It's important to remember the differential for the patient with Ventricular Assist Device (VAD) difficulties, as these patients are likely to show up in your ED.
1) Assess the patient as you usually would (signs of life, mental status, breathing, arrhythmias on monitor, etc). Listen for a hum over the chest. Don't expect to feel a pulse.
2) Look at the VAD including controller, driveline, and power source for alarms, disconnections, signs of infection, and other obvious issues.
3) Look at the power (displayed flow), pulsatility index, and pump speed on the controller to help determine the cause of the issue (see attached chart). Once you have a suspected etiology, typical management of these issues is usually similar to non-VAD patients (i.e. gentle IVF for hypovolemia, vasodilators if low flow is due to afterload/hypertension, defibrillation/CPR for arresting pts, etc).
Don't forget to call your VAD coordinator when able. Consider a-line placement for precise evaluation of blood pressure (focus on MAP).
Bottom Line: Consider obstruction/thrombosis, bleeding, infection, hypovolemia, afterload/hypertension, arrhythmia, worsening LV function, and suction events when troubleshooting VADs. The power, pulsatility index, and pump speed help differentiate these conditions.
With increasing critical care boarding and the opioid crisis leading to more intubations for overdose, extubation - which was once a very rare event in the ED - is taking place downstairs more often. Prolonged mechanical ventilation is associated with a ton of complications, so it's important for the ED physician to be comfortable assessing extubation readiness. There is no single accepted set of criteria, but most commonly used are some variant of the following:
If the above criteria are met, two additional tests are frequently considered:
And don't forget to consider extubating high risk patients directly to BiPAP or HFNC!
Bottom Line: For conditions requiring intubation where significant clinical improvement may be expected while in the ED (e.g. overdose, flash pulmonary edema, etc), be vigilant about, and have a system for, assessing readiness for extubation.
With a shortage of push dose epi, this may be an opportune time to review alternative options (see also Ashley's email on the subject).
The dose of vasopressor required to reverse hypotension has been most studied in pregnant women undergoing c-section who get epidurals and experience spinal-induced vasoplegia and hypotension (not necessarily our patient population, but we can extrapolate...)
Phenylephrine was found to reverse hypotension 95% of the time at a dose of 159 micrograms (a neo stick has 100 ug/mL, so around 1-2 mL out of the stick)
Norepinephrine reversed hypotension in 95% of patients at a dose of 5.8 ug. The starting dose for our norepi order in Epic is 0.01 ug/kg/min, so if you have a levophed drip hanging and have an acutely hypotensive patient, you may want to briefly infuse at a higher rate such as 0.1 ug/kg/min (for a typical weight patient), or bolus approximately 3-7 ug for a typical patient. Of course the degree of hypotension, particular characteristics of your patient and clinical context should be taken into consideration. When your a lucky enough to have this resource, always consult your pharmacist.
Bottom Line: To reverse acute transient hypotension you may consider:
-A bolus of phenylephrine 50-200 ug (0.5-2 mL from neo-stick)
-A bolus of norepinephrine 3-7 ug
-Briefly increasing your norepinephrine drip (if you have one) to something around 0.1 ug/kg/min in a typical weight patient
-Always search for other causes of hypotension and consider clinical context.
Some patients with severe pulmonary hypertension receive continuous infusions at home of prostacyclins, such as epoprostanol (flolan). These are generally delivered via a pump that the patient wears, which is attached to an indwelling catheter. As with any indwelling device, they are at risk for infection and other complications, including malfunction.
Interruption of delivery of the medication can result in rapid cardiovascular collapse, sometimes within minutes. In this instance, the medication should be resumed as quickly as possible (by a traditional IV if the catheter is not functional), and the patients should be treated as one would approach a patient with decompensated right heart failure.
I once saw a patient in the ED whose listed chief complaint was "medication refill", but was actually there for dislodgement of her prostacyclin catheter (thankfully she was ok). With more patients receiving devices they are dependent upon (insulin pumps, AICDs, prostacyclin catheters), be wary of chief complaints such as "medication refill" or "device malfunction."
Bottom Line: Interruption of continuous prostacyclin therapy for pulmonary hypertension can be rapidly fatal and should be addressed immediately.
Bottom Line: Consider using capillary refill as an alternate (or complimentary) endpoint to lactate clearance when resuscitating your septic shock patients.
Many, if not nearly all, of our intubated patients in the ED have altered mental status, a potential to clinically worsen, or a requirement for medications that would alter their respiratory status (e.g. propofol, opioids, paralytics). It is imperative to place these patients on appropriate ventilator modes to avoid apnea when their respiratory status changes.