--Recent meta-analysis comparing continuous infusion versus intermittent bolus dosing of beta-lactam antibiotics demonstrates mortality benefit (NNT = 15) in patients with severe sepsis or septic shock. (1)

--Consider beta-lactam continuous infusion on your septic patients if your hospital pharmacy allows

[Thanks to Anne Weichold, CRNP for providing the article for this pearl!]

Show Additional Information

Show References

PaCO2 and the Post-Arrest Patient

• Alterations in PaCO2 are common during the post-arrest period and have been associated with worse patient centered outcomes.
• Hypercarbia can dilate cerebral vessels, increase cerebral blood flow, and may increase intracranial pressure.
• Conversely, hypocarbia can constrict cerebral vessels and may reduce cerebral blood flow.
• Though the current evidence is primarily limited to observational trials, a recent meta-analysis found that "normocarbia" was associated with improved hospital survival and neurologic outcome. 
• Take Home: Adjust mechanical ventilation to target normocarbia (PaCO2 or ETCO2) in the post-arrest patient.

Show References

It is well known that the early aggressive utilization of IV nitrates and non-invasive positive pressure ventilation (NIV) in patients presenting with acute pulmonary edema will decrease the number of patients requiring endotracheal intubation and mechanical ventilation. 

Often our tepid dosing of nitroglycerine is to blame for treatment failure. Multiple studies have demonstrated the advantages of bolus dose nitroglycerine in the early management of patients with acute pulmonary edema. In these cohorts, patients bolused with impressively high doses of IV nitrates every 5 minutes, are intuabted less frequently than patients who received a standard infusion (1,2). No concerning drops in blood pressure in the patients who received bolus doses of nitrates were observed. Using the standard 200 micrograms/ml nitroglycerine concentration, blood pressure can be rapidly titrated to effect.

Show References

The Neurocritical Care Society and Society of Critical Care Medicine just came out with new Guidelines for Reversal of Antithrombotics in Intracranial Hemorrhage (ICH) [1]

--PCC is now recommended over FFP in reversal of vitamin K antagonists (VKA) with elevated INR. Either should be co-administered with 10mg IV vitamin K. (Strong recommendation, moderate quality evidence)

TAKE AWAY: PCC should be probably be given over FFP in VKA-ICH when available

Show Additional Information

Show References

Mechanical Ventilation in the Obese Patient

• Obesity can result in decreased lung volumes, decreased lung and chest wall compliance, and increased work of breathing.
• Unfortunately, there is very little literature to guide the emergency physician on mechanical ventilation in obese patients.
• A recent study of intubated ED patients by Goyal, et al found that over 1 in 5 patients were ventilated with potentially injurious tidal volumes.
• Importantly, obesity increased the odds of inappropriate ventilator settings.
• In the intubated obese patient, be sure to set tidal volume based on ideal body weight and consider starting with a higher PEEP setting (i.e., 10 to 15 cm H2O).

Show References

The prognosis of patients who experienced OHCA, who have not achieved ROSC by the time they present to the Emergency Department, is dismal. As such, it behooves us as Emergency Physicians to identify the few patients with a potentially survivable event. Drennan et al examined the ROC data base and identified the cohort of patients who had not achieved ROSC and were transported to the hospital. The overall survival in this cohort was 2.0%. Factors that predicted survival were initial shockable rhythm and arrest witnessed by the EMS providers. Patients arriving to the ED without ROSC, that had neither of those prognostic factors had a survival rate of 0.7%. 

Show References

--In this study, PE was diagnosed in ~17% of patients hospitalized for syncope (though this represents only ~4%% of patients presenting to the ED with syncope).

--Patients with PE were more likely to have tachypnea, tachycardia, relative hypotension, signs of DVT, and active cancer -- take a good history and do a good physical exam!

--Consider risk stratifying (Wells/Geneva) and/or performing a D-dimer (i.e "rule out" PE) on your syncope patients, particularly when no alternative diagnosis is apparent.

Show Additional Information

Show References

What Matters in Cardiac Arrest?

• Approximately 500,000 adults suffer sudden cardiac arrest each year in the United States.
• The most important components of cardiac arrest care that have been shown to improve outcomes are:
  1. High-quality CPR with little to no interruptions
  2. Defibrillation for ventricular arrhythmias
  3. Optimal post-arrest care
     • Target an SpO2 of 94-98%
     • Target an ETCO2 of 35-40 mm Hg (PaCO2 of 40-45 mm Hg)
     • Targeted temperature management
     • Early cardiac catheterization

Show References

It is well documented that when left to our own respiratory devices we will consistently over-ventilate patients presenting in cardiac arrest (1). A simple and effective method of preventing these overzealous tendencies is the utilization of a ventilator in place of a BVM. The ventilator is not typically used during cardiac arrest resuscitation because the high peak-pressures generated when chest compressions are being performed cause the ventilator to terminate the breath prior to the delivery of the intended tidal volume. This can easily be overcome by turning the peak-pressure alarm to its maximum setting. A number of studies have demonstrated the feasibility of this technique, most recently a cohort in published in Resuscitation by Chalkias et al (2). The 2010 European Resuscitation Council guidelines recommend a volume control mode targeting tidal volumes of 6-7 mL/kg and a respiratory rate of 10 breaths/minute (3).

It is well documented that when left to our own respiratory devices we will consistently over-ventilate patients presenting in cardiac arrest (1). A simple and effective method of preventing these overzealous tendencies is the utilization of a ventilator in place of a BVM. The ventilator is not typically used during cardiac arrest resuscitation because the high peak-pressures generated when chest compressions are being performed cause the ventilator to terminate the breath prior to the delivery of the intended tidal volume. This can easily be overcome by turning the peak-pressure alarm to its maximum setting. A number of studies have demonstrated the feasibility of this technique, most recently a cohort in published in Resuscitation by Chalkias et al (2). The 2010 European Resuscitation Council guidelines recommend a volume control mode at 6-7 mL/kg and 10 breaths/minute (3).

Show References

It's Election Day in the US, so here are some interesting facts about Presidential causes of death:

George Washington likely died from epiglottitis on 12/14/1799

• However, "iatrogenic" should also be listed on his cause of death
• Washington was blood let for almost 2.4L of blood!!!
• He also received an enema and multiple "blistering" treatments to draw the evil humors out of his throat
• He died before his fourth doctor, who planned to perform a tracheostomy, could arrive

CLICK BELOW FOR MORE INTERESTING FACTS!

Show Additional Information

Dynamic LVOT Obstruction

• Recent literature has indicated that dynamic LVOT obstruction can occur in critically ill patients without hypertrophic cardiomyopathy. In fact, a recent study found that this condition may be present in many patients with septic shock.
• Risk factors for  LVOT obstruction include any condition that decreases afterload, decreases preload, or increases heart rate.
• Consider LVOT obstruction when your ultrasound demonstrates close approximation of the lateral wall and septum plus systolic anterior motion of the anterior mitral leaflet.
• The treatment of patients with dynamic LVOT obstruction includes:
  • Increasing preload with aggressive IVFs
  • Increasing afterload (phenylephrine may be a good choice)
  • Avoiding inotropes
  • Decreasing heart rate (often with esmolol)

Show References

Recently Emergency Physicians have become far more aware of the importance of right ventricular (RV) function in our critically ill patient population. One of the methods that has been proposed to assess RV systolic function with bedside ultrasound (US) is the tricuspid annular plane systolic excursion (TAPSE). This simple bedside measurement utilizes M-mode to quantify the movement of the tricuspid annulus in systole. And while it has demonstrated reasonable accuracy at predicting RV dysfunction, adequate visualization of the lateral tricuspid annulus is not always obtainable in our critically ill patient population (1,2). In these circumstances an alternative measurement obtained in the subcostal window may be a viable option.

Similar to TAPSE, subcostal echocardiographic assessment of tricuspid annular kick (SEATAK) utilizes M-mode to assess the apical movement of the tricuspid annulus during systole. In a recent prospective observational study, Díaz-Gómez et al examined 45 ICU patients, 20 with known RV dysfunction and 25 with normal function. They compared the measurements obtained from TAPSE and SEATAK and found a strong correlation between the two measurement (Spearman’s ρ coefficient of .86, P=.03).

The small sample size and limited evaluation of RV function is far from ideal and more robust data sets are required before we cite SEATAK’s diagnostic accuracy with any confidence, but in the subset of patients where a TAPSE is unobtainable this may serve as an adequate surrogate until a more thorough echographic assessment can be obtained. 

Show References

--Massive PE is defined as PE with obstructive shock (hypotension [SBP <90] or end-organ malperfusion)

--Consider venoarterial (VA) ECMO in massive PE for hemodynamic support, particularly prior to intubation

--VA ECMO may prevent intubation/mechanical ventilation, surgical intervention, systemic and local thrombolysis

Show Additional Information

Show References

Oxygen-ICU Trial

• Recent observational trials have demonstrated an association between hyperoxia and worse outcomes in select critically ill patient populations.
• The Oxygen-ICU Trial was just published online in JAMA, and was an RCT to assess whether a conservative protocol for oxygen supplementation could improve outcomes in critically ill ICU patients compared with usual care.
• A total of 236 patients were randomized to the conservative oxgyen group (PaO2 target 70-100 mm Hg, SpO2 94-98%), whereas 244 were randomized to the usual care group (PaO2 up to 150 mm Hg, SpO2 97-100%).
• The results demonstrated that ICU mortality was lower in patients treated witih a conservative oxygen strategy, with an absolute risk reduction of 8.6%.
• Take Home Point: Be careful with the tiration of oxygen therapy and avoid hyperoxia in many of your critically ill patients.

Show Additional Information

Show References

The delta gap is a measurement intended to assess for mixed acid-base disorders. A straightforward alternative, the strong ion difference (SID), allows for a quick and simple assessment of any non-gap acidosis or alkalosis that may be present.

The SID is simply the difference between the strong cations (Na+, K+, Mg+, Ca+) and the strong anions (Cl-) present in the serum. The abbreviated SID is the difference between the serum sodium and serum chloride levels (approximately 138-102). Values typically range from 36-40 mg/dl. Values less than 36 denote the presence of some degree of hyperchloremic, non-gap, acidosis. While values greater than 40 demonstrate the presence of hypochloremic, non-gap, alkalosis. And while on rare occasions, variations in albumin or elevated levels of cations other than sodium can lead you astray, the SID is as accurate as a delta gap at identifying mixed acid-based disorders without the added mathematical complexity.

Show References

TAKE HOME POINTS:

-- High chloride load is associated with adverse outcomes in large-volume resuscitation (>60mL/kg in 24h), including increased risk of death [1]

-- Avoid supraphysiologic chloride solutions (i.e. normal saline) when resuscitation volumes are likely to exceed 60mL/kg (e.g. sepsis, DKA)

Show Additional Information

Show References

Pitfalls with PLR

• The passive leg raise (PLR) test has become a popular method to assess volume responsiveness in critically ill patients.
• PLR mobilizes a volume of approximately 150-300 mL and can be used in spontaneously breathing patients, those receiving positive pressure ventilation, or those with various arrhythmias. 
• In order to properly perform the PLR, you must have a method to monitor cardiac output. (See previously pearl on 7/26/16).
• Pitfall: Simply monitoring arterial blood pressure alone is not a sufficient method to assess a positive PLR.
• Pitfalls:Risks of performing a PLR include increased intracranial pressure, reduced cerebral blood flow, and decreased pulmonary compliance.

Show References

Question

--Aggressive BP management (SBP <140) in atraumatic intracerebral hemorrhage (ICH) does NOT signifcantly improve mortality or disability compared with traditional goal (SBP <180) [1]

--However, a lower goal (SBP <140) has been shown to decrease hematoma size and be safe compared to a higher goal (SBP <180) [2]

Show Answer

Show References

Ketamine for RSE?

• Up to 43% of patients with status epilepticus may progress to refractory status epilepticus (RSE).
• Propofol, midazolam, and barbituates are often recommended for patients with RSE.
• Importantly, all of these medications may be limited by hypotension and respiratory depression.
• Ketamine is emerging as adjuvant therapy for patients with RSE.
• The loading dose of ketamine ranges from 0.5 to 3 mg/kg, followed by a maintenance infusion of 0.3 to 4 mg/kg/h.

Show References