An Uncommon Cause of Shock
At this month’s Eastern Association for the Surgery of Trauma annual meeting there was a presentation asserting that hemodynamically unstable trauma patients have worse outcomes when intubated in the emergency department vs the operating room. This was not a study diminishing the intubating skills of EM providers but a look at the fact that hemorrhaging patients will crash after intubation and if they are not in a position for immediate surgical intervention they will die. The loss of sympathetic tone, positive inter-thoracic pressure, loss of muscle tone as well as the agents used all contribute to peri-intubation arrest. This month’s EmCrit episode tackled this topic as well.
Synthesizing all of the opinion and literature regarding hemodynamically unstable trauma patients requiring operative intervention the take home points are:
Much of this is counter to historical teaching of early airway management on ED arrival. It certainly fits with recent literature supporting resuscitation prior to airway management whenever feasible.
Should EMS place an advanced airway in out of hospital cardiac arrests? Current studies suggest that advanced airway management is not superior to BVM in pediatric out of hospital cardiac arrest (OHCA).
Pediatric OHCA carries a high mortality rate and those that do survive often have a poor neurologic outcome. This study evaluated BVM vs supraglottic airway (SGA) placement vs endotracheal intubation (ETI) in relation to one month survival and favorable neurological outcomes. SGA and ETI were also grouped together and categorized as advanced airway management (AAM).
This study was conducted using the Pan Asian Resuscitation Outcomes Study Clinical Research Network. 3131 pediatric patients were included. 85% received BVM, 11.8% SGA and 2.6 % ETI. In a matched cohort, one month survival and survival with favorable neurological outcome was higher in the BVM group compared to the AAM group and in the BVM group compared to the SGA group. There was no significant difference noted between the ETI group and BVM group.
Bottom line: In this study, AAM was associated with decreased one month survival and less favorable neurological status in pediatric OHCA.
A systemic review and meta-analysis revealed that the literature and science surrounding timing and effectiveness of prophlactic antibiotic use in tube thoracotomy for trauma is not robust. The heterogeneity of the antibiotics used, the duration of antibiotics and the nature of the trauma (majority penetrating) make it very difficult to give an iron clad recommendation. The authors conclusion, which is the practice management guideline from the Eastern Association for the Surgery of Trauma, ultimately was:
“We conditionally recommend that antibiotic prophylaxis be given at the time of insertion to reduce empyema in adult patients who require TT for traumatic hemothorax or pneumothorax.”
Humor me and imagine that your birth certificate vanished, and your age was based on the way you feel inside. How old would you say you are (subjective age) versus your actual age?
In a few studies, those individuals reporting a younger subjective age had a lower risk of depression, greater mental well-being, better physical health, and a lower risk of dementia. These individuals also had improved episodic memory and executive functioning. Subjective age also predicts incident hospitalization.
Three longitudinal studies tracked more than 17,000 middle aged and elderly individuals.
Over a 20-year period, researchers tracked: Subjective age, demographic factors, disease burden, functional limitations, depressive symptoms, and physical inactivity.
Researchers found that those who felt approximately 8, 11, and 13 years older than their actual age had an 18%, 29%, and 25% higher risk of mortality, respectively. They also had a greater disease burden even after controlling for demographic factors such as education, race and marital status. Multivariable analyses showed that disease burden, physical inactivity, functional limitations, and cognitive problems, but not depressive symptoms, accounted for the associations between subjective age and mortality.
This study provides evidence for an association between an older subjective age and a higher risk of mortality across adulthood. These findings support the role of subjective age as a biopsychosocial marker of aging. This may allow for early intervention for select individuals who may have a higher association with poor health outcomes.
Your subjective age can better predict your overall health than the date on your birth certificate.
Title:
The Impact of Thoracic Ultrasound on Clinical Management of Critically Ill Patients (UltraMan): An International Prospective Observational Study
Settings: 4 hospitals (3 in Netherlands and 1 in Italy)
Participants: All adults patients who were admitted to the ICU but patients who died within 8 hours of thoracic ultrasound were excluded.
Thoracic ultrasound procedure: cardiac, lung, diaphragm, inferior vena cava. The main indicators were Respiratory, Cardiac and Volume status.
Study Results:
725 thoracic ultrasound examinations and 534 patients. Clinical management occurred in 247 (88.5%) patients within 8 hours of ultrasound.
Thoracic ultrasound was performed by 111 operators, ranging from inexperienced to very experienced.
Common findings from thoracic ultrasound among these ICU patients.
Discussion:
Conclusion: Thoracic ultrasound provided a significant change in management of critically ill patients.
These two pieces from Becker’s Hospital Review demonstrate significant areas of weakness within the American healthcare system. Hospitals that care for underserved as well as medically and socially complicated patients should be afforded protection and financial security. Not only do they care for the most complex patients, they often educate the next generation of health care providers.
The loss of small community or rural hospitals also has a major negative impact on the US health care system. For time sensitive conditions such as trauma, myocardial infarction or stroke these facilities are often the first, closest facility to initiate care or stabilization. The loss of these critical smaller hospitals also adds to the burden at already overwhelmed larger facilities.
As medical providers, we are in a unique position to advocate for our patients, our co-workers and our communities. Join your professional societies (ACEP, AAEM, SAEM etc.), write your local and national representatives, find like minded colleagues, please get involved with the process any way you can. As a nation we can not afford to lose large essential hospitals or small critical access, rural hospitals.
Magnesium has been associated with function of serotonin and vascular tone regulation, both of which are mechanisms that implicate there may be a role in treatment of migraine. As this is a well-tolerated medication with a good safety profile, there is interest in utilizing this medication in the treatment of migraines. However, studies comparing magnesium to standard migraine treatments are lacking.
A recent single-center, double-blinded, randomized controlled trial compared magnesium, metoclopramide and prochlorperazine for treatment of migraine in the ED. Patients received either magnesium sulfate 2 grams, metoclopramide 10 mg or prochlorperazine 10 mg intravenously over 20 minutes. Adjunctive and rescue medications could be used at the providers discretion.
Pain was assessed with the 11-point Numeric Rating Scale at baseline and at several timepoints after completion of the infusion. Median change in pain score was found to be -3 in all groups at 30 minutes. Post-hoc analysis found magnesium to be non-inferior to prochlorperazine and metoclopramide at this time point. No difference in ED length of stay was found between groups. Adverse events were reported in 5% of patients receiving magnesium, 4.5% in patients receiving metoclopramide and 11.5% in prochlorperazine patients (p = 0.51). The most common adverse events were dizziness, akathisias, and anxiety.
Bottom Line: Magnesium can be used as an adjunctive agent in the treatment of migraines, and may also be considered as an alternative agent when other options such as prochlorperazine and metoclopramide are not appropriate. A reasonable dose would be 2 grams IV infused over 20 minutes. The team should follow-up 30-60 minutes after infusion to assess response to therapy.
Pelvic fractures caused by large force compression (open book) and vertical sheer injuries can lead to life threatening massive hemorrhage from arterial injury, venous injury (most common), bone bleeding or muscle hemorrhage. Advanced Trauma Life Support and many other trauma organizations recommend pelvic binding be applied after the secondary survey is complete. This should preferentially happen in the pre-hospital envirnonment. The literature has not shown a mortality benefit to pelvic binding. One reason that external compression has not been shown to be of benefit is the high percentage of incorrectly applied compression devices. Commercial pelvic compression devices are superior to the old sheet method. If the device is not applied with maxim compression over the greater trochanters the benefit of pelvic compression is lost.
Beser et al. demonstrated in their recent study in the Journal of Trauma Nursing that it takes about 8 attempts to learn to properly place the binder over the greater trochanters. This adds to the literature that appropriate education and continuing education is needed to assure that these devices are appropriately applied.
It is this pearl author’s recommendation that new EMS, nursing and ED and trauma provider staff receive training on these devices with repetitive application until proficient and that yearly competency be performed to maintain our skills in this low frequency potentially high yield procedure.
Open to thoughts and comments.
Happy New Year!
Universal Human Rights
Human rights are rights inherent to all human beings, whether our nationality, place of residency, sex, national or ethnic origin, color, religion, language defines , or any other status
The United Nations Human Rights Council (UNHRC) defines seven substantive rights: the right to life, freedom from torture, freedom from slavery, right to a fair trial, freedom of speech, freedom of thought, conscience and religion, and freedom of movement
The right to life is the essential right that a human being has a right not to be killed by another human being. This has been central in debates on issues of abortion and euthanasia.
Emergency care is an often overlooked, but essential component of the right to life in the highest attainable standard of health and universal health coverage (UHC - a WHO description used to describe access to care). Particularly for vulnerable and disadvantaged populations, emergency care is often the last chance for the health system to save a life.
The focus on vulnerable populations with little access to care and subsequent poor health outcomes has many similarities to the delivery of emergency care. Emergency conditions, such as traumatic injuries, disproportionately affect people in low- and middle-income countries. About 90% of the burden of death and disability from injuries occurs in low- and middle-income countries
COVID-19 emphatically highlighted how far countries (and differences in regulations between states in the US) are from meeting the supreme human rights command of non-discrimination, from achieving the highest attainable standard of health that is equally the right of all people everywhere, and from taking the human rights obligation of international assistance and cooperation seriously.
Implementation of a rights-based framework for emergency care requires countries to enact legislation that ensures access to non-discriminatory emergency care and establish a regulatory body with appropriate oversight and authority to enforce these laws.
In this retrospective chart review, 3720 admitted trauma patients with rib fractures were looked at for 30 day readmission. 206 patients in the group were readmitted within 30 days.
The authors concluded:
In patients with traumatic rib fractures, those with anticoagulant use, those who actively smoke, those with a psychiatric diagnosis, or those with associated abdominal injuries are at the highest risk of re-hospitalization following discharge.
While this study is retrospective and looks at patients that were sick enough to be admitted, it is a good reminder that patients with rib fractures can have high morbidity and mortality and it gives us certain patient populations in which to show extra concern.
Over half of U.S. adults in the United States consume dietary supplements.
Study design: A quality improvement study using data from the FDA’s Center for Drug Evaluation and Research, Tainted Products Marketed as Dietary Supplements
Dates: 2007 through 2016.
Results: Unapproved pharmaceutical ingredients were identified in 776 dietary supplements.
146 different dietary supplement companies were involved.
Most of these products were marketed for sexual enhancement (353 [45.5%]), weight loss (317 [40.9%]), or muscle building (92 [11.9%].
157 adulterated products (20.2%) contained more than 1 unapproved ingredient.
A 2015 NEJM study estimated that 23,000 ED visits per year are attributed to adverse effects associated with dietary supplements.
Estimated 2154 hospitalizations annually.
Frequently involve young adults between 20 and 34 years of age in addition to unsupervised children.
Excluding children, almost 66% of ED visits involve herbal or complementary nutritional products and 31.8% involved micronutrients.
Products for weight loss or increased energy were commonly implicated.
Finally, herbal and dietary supplements now account for 20% of cases of hepatotoxicity in the US.
The major implicated agents include anabolic steroids, green tea extract, and multi-ingredient nutritional supplements.
Anabolic steroids (marketed as bodybuilding supplements) typically induce a prolonged cholestatic, self-limiting liver injury.
Green tea extract and many other products, in contrast, tend to cause an acute hepatitis like injury.
Thrombolytic-induced angioedema is a known complication of alteplase or tenecteplase administration, occurring in 0.9-5.1% of patients who received thrombolytics due to ischemic stroke. Angioedema occurs due to activation of the kinin and complement pathway by plasminogen, leading to both bradykinin and histamine release.
Swelling most commonly occurs acutely while the t-PA is infusing, but can have a delayed presentation up to 24 hours post administration. It normally has an orolingual distribution, although in severe cases there can be laryngeal involvement as well. There is a 4-fold-increase occurrence in patients who take ACE inhibitor medications [1] with some studies noting a high prevalence in strokes involving the right insular brain region [2].
Once identified, the t-PA infusion should be immediately discontinued. As there may be histamine involvement in angioedema formation, patients are initially treated with steroids, H1, and H2 blockers with as needed epinephrine injections.
Given the orolingual predominance, airway obstruction must be ruled out and the patient closely monitored with emergent intubation performed if necessary.
As the kinin pathway (bradykinin) appears to play the largest role in angioedema formation, C1 esterase inhibitors and bradykinin inhibitors can be used in severe or refractory cases [3,4].
However, most cases are mild and resolve with t-PA discontinuation and the initial steroid and histamine blockade.
The use of a serratus anterior plane nerve block has previously been described as effective for anterior and lateral rib fracture pain control. A new, small study by Singh et al. shows efficacy in using this block for posterior rib fractures as well.
The reference link to the ACEPNow website shows how to perform this block using ultrasound guidance.
TACTICS
Transfusion
1:1:1
Whole Blood O+
Activate mass transfusion
TXA
TEG
Adjuncts
Arterial Line
Antibiotics( 2 grams cefazolin with first blood product, redoes 1 gram every 4th product)
Calcium
Treat hypocalcemia with CaCl2 (1 gram after every fourth product)
Check ionized calcium after second dose of calcium
Temperature
Increase room tem to 80 F
Warm blankets
Warm blood products
IV Access
Peripheral x2
I/O
Central Line
Consider
Hemostatic gauze
Tourniquet
Pelvic Binder
Reboa
IR
Cryopercipitate (10 units if fibrinogen low)
Scrub
Call OR
Hybrid Room
Call anesthesia
Call for Back up
This paper outlines a training course by Hartford Hospital for general surgery and emergency medicine residents. Their goal was to assess pre-and post-training effectiveness of hemorrhagic shock management in a simulation environment. The training was on using a novel aid (TACTICS) to prompt the participants in appropriate care decisions involving patients with massive hemorrhage.
The bottom line is having a poster in the resuscitation bay helped the health care providers manage hemorrhagic shock patients. Visual prompts work, especially for new and learning physicians.
Please click below to see their fantastic poster.
"The Tortoise and the Hare" fable has been used as a metaphor for the epidemiological differences between slower, low-intensity exercise versus faster, high-intensity physical activity.
"Current physical activity recommendations are predicated on the idea that both the hare and the tortoise can win the race for better health, but the provocative studies give an edge to the hare's higher-intensity approach,"
Regular physical activity is associated with significant health benefits, including decreased risk of cardiovascular disease, cancer, and all-cause mortality.
Traditional research has focused on exercise volume (150 minutes/week) over intensity.
Two recent studies looked at the benefits of shorter bouts of vigorous activity at higher intensities.
A recent large population-based cohort study of middle-aged adults used objective measurement of activity (wrist accelerometer) over self-reporting to investigate the role of exercise intensity and CV health.
Higher intensity physical activity is associated with lower rates of incident CVD.
This makes theoretical sense as greater stimulation will result in greater physiologic CV adaptations resulting in overall improved CV fitness.
For example. the authors extrapolate that an ambling 14-minute stroll has roughly the same cardiovascular benefits as an up-tempo 7-minute walk at a brisk pace.
Increasing the total amount of activity is not the only means of achieving health goals which can be met with raising overall intensity.
Vigorous physical activity is a time-efficient means to achieve overall health benefits of exercise.
A recent study (Ahmadi et al., 2022) involved 71,893 older adults with a mean age of 62.5. Authors found that quick bursts of vigorous physical activity throughout the day can lower older adults' risk of premature death by 16% to 27%, depending on daily frequency and weekly totals (from 15-20 min/week up to 50-57 min/week).
For example, doing one two-minute burst of high-intensity exercise every day for a total of 14 minutes per week was associated with an approximately 18% lower risk of all-cause mortality. The authors also found that doing as little as one to nine minutes per week of vigorous activity in quick bursts versus doing no vigorous activity was associated with significantly lower all-cause mortality risk over five years.
Exercise may not need to be a planned hour-long session at the gym for our middle-aged and older population. Accruing small amount sporadically over the day/week is an attractive option to reap the CV benefits of exercise. Existing exercise guidelines will need to be modified with future research to pinpoint the optimal exercise intensity and duration for adults in different stages of life.
Although extubation has historically been the purview of critical care, as ED lengths of stay continue to worsen, and as we see more and more rapidly reversible respiratory failure (e.g. opioid overdose), it is valuable for ED providers to be facile in extubating patients. In addition, a longstanding debate in critical care has revolved around the proper device to extubate patients to, specifically: regular nasal cannula (NC) vs high flow nasal cannula (HFNC) vs noninvasive positive pressure ventilation (NIPPV). Although data are mixed, the literature suggests extubation to HFNC or NIPPV may reduce risk of reintubation, esspecially in patients at a high risk of reintubation, but doesn't show a clear difference between HFNC and NIPPV.
Hernandez et al recently conducted an RCT in two Spanish ICUs looking at HFNC vs NIPPV upon extubation for high risk patients. NIPPV was associated with a lower reintubation rate (23%) as opposed to HFNC (39%). Hospital LOS was also shorted in the NIPPV group, but no other differences were observed.
It should be noted that this study, and pretty much the entirety of this literature base, is in ICU patients. In fact, in this study, patients were excluded if they were intubated less than 24 hours. Generally speaking, patients with shorter intubation tend to be lower risk for reintubation and other post-extubation negative outcomes, so I would use caution extrapolating this too much to the ED. Unfortunately however, there is very limited literature to guide ED extubation practices.
Bottom Line:
1) Know how to assess readiness for extubation and consider extubation in the ED if they meet criteria
2) For patients at higher risk of reintubation (older, sicker, CHF, COPD, obesity, airway issues) who you are considering extubating, you may wish to extubate them to Noninvasive Positive Pressure Ventilation, even though there is little solid literature showing best practices in terms of post-extubation respiratory support in the ED.
In follow-up to last week’s pearl regarding the inequitable distribution of trauma care, there were a few more thoughts:
1. A huge shout out to those ED physicians working in critical access facilities without surgical back up, access to specialists, and who are regularly struggling to get their patients transferred to trauma centers to receive the care they need.
2. All centers, big and small, are struggling with crowding, staffing, and patient flow. It is critical to the entire system that these issues get addressed. They need to be addressed at a system level by all stake holders. Smaller EDs, critical access EDs, or Level 2 and 3 centers holding patients that need to be transferred has a deleterious effect not only on that individual patient, but the patients that can’t be seen while the most critically ill are being attended to.
3. Hospital administrators, medical directors, national organizations, department leaders, and each of us in the trenches owe it to our communities and patients to get involved in fixing the problems. These issues are best addressed by a meeting of stake holders than by an overwhelmed ED provider at 2 am desperately trying to do the right thing for their patient.
4. The best systems have:
a. ongoing education for EMS providers, hospital providers, nurses and the general public,
b. pre-hospital protocols regarding trauma patients,
c. a timely means to get patients to the correct facility,
d. injury prevention programs,
e. post-acute care rehabilitation services, and
f. family support services in place.
5. Those with well-functioning systems, please publish your results and the steps you have taken to become well-functioning. We need leadership. We do not need to reinvent the wheel. Please take an active role in lifting the less functional systems to your level.
6. Those that are struggling, ask for help! Also publish your efforts, your struggles, and your needs.
For those interested in a deeper dive into where we have come from and the concept of trauma systems, please read the attached reference. This is a call to all that care for the critically ill to work to improve our stressed system, publish your work so we ca all learn and to advocate and lobby for your patients.
This pearl's author is open to comments, criticism, concerns and questions.
Back to clinical pearls next week.
