The incidence of empyema as a complication of pneumonia has been increasing since the 1990's and source control requires removing the pus from the chest as soon as possible, but how large should the drain be? The American Association for Thoracic Surgery (AATS) released the most recent guidelines for identifying and managing empyema in June 2017 and at the time had no certain evidence to guide the choice of large-bore vs small-bore catheters. Most studies to guide us are flawed (not randomized), but no recently published randomized studies exist to provide a definitive answer.
Bottom line: a small-bore pigtail catheter is a reasonable choice to drain empyema and flushing it every 6 hours has been shown to prevent clogging.
POCUS in the Critically Ill Pregnant Patient
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.
Wound botulism presents as descending paralysis when Clostridium botulinum spores germinate in anaerobic necrotic tissue. There have been hundreds of cases in the last decade, but it is poorly reported outside of California.
Black tar heroin and subcutaneous injection (“skin popping”) carry the highest risk, but other injected drugs and other types of drug use suffice. C botulinum spores are viable unless cooked at or above 85°C for 5 minutes or longer and this is not achieved when cooking drugs.
Early administration of botulism anti-toxin (BAT) not only saves lives but can prevent paralysis and mechanical ventilation. An outbreak of 9 cases between September 2017 and April 2018 cost roughly $2.3 million, in part because patients didn’t present on average until 48 hours after symptom onset and it took an additional 2-4 days before the true cause of their respiratory depression and lethargy were understood. One patient died.
PEARL: talk to your injecting drug users about the symptoms of botulism: muscle weakness, difficulty swallowing, blurred vision, drooping eyelids, slurred speech, loss of facial expression, descending paralysis, and difficulty breathing. Consider botulism early in your patients who inject drugs but who do not respond to naloxone or who exhibit prolonged symptoms. Testing at the health department is performed with mouse antibodies to Botulism Neurotoxin (BoNT) combined with the patient’s serum.
Don’t miss the injecting drug users with botulism!
Wound botulism presents as descending paralysis when Clostridium botulinum spores germinate in anaerobic necrotic tissue. There have been hundreds of cases in the last decade, but it is poorly reported outside of California.
Black tar heroin and subcutaneous injection (“skin popping”) carry the highest risk, but other injected drugs and other types of drug use suffice. C botulinum spores are viable unless cooked at or above 85°C for 5 minutes or longer and this is not achieved when cooking drugs.
Early administration of botulism anti-toxin (BAT) not only saves lives but can prevent paralysis and mechanical ventilation. An outbreak of 9 cases between September 2017 and April 2018 cost roughly $2.3 million, in part because patients didn’t present on average until 48 hours after symptom onset and it took an additional 2-4 days before the true cause of their respiratory depression and lethargy were understood. One patient died.
PEARL: talk to your injecting drug users about the symptoms of botulism: muscle weakness, difficulty swallowing, blurred vision, drooping eyelids, slurred speech, loss of facial expression, descending paralysis, and difficulty breathing. Consider botulism early in your patients who inject drugs but who do not respond to naloxone or who exhibit prolonged symptoms. Testing at the health department is performed with mouse antibodies to Botulism Neurotoxin (BoNT) combined with the patient’s serum.
Post-Arrest Prophylactic Antibiotics?
Little people (patients with achondroplasia or "dwarfism") have little lungs. Even though the trunk may appear to be a normal size with small limbs, the vital capacity is actually about 75% the predicted value based on the patient's sitting height. Macrocephaly and a decreased anterior-posterior depth are the cause for this. When you want to mechanically ventilate a little person, you can estimate their height based on a typical person with the same sitting height, but their actual volume will be about 3/4 the tidal volume predicted.
When intubating, remember these patients also have a high risk of basicranial hypoplasia (the foramen magnum may be small and key-hole shaped). These patients will be predisposed to compress the vertebral arteries when you tilt the head back and this itself can cause ischemia of the medulla and pons leading to central apnea.
Stokes DC, Wohl ME, Wise RA, et al. The lungs and airways in Achondroplasia. Do little people have little lungs? CHEST. 1990; 98(1):145-52
Pauli RM. Achondroplasia: A comprehensive review. Orphanet Journal of Rare Diseases. 2019; 14(1):
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.
In a study of alarms from 77 monitored ICU beds over the course of a month at the University of California, San Francisco, false alarms were common. Accellerated Ventircular Rhythms (AVRs) made up roughly one third of the alarms, and of the more than 4,361 AVRs, 94.9% were false while the remaining 5.1% did not result in a clinical action.
While this study had a majority of patients in the Med/Surg ICUs, a minority were from the cardiac and neurologic ICUs giving it some broad applicability. This study adds to the literature indicating there are subsets of alarms which may not be necessary or which may require adjustment to increase specificity.
Suba S, Sandoval CS, Zegre-Hemsey J, et al. Contribution of Electrocardiographic Accelerated Ventricular Rhythm Alarms to Alarm Fatigue. American Journal of Critical Care. 2019; 28(3):222-229
In a study of alarms from 77 monitored ICU beds over the course of a month at the University of California, San Francisco, false alarms were common. Accellerated Ventircular Rhythms (AVRs) made up roughly one third of the alarms, and of the more than 4,361 AVRs, 94.9% were false while the remaining 5.1% did not result in a clinical action.
While this study had a majority of patients in the Med/Surg ICUs, a minority were from the cardiac and neurologic ICUs giving it some broad applicability. This study adds to the literature indicating there are subsets of alarms which may not be necessary or which may require adjustment to increase specificity.
Suba S, Sandoval CS, Zegre-Hemsey J, et al. Contribution of Electrocardiographic Accelerated Ventricular Rhythm Alarms to Alarm Fatigue. American Journal of Critical Care. 2019; 28(3):222-229
Bottom Line: Consider using capillary refill as an alternate (or complimentary) endpoint to lactate clearance when resuscitating your septic shock patients.
Management of Coagulopathy in Acute Liver Failure
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.
Gallstones account for 35-40% of cases of pancreatitis and the risk increases with diminishing stone size. Bile reflux into the pancreatic duct can form stones there, beyond where they can be visualized by ultrasound. Biliary colic may precede the pancreatitis, but not necessarily. The pain typically reaches maximum intensity quickly but can remain for days.
Alanine aminotransferase (ALT) > 3x normal is highly suggestive of biliary pancreatitis.
Abdominal ultrasound is not sensitive to common bile duct stones but may find dilation.
In the absence of cholangitis, endoscopic ultrasound or MRCP are sensitive tests and permit intervention. Patients who recover are much more likely to develop cholangitis, therefore cholecystectomy is indicated in patients after they recover from gallstone pancreatitis.
Bottom Line: a patient presenting with days of abdominal pain but an absence of gallstones or cholangitis may still suffer from gallstone pancreatitis which requires further intervention, including cholecystectomy.
Mechanical Ventilation in the Obese Critically Ill
Background: Previous systematic reviews1,2,3 have indicated that the absence of cardiac activity on point-of-care ultrasound (POCUS) during cardiac arrest confers a low likelihood of return of spontaneous circulation (ROSC), but included heterogenous populations (both traumatic and atraumatic cardiac arrest, shockable and nonshockable rhythms).
The SHoC investigators4 are the first to publish their review of nontraumatic cardiac arrests with nonshockable rhythms, evaluating POCUS as predictor of ROSC, survival to admission (SHA), and survival to discharge (SHD) in cardiac arrests occurring out-of-hospital or in the ED.
Bottom Line: In nontraumatic cardiac arrest with non-shockable rhythms, the absence of cardiac activity on POCUS may not, on its own, be as strong an indicator of poor outcome as previously thought.
The Lung Transplant Patient in Your ED
When managing transplant patients it is important to keep in mind the anatomic and physiologic changes that occur with the complete extraction of one person's body part to replace another's.
For cardiac transplant patients with symptomatic bradycardia:
For cardiac transplant patients with tachyarrythmias:
Hyponatremia in the Brain Injured Patient
The PROTRACH study recently compared preoxygenation with standard bag valve mask (BVM) at 15 lpm to preoxygenation + apneic oxygenation with high flow nasal cannula 60 lpm/100% FiO2 in patients undergoing rapid sequence intubation.