Critical Care

Podcast #500: 2018-19 Rapid Fire EM Literature Review

Author: Dave Saintsing

Educational Pearls:

  • Poor sleep is an independent risk factor for development of health problems such as type 2 diabetes.  A 2019 study, randomized participants to 3 groups: 9 hours of sleep, 5 hours of sleep with weekend catch-up sleep, and 5 hours of sleep without catch-up sleep.  In the sleep deprived (5 hour) groups, there was significantly more insulin resistance, calorie intake, and weight gain regardless of catch-up sleep.
  • Tramadol is prescribed 25 million times a year in the USA, usually to avoid prescribing traditional opiates such as Percocet or Oxycodone. Tramadol has complex pharmacology in that is is both an SNRI and mu-opiate agonist after metabolism in the liver. The pharmacogenetics of this vary greatly between people. Many people have rapid metabolism that will lead to increased opiate effects. Other medications interfere with metabolism (such as SSRI’s). A recent study demonstrated increased risk of hypoglycemia in diabetics taking Tramadol. Use caution when prescribing this drug.
  • Sepsis resuscitation has traditionally been gauged by following lactate levels on the  presumption that lactate is an adequate marker of organ perfusion. Unfortunately, lactate levels are often elevated by medications and other health conditions such as kidney or liver disease, making lactate an often ineffective biomarker for perfusion. The Andromeda-Shock trial compared using capillary refill to lactate as guides for resuscitation with the primary endpoint of reducing 28-day mortality.  The capillary refill group had a 9% absolute risk reduction in mortality, but this did not reach statistical significance. However, capillary refill can be used as another data point while resuscitating your septic patients.
  • When should you start pressors for patients in septic shock? A 2019 study compared routine resuscitation (30cc/kg fluid bolus) to initiation of norepinephrine with the first 30cc/kg crystalloid. They found that the early pressor group had significantly more “shock control” (MAP>65) at 6 hours, compared to the control group. While there was a trend towards less mortality in the early pressor group, it was not statistically significant. Keep an eye out for more studies in this area!
  • A recent study in JAMA found that 88% of deaths from sepsis were unavoidable, due to severe chronic comorbidities. Remember that patients will still die from septic shock despite your best efforts and knowledge of the newest literature.

References

Depner CM, Melanson EL, Eckel RH, Snell-Bergeon JK, Perreault L, Bergman BC, Higgins JA, Guerin MK, Stothard ER, Morton SJ, Wright KP Jr. Curr Biol. 2019 Feb 11. pii: S0960-9822(19)30098-3. doi: 10.1016/j.cub.2019.01.069. [Epub ahead of print]. PMID:30827911.

Fournier J, Azoulay L, Yin H, Montastruc J, Suissa S. Tramadol Use and the Risk of Hospitalization for Hypoglycemia in Patients With Noncancer Pain. JAMA Intern Med. 2015;175(2):186–193. doi:10.1001/jamainternmed.2014.6512

Hernández G, Ospina-Tascón GA, Damiani LP, et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. Published online February 17, 2019321(7):654–664. doi:10.1001/jama.2019.0071

Permpikul C, Tongyoo S, Viarasilpa T, Trainarongsakul T, Chakorn T, Udompanturak S. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER). A Randomized Trial. Am J Respir Crit Care Med. 2019 May 1;199(9):1097-1105. doi: 10.1164/rccm.201806-1034OC.

Rhee C, Jones TM, Hamad Y, et al. Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals. JAMA Netw Open. Published online February 15, 20192(2):e187571. doi:10.1001/jamanetworkopen.2018.7571

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

From CarePoint PA Academy, 2019

Podcast # 484: Elevated ICP

Contributor: Charleen Gnisci, PharmD

Educational Pearls:

  • Causes of increased intracranial pressure may include intracranial hemorrhage, malignancy, and trauma. 
  • While definite treatment is to remove the offending cause, there are emergency medicine  
  • Non-pharmacologic methods include elevating head of bed and removing noxious stimuli
  • Pharmacologic options include mannitol and hypertonic saline
  • Hypertonic saline is best delivered through a central line but not required
  • Both these agents benefit from adequate renal function
  • Before using mannitol, be sure to inspect the bag to ensure that it has not precipitated. If it has, try warming the bag before administration. 

References

https://pulmccm.org/critical-care-review/hyperosmolar-therapy-for-increased-intracranial-pressure-review-nejm/

Burgess S, Abu-Laban RB, Slavik RS, Vu EN, Zed PJ. A Systematic Review of Randomized Controlled Trials Comparing Hypertonic Sodium Solutions and Mannitol for Traumatic Brain Injury: Implications for Emergency Department Management. Ann Pharmacother. 2016 Apr;50(4):291-300. doi: 10.1177/1060028016628893. Epub 2016 Jan 29. Review. PubMed PMID: 26825644.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 461: Breath Stacking

Author: Gretchen Hinson, MD

Educational Pearls:

  • Breath stacking occurs when a patient is unable to expire fully before another inspiration
  • In intubated/ventilated patients, this is because adequate time has not passed before exhalation
  • Asthmatics are susceptible due to the prolonged expiratory phase
  • Complications can include reduction in cardiac preload and cardiovascular collapse
  • Pursed-lip breathing can help in the spontaneously breathing patient
  • Intubation may be required when patients present with status asthmaticus and breath stacking

References

Phipps P, Garrard CS. The pulmonary physician in critical care . 12: Acute severe asthma in the intensive care unit. Thorax. 2003 Jan;58(1):81-8. Review. PubMed PMID: 12511728; PubMed Central PMCID: PMC1746457.

Pohlman MC, McCallister KE, Schweickert WD, Pohlman AS, Nigos CP, Krishnan JA, Charbeneau JT, Gehlbach BK, Kress JP, Hall JB. Excessive tidal volume from breath stacking during lung-protective ventilation for acute lung injury. Crit Care Med. 2008 Nov;36(11):3019-23. doi: 10.1097/CCM.0b013e31818b308b. PubMed PMID: 18824913.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 457: Stroke Scores

Author: Jared Scott, MD

Educational Pearls:

 

  • Modified Rankin Score:  measure of disability often used to qualify outcomes following stroke  = no disability, 6=dead, 0-1 indicate good outcome)
    • 0-6 Scale
    • 0-1 indicative of good outcome
  • ASPECT score: uses CT to quantify the extent of changes in the brain due to ischemia
    • 0-10 Scale
    • 10 areas are assessed on non-contrast CT to assess for early stroke changes
    • -1 for each area with these findings
    • 8-10 is indicative of better outcomes

 

References

Aviv RI, Mandelcorn J, Chakraborty S, Gladstone D, Malham S, Tomlinson G, Fox AJ, Symons S. Alberta Stroke Program Early CT Scoring of CT perfusion in early stroke visualization and assessment. AJNR Am J Neuroradiol. 2007 Nov-Dec;28(10):1975-80. Epub 2007 Oct 5. PubMed PMID: 17921237.

https://manual.jointcommission.org/releases/TJC2018A/DataElem0569.html

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 456 Hypoglycemia: Not feeling so sweet

Author: Jared Scott, MD

Educational Pearls:

 

  • Beta-blockers can mask the effects of hypoglycemia
  • Prolonged/refractory hypoglycemia should raise a suspicion for sulfonylurea (or other oral hypoglycemic) overdose
  • Interventions to reverse hypoglycemia include feeding the patient, IV dextrose, glucagon
  • Octreotide can be used as an antidote with sulfonylurea ingestion 

Editor’s note: Here is an interesting case report on using steroids for severe hypogylcemia caused by insulin overdose. Perhaps another treatment modality to keep in your back pocket?

References

Alsahli M, Gerich JE. Hypoglycemia. Endocrinol Metab Clin North Am. 2013 Dec;42(4):657-76. doi: 10.1016/j.ecl.2013.07.002. Review. PubMed PMID: 24286945.

Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial.Emerg Med J. 2005 Jul;22(7):512-5. PubMed PMID: 15983093; PubMed Central PMCID: PMC1726850.

Fasano CJ, O’Malley G, Dominici P, Aguilera E, Latta DR. Comparison of octreotide and standard therapy versus standard therapy alone for the treatment of sulfonylurea-induced hypoglycemia. Ann Emerg Med. 2008 Apr;51(4):400-6. Epub 2007 Aug 30. PubMed PMID: 17764782.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 454: Tylenol Overdose

Educational Pearls:

 

  • Acetaminophen overdose can also present in patients taking too much over the course of days to weeks – not just intentional ingestions
  • If acute overdose is suspected, refer to the Rumak-Matthew nomogram to guide treatment based on time of ingestion and the time of level
  • In chronic overdose, Tylenol levels will not guide treatment
  • NAPQI is the toxic metabolite of acetaminophen
  • N-acetylcysteine (NAC) can be effective treatment in both acute and chronic overdoses
  • 7.5 g is the daily toxic dose of Tylenol in adults, 150mg/kg in children

 

 

References:

Smilkstein MJ. Acetaminophen. In: Goldfrank’s Toxicologic Emergencies, Goldfrank LR, Flomenbaum NE, Lewin NA, et al (Eds), Appleton & Lange, Stamford 1998. P.541.

Chiew AL, Gluud C, Brok J, Buckley NA. Interventions for paracetamol (acetaminophen) overdose. Cochrane Database Syst Rev. 2018 Feb 23;2:CD003328. doi: 10.1002/14651858.CD003328.pub3. Review. PubMed PMID: 29473717.

Lancaster EM, Hiatt JR, Zarrinpar A. Acetaminophen hepatotoxicity: an updated review. Arch Toxicol. 2015 Feb;89(2):193-9. doi: 10.1007/s00204-014-1432-2. Epub 2014 Dec 24. Review. PubMed PMID: 25537186.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 372: The Latest on Epinephrine in Cardiac Arrest

Author:  Don Stader, MD

Educational Pearls:

  • 8014 patients with out-of-hospital cardiac arrest randomized to epinephrine vs placebo
  • 30-day survival was not dramatically better between groups (3.2%in the epinephrine group and 2.4% in the placebo group)
  • Functional neurological outcome was nearly identical at 2.2% and 1.9% of patients
  • Adds to literature that epinephrine provides little important benefit in cardiac arrest – focus on chest compressions and early defibrillation

 

Editor’s note: NNT for epinephrine to prevent one death in this study was 115 – compared to bystander CPR (NNT 15) and defibrillation (NNT 5) from prior studies.

 

References

Perkins GD et. al. . A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest.    N Engl J Med. 2018 Aug 23;379(8):711-721. doi: 10.1056/NEJMoa1806842. Epub 2018 Jul 18.

Kitamura T, Kiyohara K, Sakai T, et al. Public-access defibrillation and out-of-hospital cardiac arrest in Japan. N Engl J Med 2016;375:1649-1659.

Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2015;372:2307-2315.

Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA. 2012 Mar 21;307(11):1161-8. doi: 10.1001/jama.2012.294. PubMed PMID: 22436956.

Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. JAMA Intern Med. 2015 Feb;175(2):196-204. doi: 10.1001/jamainternmed.2014.5420.

Podcast # 370:  Rapid Fire Neonatal Resuscitation

Author:  Erik Verzemnieks, MD

Educational Pearls:

  • In the panic of a precipitous ED delivery, remember: Warm. Dry. Stim.  It will solve most of your problems in most scenarios
  • Start compressions if heart rate is less than 60
  • Put the pulse ox on the right hand – it may make a difference as it is preductal

Editor’s note: detecting a heart rate can be tough in a newborn – you can feel the umbilical stump or just listen with your stethoscope

 

References

Gary Weiner & Jeanette Zaichkin. Textbook of Neonatal Resuscitation (NRP), 7th Ed, 2016. American Academy of Pediatrics & American Heart Association.

Podcast # 350: Pressors and Ischemia

Author: Nick Hatch, MD.

Educational Pearls:

  • A common concern using vasopressors is the risk of digital and mesenteric ischemia.
  • The absolute risk of digital ischemia and/or mesenteric ischemia is pretty low. Norepinephrine at its highest doses carries a 5% digital ischemia rate and a 2% mesenteric ischemia rate.
  • The studies demonstrating this complication were predominately patients with pre-existing liver disease.
  • Providers commonly mistake purpura fulminans, a common complication of sepsis, for digital ischemia.

 

References

Brown, SM. et al.  Survival After Shock Requiring High-Dose Vasopressor Therapy. Chest. 2013. 143(3), 664?671. http://doi.org/10.1378/chest.12-1106.

Malay MB et al. Heterogeneity of the vasoconstrictor effect of vasopressin in septic shock. Critical Care Medicine. 2004. 32(6), 1327-31.

Podcast # 340: Drowning

Author: Chris Holmes, MD

Educational Pearls:

  • Epidemiology: 80% male, ages 1-4 at greatest risk, African-American > Caucasian.
  • Freshwater and ocean water may have more bacteria than pool water.
  • Salt water is hyperosmolar, which theoretically increases risk of pulmonary edema.
  • Greatest physiologic insult is from hypoxia secondary to fluid aspiration or laryngeal spasm. Patient survival is related to presentation on arrival.
  • Workup includes CXR and ABG; consider C-spine immobilization/imaging when cervical injury is strongly suspected (i.e. diving injury).
  • Treatment consists of supplemental oxygen therapy. Consider CPAP or intubation.

References

Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. Drowning. N Engl J Med. 2012. 366(22):2102-10. doi: 10.1056/NEJMra1013317.

Schmidt A, Sempsrott J. Drowning In The Adult Population: Emergency Department Resuscitation And Treatment. Emerg Med Pract. 2015. 17(5):1-18.

 

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