UMEM Educational Pearls

Category: Trauma

Title: Comparing police vs. ALS transport in penetrating trauma pateints

Keywords: trauma, transport, police, ALS, penetrating trauma, rapid transport, prehospital, EMS (PubMed Search)

Posted: 10/12/2022 by Robert Flint, MD (Emailed: 10/16/2022) (Updated: 10/16/2022)
Click here to contact Robert Flint, MD

In this prospective, observational study performed at 25 urban trauma centers, police transport (18%) was compared to Advanced Life Support (ALS) transport (81%) for mortality in penetrating trauma patients with an injury severity score over 16. There was no difference in outcome for those transported by ALS.

The authors conclude "Police transport of penetrating trauma patients in urban locations results in similar outcomes compared with ALS. Immediate transport to definitive trauma care should be emphasized in this patient population."

Show References


Category: Critical Care

Title: Steroids in COVID -- If Some is Good then More is Better... right?

Keywords: COVID, Steroids, Dexamethasone (PubMed Search)

Posted: 10/11/2022 by Mark Sutherland, MD (Updated: 11/30/2022)
Click here to contact Mark Sutherland, MD

Needless to say, therapeutics for COVID-19 pneumonia have been controversial.  From hydroxychloroquine to ivermectin to remedesivir to steroids to bleach (sorry, but it had to be said...),  it depends on who you ask whether medications make a difference in COVID, how much of a difference, when they should be given, and what the correct dose is. 

Dexamethasone, however, ala the RECOVERY trial, is one of the relatively few therapies supported by the majority of the literature and guidelines, and generally is recommended when respiratory support is required for COVID-19 pneumonia.  Further add to this that steroids for ARDS is a long-running point of critical care controversy (e.g. DEXA-ARDS, Meduri, etc), and all you need to say to an intensivist is "how much steroid should I give this patient?" and you can walk away and come back 10 minutes later to find them having not noticed you had ever left.

Wu et all did a fairly small (n=107) single-centered RCT looking at dexamethasone 6 mg daily vs dexamethasone 20 mg daily for COVID-19 requiring O2.  There are several notable limitations to this study, but in short it did NOT add support to the notion that higher dose dexamethasone is a good thing for COVID-19 pneumonia.  In fact, the 20 mg group trended towards worse outcomes.  Small sample size, single-center, limited follow up, variable use of biologics between the groups, and failure to investigate intermediate doses between 6 and 20 are all significant limitations of this trial. Of note, DEXA-ARDS, which was conducted before COVID (2013-2018), looked at 20 mg x 5 days followed 10 mg x 5 days and DID find a significant benefit, as well as pretty darn good NNT and p values (and was a higher quality trial), so in my opinion it is also not unreasonable to use DEXA-ARDS dosing if the patient meets moderate-severe ARDS (P:F < 200) criteria, even though of course DEXA-ARDS was before COVID and Wu et al slightly contradicts it. 

When faced with a very sick COVID-19 pneumonia patients many intensivists will do either RECOVERY or DEXA-ARDS dexamethasone (with relatively limited basis to choose one vs the other), and some will do Meduri protocol methylprednisolone (1-2 mg/kg/day).  Relatively few nowadays will omit steroids unless there's a contraindication.

 

Bottom Line: It probably remains a good idea to give dexamethasone to your COVID-19 pneumonia patients with hypoxia, but you can probably stick to RECOVERY (see reference below; 6 mg daily x 10 days) dosing as opposed to higher doses.  If they're REALLY sick (P:F < 200), consider DEXA-ARDS (20 mg x 5 days followed by 10 mg x 5 days) dosing.

 


Category: Trauma

Title: Use of shock index in trauma patients

Keywords: Shock, Shock index, trauma, mass transfusion, mortality, geriatric trauma (PubMed Search)

Posted: 10/9/2022 by Robert Flint, MD
Click here to contact Robert Flint, MD

The use of the shock index (systolic blood pressure/heart rate) value under 0.9 has been shown to be effective in predicting the need for mass blood transfusion as well as mortality for trauma patients age 16-64. Using age times shock index has been shown to be an effective marker of mortality and the need for transfer/transport to a trauma center in those over age 65. The change in shock index over time is also useful for pre-hospital providers deciding the appropriate destination for traumatically injured individuals. 

 

Show References


Category: Airway Management

Title: Popliteal artery entrapment syndrome (PAES)

Keywords: leg pain, compartment syndrome (PubMed Search)

Posted: 10/9/2022 by Brian Corwell, MD (Updated: 11/30/2022)
Click here to contact Brian Corwell, MD

Popliteal artery entrapment syndrome (PAES)

 

 

CC:  Exertional lower leg pain, however, compression of posterior neurovascular structures can lead to nonspecific vascular and neurogenic symptoms.

Challenging diagnosis to make because of close overlap with chronic exertional compartment syndrome (CECS).

Anatomic PAES has a prevalence of 0.62% to 3.5% in the general population. Patients are more likely to be older be older, male, and have lower levels of activity.

Functional popliteal artery entrapment (FPAE) however has no anatomic anomaly. Sx’s are thought to be because of bulky surrounding muscle crowding with repetitive dynamic injury. This is most commonly from the medial head of the gastrocnemius.  Patients are younger and more likely to be involved in athletics. Most athletes were involved in sports that put high value on repetitive plantarflexion, such as track and field (45%), soccer (25%), water sports (8%), lacrosse (6%), basketball (6%), 

Sx’s:  bilateral (25-75% of cases) cramping in the region of the soleus and plantar paresthesias.

Common exacerbating mechanism: ascending stairs or climbing inclines because of leg/knee position of extension with plantarflexion 

 

In one review, 31% of patients who underwent debulking surgery for FPAES had been previously treated and extensively worked up at outside institutions for CECS, and already undergone various compartment releases.

 

Patients in one study underwent a dynamic CTA protocol. A positive test demonstrated normal flow in neutral position and compression or complete occlusion of the popliteal artery by the medial head of the gastrocnemius muscle against the lateral femoral condyle with provocative foot plantarflexion. Images below.

https://images.journals.lww.com/acsm-csmr/Original.00149619-202210000-00008.F1.jpeg

 

Nearly three-fourths of athletes limited by FPAES demonstrated full return to prior competitive levels with four compartment fasciotomy AND surgical debulking of the anterolateral quadrant of the medial head of the gastrocnemius muscle. 

 

 

 

Show References


Category: Pediatrics

Title: What Sound Does an ALCAPA Make?

Keywords: pediatric cardiology, ALCAPA (anomalous left coronary artery from the pulmonary artery) (PubMed Search)

Posted: 10/7/2022 by Rachel Wiltjer, DO
Click here to contact Rachel Wiltjer, DO

 

  • Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital defect in which there is an altered origin of the left coronary artery (also known as Bland-White-Garland syndrome)
  • Generally asymptomatic at birth, but can present in late infancy, toddlerhood, or later with signs of congestive heart failure, a myocarditis picture, or sudden cardiac death
  • Flow through the left coronary artery is normal at birth due to high pulmonary pressures, but as those pressures drop the blood flow drops as well and may become reversed due to the pressure gradient
  • This can cause chronic myocardial ischemia, the severity of which, is dependent on collateral flow
  • Most patients will also develop mitral regurgitation
  • Cardiomegaly may be seen on CXR (and some patients will present with respiratory symptoms/wheezing)
  • EKG findings include: findings consistent with ischemia (ST changes, q waves – specifically in the anterolateral leads), leftward axis (for age), abnormal R wave progression (loss of R wave amplitude in affected leads)
  • Diagnosis can generally be made with echocardiogram (although not 100% sensitive) and the disease is generally treated with surgical repair

 

Show References


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.

Show References


Category: Pharmacology & Therapeutics

Title: Beware of piperacillin-tazobactam dose reductions in septic shock

Keywords: sepsis, piperacillin-tazobactam (PubMed Search)

Posted: 9/29/2022 by Ashley Martinelli (Emailed: 10/3/2022) (Updated: 11/30/2022)
Click here to contact Ashley Martinelli

Piperacillin-tazobactam is one of the most commonly used antipseudomonal antibiotics in the empiric management of patients with septic shock. The package insert recommends dose reductions for renal impairment in other infectious etiologies, but the impact of dose reduction has not been previously studied in patients with septic shock.

A recent retrospective, observational cohort study compared outcomes of patients with septic shock who received ≥ 27 grams (at least 3.375 gm q6 hours x 48 h-“NORM”) versus those who received < 27 grams (“LOW”) over the initial 48 h of septic shock (defined as concomitant norepinephrine infusion).  

Patients were excluded if they had death or hospice disposition within the 48h study period. The primary outcome was the number of norepinephrine free days (NFD) at day 28. Propensity matching was utilized to account for confounders.

Results: 351 in the LOW group, 928 in the NORM group with 608 pairs in the propensity matched assessment.

  • Patients in the LOW group were
    • Older (65 v 61, p < 0.001)
    • More likely to have lower renal function (20% with CrCl < 20, 35% with CrCl 20-40) which corresponds to package insert dose reduction recommendations
    • Received lower doses of piperacillin/tazobactam (20.3 g v 30.4 g, < 0.001)
  • Norepinephrine free days were statistically significantly higher in the NORM dosing group when looking at all patients and the propensity score matched patients.
  • In-hospital mortality/hospice disposition was also lower in the NORM group (25.9% v 35.5%, p=0.014

Bottom Line: Dose reductions of piperacillin-tazobactam appears to be harmful early in the management of patients with septic shock.

 

Show References


Category: Trauma

Title: Whole Blood vs Blood products in trauma resuscitation

Keywords: trauma, whole blood, blood products, resucitation (PubMed Search)

Posted: 10/2/2022 by Robert Flint, MD (Updated: 11/30/2022)
Click here to contact Robert Flint, MD

A fourteen center study enrolling 1623 trauma patients (53% penetrating) comparing cold-stored whole blood vs. blood component products found no difference in AKI, thromboembolism, or pulmonary complications. And more interestingly, patients receiving whole blood were 48% less likely to die than those receiving standard blood component products. Add this data point to a growing trend toward cold-stored whole blood for trauma patients.

Show References


Enter the WATERFALL trial into the present flood of fluid strategy trials, a multi-country (primarily Spain) open-label RCT of “Aggressive” versus “Moderate” fluid resuscitation with lactated ringers for early mild acute pancreatitis.

Population: 249 adults (1/3 of the planned enrollment) presenting to the ED within 24hrs hours of abdominal pain onset diagnosed with mild acute pancreatitis. Numerous exclusions for local pancreatic complications, acute or chronic organ dysfunction (including CHF and CKD), among many others. Average age of 57, 51% female, 61% due to gallstones, median Charleson index of 2, median BISAP of 1, and 52% clinically judged hypovolemic on enrollment.

Interventions: 1:1 randomization to two complex protocols, both with time points every 48 hours and same criteria for initiating oral diet.

  • “Aggressive”: Immediate 20ml/kg bolus of LR hours with repeat 20ml/kg boluses for hypoperfusion followed by 3ml/kg/hr infusion for 12hrs, then 1.5-3ml/kg/hr for at least 36hrs
  • “Moderate”: 10ml/kg bolus only if hypovolemic with repeat 10ml/kg boluses for hypoperfusion followed 1.5 ml/kg/hr infusion for 20hrs

Outcomes/Results: Primary outcome was development of moderate of severe pancreatitis with no difference found between the two strategies. Median fluid at 72 hours was 8.3L (IQR 7.1- 10.8) in the aggressive arm and 6.6L (IQR 4.1 - 8.0) in the moderate arm.  Several point estimates favor the moderate group, but none statistically significant and there was not a difference in symptom or SIRS improvement at 72 hours.  The trial was stopped after 1/3 enrollment when the monitoring board noted a significantly increased rate of fluid overload in the aggressive arm (20.5%) versus the moderate arm (6.6%). 

Discussion:

-Aggressive fluids for mild acute pancreatitis didn’t show benefit over a moderate strategy and showed some harms in contrast to previous smaller studies and some guideline recommendations in mild disease

-Only reached 1/3 of target enrollment significantly limiting analysis

-This was by design not a trial of severe or critical disease

-The open label nature may have affected some endpoints, including safetly endpoints

-Another trial to shift our thinking a bit about how to use and safely limit fluid resuscitation

Show References


Category: Airway Management

Title: Decompression of Traumatic Tension Pneumothorax

Keywords: trauma, PTX, finger thoracostomy, needle decompression, 2nd intercostal space, 5th intercostal space, pneumothorax (PubMed Search)

Posted: 9/25/2022 by Robert Flint, MD (Updated: 11/30/2022)
Click here to contact Robert Flint, MD

Finger thoracostomy is superior to needle decompression in the fifth mid-axiallary intercostal space which is superior to the traditionally taught needle decompression in the second mid-clavicular intercostal space for traumatic tension pneumothorax/trauamtic arrest.

Show References


Pes Anserinus pain syndrome (formerly pes anserine Bursitis)

Occurs at the bursa of the pes anserinus which overlies the attachment of the 1) Sartorius 2) gracilis and 3) semi-tendinosis tendons. Insertions resemble a Goose’s foot.

An inflammatory condition of the medial knee

Location is 2-3 inches below the knee joint on the medial side

1st layer of medial compartment

https://sportsclinicnq.com.au/wp-content/uploads/2019/01/Screen-Shot-2019-01-30-at-8.55.48-am-300x291.png

 

https://www.dramynrajani.com/wp-content/uploads/2018/05/pes-anserine-bursitis-clinical-test.jpg

 

Patients complain of knee pain just below medial joint line (esp with stairs)

History may include sudden increase in running distance especially with hills (common)

Associated with obesity, tight hamstring muscles and with knee OA

PE:  Tenderness to palpation of the bursa possibly with mild swelling

DDx: MCL tear, medial meniscus injury, medial (knee) compartment arthritis, tibial stress fracture

 

Treatment: Cessation/modification of offending activities, Icing and ice massage, NSAIDs, hamstring stretching and physical therapy. Failure of the above should prompt referral for bursal steroid injection.

 

 


Category: Critical Care

Title: 30 ml/kg in sepsis: more is not better

Keywords: 30 ml/kg, sepsis, fluid overload, ESRD, CHF (PubMed Search)

Posted: 9/20/2022 by Quincy Tran, MD (Updated: 11/30/2022)
Click here to contact Quincy Tran, MD

Have you ever encountered an ESRD patient who missed dialysis because the patient "felt too sick to go to dialysis"? The patient then had hypotension from an infected catheter line? Do we give 30 ml/kg of balanced fluid now?

__________________________

 

Title: Outcomes of CMS-mandated ?uid administration among ?uid-overloaded patients with sepsis: A systematic review and meta-analysis.

 

Settings: This is a meta-analysis

Patients: Septic patients who have underlying fluid overload conditions (CHF or ESRD).

Intervention: intravenous fluid administration according to the mandate by the Center for Medicare/Medicaid as 30 ml per kilograms of bodyweight.

Comparison: fluid administration at less than 30 ml/kg of body weight.

Outcome: 30-day mortality, rates of vasopressor requirement, rates of invasive mechanical ventilation

Study Results:

  • Random-effects meta-analysis of 5 studies, including 5804 patients.  There were 5260 (91%) patients receiving non-aggressive IVF at < 30 ml/kg versus 544 (9%) patients received aggressive IVF at rates > 30 ml/kg.
  • Patients who received aggressive IVF > 30 ml/kg were associated with 30-day all-cause mortality OR 1.42 (95% CI 0.88-2.3, P = 0.15, I2 =35%).
  • The need for vasopressor during stay was similar: OR 0.69 (95%CI 0.42-1.15, P=0.21, I2 = 33%)
  • The need for invasive mechanical ventilation during hospitalization was similar: OR 0.85 (95% CI 0.57-1.26, P = 0.42, I2 = 0)
  • Both groups had similar ICU length of stay: Standard Difference in Means -0.002 (Very small magnitude), 95% CI -0.35 to 0.34, P= 0.99, I2 = 53)
  • Similar hospital length of stay: Standard Difference in means -0.11 (small magnitude), 95% CI -0.62 to 0.38), P= 0.67, I2=77%

 

Discussion:

  • All studies were retrospective studies, as it’s hard to do RCT when the treatment is required by guidelines.  Although the studies were graded as high quality but there was still risk of bias.
  • Until there is significant evidence to change the guidelines, please document thoroughly in your charts if you do not give sepsis patients who have fluid overload the required volume of IVF at 30 ml/kg.
  • Consider early vasopressor.

Conclusion:

  • Patients who have fluid overload and sepsis had similar outcomes when they were given IVF at rates < 30 ml/kg, compared to those given IVF > 30 ml/kg as required by CMS.

Show References


Category: Trauma

Title: Managing the Airway in Trauma Patients

Keywords: Trauma, Airway Management, Resuscitation (PubMed Search)

Posted: 9/18/2022 by Robert Flint, MD
Click here to contact Robert Flint, MD

Takeaways

Manageing the airway of a trauma patient presents difficulties because of both anatomic and physiologic derangement. 

The Bottom Line: Trauma patients requiring intubation are a challenge and should be managed by the most expereinced person in the room. No study shows superiority of direct vs.video laryngoscopy. Use the technique you are most facile with and develop more techniques through courses, mentoring, and expanding your repertoire in less ill patients first. Use induction agents with lower liklelihood of causing hypotension like Etomidate and ketamine (avoid propofol and benzodiazepenes). Avoid hypoxia, hypotension and hypocarbia by resucitating as much as possible prior to intubation (use blood products and pressors where appropriate). Have a plan, a back up plan, and know when to switch to a surgical airway approach. This ia a low frequency, high risk proceedure. Mentally visualize yourself doing this proceedure regualrly to create a comfort level when it is actually needed. 

PEARLS:

1. Blood/Emesis  A. Use a double suction set up with one suction placed into the airway near the esophagus and then moved to the left of the mouth with the second used by the intubator to clear their view. 

B. If you can't visualize becaue of vomit/emesis it is very likely BVM and super glotic airways are not going to be possible and you will need to move to a surgical (front of neck) airway.

2. Limited Jaw Opening  Cervical collars can impede jaw opening. Loosen/open the collar to allow more jaw opening. Studies show that there is limited movement of C-Spine when the intubator uses caution not to flex the neck during intubation meaning the collar does not have to be in place. No study shows diret or video laryngoscopy to be superior. 

3. Blunt or penetrating neck injury Highest level of difficulty. Should be most expereienced intubator. Can use an awake intubation technique if you are adept at this method. Go with the airway approach that gives YOU the best first pass success chance. Another situation where BVM or suprglotic airway device may not work and requires surgical airway. May require low tracheostomy approach. 

4. Hypoxia  Avoiding hypoxia is a must especially in traumatic brain injured patients. Pre-oxygenate and use the airway technique that is going to give you the best first past chance of success.

5. Hypotension:  A. Resuscitate with blood products as much as possible before intubation. B. Use induction agents that are the most hemodynamically neutral such as Etomidate or Ketamine (safe in head injury patients!)

6.. Hypocarbia: Congrats on getting the tube! Now slow down your bagging. Hypocarbia leads to increased injury in traumatic brain injured patients. 

Show More In-Depth Information

Show References


Laryngospasm is defined as the cessation of ventilation despite persistent respiratory effort related to glottic closure.  Complications include hypoxia, bradycardia, and cardiac arrest.  In OR cases, one recent study found the laryngospasm to occur in 0.45/1000 cases.  In these children undergoing general anesthesia, risk factors included current upper respiratory infection, active asthma, airway anomalies, airway procedures, age < 3 months and the use of an LMA.  
Studies of the rates of laryngospasm in pediatric sedation have shown varied incidence, with prevalence between 0.43/1000 to 2.1/1000.  A metaanalysis showed that laryngospasm was more common with a combination of propofol and ketamine.
This study looked at moderate sedation cases where laryngospasm was not relieved with chin repositioning or the use of an airway adjunct.  Over a 7 year study period, 276,832 sedations were examined with 913 patients experiencing laryngospasm (3.3/1000 cases).  About 5% of these patients required intubation.  There were 2 cases of cardiac arrest, one with an underlying cardiac condition and one with a URI who was undergoing an echo.  Both of these patients had multiple agents used for sedation.
The isolated use of IV ketamine had a laryngospasm rate of 1.4/1000 cases.  The highest prevalence occured with propofol + ketamine (6.6/1000), propofol + midazolam + opiate (6.1/1000) and propofol + dexmedetomidine (5.8/1000).
The risk of laryngospasm was associated with a higher ASA status, younger age, presence of a URI, airway procedures, and certain propofol combination regimens.
Bottom line: While the prevalence of laryngospasm remains low during pediatric sedation, risk factors should be taken into consideration and the risk/benefits should be discussed in detail with the families.  Always be prepared for an airway emergency during sedation.

Show References


Point-of-care ultrasound compression of the carotid artery for pulse determination in cardiopulmonary resuscitation

Background:

-shorter (and accurate) pulse/rhythm checks are better
-manual pulse checks are often not reliable and frequently exceed the recommended 10s window
-cardiac POCUS has been used as a possible adjunct but there have been concerns about interruptions in compressions 
 
Study:
-Single center, prospective, 25 patients with OHCA (155 pulse checks total)
-some exclusions: early cessation of CPR (49), "manpower shortage" (35)
-two physicians concurrently performing manual palpation (MP) of femoral artery and POCUS-carotid artery compression (POCUS-CAC) during pulse checks
-each with stopwatch to measure time to pulse judgment
-prev training with hour lecture and hands-on demonstration on how to assess/interpret the compressibility and pulsatility of the carotid artery
 
POCUS-CAC: 
-linear probe placed transversely across patient’s middle neck to identify the carotid artery and internal jugular vein on the screen
-probe pressure was applied until the internal jugular vein was completely compressed
-absent pulse = lack of pulsation and complete compression of the carotid artery under probe pressure
-present pulse = any visual pulsation or incomplete compression of the carotid artery
 
Results:
-the average time for carotid pulse identification per patient significantly different
      -POCUS-CAC was 1.62 (1.14– 2.14) s 
      -MP 3.50 (2.99–4.99) s
-in all 155 pulse checks, the time to complete a pulse check with POCUS-CAC never exceeded 10 s, whereas five cases with MP exceeded this.
 
Takeaways/caveats:
-larger study is needed and focus should be on rhythm checks, but if staffing allows, can consider utilizing POCUS-CAC as an adjunct for pulse checks 
-the MP time in this study is much shorter than in prev studies
-would be interesting to see if the findings would be even more exaggerated in a larger patient population (average BMI in the study was 23!)
-small sample, did not address carotid stenosis/atherosclerosis, no standardization for intensity of compression applied

 

Show References


Category: Orthopedics

Title: Walk don't run to the nearest exit

Keywords: mortality, exercise, dementia, walking (PubMed Search)

Posted: 9/10/2022 by Brian Corwell, MD (Updated: 11/30/2022)
Click here to contact Brian Corwell, MD

Exericse as preventative medicine!

A recent cohort study of over 2,000 adults (mean age approx. 45) over approximately 11 years of follow-up investigated the association of step count with mortality.

This study found that those participants taking at least 7,000 steps per day compared to those taking fewer steps had a 50%-70% lower risk of mortality. They did not find an association with step intensity.

 

Another recent study investigated the dose-response association between daily step count and intensity and the incidence of all-cause dementia.

 

Uk based study of >78,000 adults aged 40 to 79 years with approximately 7 years of follow-up. Data from wrist accelerometer and registry-based dementia diagnoses.

 

Optimal step dose was 9826 steps. Minimal dose was 3826 steps (value at which the risk reduction was 50% of the observed max).

In this study, steps performed at higher intensity (112 steps/min) resulted in stronger associations.

 

Conclusions:  A great exercise goal for middle aged and older adults is just under 10,000 steps per day to decrease risks of both overall mortality and dementia.

 

 

 

 

Show References


Category: Critical Care

Title: INTUBE Study: Propofol in the Critically Ill

Keywords: intubation, propofol, RSI, SOFA (PubMed Search)

Posted: 9/7/2022 by William Teeter, MD (Updated: 11/30/2022)
Click here to contact William Teeter, MD

Take Home:

This is essentially a secondary analysis of a previous prospective observational cohort study with high quality methods. The authors have an excellent discussion of the previous studies on this topic (which for those with an interest I highly recommend you read). They conclude that this study supports previous literature which I would think would be seemingly obvious, which is that those who are more ill to begin with have less tolerance of propofol (in a dose-independent relationship) in this and previous studies. Their use of IPTW extends the analysis on this large international population by addressing confounders in a novel way.

Their overall conclusion is that propofol is bad for the critically ill, and especially bad for those with pre-existing risk factors for intubation complications. I agree: This study suggests in even stronger terms that propofol should be used carefully and probably only in unhealthy patients when other options are unavailable.

 

Study Background and Characteristics

  • INTUBE study1 was a prospective cohort study conducted from October 1, 2018, to July 31, 2019
  • Enrolled consecutive “critically ill” patients over 8 week period at 197 clinical sites from all over the world. Critically ill was defined as those with “an underlying life-threatening condition causing cardio–respiratory failure or neurologic impairment”.
  • Outcome of “cardiovascular instability/collapse” as one or more of the following events within 30 minutes of intubation start: (1199 of 2760 enrolled patients; 43.4%)
    • systolic arterial pressure <65 mm Hg recorded at least once (collapse criteria) – 12.8%
    • cardiac arrest (collapse criteria) – 7.8%
    • systolic arterial pressure <90 mm Hg for >30 minutes – 24%
    • new requirement or increase of vasopressors – 87.8%
    • fluid bolus >15 ml/kg to maintain the target blood pressure – 13.2%
  • STROBE Compliant

 

Findings

  • CV-instability group were significantly older, high SOFA scores, and higher rates of ischemic heart disase, NYHA 3/4 heart failure, poor oxygenation (SPO2/FIO2 ration), pressors, fluid bolus/total, systolic/diastolic BP, and more commonly respiratory failure and cardiovascular instability as the reason for intubation.
  • CV-stability group was less likely to receive propofol and at lower doses and more likely receive ketamine.
  • Notably, CV-instability patients were less likely to be intubated by emergency physicians versus anesthesiology.
  • Anesthesiologists were more likely to use propofol and more emergency medicine physicians using ketamine.
  • Higher incidence of CV-instability in ischemic heart disease and heart failure, noninvasive ventilation and apneic oxygenation, and in the 30–45° head-up position.
  • ICU mortality associated with:
    • vasopressors/fluids without hypotension (OR, 1.47; 95% CI, 1.21–1.79)
    • systolic blood pressure <90 mm Hg for >30 min despite vasopressors (OR, 2.65; 95% CI, 1.87–3.75)
    • systolic blood pressure <65 mm Hg (OR, 1.89; 95% CI, 1.31–2.71)
    • cardiac arrest (OR, 8.79; 95% CI, 5.46–14.7)
  • Inverse Probability Treatment Weighting2 (IPTW) analysis found that the only treatment effect with significance associate with the entire CV-instability group was propofol usage (OR, 1.23; 95% CI, 1.02–1.49).
    • No treatment effect, including propofol use or dosage, was associated with those meeting cardiovascular collapse criteria.

 

Show References


Takeaways

Intraosseous (IO) administration uses bone marrow to deliver fluids and medications during cardiac resuscitation or other emergent situations where IV access cannot be established.

IV versus IO

  • No statistically significant difference between the pharmacokinetics!
  • Flow rates of IV cannula typically range from 20 to 200 mL/min versus IO ranging from 0.33 to >50 mL/min under pressure
    • Maximum rate of administration through IO is comparable to a 21G peripheral cannula.

Considerations When Using IO Access

  • Single line, ensure all drugs running through the IO are compatible with one another.
    • For example: plasmalyte is not compatible with most medications
  • If trying to quickly administer fluids utilize a pressure bag.
    • If medication administration (i.e. vasopressors) pump should be used
  • Contraindications to IO include:
    • Placement in fractured bone with vascular injury
    • Compartment syndrome
    • Cellulitis/burns at the site
    • Underlying bone disease
    • Soft tissue infection
    • Recent orthopedic surgery
  • Once a bone has been punctured by an IO attempt, it should not be used again for at least 48 hours. 
  • Intraosseous aspiration of blood is usable for lab tests, though accuracy has varied in studies. 

 

Show More In-Depth Information

Show References


Category: Critical Care

Title: Ultrasound Central Line Confirmation

Keywords: ultrasound, central Line, confirmation, venous, cavoatrial junction, agitated saline, pneumothorax (PubMed Search)

Posted: 8/30/2022 by Zach Rogers, MD
Click here to contact Zach Rogers, MD

Takeaways

Traditionally, internal jugular and subclavian central line placement has required chest x-ray confirmation of correct placement (venous cavoatrial junction placement) as well as demonstrating lack of complication (no pneumothorax) prior to use of that central line. However, current evidence supports similar if not superior complication identification and placement confirmation with ultrasound,(1-7) allowing for a much quicker confirmation time than traditional chest x-ray, which can be vital in critically ill patients who need immediate medication administration.

Venous placement is confirmed with prompt visualization of microbubbles in the right atrium and ventricle with a rapid flush of 5-10 ml of agitated saline via the distal central line port. Additionally, if the opacification occurs <2 seconds after injection then the catheter tip is sufficiently distal in the central venous system to not require additional verification. Additional confirmation of lung sliding in both lung apices will rule out pneumothorax.

Some authors recommend checking the contralateral internal jugular vein to ensure that the central line catheter has not traveled up the internal jugular towards the head, however this may be redundant as long as the time from agitated saline injection to right atrial visualization of microbubbles is clearly less than 2 seconds.

Bottom Line: Utilization of ultrasound for central line placement confirmation is a relatively simple, rapid, safe, and accurate means of confirmation of venous catheter placement and catheter tip location, as well as ruling out pneumothorax complications.

Show More In-Depth Information

Show References


Approximately 284,000 immigrants reside in Baltimore (10% of the total population). In April 2022, Governor Abbott of Texas began sending migrants from the US southern border to Washington, DC, with Arizona joining soon after. It is important for emergency providers to be aware of these changes and how new disparities may arise.

1. Social Determinants of Health: A meta-analysis in 2018 suggests that Health literacy is a key determinant of health in refugee and migrant populations living in in high-income countries such as America. Using patient centered language and taking time to explain diagnoses are CRITICAL in caring for immigrant populations particularly in the ED. Use of appropriate language services are also important.
 

2. Assess acute vs non-acute needs: A study done in pediatric migrant populations suggests that the severity of the reasons for visiting the ED and the hospitalization rates were not higher in the pediatric migrant population than in the general pediatric population. Some common non-urgent diagnoses include scabies, anemia, oral and dental disorders.

 

3. Create a safe environment: In a study done in 2013, up to 12% of undocumented immigrants that presented to the ED expressed fear of discovery and consequent deportation. On further assessment there was the belief that medical staff are required to report these patients to immigration. It is important to proactively address inaccurate beliefs to promote a safe trusting environment.

 

Resources in Baltimore/Maryland:

-CASA

-Esperanza Center

-International Rescue Committee

- John's Hopkins Centro Sol

- National Immigration Law Center

 

National Resources (US):

-Rural Health Information Hub

-National Resource Center for Refugees, Immigrants, and Migrants

 

Show References