Hypoxemic respiratory failure is a common presentation of critically ill patients. If the degree of hypoxemia is severe and disproportionate to the patient's radiographic findings and not responding to increasing FiO2, a right-to-left shunt should be considered. To evaluate for an anatomic shunt, an intravenous agitated saline contrast (ASC) echocardiographic evaluation can be conducted by an ED provider at the bedside.

Technique:

1. Use two operators, nursing can perform the ASC with the physician obtaining the echo views
2. Set-up:
   • 20 gauge (or larger) PIV in the AC fossa or more proximal is sufficient (does not have to be a CVC)
   • Flush PIV aggressively prior to attempt to make sure it won't blow
   • Obtain 3-way stopcock and 2 10 cc syringes
   • One port is connected to the PIV, and a second port to an empty 10cc syringe with the plunger fully depressed 
   • Third port connected to a syringe filled with 9ccs of saline and 1cc of air (eject 1cc of saline from the syringe of normal saline (NS) and replace it with air)
3. Echo technique:
   • Any view where the RA, LA, and IAS can be seen will suffice
   • Apical 4-chamber view is favored, with a focus on the bilateral atria (can also do sub-xiphoid)
4. Procedure:
   • With the equipment connected to the PIV, bubbles are created by turning the stopcock valve to “off” toward the patient and alternately depressing the plungers on the 2 syringes to send the air/NS mixture back-and-forth between them (should be done forcefully)
   • Push ASC completely into one of the syringes and quickly turn the stopcock “off” toward the other, and inject the ASC into patient while maintaining echo view and actively recording

Interpretation:

1. Quality control check:
   •  A vigorous injection should result in dense opacification of the RA
     • If the chamber is not densely opacified, likely technique issue and the exam should not be interpreted
2. The LA should be examined for a period of at least 10 full beats
3. Timing when microbubbles are seen in the LA:
   • Immediately (within 3-6 beats is a typically used cutoff):  likely to be intracardiac (most likely PFO)
     • Under ideal circumstances, bubbles can be seen to transit across the septum in real time
   • After the 3-6 beat cutoff: more likely to be due to a transpulmonary shunt, either an AVM or hepatopulmonary syndrome, depending on the clinical circumstances
     • Further workup might include a CT angiogram of the chest or workup for cirrhosis
4. Rough qualitative interpretation
   • no bubbles
   • a small number (roughly <10)
   • a large number (roughly >10)
   • enough to completely opacify the LA
   • (Significant continuous hypoxemia requires significant continuous right-to-left shunting, and thus the ongoing passage of many ASC bubbles)

Show References

This is a review of the literature surrounding using mechanical compression devices for in-hospital cardiac arrest. The bottom line is there isn’t much evidence to support the use of these devices and there is scant literature in general on this topic. This is an area in need of further research

Show References

Show References

CCM recently published Stanford's experience with their Emergency Critical Care Program (ECCP), an ED based intensivist consultation/management model staffed by EM/CC during peak hours with the "goals of improving care of the critically ill in the ED, offloading the ED team, and optimizing ICU bed utilization without the need for a dedicated physical space." 

Conclusions:

This is the third group to document decrease in overall mortality utilizing an early or dedicated critical care consult model. EC3 and the CCRU here at UMMC have also both shown improvements in patient transfer and resource utilization metrics. As with all studies in this space, there are many limitations to these studies in both design and generalizability, even amongst each other. However, the literature is replete with data that increased boarding time in the ED for critically ill patients is associated with worse outcomes and these studies are now a body of complementary and growing evidence that teams such as this can perhaps bridge that gap. Hopefully come to an ED near you soon...

Study Details:

Objectives: To determine whether implementation of an Emergency Critical Care Program (ECCP) is associated with improved survival and early downgrade of critically ill medical patients in the emergency department (ED).

Design: Single-center, retrospective cohort study from a tertiary academic medical center using ED-visit data between 2015 and 2019 for adult medical patients presenting to the ED with a critical care admission order within 12 hours of arrival.

Pre and post intervention (2017) cohort analysis of patients when facility implemented dedicated bedside critical care by an ED-based intensivist "following initial resuscitation by the ED team". A difference-in-differences (DiD) analysis compared the change in outcomes for patients arriving during ECCP hours (2 pm to midnight, weekdays) between the preintervention period (2015–2017) and the intervention period (2017–2019) to the change in outcomes for patients arriving during non-ECCP hours (all other hours).

Primary outcomes: In-hospital mortality and proportion of patients downgraded to non-ICU status while in the ED within 6 hours

Results:

• The primary cohort included 2,250 patients
• emergency critical care Sequential Organ Failure Assessment (eccSOFA) score. The DiDs for the eccSOFA-adjusted inhospital mortality decreased by 6.0% (95% CI, –11.9 to –0.1)
  • Largest difference in the intermediate illness severity group (DiD, –12.2%; 95% CI, –23.1 to –1.3)
• The increase in ED downgrade less than 6 hours was not statistically significant (DiD, 4.8%; 95% CI, –0.7 to 10.3%) for all patients
  • The intermediate group was statistically significant (DiD, 8.8%; 95% CI, 0.2–17.4).

Show References

In a systematic review looking at patients over age 65 who sustained a cervical spine injury from a low-level fall, there was a 3.8% prevalence of injury identified. The paper could not correlate injury with GCS level or altered level of consciousness due to the quality of the data available.

Bottom line again is patients over age 65 with low-level falls should be considered to have significant injury until proven otherwise.

Show References

Glucagon therapy in beta blocker and calcium channel blocker overdose is controversial and no high level evidence is available to support or refute its use in overdose treatment.

Glucagon has the ability to bypass adrenergic blockade from beta and calcium channel blocking agents and theoretically increase myocardial contraction, increase heart rate, and increase AV conduction through cyclic AMP production.

However, practically, the use of glucagon is limited due to high risk of vomiting and subsequent risk of aspiration with administration as well as the high cost and limited hospital stock available for continued use.  

Given these limitations, glucagon therapy is no longer recommended for calcium channel blocker overdose in the 2017 Critical Care Medicine Expert Consensus*. The use in beta blocker therapy is still recommended. However, caution must be taken to ensure that more advanced (and possibly more efficacious) therapies such as vasopressors and high dose insulin are administered without delay.

The dose of glucagon therapy for this indication is 3-10 mg IV. You can repeat this dose a second time if no response is seen with the first dose. If clinical response is seen with bolus dosing, transition to continuous infusion at the dose of clinical response (eg. if two 5 mg boluses produced the desired response; start 10 mg/hr infusion). Antiemetic administration prior to initial bolus dose is highly recommended to avoid vomiting.

Show References

This paper looks at the possibility of intramuscular tranexamic acid (TXA) administration. Pharmacologic studies support this route as giving correct drug bioavailability to control hemorrhage. Several London, England pre-hospital services have begun using intramuscular TXA for trauma patients when intravenous access cannot be quickly obtained. This paper suggests 500 mg intramuscular injection dosing. 

Show References

 Acute lower back pain is a very common emergency department presenting complaint. Over the last several years there has been impetus to move away from opioids in the management of lower back pain.

A recent systematic review investigated the pharmacologic management of acute low back pain. This review looked at RCTs investigating the efficacy of muscle relaxants, NSAIDs, and acetaminophen for the treatment of acute nonspecific lower back pain of fewer than 12 weeks duration in patients > 18 years of age. Studies that investigated the use of opioids were not considered.

18 RCTs, totaling 3478 patients were included. 54% were women. The mean patient age was 42.5 ± 7.3 years. The mean length of follow-up was 8.0 ± 5.6 days. The mean duration of symptoms before treatment was 15.1 ± 10.3 days. 

Results:  Muscle relaxants and NSAIDs were effective in reducing pain and disability in acute LBP at approximately 1 week.

The combination of NSAIDs and acetaminophen was associated with a greater improvement than the sole administration of NSAIDs.

However, acetaminophen alone did not promote any significant improvement. Placebo administration was not effective.

Limitations: Most patients with acute LBP experience spontaneous recovery or at least reduction of symptoms, therefore, the real impact of most medications is uncertain. The present study wasn't able to distinguish among different classes of NSAIDs. A best practice treatment protocol cannot be extrapolated from this study.

Take home:  In my practice, patients are treated with NSAIDs and Acetaminophen first line. I also include Licocaine patches for all patients. If there is a contraindication to NSAIDs, I treat with muscle relaxants alone.

This study highlights the lack of benefit of acetaminophen as mono therapy (which has been noted in other studies).

Show References

Bottom Line: IN dexmedetomidine may be a reasonable agent to utilize for anxiolysis in pediatric patients, especially those who have previously had paradoxical reactions or poor efficacy of benzodiazepines. It may be specifically useful when effects are desired for a slightly longer time and for non-painful/minimally painful interventions.  

Show References

Background: The use of steroids in pneumonia has long been controversial with conflicting data, and the recent ESCAPe randomized controlled trial by Meduri et al. showing no mortality benefit with their use, but likely underpowered due to recruitment issues. The recently published CAPE COD study by Dequin et al. may change the game.

Design: Double-blind, placebo-controlled, multicenter, RCT

• 31 hospitals in France, 2015 to March 2020
• Adults with severe (P:F <300 on 50% FiO2 or NRB, mechanical ventilation, or pulmonary severity index >130) CAP (+symptoms and imaging)
• Notable exclusion criteria: vasopressors, aspiration-related, influenza, chronic steroids (equiv to >15mg prednisolone)

Intervention: Early hydrocortisone within 24 hrs, 200mg/day x 4-8 days depending on improvement, then preset taper

• 800 patients: 401 hydrocortisone, 399 placebo

Primary outcome:  Death at 28 days

• Hydrocortisone 6% vs Placebo 12% (p = 0.006)

Secondary outcomes:

• Death at 90 days: Hydrocortisone 9.3% vs placebo 14.7%
• Decreased cumulative incidence of endotracheal intubation by day 28 (if not initially intubated)
• Decreased cumulative incidence of vasopressor initiation by day 28
• Higher median daily dose insulin in hydrocortisone group
• No difference in rate of hospital acquired infections or GIB

Bottom Line:  The addition of hydrocortisone to antibiotics in severe CAP may decrease need for intubation and development of shock, and in this well-done study, decreased 28 and 90-day mortality. 

Show References

A retrospective review of patients over age 13 presenting to one urban level one trauma center and one urban community hospital looked at traumatic injuries in patients presenting for sexual assault. They looked at 157 patients and found 61% of assailants were acquaintances, 22% strangers, and 15% intimate partners. One third of all patients had some traumatic injury however only 12 patients has serious injuries such as non-fatal strangulation or a fracture. Assault by an intimate partner was more likely to lead to injury/trauma including non-fatal strangulation. Drug and alcohol use was not associated with presence of injury.

Show References

Myasthenia gravis is an autoimmune disease of the neuromuscular junction, most commonly due to antibodies attacking acetylcholine receptors in the postsynaptic membrane. Up to 30% of patients with myasthenia gravis will experience a myasthenic crisis during their disease course. If rapid sequence intubation is indicated, the unique characteristics of this patient population must be considered in the event use of a paralytic is necessary. All paralytic agents can be expected to last significantly longer, and an unpredictable response may be seen with depolarizing agents - therefore non-depolarizing agents are preferred in this population.

Non-Depolarizing Agents (Rocuronium, Vecuronium)

• MG patients have increased sensitivity to non-depolarizing agents and require lower doses than typically used
• It is reasonable to dose non-depolarizing agents at one-half the standard dose used. For example, rocuronium would be dosed at 0.5-0.6 mg/kg instead of the standard 1-1.2 mg/kg

Depolarizing Agents (Succinylcholine)

• MG patients have decreased expression of normal acetylcholine receptors which are required for depolarizing agents to work effectively and require higher doses than typically used
• Succinylcholine is typically dosed at 1.5-2.0 mg/kg (roughly double the dose used in other patient populations)

Show References

The classic teaching is that patients with acute pancreatitis should be aggressively hydrated with IV fluids.  But as we increasingly question heavy handed fluid strategies in other areas such as sepsis, should we look at pancreatitis management too?

Li et al did a systematic review of the literature on aggressive fluid resuscitation (the exact protocol/definition varied per study, but we're mostly talking 15-20 mL/kg boluses followed by 3-5 mL/kg/hr infusion) vs less aggressive fluid resuscitation (mostly 10 mL/kg boluses followed by 1.5 mL/kg/hr infusion).  They found that aggressive resuscitation worsened mortality in severe pancreatitis (RR 2.45) and trended towards worse mortality in non-severe pancreatitis (RR 2.26, but CI crossed 1).  Aggressive was associated with more complications in both severe and non-severe pancreatitis pancreatitis.

Multiple society guidelines still call for aggressive IVF resuscitation for acute pancreatitis, but probably need to be updated given mounting evidence that this is harmful.  More recent guidelines suggest "goal-directed therapy", but no one is completely sure what that means.  

Bottom Line:  In acute pancreatitis, a more conservative empiric IVF resuscitation is probably better than the clasically taught aggressive approach.  Whether even less fluids would be better or worse is not known, but for now it's probably best to stick to a 10 mL/kg bolus and 1-2 mL/kg/hr infusion when ordering fluids for these patients unless you have another indication.

Show References

This study is a secondary analysis of another studying looking at hypertonic saline in traumatic brain injury (TBI) making it not the most robust study however it found that TBI patients who’s PaO2 dropped below 100 had a worse outcome than those whose PaO2 did not fall below 100.

Bottom line: This is a reminder that traumatic brain injury patients do not do well with hypoxia or hypotension even if transient (during intubation, etc.). Pre-oxygenate and resuscitate prior to intubation and maintain oxygen saturations in the mid-90s for your traumatic brain injured patients.  This applies to prehospital, emergency department, and ICU settings

Show References

Patellofemoral anatomy and disease (part 1)

During normal knee flexion, the patella slides within the trochlear grove. Both (patella and the trochlear groove) are lined with articular cartilage at the patellofemoral articulation.

https://www.stvincentsboneandjoint.com.au/images/patellofemoral-joint2.jpg

Multiple forces act on the patella which can affect proper tracking:  Proximately, by the quadriceps tendon, distally, by the patellar tendon, medially, by the medial retinaculum/vastus medialis and laterally by the lateral retinaculum and the vastus lateralis.

Patellofemoral OA can occur when this cartilage starts to wear and can be seen in skyline/sunrise/notch or equivalent views. OA here rarely occurs in isolation (<10%) and is usually part of medial or lateral knee OA.

https://www.stvincentsboneandjoint.com.au/images/patellofemoral-joint3.jpg

Patellofemoral pain is usually from overuse/training overload or malalignment.

Contributors to overuse involve total joint load which may have influence from training volume (total miles), intensity (competitive sports) in addition to BMI (>25) in addition to overall fitness level.

Malalignment aka abnormal patellar tracking involves both static (leg length discrepancy, hamstring tightness, etc.) and dynamic components (hip weakness, gluteus medius weakness, excessive foot pronation, etc.).

Patients with anterior knee pain should have activity modification, ice, NSAIDs (not steroids) and long-term engagement in physical therapy (>6 months) with a focus on flexibility and strengthening of lower extremity kinetic chain including the vastus medialis, gluteus medius, hip external rotators and core.

Also, consider looking for hyper supination or pronation. Foot orthotics can be of help with this.

Things to Consider for Persistent or Worsening Septic Shock

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

Show References

Predicting the need for a mass hemorrhage protocol (MHP) activation is important both for individual patient outcome as well as for proper utilization of critical resources such as blood products and healthcare workers time and effort. These two studies look at using the RABT score to predict the need for mass transfusion. The RABT score is:

A 4-point score

blunt (0)/penetrating trauma (1),

shock index (hr/SBP)≥ 1 (1),

pelvic fracture (1)

FAST positive (1)

With a score >2 predictive of needing MHP.

These studies (one in Canadian trauma centers, the other in US trauma centers) validate the use of this score to predict the need for activation of a mass hemorrhage protocol.

Show References

Show References

This study from Sweden looked at 2397 trauma patients and identified 768 with thoracic injury. Those with thoracic injury had a 30-day mortality of 11% whereas those without thoracic injury had a 4% 30-day mortality. Patients over age 60 had higher mortality and were more likely to have rib fractures. Those under 60 with thoracic injury were more likely to have thoracic organ injury than rib fracture.

Bottom line: Rib fractures were more common over age 60 and there was a higher mortality for those with thoracic vs non-thoracic trauma.

Show References

Title: Electrocardiographic Changes at the Early Stage of Status Epilepticus: First Insights From the ICTAL Registry.

As the song goes: “the thigh bone is connected to the hip bone, the hip bone is connected to the back bone.” It turns out that the brain electrical activities are also connected to the heart conduction activities.

In a multi-center (23 French ICUs) retrospective analysis of 155 critically ill patients with status epilepticus, ECGs were done within 24 hours of onset of status epilepticus, and were independently reviewed by cardiologists showed abnormalities in 145 (93.5%) of patients.

Below is a list of events that occurred more than 10% of events.

Abnormal rate (<60 or > 100 beats/min         64 (44%)

Negative T-waves                                           61 (42%)

Flattened T-waves                                           18 (12%)

ST elevation                                                    24 (16.6%)

ST depression                                                 26 (17.9%)

Left axis deviation                                          22 (15.9%)

Discussion:

Major ECG abnormalities were not associated with 90-day functional outcome in multivariable logistic regression.

The brain-heart axis could be affected by antiseizure medication. For example, phenytoin, lacosamide are sodium channel blockers while benzodiazepines, propofol, barbiturates with their GABAnergic effects will also display cardiac side effects.  This current study was not able to tease out whether the cardiac effects were from medication. Therefore, further studies are needed to figure out the cardiac effect for patients with status epilepticus.

Show References