last decade, but it is poorly reported outside of California.
Black tar heroin and subcutaneous injection (“skin popping”) carry the highest risk, but other injected drugs and other types of drug use suffice. C botulinum spores are viable unless cooked at or above 85°C for 5 minutes or longer and this is not achieved when cooking drugs.
Early administration of botulism anti-toxin (BAT) not only saves lives but can prevent paralysis and mechanical ventilation. An outbreak of 9 cases between September 2017 and April 2018 cost roughly $2.3 million, in part because patients didn’t present on average until 48 hours after symptom onset and it took an additional 2-4 days before the true cause of their respiratory depression and lethargy were understood. One patient died.
PEARL: talk to your injecting drug users about the symptoms of botulism: muscle weakness, difficulty swallowing, blurred vision, drooping eyelids, slurred speech, loss of facial expression, descending paralysis, and difficulty breathing. Consider botulism early in your patients who inject drugs but who do not respond to naloxone or who exhibit prolonged symptoms. Testing at the health department is performed with mouse antibodies to Botulism Neurotoxin (BoNT) combined with the patient’s serum.
Peak CM, Rosen H, Kamali A, et al. Wound Botulism Outbreak Among Persons Who Use Black Tar Heroin – San Diego County, California. MMWR. January 4, 2019; 67(5152):1415-1418.
Category: Critical Care
Keywords: Alarm Fatigue (PubMed Search)
Posted: 5/20/2019 by Robert Brown, MD
(Updated: 12/9/2024)
Click here to contact Robert Brown, MD
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: lung protective ventilation, ARDS (PubMed Search)
Posted: 3/21/2017 by Rory Spiegel, MD
Click here to contact Rory Spiegel, MD
While lung protective ventilatory strategies have long been accepted as vital to the management of patients undergoing mechanical ventilation, the translation of such practices to the Emergency Department is still limited and inconsistent.
Fuller et al employed a protocol ensuring lung-protective tidal volumes, appropriate setting of positive end-expiratory pressure, rapid weaning of FiO2, and elevating the head-of-bed. The authors found that the number of patients who had lung protective strategies employed in the Emergency Department increased from 46.0% to 76.7%. This increase in protective strategies was associated with a 7.1% decrease in the rate of pulmonary complications (ARDS and VACs), 14.5% vs 7.4%, and a 14.3% decrease in in-hospital mortality, 34.1% vs 19.6%.
Fuller BM, Ferguson IT, Mohr NM, et al. Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial. Ann Emerg Med. 2017;
Category: Critical Care
Keywords: peri-Intubation, shock index (PubMed Search)
Posted: 2/7/2017 by Rory Spiegel, MD
Click here to contact Rory Spiegel, MD
Identifying patients at risk of hypotension during intubation is not always straight forward. The prevalence of peri-intubation hypotension in the Emergency Department has been demonstrated to be approximately 20%.1 And while certain variables increase the likelihood of peri-intubation hypotension (ex. Shock index> 0.80), no single factor predicts it accurately enough to be used at the bedside.2 In the majority of patients undergoing intubation, clinicians should be prepared for peri-intubation hypotension with either vasopressor infusions or push dose pressors.
1. Heffner AC, Swords D, Kline JA, Jones AE. The frequency and significance of postintubation hypotension during emergency airway management. J Crit Care. 2012;27(4):417.e9-13.
2. Heffner AC, Swords DS, Nussbaum ML, Kline JA, Jones AE. Predictors of the complication of postintubation hypotension during emergency airway management. J Crit Care. 2012;27(6):587-93.
Category: Critical Care
Keywords: CPR, Cardiac Arrest (PubMed Search)
Posted: 11/15/2016 by Rory Spiegel, MD
Click here to contact Rory Spiegel, MD
It is well documented that when left to our own respiratory devices we will consistently over-ventilate patients presenting in cardiac arrest (1). A simple and effective method of preventing these overzealous tendencies is the utilization of a ventilator in place of a BVM. The ventilator is not typically used during cardiac arrest resuscitation because the high peak-pressures generated when chest compressions are being performed cause the ventilator to terminate the breath prior to the delivery of the intended tidal volume. This can easily be overcome by turning the peak-pressure alarm to its maximum setting. A number of studies have demonstrated the feasibility of this technique, most recently a cohort in published in Resuscitation by Chalkias et al (2). The 2010 European Resuscitation Council guidelines recommend a volume control mode at 6-7 mL/kg and 10 breaths/minute (3).
1. Aufderheide TP, Sigurdsson G, Pirrallo RG, Yannopoulos D, McKnite S, von Briesen C, Sparks CW, Conrad CJ, Provo TA, Lurie KG. Hyperventilation-induced hypotension during cardiopulmonary resusci- tation. Circulation. 2004;109:1960 –1965.
2. Chalkias, Athanasios et al. Airway pressure and outcome of out-of-hospital cardiac arrest: A prospective observational study. Resuscitation. November 2016
3. Deakin CD, Nolan JP, Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation 2010;81:1305–52.
Category: Critical Care
Posted: 4/12/2013 by Haney Mallemat, MD
(Updated: 12/9/2024)
Click here to contact Haney Mallemat, MD
Adrenal insufficiency (AI) can be a life-threating condition and is classified as primary (failure of the adrenal gland) or secondary (failure of hypothalamic- pituitary axis).
Common causes of primary adrenal insufficiency include autoimmune destruction, infectious causes (TB and CMV), or interactions with drugs (e.g., anti-fungals, Etomidate, etc.). Secondary causes are usually due to abrupt withdrawal of steroids after chronic use, although sepsis and diseases of the hypothalamus or pituitary (e.g., CVA) may occur.
Signs and symptoms include fatigue, weakness, skin pigmentation, dizziness, abdominal pain, and orthostatic hypotension; it should be suspected with any of the following: hyponatremia, hyperkalemia, hypoglycemia, hypercalcemia, low free-cortisol level, and hemodynamic instability despite resuscitation.
Treatment:
• Correct underlying the disorder
• Resuscitation and hemodynamic support
• Correct hypoglycemia and electrolyte abnormalities
• Treat with hydrocortisone, cortisone, prednisone, or dexamethasone +/- fludrocortisone (Note: dexamethasone is attractive choice in the ED because it will not interfere with ACTH stimulation test)
Neary, N and Nieman, L. Adrenal Insufficiency: Etiology, diagnosis and treatment. Curr Opin Endocrinol Diabetes Obes. 2010 Jun;17(3):217-23.
Category: Critical Care
Posted: 3/11/2009 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
Click here to contact Mike Winters, MBA, MD
Oxygenation goals