Background: Achieving ROSC in out of hospital cardiac arrest (OHCA) is no easy feat but, care doesn’t end with ROSC. Post-ROSC management is nuanced and challenging but helps to ensure good outcomes. Identification of the underlying cause of the cardiac arrest is a critical area of focus in post-arrest care. Although myocardial infarction, dysrhythmias and pulmonary emboli are common pathologies to consider, there are a host of other causes including subarachnoid hemorrhage, trauma and electrolyte disturbances.

In theory, rapid identification of the underlying cause should improve outcomes by allowing clinicians to tailor management. Advanced imaging post-arrest is a possible modality to achieve this end.

Article: Branch KHR et al. Diagnostic yield, safety, and outcomes of Head-to-pelvis sudden death CT imaging in post arrest care: The CT FIRST cohort study. Resus 2023. PMID: 37019352

Clinical Question: Does protocolized head-to-pelvis sudden death CT (SDCT) scanning improved the diagnostic yield post-ROSC in comparison to standard practice?

Population: Patients successfully resuscitated from OHCA without a clear diagnosis on presentation who were stable for CT.

Outcomes:

• Primary: Diagnostic yield (defined as the number of patients with an adjudicated diagnosis that was the presumed cause for OHCA) of SDCT in comparison to standard practice in identifying the cause of cardiac arrest.
• Secondary:
  • Time to adjudicated diagnosis.
  • Percentage of correct diagnoses
  • Diagnosis of time critical diagnoses
  • Delayed diagnosis > 6 hours from hospital arrival
  • Safety: Acute Kidney Injury

Intervention: “The SDCT scan protocol consisted of three CT scans: 1) a non-contrast head CT, 2) retrospective ECG-gated thoracic CT contrast angiogram for most of the cardiac cycle (initially 20–90% and later 30–80% of the cardiac cycle to reduce radiation dose), and 3) a venous phase, non-ECG gated, spiral abdominal and pelvis CT,” performed within 6 hours of presentation.

Control: Standard approach to diagnosis post-arrest but would be eligible for SDCT.

Design: Prospective, observational, before and after implementation of a protocol study.

Excluded:

• Obvious cause for OHCA prior to SDCT or on hospital arrival.
• Indication for emergency invasive coronary angiography or had coronary angiography within 1 hour of arrival.
• Known obstructive coronary artery disease or known coronary stent.
• Known cardiac defibrillator.
• Pre-existing DNR order.
• Severe renal dysfunction.

Primary Results

• • Standard care enrollment period
    • 143 of 273 patients with ROSC after OHCA were eligible for enrollment.
    • Most common reason for exclusion: Would not have been able to undergo SDCT.
  • SDCT enrollment period
    • 111 of 307 patients with ROSC after OHCA were eligible for enrollment. Several were later excluded.
    • Most common reason for exclusion: Patient was not scanned.
  • CT scanning was common in the standard care cohort (84% received at least one CT – usually NCHCT)

Critical Findings:

Strengths:

• Investigates an important area with limited prior research.
• Most baseline demographics were similar between the two groups.
• Post-arrest care (aside from the studied intervention) appears to be similar between the two groups.

Limitations:

• Observational, before and after studies cannot show causality; they can only reveal associations.
• Small sample size of patients.
• Risk of selection bias based on the large number of patients that were not included.
• The authors did not give detailed information on why patients were excluded particularly in the SDCT enrollment period when the vast majority of ROSC patients were not included.
• No 95% confidence intervals are supplied for the primary or secondary outcomes making it impossible to assess confidence of the findings.

Discussion

• Framing this as a diagnostic study reveals that SDCT was successful in what it is intended to do: identify pathology. However, it’s important to determine the benefit of the improvement in diagnosis.
  • An improvement in diagnostic accuracy is important if it leads to improved outcomes for the patient. In the absence of improved outcomes, the costs (however modest) likely outweigh the benefits.
  • Costs include actual cost of the scans as well as delaying other patients’ scans but also includes time taken away from resuscitation to move the patient to and from CT. The cost difference may be modest here as many of the patients in the standard care cohort were getting CTs as well.
• In real life, many of the exclusion criteria will not be known at the point of first contact (ie DNR order, history of obstructive coronary artery disease).
• Treatment implications of the study
  • Before and after studies (in terms of treatment) can be biased by other advances in care that occur during the intervening time. For example, if some other proven intervention became available to the after group, this group would have more favorable outcomes regardless of the intervention being studied.
  • Bystander CPR, a known predictor of good outcomes, was more common in the SDCT cohort than in the standard care cohort.
• There is no discussion of how many of the diagnoses made by SDCT could have been made clinically instead.
  • This is similar to what we see in the trauma “pan-scan” literature: if you don’t look for clinical pathology, CT scan will identify a number of things you didn’t recognize.
• Many patients in the standard care cohort underwent CT imaging. This may reduce the impact of protocolized SDCT in comparison to an institution where CT use post-ROSC is minimal.
• Majority of patients excluded in the SDCT cohort were excluded for inability to get to CT within 6 hours. A protocol encouraging CT within 6 hours may increase risk for the patient by prioritizing imaging over resuscitatin.

Authors Conclusions: “SDCT scanning early after OHCA resuscitation safely improved the efficiency and diagnostic yield for causes of arrest compared to the standard of care alone.”

Our Conclusions: The authors conclusions overstep what their data can reveal. SDCT was associated with a higher and more rapid diagnostic yield post-arrest than standard practice. However, this improvement did not translate to improved patient outcomes.

Potential to Impact Current Practice: This data should not change clinical practice. High-quality, randomized studies are needed to further elucidate the utility of SDCT.

Bottom Line: Routine SDCT should not be part of standard practice in patients with ROSC after OHCA. Clinicians should use their clinical assessment to guide advanced imaging in this group.

References:

1. Branch KHR et al. Diagnostic yield, safety, and outcomes of Head-to-pelvis sudden death CT imaging in post arrest care: The CT FIRST cohort study. Resus 2023. PMID: 37019352

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

The post The CT FIRST Trial: Should We Pan-CT After ROSC? appeared first on REBEL EM - Emergency Medicine Blog.

Background: Sepsis can induce numerous physiologic derangements.  At the most severe end, this includes endothelial dysfunction leading to increased vascular permeability, abnormal nitric oxide metabolism, and vasodilation (i.e. septic shock).  Judicious fluid resuscitation is indicated in patients with signs of hypo perfusion but is often inadequate necessitating the administration of vasoactive medications.

Norepinephrine is the 1^st line vasopressor but at high doses can have increased adverse effects including tachyarrhythmias, myocardial disfunction, and peripheral ischemia. Higher doses and longer duration of exposure to vasopressors can be associated with increased risk of organ failure, and death [5]. Adding catecholamine-sparing agents such as methylene blue (MB) “earlier” in treatment may reduce the norepinephrine exposure (both dose and duration).

MB decreases nitric oxide levels by inhibiting inducible nitric oxide synthase (iNOS) and soluble guanylate cyclase (sGC).  Through these mechanisms it restores vasoregulation.  Most of the research on the use of MB has been in patients with vasoplegia following cardiopulmonary bypass. Limited, small studies on its use in septic shock do not make a clear argument for use.

Paper: Ibarra-Estrada, M et al. Early Adjunctive Methylene Blue in Patients with Septic Shock: A Randomized Controlled Trial. Crit Care 2023. PMID: 36915146 [Access on Read by QxMD]

Clinical Question: Does adjunctive methylene blue reduce time to vasopressor discontinuation in patients with septic shock?

What They Did:

• Single-center, parallel, double blind, randomized controlled trial performed in a medical-surgical ICU (Mexico)
• Both groups received:
  • Adjunctive vasopressin initiated at a dose of 0.03 IU/min if norepinephrine dose reached ≥0.25mcg/kg/min
  • Evaluation of volume responsiveness repeated at least 3x/day as long as vasopressors were needed
  • Hydrocortisone 200mg/day by continuous infusion
  • Nurse-led vasopressor tapering protocol with titration of vasopressors at 15 to 20min intervals to maintain MAP between 65 and 75mmHg until complete discontinuation
  • Vasopressin was progressively withdrawn by 0.005UI/min each hour only after complete discontinuation of norepinephrine
  • Methemoglobin capillary saturation was continuously monitored along the intervention timeframe by pulse co-oximetry
• Patients with septic shock according to Sepsis-3 criteria randomized to:
  • Methylene Blue (MB): IV infusion of 100mg of MB in 500mL of 0.9% NaCl over 6hrs once daily x3 doses
  • Placebo: 500mL of 0.9% NaCl without MB

Outcomes:

• Primary: Time to vasopressor discontinuation(Defined as discontinuation of all vasopressors for at least 48 consecutive hours)
• Key Secondary Outcomes:
  • Vasopressor-free days at 28d
  • Days on mechanical ventilator
  • Length of stay in ICU
  • Length of stay in Hospital
  • 28d Mortality

Inclusion:

• Adult patients (≥18 years of age)
• Septic shock as defined by Sepsis-3 criteria
  • Highly suspected or confirmed infection
  • Requiring norepinephrine to maintain a MAP≥65mmHg
  • Serum lactate >2mmol/L after adequate fluid resuscitation 

Exclusion:

• >24hr since initiation of norepinephrine
• Pregnancy
• High probability of death within 48hrs
• Concurrent hemorrhagic, obstructive, or hypovolemic shock
• Pending damage control surgery
• Major burn injury
• Personal or familiar history of glucose-6-phosphate dehydrogenase deficiency
• Allergy to methylene blue, phenothiazines, or food dyes
• Recent intake (4wks) of selective serotonin re-uptake inhibitors
• Refusal of patient or decision maker to participate
• During the COVID-19 pandemic, data safety monitoring board did not allow recruitment of patients with COVID-19 due to unknown pathophysiologic underpinnings and unknown response to MB

Results:

• 308 patients evaluated for eligibility
  • 216 not eligible (Most common reason was diagnosis of COVID-19)
  • 92 patients underwent randomization
  • Took over 5 years (2017 to 2022) to recruit these patients
  • 1 patient withdrew in the MB group leaving 91 patients with data available for analysis
• Characteristics of Patients:
  • Median Age ≈46years
  • Source of Infection: PNA ≈50%; Intra-Abdominal ≈38%; UTI ≈9%
  • Shock Diagnosis to Intervention ≈8hrs
  • Positive Fluid Response at Enrollment ≈46%
  • Norepinephrine Dose ≈0.41mcg/kg/min
  • Vasopressin Use ≈76%
  • Serum Lactate ≈5.6mmol/L
  • Mechanical Ventilation ≈87%
  • ARDS ≈75%
  • Ejection Fraction ≈60%
  • SOFA Score = 10
  • APACHE II Score ≈22
  • No other vasopressors (phenylephrine, angiotensin II, epinephrine, midodrine) or inotropes (milrinone, dobutamine) were used in this study
• Time to vasopressor discontinuation at 28d (Primary Outcome)
  • MB: 69hrs (Range 59 to 83hr)
  • Placebo: 94hrs (Range 74 to 141hrs)
  • Median difference: 29.4; 95% CI 15.4 to 50.7; P<0.001
  • Norepinephrine dose requirement decreased more pronouncedly in the MB group as compared to placebo over the first 4 days
  • 5/45 (11%) patients in MB group and 13/46 (28%) patients required re-initiation of NE within 48hrs after discontinuation (p = 0.06)
• Early adjunctive MB compared to placebo also led to:
  • One more vasopressor-free day at day 28 (P = 0.008)
  • Lower cumulative fluid balance by 741mL (p = 0.001)
  • Shorter ICU length of stay by 1.5 days (P = 0.039)
  • Shorter hospital length of stay by 2.7d (P = 0.027)
• No difference in days on mechanical ventilation and mortality between groups
• No serious adverse events related to MB administration
  • Most common adverse effect was green-blue discoloration of urine in 42/45 (93%) of patients

Strengths:

• Patients, clinicians, investigators, and outcome assessors were blinded to the treatment received
  • To avoid visual identification, all infusion bags and polyvinylchloride lines were prepared at a central pharmacy with opaque envelopes
• Baseline characteristics of patients were similar between groups
• Largest RCT comparing MB to placebo in patients with septic shock
• Treatments outside of the intervention were standardized across groups by protocol. 

Limitations:

• Green-blue discoloration of urine could have led to unblinding of groups
• Non-patient centered primary outcome
• Decreased generalizability due to numerous exclusions
• Decreased generalizability due to small number of enrolled patients over a long interval time
• Single-center study performed in Mexico which may have different practice patterns than other facilities and countries, which could limit generalizability
• These patients had dynamic testing of fluid responsiveness quite frequently, which may not be possible in settings outside the ICU
• Patients with COVID-19 were excluded in this study and its results can not be extrapolated to this population
• Study was underpowered to make any real conclusions on mortality. Larger studies would be needed to confirm the results of this trial

Discussion:

• All fluid resuscitation of septic shock was guided by dynamic tests for prediction of volume responsiveness. Most common methods were:
  • Aortic velocity-time integral change after passive leg raise (Cut-off 10%)
  • Arterial pulse pressure variation (Cut-off 13%)
  • Tidal volume challenge (Cut-off 3.5%)
  • Respiratory variation of carotid peak flow velocity (Cut-off 14%)
  • Adequate fluid resuscitation was defined as at least 500mL bolus of balanced crystalloids followed by negative volume responsiveness by at least 2 different methods
• Performed a sample size calculation with an expected mean vasopressor duration of 97 +/- 69hrs (Mean 83hrs), and considering a decrease of 24hrs as clinically relevant, the calculated sample size was 88 for the trial to provide a statistical power of 80%
• Previous Evidence:
  • Kirov et al 2001 [2]: 20 patients with septic shock randomized to placebo or a bolus injection of 2mg/kg of MB, followed by a continuous 4hr infusion to a total dose of 5.75mg/kg
    • More patients died in placebo group (7 vs 3)
    • Duration of vasopressor support shorter in MB group (71hr vs 93hr)
    • Both outcomes not statistically significant
  • Memis et al 2002 [3]: 30 patients with septic shock randomized to placebo vs MB 3mg/kg over 6hrs
    • No difference in cytokine levels
    • Significant but transient increase in MAP in patients of MB group
  • Most common use of MB is in patients after cardiopulmonary bypass
    • 50% of patients will develop vasoplegia, but typically this is limited to a few hours
    • Sepsis on the other hand has a less predictable inflammatory insult and can last for several days
      • Doses <2mg/kg rarely present with adverse effects (i.e worsening oxygenation from pulmonary vasoconstriction, methemoglobinemia)
      • In this study, patients received 100mg vials over 6hours 1x/day which is the equivalent of 1mg/kg in a 100kg patient Total cumulative dose of 3.6mh/kg over 54 hours)
        • This dose reduced vasopressor support with no detrimental effects
        • Methemoglobin levels were higher in the MB group (2.9% (Range 2.2. to 3.3) vs 0.5% (Range 0.4 to 0.7) BUT significantly lower than the clinically relevant threshold of 10%

Author Conclusion: “In patients with septic shock, MB initiated within 24h reduced time to vasopressor discontinuation and increased vasopressor-free days at 28 days. It also reduced length of stay in ICU and hospital without adverse effects.  Our study supports further research regarding MB in larger randomized clinical trials.”

Clinical Take Home Point: This small, single-center RCT found that adjunctive MB administered within 24hrs of septic shock reduced time to vasopressor discontinuation. The study was too small to make strong conclusions about adverse events. Without larger studies and a patient centered outcome, the addition of methylene blue within 24 hours of septic shock should still not be part of a general approach but rather an adjunct in specific circumstances (i.e. Septic shock and significant vasopressor requirements).

References:

1. Ibarra-Estrada, M et al. Early Adjunctive Methylene Blue in Patients with Septic Shock: A Randomized Controlled Trial. Crit Care 2023. PMID: 36915146 [Access on Read by QxMD]
2. Kirov MY et al. Infusion of Methylene Blue in Human Septic Shock: A Pilot, Randomized, Controlled Study. Crit Care Med 2001. PMID: 11588440
3. Memis D et al. The Influence of Methylene Blue infusion on Cytokine Levels During Severe Sepsis. Anaesth Intensive Care 2002. PMID: 12500513
4. Lopez A et al. Multiple-Center, Randomized, Placebo-Controlled, Double-Blind Study of the Nitric Oxide Synthase Inhibitor 546C88: Effect on Survival in Patients with Septic Shock. Crit Care 2004. PMID: 14707556
5. Richards-Belle et al. Lower Versus Higher Exposure to Vasopressor Therapy in Vasodilatory Hypotension: A Systematic Review with Meta-Analysis. Crit Care Med 2023. PMID: 36398968

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)

The post Adjunctive Methylene Blue in Septic Shock? appeared first on REBEL EM - Emergency Medicine Blog.

I recently gave a talk on the initial management of trauma patients with hemorrhagic shock.  In the initial management of trauma resuscitation there are 4 key principles that should be followed:

1. Control bleeding
2. Restore tissue perfusion
3. Minimize iatrogenic injury from resuscitation itself
4. Promote hemostasis

In this blog post I will summarize the lecture and the evidence for each of these principles…

MINIMIZE IATROGENIC INJURY

• PERMISSIVE HYPOTENSION
  • Maintaining a lower blood pressure than physiologic levels in patients suffering from hemorrhagic blood loss/shock
  • Dutton RP et al. J Trauma 2002 [1]
    • 110 trauma patients with hemorrhagic shock were randomized to two resuscitation protocols: Target SBP >100mmHg vs Target SBP > 70mmHg
    • There was no difference in mortality regardless of which target SBP patients were randomized too
  • My best guess for target SBP goal in trauma patients with hemorrhagic shock would be 70 to 90mmHg (Excluding patients with TBI)
  • By having a set goal you get what’s called cyclic hyper-resuscitation (SEE IMAGE BELOW)
    • Low BP or MAP –> Aggressive Resuscitation –> Nl/High BP or MAP –> Low BP

• Clinical Take Home: Targeting physiologic markers of perfusion (i.e. mental status, urine output, capillary refill) is more important than an actual goal
• PERMISSIVE HYPOTENSTION IN PTS WITH TBI
  • Brotfain E et al. Shock 2012 [5]
    • 48 rats given TBI and hypovolemic shock
    • Resuscitation goals included MAP target of 80, 100, and 120mmHg at 15min
    • The group with the highest MAP target had the largest amount of resuscitation
    • Neurological outcomes and mortality were inversely correlated with aggressiveness of resuscitation (MAP target of 80mmHg provided the best results)
  • Spaite DW et al. Ann Emerg Med 2017 [6]
    • This was a retrospective database review of 7521 traumatic brain injury patients
    • SBP target ≥90mmHg resulted in a mortality of 7.8% vs SBP target <90mmHg which resulted in a mortality of 33.4%
  • Clinical Take Home Point: In patients with TBI and hypovolemic shock, target a SBP or MAP ≥90mmHg, but know this is based on limited evidence.
• CRYSTALLOIDS
  • Too much crystalloid resuscitation in traumatic hemorrhagic shock can increase dilutional coagulopathy, as well as increase morbidity and mortality
  • Bickell WH et al. NEJM 1994. [2]
    • Prospective trial comparing immediate vs delayed fluid resuscitation in 598 adult patients with penetrating torso injuries presenting with a pre-hospital SBP ≤90mmHg
    • Immediate fluid resuscitation had a higher mortality, more complications and longer hospital length of stay
  • Clinical Take Home Point: Crystalloid fluid resuscitation can be counterproductive and delay of aggressive crystalloid fluid resuscitation until hemorrhage control is achieved improves outcomes (If blood products not available consider small volume crystalloid boluses (i.e. 250 cc) up to 1L)
• VASOPRESSORS
  • Current dogma is that vasopressors are not helpful in trauma patients as they can worsen ischemia (no reason to squeeze the pipes if the tank is empty).
  • Richards JE et al. Anesth Analg 2021 [3]
    • This was a narrative review article
    • Concluded that the pathophysiology of shock in trauma patients is complex
      • Initial sympathoexcitatory phase: Attempt to compensate for acute blood loss and characterized by vasoconstriction, tachycardia, and preserved MAP
      • Subsequently a sympathoinhibitory vasodilation phase occurs: Leads to hypotension
      • Resuscitation of traumatic shock needs to target an appropriate balance with intravascular volume and vascular tone
  • Sims et al. JAMA Surg 2019 [4]
    • The AVERT-Shock Trial
    • Only RCT in human trauma patients with vasopressors to date
    • Randomized, double-blind, placebo-controlled clinical trial of 100 adult trauma patients having received at least 6U of any blood product within 12hrs of injury
    • Randomized to: After administration of a vasopressin bolus (4U) vs placebo, pts received vasopressin (0 to 0.04U/min) or placebo for 48hrs to maintain a MAP of at least 65mmHg
    • Vasopressin was only given after definitive hemorrhage control was achieved
    • The use of vasopressin resulted in less blood products at 48 hrs (1.7 vs 3U) but no difference in mortality (Study not powered for this outcome)
  • Clinical Take Home Point: The use of vasopressors is controversial and requires a nuanced approach

SUMMARY OF MINIMIZING IATROGENIC INJURY

RESTORE PERFUSION

• VOLUME REPLACEMENT
  • Blood Products >>> Crystalloids
  • Holcomb JB et al. JAMA 2015 [7]
    • The PROPPR Trial
    • 680 severely injured adult trauma patients
    • Patients randomized to Plasma, Platelets, and PRBCs in a 1:1:1 ratio vs 1:1:2 ratio
    • No difference in overall mortality at 24 hrs BUT 1:1:1 achieved hemostasis faster and fewer experienced death due to exsanguination at 24hrs
  • Crombie N et al. Lancet Haematol 2022 [8]
    • The RePHILL Trial
    • 432 adult trauma patients with trauma related hemorrhagic shock and hypotension (defined as SBP <90mmHg or absense of radial pulse) resuscitated with pre-hospital blood products
    • Patients randomized to PRBCs/Lyophilised plasma vs saline solution
    • Trial recruitment was stopped prior to intended sample size or 490 patients due to COVID-19 pandemic
    • Composite primary outcome was mortality, impaired lactate clearance or both
    • No difference in composite primary outcome
    • Reasons why trial may have been negative
      • Mostly blunt trauma patients (not penetrating injuries)
      • Transport times were short for many patients
      • Better resuscitation pre-hospital (Sicker patients getting to the hospital which could drive up mortality overall)
    • Clinical Take Home Point: Current evidence shows plasma, platelets, PRBCs in a 1:1:1 ratio is best strategy for resuscitation of trauma patients with hemorrhagic shock
• MASSIVE TRANSFUSION PROTOCOL (MTP)
  • Who Needs a MTP?
    • ABC Score:
      • Penetrating Mechanism
      • SBP ≤90mmHg
      • HR ≥120 BPM
      • Positive FAST Abdominal Views
      • If ≥2 present, consider MTP
    • RABT Score
      • Revised Assessment of Bleeding and Transfusion Score
      • Penetrating Injury
      • Positive FAST
      • Shock Index >1.0
      • Pelvic Fracture
      • A score ≥2 present, consider MTP
    • Clinical Take Home Point: Use of balanced transfusion (including PRBCs and clotting factors) helps avoid dilutional coagulopathy
• WHOLE BLOOD VS COMPONENT THERAPY
  • Kronstedt S et al. Cureus 2022 [9]
    • Narrative Review
    • Whole blood logistically makes sense but thus far mostly small prospective or retrospective studies have failed to demonstrate a significant benefit of whole blood vs blood component therapy
    • Clinical Take Home Point: Current literature suggests that whole blood therapy shows promise as a treatment strategy for adult trauma patients

SUMMARY OF RESTORING PERFUSION

PROMOTE HEMOSTASIS

• TRANEXAMIC ACID (TXA)
  • CRASH-2 Trial Collaborators et al. Lancet 2010 [10]
    • >20,000 adult trauma patients with SBP <90mmHg
    • Patients randomized to TXA 1g over 10 min + 1g IV over 8hrs vs Placebo given within 8hrs of injury
    • In-hospital mortality by 28d reduced (14.5% vs 16%; ARR 1.5%; NNT = 67)
    • Clinical Take Home Point:
      • TXA 1g over 10 min + 1g IV over 8 hrs reduces the risk of death in bleeding trauna patients when given within 3hrs of injury
      • TXA given as a 2g bolus (Single bolus easier to remember than giving two doses; No evidence of harm)
  • CRASH-3 Trial Collaborators et al. Lancet 2019 [11]
    • >12,000 Adults with TBI within 3hrs of injury, GCS ≤12 or any ICH on CT scan, and no major extracranial bleeding were eligible
    • Patients randomized to TXA 1g over 10 min + 1g IV over 8hrs vs Placebo given within 8hrs of injury (Later amended to within 3hrs of injury)
    • Patients randomized to TXA 1g over 10 min + 1g IV over 8hrs vs Placebo
    • Primary outcome of head injury-related death within 28 days was the primary outcome (NO DIFFERENCE)
      • Risk of head injury-related death in patients with mild-to-moderate head injury (GCS 9 to 15) was reduced but not in patients with severe head injury (GCS 3 to 8)
    • Clinical Take Home Point: TXA didn’t benefit in the primary outcome of head injury-related death within 28 days, but the authors had to narrow down the group to get a significant benefit making it more difficult to apply the results to all TBI patients
• CRYOPRECIPITATE
  • Curry N et al. British Journal of Anaesthesia 2015 [12]
    • CRYOSTAT-1 trial
    • Unblinded feasibility RCT
    • 202 Adult trauma patients requiring MTP
    • 85% got cryoprecipitate within 90min
    • No difference in 28d all cause mortality
    • Clinical Take Home Point: It is feasible to administer cryo within 90min of admission to hospital
  • CRYOSTAT-2 Trial
    • Pending Publication
• LABS TO FOLLOW
  • PLATELETS
    • Target >50,000
    • If head injury suspected or ICH target >100,000
  • INR
    • Target INR <2
  • FIBRINOGEN
    • Target 150 to 1000mg/dL
    • 10U Cryoprecipitate ≈75mg/dL
  • CALCIUM
    • Citrate in blood products dilutes out calcium
    • Calcium also augments clot formation
    • 1 to 2g CaCl or 3 to 6g CaGluc for every 6U of blood products
    • 1amp of CaCl = 3amps of CaGluc (1 to 3 ratio)
• TEG/ROTEM

• • Badsaas-Aasen K et al. Intensive Care Med 2020. [13]
    • ITACTIC Trial
    • 480 Adult trauma patients getting MTP augmented by Viscoelastic Hemostatic Assays vs Conventional Coagulation Tests
    • No difference in proportion of patients alive and free of massive transfusion at 24hrs after injury
    • Major flaw of study is many patients did not develop coagulopathy in this study
    • Clinical Take Home Point: Blood products are given so rapidly during resuscitation that it’s practically impossible to use standard labs to guide product administration (By the time a set of labs has returned, it is already obsolete). Not every institution will have TEG/ROTEM and more evidence is needed to support or refute its use
• 4F-PCC
  • Bouzat P et al. JAMA 2023 [14]
    • PROCOAG Trial
    • 324 trauma patients receiving standard trauma resuscitation management at risk of needing MTP randomized to 4F-PCC vs placebo
    • No difference in the median 24hr blood product consumption (primary outcome)
    • Way more thromboembolic events in the 4F-PCC group (35% vs 24%)
    • Clinical Take Home Point: The addition of 4F-PCC does not result in decreased blood product consumption compared to placebo and resulted in a higher rate of thromboembolic events. At this time the use of 4F-PCC is not supported in patients with trauma at risk of MTP

SUMMARY OF PROMOTING HEMOSTASIS

CONTROL BLEEDING

• STRATEGY
  • Use the fastest strategy to get hemorrhage control
    • Tourniquets
    • Direct Pressure
    • Packing
    • Sutures
    • Interventional Surgical Repair
    • Definitive Surgical Repair
  • Be systematic in finding bleeding (SCALPER)
    • S = Scalp
    • C = Chest
    • A = Abdomen
    • L = Long Bones
    • P = Pelvis
    • E = Extremities
    • R = Retroperitoneum
• TOURNIQUETS
  • Schroll R et al. J Trauma Acute Surg 2022 [15]
    • Multicenter prospective observational trial
    • ≈1400 adult patients with extremity trauma injuries requiring a trauma center
    • Patients either received prehospital tourniquets or no tourniquets
    • Tourniquets controlled bleeding in 87.7% of injured limbs
    • Tourniquet patients were less likely to arrive in shock compared to no torniquets (13.0% vs 17.4%)
    • No difference in limb complications
    • Clinical Take Home Point: Tourniquets result in decreased incidence of shock without an increase in limb complications
• CHEST TUBES
  • Kulvatunyou N et al. J Trauma acute Care Surg 2021 [16]
    • Non-inferiority randomized trial of 120 patients randomized to 14Fr pigtail vs 28 to 32Fr chest tube for traumatic hemothorax (Patients were all hemodynamically stable)
    • No difference in failure rate
    • Inferiority margin of 15% is very wide making it easier to show non-inferiority
    • Additionally, this seems to be a convenience sample (i.e. patients were hand picked)
    • Clinical Take Home Point: In selected hemodynamically stable trauma patients with hemothorax the use of 14Fr pigtail catheters appear to have drainage rates and complication rates that are at least equal and your patient will thank you for using a smaller tube
• REBOA
  • Joseph B et al. JAMA Surg 2019 [17]
    • Retrospective case-control analysis of 140 adult trauma patients undergoing REBOA
    • Looked at mortality in the ED, 24hrs, and after 24hrs
    • There was a higher 24hr mortality, rate of AKI, and rate of lower limb amputation in the REBOA group compared to standard care
    • Additionally, there was a longer time to interventional radiology angioembolization or laparotomy in the REBO group
    • Clinical Take Home Point: Currently at some institutions REBOA is still being used in non-compressible torso trauma, but more evidence is needed before adoption into standard practice
  • Cralley AL et al. JAMA Surg 2022 [18]
    • Prospective multicenter comparative effectiveness study from the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Registry
    • Performed propensity score matching and subgroup multivariate analysis to control for confounders
    • Aorta occlusion via REBOA zone 1 (above celiac artery) vs Resuscitative thoracotomy
    • Primary outcome was survival
    • 991 patients included
    • Propensity score matching selected 112 comparable patients (56 pairs)
    • REBOA zone 1 aortic occlusion was associated with a statistically significant lower mortality compared with resuscitative thoracotomy (78.6% vs 92.9%)
      • Multivariate analysis confirmed survival benefit of REBOA zone 1 after adjustment for significant confounders (RR 1.25; 95% CI 1.15 to 1.36)
      • In all subgroup analyses (Cardiopulmonary resuscitation on arrival, traumatic brain injury, chest injury, pelvic injury, blunt/penetrating mechanism, SBP ≤60mmHg on Aortic occlusion injury) REBOA zone 1 offered an either similar or superior survival
    • Clinical Take Home Point: REBOA zone 1 aortic occlusion was associated with a better or similar survival than resuscitative thoracotomy. This study establishes a clinical equipoise between the above two resuscitation strategies to justify the planning of a randomized controlled trial to evaluate safety and effectiveness of REBOA zone 1 aortic occlusion in trauma resuscitation

SUMMARY OF BLEEDING CONTROL

As stated at the top of this post, this is simply a summary of the best current evidence in initial trauma resuscitation. In the initial management of trauma patients there are 4 key principles that should be followed:

1. Control bleeding
2. Restore tissue perfusion
3. Minimize iatrogenic injury from the resuscitation itself
4. Promote hemostasis

References:

1. Dutton RP et al. Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality. J Trauma. 2002. PMID: 12045644
2. Bickell WH et al. Immediate Versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries. NEJM 1994. PMID: 7935634
3. Richards JE et al. Vasopressors in Trauma: A Never Event? Anesth Analg 2021. PMID: 33908898
4. Sims et al, “Effect of Low-Dose Supplementation of Arginine Vasopressin on Need for Blood Product Transfusions in Patients With Trauma and Hemorrhagic Shock: A Randomized Clinical Trial,” JAMA Surg, Aug. 2019. PMID: 31461138
5. Brotfain E et al. Severe Traumatic Brain Injury and Controlled Hemorrhage in Rats: Quest for the Optimal Mean Arterial Blood Pressure After Whole Fresh Donor Blood Resuscitation. Shock 2012. PMID: 23143053
6. Spaite DW, Hu C, Bobrow BJ, et al. Association of out-of- hospital hypotension depth and duration with traumatic brain injury mortality. Ann Emerg Med. 2017. PMID: 28559036
7. Holcomb JB et al. Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 ratio and Mortality in Patients with Severe Trauma: The PROPPR Randomized Clinical Trial. JAMA 2015. PMID: 25647203
8. Crombie N et al. Resuscitation with Blood Products in Patients with Trauma-Related Haemorrhagic Shock Receiving Prehospital Care (RePHILL): A Multicentre, Open-Label, Randomised, Controlled, Phase 3 Trial. Lancet Haematol 2022. PMID: 35271808
9. Kronstedt S et al. The Role of Whole Blood Transfusions in Civilian Trauma: A Review of Literature in Military and Civilian Trauma. Cureus 2022. PMID: 35481238
10. CRASH-2 trial collaborators, Shakur H, Roberts I, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet (London, England). 2010; 376(9734):23-32.PMID: 20554319
11. The CRASH-3 Trial Collaborators. Effects of Tranexamic Acid on Death, Disability, Vascular Occlusive Events and Other Morbidities in Patients with Acute Traumatic Brain Injury (CRASH-3): A Randomised, Placebo-Controlled Trial. Lancet 2019. PMID: 31623894
12. Curry N et al. Early Cryoprecipitate for Major Haemorrhage in Trauma: A Randomised Controlled Feasibility Trial. British Journal of Anaesthesia 2015. PMID: 25991760
13. Badsaas-Aasen K et al. Viscoelastic Haemostatic Assay Augmented Protocols for Major Trauma Haemorrhage (ITACTIC): A Randomized, Controlled Trial. Intensive Care Med 2020. PMID: 33048195
14. Bouzat P et al. Efficacy and Safety of Early Administration of 4-Factor Prothrombin Complex Concentrate in Patients with Trauma at Risk of Massive Transfusion: The PROCOAG Randomized Clinical Trial. JAMA 2023. PMID: 36942533
15. Schroll R et al. AAST Multicenter Prospecitve Analysis of Prehospital Tourniquet Use for Extremity Trauma. J Trauma Acute Care Surg 2022. PMID: 35609289
16. Kulvatunyou N et al. the Small (14Fr) Percutaneuos Catheter (P-CAT) Versus Large (28 – 32Fr) Open chest Tube for Traumatic Hemothorax: A Multicenter Randomized Clinical Trial. J Trauma Acute Care Surg. 2021. PMID: 33843831
17. Joseph B et al. Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma. JAMA Surgery 2019. PMID: 30892574
18. Cralley AL et al. Zone 1 Endovascular Balloon occlusion of the Aorta vs resuscitative Thoracotomy for Patient Resuscitation After Severe Hemorrhagic Shock. JAMA Surg 2022. PMID: 36542395

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)

The post Trauma Resuscitation Updates appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points

1. The Parkland formula can be used to be a guide for initial fluid resuscitation. This is based on second- and third-degree burns (not first-degree). Utilize response to treatment as a guide to continue fluid resuscitation.
2. Patients in fires in closed spaces for a prolonged time are at risk for airway edema and need for intubation. History of fire is very important and please monitor patient condition, patients’ voice, and repeat physical exam.
3. Prophylactic antibiotics can be avoided in most burn cases.
4. Checking extremity pulses for extremity burns are important. Loss of pulse should trigger an escharotomy. Continued loss of pulse should trigger a fasciotomy.
5. Have a low threshold for starting Hydroxocobalamin for possible cyanide toxicity and for testing for a carboxyhemoglobin level for possible carbon monoxide toxicity.

The post REBEL Core Cast 102.0 – Burn Management appeared first on REBEL EM - Emergency Medicine Blog.

Background: The geriatric patient population is at high risk for undertreatment of pain (Hwang et al. 2010). Regrettably, they are less likely to receive pain medication and commonly experience longer delays in treatment (Hwang et al. 2010). Likewise, there are many important considerations when prescribing analgesics in this group. Factors such as concomitant anticoagulation use and a history of gastrointestinal bleeding are vital historical elements that would likely alter treatment. Furthermore, many emergency medicine clinicians are apprehensive about treating elderly patients with opiates out of fear of untoward side effects.

In 2010, the United States Food and Drug Administration (FDA) granted approval for intravenous (IV) acetaminophen as a pain management option. However, its use remained limited in emergency medicine due to exorbitant costs and stringent prescribing restrictions. A turning point occurred in 2016 when a generic formulation of IV acetaminophen became available, significantly reducing costs and potentially facilitating broader utilization in routine practice. Nevertheless, the comparative analgesic efficacy of IV acetaminophen versus opioids remains uncertain, warranting further investigation.

Article: Kolli S, Friedman BW, Latev A, et al. A Randomized Study of Intravenous Hydromorphone Versus Intravenous Acetaminophen for Older Adult Patients with Acute Severe Pain. Ann Emerg Med. 2022;80(5):432-439. PMID: 35965162

Clinical Question: In patients over 65, what is the effect of 1 gram of IV acetaminophen on the reduction of severe pain compared with 0.5mg IV hydromorphone?

What They Did:

• Double-blinded, parallel-group, randomized trial
• Performed in 2 urban EDs in the Bronx, New York.  
• Drugs were mixed in 100 ml of normal saline and administered via a parenteral drip over 10 minutes, followed by a 2 ml NS push. 
• Pain was measured on a verbal scale from 0 to 10 (10 being worst, 0 being no pain at all), and pain level was measured at baseline, 15, 30, 60, 90, and 120 minutes.
• Clinicaltrials.gov Registry number: NCT03521102

Population: 

Inclusion:

• Patients ≥ 65 years of age experiencing acute pain defined as onset within 7 days of ED visit in whom the attending physician planned to treat with intravenous opioids.

Excluded: 

• Patient use of opioids or tramadol within the last 7 days
• Use of acetaminophen or NSAIDs within the previous 8 hours
• Any prior adverse reaction to opioids or acetaminophen
• Any daily or frequently recurrent pain that lasted for 3 months or more
• Patients with dementia
• Patients with chronic liver or kidney disease
• Use of monoamine oxidase inhibitors
• Systolic blood pressure <100mmHg, HR<60bpm, O2 saturation <92% on room air

Intervention: 

• Acetaminophen 1,000mg administered IV in a 100 mL bag of 0.9% saline

Comparator: 

• Hydromorphone 0.5mg administered IV in a 100 mL bag of 0.9% saline

Outcomes:

Primary:

• Improvement in pain, measured on a 0 to 10 pain scale from baseline to 60 minutes later

Secondary: 

• Use of additional medication for the treatment of pain at any time during the ED course
• Percentage of patients who failed to achieve clinically important improvement in pain (<1.3)
• Percentage of patients who failed to achieve 50% improvement in their pain
• Absolute pain score at each time point
• Reported adverse event related to medication during the ED visit

Primary Results:

• 2 centers enrolled patients
• 2,363 patients were screened for participation though only 162 were enrolled
• Median Baseline pain rating 10/10

Critical Findings:

• By 60 minutes:
  • Patients receiving IV Acetaminophen improved by 3.6 (SD 2.9) on 0–10 pain scale
  • Patients receiving IV Hydromorphone improved by 4.6 (SD 3.3) on 0–10 pain scale
  • 95% CI for the difference of 1.0 was 0.1-2.0

Strengths:

• Investigators asked a patient-centered research question.
• Outcomes were patient-oriented
• Double-blind, randomized trial design increases internal validity
  • Patients, physicians, and outcome assessors were blinded to patient allocation
  • Randomization occurred electronically by a random sequence generator
  • Pharmacists prepared formulations away from the ED in a secure location, and clinical nurses retrieved them sequentially from a secure cabinet.
  • Medications were administered the same way—100 mL IV drip followed by 2 mL IV push.
    • Medications appeared colorless and were indistinguishable to the eye
• Research staff was available 24 hours, 7 days a week
• Patients were analyzed in the group they were assigned
• Follow-up was complete
• The trial was registered, increasing transparency

Limitations:

• The study was performed within a single hospital system, limiting generalizability
• Patients were referred for inclusion by the attending physician which introduces selection bias.
• Investigators defined severe pain as an intention to use opiates which excludes patients to whom other meds were given, also introducing selection bias.
• The broad inclusion criteria lead to a heterogenous population which is difficult to compare.
• It is unclear how many patients were eligible for enrollment during the trial period but not enrolled.
• Investigators only studied one dose of each medication, and it is unclear how other doses would have performed.
• There were important demographic considerations and patient population differences between the study’s two arms.
  • Two-thirds of the population enrolled were women
  • More 90-year-old patients were enrolled in the acetaminophen group.
  • More patients with extremity pain were in the acetaminophen group.
  • More patients with chest pain in the hydromorphone group.

Discussion:

• The study design necessitated a single parenteral dose of either hydromorphone or acetaminophen in each arm. Although 0.5 mg of IV hydromorphone is commonly considered the minimum dose for adult patients, it is crucial to recognize that various factors, most notably body weight, significantly influence the appropriate dosage of pain medications. It is reasonable to assume that a higher dose of hydromorphone would result in more pronounced analgesia, emphasizing the importance of individualized dosing strategies.
• Pain, an immensely diverse complaint with many causes, presents a substantial challenge. Beyond the patient’s age and location of pain, we know very little of the cause or prognosis in this paper. Moreover, we have insufficient knowledge regarding alternative interventions that could have alleviated pain. For instance, while pain resulting from extremity fractures and dislocations can often be relieved after reduction and splinting, abdominal pain poses a more elusive and complex scenario involving multiple contributing factors.
• Undoubtedly, some patients cannot tolerate oral medications and may benefit from parenteral administration. However, for individuals with a functional gastrointestinal tract, it remains unclear whether the intravenous formulation of acetaminophen offers any distinct advantages over its oral counterpart. Additionally, a recent systematic review encompassing six randomized controlled trials discovered no discernible difference in pain reduction between parenteral and oral formulations of acetaminophen when administered at equivalent doses (Jibril et al., 2015). Moreover, it is worth noting that even the now generic parenteral formulation of acetaminophen is considerably more expensive than its oral counterpart, raising questions about its cost-effectiveness and utility in practice.

Author’s Conclusions: “Although 0.5 mg of the intravenously administered hydromorphone was statistically superior to 1,000 mg of intravenous acetaminophen administered in older patients with acute severe pain in the ED, this difference was not clinically significant. Regardless of the medication received, many participants experienced minimal or incomplete pain relief.”

Our Conclusion:

We agree with the author’s conclusion. Investigators found no clinically significant differences in elderly patients with acute severe pain who received either 1,000 mg of IV acetaminophen or 0.5 mg IV hydromorphone. Nevertheless, it is imperative to acknowledge the intricate nature of pain, as a single dosage of any medication cannot be universally effective without considering the individualized aspects of each patient and the condition influencing their pain.

References:

1. Montandon G. The pathophysiology of opioid-induced respiratory depression. Respiratory Neurobiology – Physiology and Clinical Disorders, Part I. Published online 2022:339-355. PMID: 35965031
2. Acetaminophen. American Chemical Society. https://www.acs.org/molecule-of-the-week/archive/a/acetaminophen.html
3. Hwang U, Richardson LD, Harris B, Morrison RS. The quality of emergency department pain care for older adult patients. Journal of the American Geriatrics Society. 2010;58(11):2122-2128. PMID: 21054293
4. Platts-Mills TF, Esserman DA, Brown DL, Bortsov AV, Sloane PD, McLean SA. Older US emergency department patients are less likely to receive pain medication than younger patients: Results from a national survey. Annals of Emergency Medicine. 2012;60(2):199-206. PMID: 22032803
5. Kolli S, Friedman BW, Latev A, et al. A randomized study of intravenous hydromorphone versus intravenous acetaminophen for older adult patients with acute severe pain. Annals of Emergency Medicine. 2022;80(5):432-439. PMID: 35965162
6. Jibril F, Sharaby S, Mohamed A, Wilby KJ. Intravenous versus oral acetaminophen for pain: Systematic review of current evidence to support clinical decision-making. The Canadian Journal of Hospital Pharmacy. 2015;68(3). PMID: 26157186

Guest Post By:

Andrew Michalak, MD
PGY-1, Emergency Medicine Resident
Vassar Brothers Hospital, Poughkeepsie, New York
E-mail: Andrew.Michalak@nuvancehealth.org

Marco Propersi, DO FAAEM
Vice-Chair, Emergency Medicine
Assistant Emergency Medicine Program Director
Vassar Brothers Hospital, Poughkeepsie, New York
Twitter: @marco_propersi

Post-Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie), Anand Swaminathan, MD (Twitter: @EMSwami)

The post Managing Pain in the Elderly: Acetaminophen VS. Hydromorphone appeared first on REBEL EM - Emergency Medicine Blog.

Background: IV fluids are part of the standard resuscitation bundle in septic shock, however it is unclear if they provide a significant benefit. These patients can have a vasodilated vascular bed and the initial use of fluids is hypothesized to serve two purposes: Augmenting the macrovascular system (stroke volume and cardiac output) and augmenting the microvascular perfusion (capillary blood flow). However, IV fluids are not a benign intervention as they can cause coagulopathy and fluid overload.

The CENSER Trial (Link is HERE) was a randomized, double-blind, placebo-controlled clinical trial evaluating the use of early low-dose norepinephrine vs standard care (placebo) in adults with septic shock.  The goal of the trial was to see if early vasopressors improved shock control by 6 hours. Patients were started on low-dose norepinephrine at a median time from ED arrival of 93 minutes compared to 192minutes in the standard care arm.  This resulted in better shock control by 6hrs (76.1% vs 48.4%). The secondary outcome of mortality was not statistically different however numerically favored the early use of norepinephrine.

Physiologically it makes sense to initially use lower volumes of fluids and earlier initiation of vasopressors. However, there is a lack of robust evidence to help guide what fluid and vasopressor strategy is best in patients with septic shock.

REBEL Cast Ep116:  The CLOVERS Trial – Restrictive vs Liberal Fluids in Sepsis-Induced Hypotension

Paper: The National Heart, Lung and Blood Institute Prevention and Early Treatment of Acute Lung Injury Clinical Trials Network. Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension. NEJM 2023. PMID: 36688507 [Access on Read by QxMD]

Clinical Question: In patients with sepsis-induced hypotension, after an initial 1 to 3L of IV crystalloids, does using a restrictive fluid strategy improve 90d all-cause mortality compared to a liberal fluid strategy?

What They Did:

• Crystalloid Liberal or Vasopressor Early Resuscitation in Sepsis (CLOVERS)
• Multicenter, unblinded, randomized, superiority clinical trial conducted at 60 US centers
• Randomization occurred within 4 hours after patients met the criteria for sepsis-induced hypotension refractory to initial treatment with 1 to 3L of IV fluid
• Patients randomized 1:1 to one of two arms for a 24 hour period:
  • Restrictive Fluid Strategy: Prioritizing vasopressors and lower IV fluid volumes; Rescue fluids were allowed
  • Liberal Fluid Strategy: Prioritizing higher volumes of IV fluids before vasopressor use; Recommended initial 2000cc of isotonic crystalloid followed by fluid boluses based on clinical triggers
  • In October 2019 a protocol amendment was made allowing for limited initial infusion of crystalloids to 1000cc if patients’ blood pressure and heart rate had been stabilized (SBP ≥110mmHg or MAP ≥70mmHg and HR <90BPM) and patient was volume replete (unlikely to benefit from additional IV fluids)

Outcomes:

• Primary: All -cause mortality before discharge home by 90d
• Secondary:
  • Number of days free from ventilator at 28d
  • Days free from renal-replacement therapy at 28d
  • Days free from vasopressor use at 28d
  • Days of the ICU at 28d
  • Days out of the hospital at 28d
• Safety:
  • Initiation of mechanical ventilation
  • New onset atrial and ventricular arrhythmias
  • Complications related to peripheral and central venous catheter use

Inclusion:

• Adult (≥18 years of age) patients
• Suspected or confirmed infection
• Sepsis-induced hypotension (SBP <100mmHg after administration of ≥1000mL of IV fluids)

 Exclusion:

• >4hrs since meeting criteria for hypotension refractor to IV fluids of at least 1000cc
• >24hrs since presentation to the hospital
• Previous receipt of >3000cc of IV fluids
• Presence of fluid overload
• Presence of severe volume depletion from nonsepsis causes

Results:

• 1563 patients enrolled
• Resuscitation therapies administered prior to randomization were similar between two groups:
  • Restrictive: Median 2050mL (Range: 1500 to 2457mL)
  • Liberal: Median 2050mL (Range: 1371 to 2442mL)
• Median time from meeting trial eligibility criteria to randomization: 61min (No real difference between groups)
• Majority of patients were randomized from the ED: 91.9% of enrolled patients
• Resuscitation therapies administered during the 24hr protocol period differed between the two groups:
  • Restrictive fluid strategy group received less fluids than the liberal fluid strategy group (Median difference: -2134mL; 95% CI -2318 to -1949)
  • Restrictive fluid strategy group received earlier, more prevalent, and longer duration of vasopressors vs the liberal fluid strategy group
• Median Volume of Fluid During 1^st 6 Hours After Randomization:
  • Restrictive: 500mL (Range 130 to 1097mL)
  • Liberal: 2300mL (Range 2000 to 3000mL)
  • Difference: -1800mL
  • This difference remained for the 1^st 24hrs after randomization as well (1267mL vs 3400mL)
  • The difference also remained for the 1^st 24hrs after randomization when including fluids administered pre-enrollment: 3300mL vs 5400mL
  • Most common fluid type used was Lactated Ringer’s Solution
• Vasopressor Use in the 1^st 24hrs After Randomization:
  • Restrictive: 59%
  • Liberal: 37%
  • Also initiated earlier (mean difference -1.4hrs) and used for longer (mean difference 4.2hrs)
• 90d All-Cause Mortality:
  • Restrictive: 14.0%
  • Liberal: 14.9%
  • Estimated Difference: -0.9%; 95% CI 04.4 to 2.6; p = 0.61
  • Prespecified subgroup analyses did not show differences in treatment effects (Included SBP <90mmHg, Chronic Heart Failure, ESRD, Pneumonia as Cause of Sepsis)
• Number of reported serious adverse events were similar between groups

Strengths:

• Asked a clinically important question
• Primary outcome was objective (i.e. mortality)
• Monitored protocol adherence in the first 300 patients and in a 10% random sample of patients throughout the rest of the trial
• Groups had similar baseline characteristics and treatment before randomization
• Audited protocol adherence was high in both groups with overall adherence of 97% in the restrictive group and 96% in the liberal group. Adherence was sustained throughout the duration of the trial
• Authors achieved separation between groups in terms of the amount of fluid given between both strategies

Limitations:

• Convenience sample of enrolled patients mostly during weekdays may have caused a selection bias (Only enrolled ≈1500 patients from 60 hospitals over a near 4 year period).
• Also ≈3300 eligible patients screened of which many not enrolled. 900 patients could not get informed consent, ≈880 patients refused consent, ≈880 patients the MD refused to enroll, and ≈350 not excluded but not enrolled
• Excluded patients with extremes of volume overload or volume depletion which makes drawing conclusions in these populations not possible
• Although there was high adherence to the protocol, some patients in the restrictive fluid group received more fluid than was intended and vasopressors were started later than intended. Additionally, some patients in the liberal fluid group received less fluid than was intended and vasopressors were started earlier than was intended.  Both of these protocol violations could have diluted the difference between groups
• Unblinded trial: Clinical team was aware of which group patients were randomized to. This could have influenced care the patients received as well as reporting of adverse events (i.e. higher reporting of volume overload in the liberal fluid group or lesser reporting of volume overload in the restrictive fluid group)
• Goals of care were driven by blood pressure and lactic acid targets. It is unclear if outcomes would have differed with different targets or allowing for lower blood pressure values
• Trial protocol was only for 24 hours after randomization. It is unclear if a longer treatment period would have produced differing results
• Study terminated early which did not allow authors to achieve the appropriate statistical power required to find a between group difference of 4.5% in the incidence of death before discharge home by day 90. Even if the authors had completed the trial with the remaining patients having good outcomes in the restrictive strategy group, this trial still may not have reached statistical significance.
• The patients enrolled didn’t seem that sick (Baseline SBP 93.5mmHg and Lactic Acid of 2.9) with only ≈60% of patients in the restrictive group requiring vasopressors at all. Additionally, mortality rate was ≈14% in this trial (Compared to ProCESS 19%, ARISE 18.5%, and ProMISe ≈29%).

Discussion:

• Authors were looking for an absolute between-group difference of 4.5% in the incidence of death before discharge home by day 90 (Primary outcome) assuming death would occur in 15% of patients in the liberal fluid group and 10.5% in the restrictive fluid group. This would require a sample of 2320 patients to be enrolled to achieve a 90% power (Trial did not reach this number as the trial was terminated for futility after 2/3rds of patients enrolled)
• 3 instances of vasopressor extravasation among 500 patients who received peripherally administered vasopressors between randomization and 72hrs; All 3 events resolved without intervention and did not have any residual clinical consequences
• My biggest issue not only with this study, but even previous trials is lumping sepsis patients into one group as if they are all the same. Sepsis is a heterogenous process with different causes, and different responses by patients. Clinical judgement is still alive and well…one protocol will not work for a heterogenous disease process.

Author Conclusion: “Among patients with sepsis-induced hypotension, the restrictive fluid strategy that was used in this trial did not result in significantly lower (or higher) mortality before discharge home by day 90 than the liberal fluid strategy.”

Clinical Take Home Point: In a group of patients with septic shock (sepsis-induced hypotension), receiving initial treatment with 1 to 3 liters of IV fluids, a restrictive fluid strategy (with early vasopressor use) did not result in a significantly lower (or higher) mortality before discharge home by day 90 compared to a liberal fluid strategy. Basically, in a heterogenous disease process like sepsis, use your clinical judgement to determine how much fluid any particular patient needs.

References:

1. The National Heart, Lung and Blood Institute Prevention and Early Treatment of Acute Lung Injury Clinical Trials Network. Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension. NEJM 2023. PMID: 36688507 [Access on Read by QxMD]

For More Thoughts on This Topic Checkout:

• The Bottom Line: CLOVERS
• First10EM: The CLOVERS Trial – Does Nothing Matter in Sepsis
• FOAMcast: CLOVERS Trial – Restricted vs Liberal Fluids in Sepsis-Induced Hypotension
• REBEL EM: The CENSER Trial – Early Norepinephrine in Septic Shock
• EMCrit: EMCrit 345 – I Guess We Need to Talk About CLOVERS and Fluids in Sepsis (Hopefully for the Last Time Ever)

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)

The post REBEL Cast Ep116: The CLOVERS Trial – Restrictive vs Liberal Fluids in Sepsis-Induced Hypotension appeared first on REBEL EM - Emergency Medicine Blog.

You are working in a rural ED, and an older woman from a local assisted care facility arrives via ambulance in obvious respiratory distress. EMS is able to tell you that she is currently being treated for pneumonia. The patient is on a nonrebreather mask, and vital signs on arrival are BP 110/50 mm Hg, HR 120 bpm, RR 40/min, T 98.6°F (37°C), and SpO2 86%. The patient’s emergent portable chest X-ray is shown below. Which of the following is the most appropriate next step in this patient’s care?

1. Frantically look through the assisted care documents for do-not-resuscitate paperwork
2. Place a chest tube on the left side
3. Place a chest tube on the right side
4. Start noninvasive or mechanical ventilation

FOR THE RIGHT ANSWER CLICK ON THE ROSH REVIEW LOGO BELOW

References:

1. Dixon A. Mucous plug with left lung collapse. Radiopaedia website. Accessed October 19, 2022.
2. Friesen B. Left upper lobe collapse due to mucous plugging. Radiopaedia website. Accessed October 19, 2022.

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

The post Rosh Review EM Scholar Monthly Question appeared first on REBEL EM - Emergency Medicine Blog.

Background: The emergency department is frequently visited by patients suffering from symptomatic alcohol withdrawal, and the traditional management has been dominated by repeated doses of benzodiazepines.1, 2 Phenobarbital has been studied as an alternative or adjunct to benzodiazepines with encouraging results, but primarily among inpatient services.3, 4 Much of the appeal of phenobarbital lies in its ability to stave off severe alcohol withdrawal symptoms days after administration, without the necessity of daily redosing.5  

Paper: Lebin J et al. Return Encounters in Emergency Department Patients Treated with Phenobarbital Versus Benzodiazepines for Alcohol Withdrawal. J Med Toxicol 2022. PMID: 34697777

Clinical Question: In patients with moderate to severe alcohol withdrawal being discharged from the emergency department (ED), does treatment with phenobarbital alone and phenobarbital plus benzodiazepines compared to benzodiazepines alone decrease the odds of returning to the ED within 3 days after initial discharge?

What They Did:

• Retrospective cohort study at a single academic medical center between July 1, 2016 to June 30, 2019.
• Electronic Health Record (EHR) database review using keywords for demographics, triage vital signs, and administered medications.  
• History of liver disease, history of substance abuse disorder, and history of delirium tremens were also extracted from the hospital EMR.
• 470 patients found that were treated with phenobarbital, a benzodiazepine, or a combination of both and then discharged.
  • For comparison’s sake, the medications administered were converted to benzodiazepine equivalents in milligrams of lorazepam.
• Authors assessed how many of the 470 had return ED visits (for any reason) within 3 days of discharge, within 3-7 days, and after 7 days of discharge.

Inclusion Criteria

• Adult patients discharged with diagnosis of “alcohol withdrawal” from the ED

Exclusion Criteria

• Incarcerated 
• Transferred or discharged to another facility
• Patients who were not treated with any pharmaceuticals for alcohol withdrawal, interpreted by the authors as indicating “mild” withdrawal or predominance of alternative diagnosis.

Outcomes

Primary

• Return encounter within 3 days to any ED 

Secondary 

• Return encounter between 3-7 days to ED 
• Return encounter within 7 days to ED
• Diagnosis and disposition for follow-up encounter 
• Survival to beyond 3 days after index ED visit

Results 

• Return rate (BZD vs PB vs PB+BZD) to the ED
  • @ 3 days: 25% vs 13% vs 10% (p=0.001)
  • >3 to 7 days: 18% vs 7% vs 10% (p=0.36)
  • @ 7 days: 38% vs 18% vs 20% (p=0.003)

• PB and PB+BZD group had lower odds ratio of return ED visit at three days compared to BZD group
• No statistically significant difference in odds ratio of return ED visit at three days between PB and PB+BZD groups
• No statistically significant difference in odds of return visit among treatment groups between 3-7 days 
• This result persisted when the odds ratio was adjusted for age, history of delirium tremens, history of substance use disorder, and history of liver disease.
• There were no significant differences in the prevalence of liver disease, history of substance use disorder, history of delirium tremens, mean age, triage heart rate, or triage blood pressure across treatment groups.
• No statistically significant difference in survival beyond 3 days 
• 92 of the total 120 patients who returned to the ED were associated with a diagnosis of alcohol withdrawal or intoxication. 11 of those were admitted to the hospital.

Strengths

• Investigators asked a clinically valuable question that is patient-oriented.
• Patients selected consecutively and not a convenience sample, reducing the chance of selection bias.
• Patients in the study groups were similar regarding demographics.
• Possible confounders such as pre-existing liver disease, history of delirium tremens, history of substance use disorder were accounted for in results
• Patients being studied were ED patients
• One of only a few studies looking at outpatient efficacy of phenobarbital after administration in the ED

Limitations

• Endpoints collected did not include things such as resolution of withdrawal symptoms in the ED.
• Retrospective in design
• No randomization, and therefore possibly unbalanced groups
• Did not include enough possible confounders, such as socioeconomic status, unhoused status, presence of other intoxicating substances on drug screen, coexistence of complicating acute medical illness.
• Did not account for patients with polypharmacy use, which would have potentially altered the required dosing of benzodiazepines
• Did not account for withdrawal severity determining choice to use phenobarbital or not, leading to confounding by indication
• Single center 
• Clinical Institute Withdrawal Assessment (CIWA) scores – or some other more universal diagnostic tool for alcohol withdrawal – not routinely used, so dose variations were secondary to physician choice rather than objective measurement
• Alcohol withdrawal is a clinical diagnosis, and therefore could have been inappropriately applied to some of the patients in the study
• No protocolized dosing or choice of medications – therefore patients with more severe alcohol withdrawal may have been selected to receive phenobarbital vs benzodiazepines alone, allowing for potential bias in selection
• Did not examine patient use of discharge prescriptions or undocumented outpatient medication
• Patients may have presented to EDs outside of the included catchment area, and thus were not included in the study

Discussion

• This study is a useful addition to the body of literature supporting the treatment of alcohol use disorder in the ED with phenobarbital, but it is unable to establish a causal relationship between the use of phenobarbital for alcohol withdrawal and decreased ED bounce backs in the short-term.
• Phenobarbital also has some other benefits making it a great first-line agent for alcohol withdrawal in the ED.
  • Long half-life could obviate the need for discharge medications.
  • Provides ongoing GABA agonist therapy after ED discharge during the time period of highest odds of withdrawal symptoms.
  • Could be used as a therapeutic bridge during the initial days of treatment until patients are able to get into community care or other medication assisted therapy treatments.
• It is unclear if the difference in return encounters is due to differential use of benzodiazepine equivalents, or the inherent pharmacodynamics of phenobarbital. There was a massive difference in benzodiazepine equivalents between treatment groups: 26 mg and 28 mg in the PB and PB+BZD groups, respectively, and 6 mg in the BZD group. Accounting for outpatient prescriptions or out-of-hospital use of other undocumented GABA agonists may have accounted for this vast divergence in dosing, but the authors justifiably remark that this information, even if gathered, is notoriously inaccurate. 
• CIWA scores or some other more universal diagnostic tool for alcohol withdrawal were not routinely used so we have no idea why one patient got more than another.
• Tracking the success or failure in the treatment of alcohol withdrawal in patients discharged from the ED is a difficult task given the inherent tendency of substance use disorders to create instability in the lives of those afflicted by them. However, it is precisely because of this instability that phenobarbital presents an attractive alternative: it’s given as a single dose in a monitored setting, and it covers the first few days of treatment, obviating the need for frequent redosing and complicated medication management. 

Author’s Conclusion

“In this cohort of patients with acute alcohol withdrawal who were discharged from the ED, those who received phenobarbital were less likely to return to the ED within three days of the index visit when compared to those who received benzodiazepines alone.”

Our Conclusion

Phenobarbital appears to be an effective treatment of alcohol withdrawal when given alone or in combination with benzodiazepines. Although hampered by its retrospective design and lack of protocolized regimen, this study supports using phenobarbital as a first-line agent in the emergency department for treatment of alcohol withdrawal. 

Clinical Bottom Line:

Phenobarbital is a useful alternative or adjunct to benzodiazepines in the treatment of alcohol withdrawal in the emergency department. 

Guest Post By:

J.D. Cambron, DO
Assistant Professor
Department of Emergency Medicine
Christus Health/Texas A&M University School of Medicine

References:

(1) Kosten, T. R.; O’Connor, P. G. Management of Drug and Alcohol Withdrawal. New England Journal of Medicine 2003, 348 (18), 1786-1795. DOI: 10.1056/NEJMra020617.

(2) Schuckit, M. A. Recognition and management of withdrawal delirium (delirium tremens). N Engl J Med 2014, 371 (22), 2109-2113. DOI: 10.1056/NEJMra1407298  From NLM.

(3) Ibarra, F., Jr. Single dose phenobarbital in addition to symptom-triggered lorazepam in alcohol withdrawal. Am J Emerg Med 2020, 38 (2), 178-181. DOI: 10.1016/j.ajem.2019.01.053  From NLM.

(4) Rosenson, J.; Clements, C.; Simon, B.; Vieaux, J.; Graffman, S.; Vahidnia, F.; Cisse, B.; Lam, J.; Alter, H. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med 2013, 44 (3), 592-598.e592. DOI: 10.1016/j.jemermed.2012.07.056  From NLM.

(5) Stehman, C. R.; Mycyk, M. B. A rational approach to the treatment of alcohol withdrawal in the ED. Am J Emerg Med 2013, 31 (4), 734-742. DOI: 10.1016/j.ajem.2012.12.029  From NLM.

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

The post Return Encounters in Emergency Department Patients Treated with Phenobarbital Versus Benzodiazepines for Alcohol Withdrawal appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points

1. Many patients with renal colic require a CT scan.
2. Diagnostic imaging should focus on eliminating concerning mimics; not on clinching the diagnosis of renal colic.
3. POCUS and radiology department US are important modalities in evaluation of renal colic.

The post REBEL Core Cast 101.0 – Imaging in Renal Colic appeared first on REBEL EM - Emergency Medicine Blog.

Background: Clinically significant pneumothoraces in patients on mechanical ventilation can be dangerous as positive pressure ventilation can cause an increase in intrapleural pressure and trigger tension physiology. Occult pneumothoraces are those not suspected clinically or not evident on plain radiographs but later identified on computerized tomography (CT) imaging. The pendulum is swinging towards conservative management for occult pneumothoraces. However, minimal evidence supports conservative management of occult, traumatic pneumothoraces in ventilated patients.

Paper: Smith JA, Secombe P, Aromataris E. Conservative management of occult pneumothorax in mechanically ventilated patients: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2021 Dec 1;91(6):1025-1040. PMID: 34225346.

Clinical Question: In hemodynamically stable mechanically ventilated patients with occult pneumothorax, what is the effectiveness and safety of conservative management compared to prophylactic ICC insertion?

What They Did:

• The authors performed a systematic review and meta-analysis of multiple databases and considered randomized controlled trials (RCTs) and comparative prospective and retrospective cohort studies for inclusion. 
• The paper was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines and registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42019132958).

Inclusion Criteria

• Patients of any age diagnosed with a blunt or penetrating traumatic occult pneumothorax on thoracoabdominal CT scan receiving mechanical ventilation.

Exclusion Criteria:

• Patients with occult hemopneumothorax

Outcomes:

Main Outcomes

• Intercostal Catheter insertion
• Incidence of tension pneumothorax (diagnosed clinically)
• Incidence of pneumothorax progression (seen on Chest x-ray)
• Incidence of pneumonia/empyema

Additional Outcomes

• Mortality
• ICC insertion (tension pneumothorax)
• ICC insertion (progression to simple pneumothorax)
• ICC insertion (non-pneumothorax reasons)
• Length of stay in hospital and Intensive Care (days)
• Duration of mechanical ventilation (hours)
• Hemodynamic instability (measured as need for vasopressor support)
• Pain (measured by validated pain scoring tools for sedated ICU patients, i.e., Behavioural pain scale (BPS) and Critical-Care Pain Observation Tool (CPOT))
• Analgesia requirements (measured in parenteral morphine equivalents per 24 hours as per ANZCA opioid conversion)

Results:

Paper Selection:

• Researchers identified 3,356 articles.
• 2,230 records remained after the elimination of duplicates.
• 2,210 records were excluded after screening.
• Researchers performed a full-text review of 20 publications.
  • 2 additional articles were identified from reference lists.
• 12 studies included
  • 3 RCTs
  • 9 cohort studies (2 prospective and 7 retrospective)
• 354 total participants 
  • 178 in the RCTs and 176 in the cohort studies

Critical Results

• ICC insertion for any reason
  • There was a statistically significant difference favoring prophylactic ICC insertion group for the outcome of ICC insertion for any reason
  • 2 RCTs, including high-quality trial
  • Logistic Regression OR , 95% CI ​​2.86 (1.26–6.43)
• Progression of Pneumothorax
  • There was a non-statistically significant trend of progression of pneumothorax in the conservative group favoring the ICC insertion group
  • Informed by all 3 RCTs, including low and high qualities
• Length of stay
  • No difference in RCTs
  • 2 cohort studies suggested conservative management had shorter LOS
• Duration of mechanical ventilation
  • No difference
• Tension pneumothorax
  • Low incidence in both groups (2.8% in conservative, .5% in ICC group)
• ICC complications
  • 19.5% in ICC group, 5.8% in conservative management when ICC was required
  • RCTs Logistic Regression Odds Ratio: 0.12 (0.02-0.62 95% Confidence Interval)
• Incidence of pneumonia/empyema
  • no statistically significant difference
  • RCTs Logistic Regression Odds Ratio: 1.92 (0.79-4.70 95% Confidence Interval)
  • Cohort Studies Logistic Regression Odds Ratio: 0.7 (0.19-2.5 95% Confidence Interval)
• All-cause mortality
  • analysis trended towards conservative management
  • RCTs Logistic Regression Odds Ratio: 0.58 (0.15-2.14 95% Confidence Interval)
  • Cohort Studies Logistic Regression Odds Ratio: 0.36 (0.1-1.27 95% Confidence Interval)

Strengths:

• The study addresses a patient-centered clinical question that is relevant to ED practice.
• The authors searched multiple databases comprehensively and included their search strategy making replication possible.
  • Contacted authors of included studies for additional information when necessary
  • Checked multiple trial registries for unpublished literature
  • Included studies from multiple countries
  • Included all ages
  • Included all languages
• Investigators assessed quality with standardized critical appraisal instruments from the Joanna Briggs Institute (JBI).
• Used PRISMA and registered the meta-analysis with PROSPERO, which increases transparency and reproducibility

Limitations:

• The patient population was very broad and heterogeneous.
• The initial screening process was performed by one reviewer, increasing the potential for the omission of relevant articles. 
  • Additional reviewers were used if there were uncertainties.
• Only 3 of 12 studies were RCTs
• Many of the studies included patients who were not mechanically ventilated. Only 1 RCT and 1 cohort study had only mechanically ventilated patients.
• Neither patients, physicians, nor outcome assessors were blinded in the included RCTs.
• Small sample size, leading to wide confidence intervals and low certainty of findings.
• Two cohort studies did not report complete data for the ICC group and, therefore, could not be included in any analyses. 
• The authors did not discuss explanations for between-study differences.
• It is unclear what criteria were used to determine hemodynamic instability.
• It is unclear if the results would be similar across the range of included patients (young vs. old, sick vs. less sick, etc.).
• One trial had higher rates of ICC insertion and progression of pneumothorax which inflated some data.

Discussion:

• The inclusion criteria were extensive and included all patients of any age with occult pneumothorax from blunt and penetrating trauma. More stringent inclusion criteria would likely decrease the number of potential studies available for inclusion. While pragmatic, we cannot assume a young, otherwise healthy injured child would respond like an elderly patient with comorbid conditions. The patient population appears too heterogeneous to pool in a systematic review and meta-analysis.
• There was a statistically significant difference in ICC insertion “for any reason” between the two groups. However, the outcome is somewhat misleading. In a comparison of patients with an occult traumatic pneumothorax who were treated with either conservative management or prophylactic ICC insertion, it seems obvious that patients in the prophylactic ICC insertion group would have more chest tubes.
• However, this data was driven by a single small trial (Enderson et al.), which found higher incidences of pneumothorax progression. The authors performed a sensitivity analysis with the Enderson paper removed, which showed a dramatic reduction in the effect size.
• The thirteen included publications contained numerous deficiencies. For example, only two publications included patients exclusively mechanically ventilated. The total sample size of 355 patients is relatively small, and approximately 40% came from just one publication. 
• Additionally, many studies contained significant bias. Just ⅔ s of the papers were randomized. Patients were treated the same other than the intervention in only ⅓ of the RCTs. Neither patients, treating clinicians, nor outcome assessors were blinded in any RCTs. Outcomes were measured the same in only ⅓ of all included papers.
• While the data is thought-provoking, included trials have too many inherent flaws to draw any meaningful conclusion or drive practice change.

AUTHORS CONCLUSIONS: “More evidence is required to fully inform the effectiveness of conservative management for occult pneumothoraces in mechanically ventilated patients. However, the evidence we have to date suggests that conservative management is a safe alternative to prophylactic ICC insertion for the initial management of occult pneumothoraces in mechanically ventilated patients, provided that the patients are in a highly monitored environment, the treating clinicians are aware that the patient has an occult pneumothorax and that there is appropriate staff available to recognize and treat tension pneumothorax if it occurs.”

Our Conclusion:

While interesting, the data in this systematic review and meta-analysis are derived from publications with small sample sizes and a serious risk of bias. There is not enough high-quality evidence to draw firm conclusions.

References:

Smith JA, Secombe P, Aromataris E. Conservative management of occult pneumothorax in mechanically ventilated patients: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2021 Dec 1;91(6):1025-1040. PMID: 34225346.

Guest Post By:

Patrick Callan, DO
PGY-1, Emergency Medicine Resident
Vassar Brothers Hospital, Poughkeepsie, New York
E-mail: patrick.callan@nuvancehealth.org

Marco Propersi, DO FAAEM
Vice-Chair, Emergency Medicine
Assistant Emergency Medicine Program Director
Vassar Brothers Hospital, Poughkeepsie, New York
Twitter: @marco_propersi

Post-Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie), Anand Swaminathan, MD (Twitter: @EMSwami)

The post Shifting the Paradigm: Can We Manage Mechanically Ventilated Patients with Occult Traumatic Pneumothorax Conservatively? appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points

1. Alcoholic Ketoacidosis (AKA) can present with significant acidemia (pH < 7.00). Despite the significant acidemia, patients with AKA can remain alert and lucid despite their severe metabolic derangement.
2. Relying on urine ketones for diagnosis can be misleading, as acetoacetate is the primary ketone detected in the urine but not the most common ketone generated in AKA. Given the redox ratio in patients with severe ethanol use disorder, urine ketones may be low or negative, as beta-hydroxybutyrate is the predominant ketone body.
3. Treatment consists of thiamine, dextrose, and volume repletion.
4. Remember to evaluate for concurrent medical illness: gastritis, pancreatitis, pyelonephritis, pneumonia, sepsis.

The post REBEL Core Cast 100.0 – Alcoholic Ketoacidosis appeared first on REBEL EM - Emergency Medicine Blog.

Background: The increased utility and accessibility of point-of-care ultrasound (POCUS) has allowed clinicians the freedom to rethink their diagnostic approach for many common diseases, including peritonsillar abscess (PTA). Clinical evaluation may prove difficult since many PTA and peritonsillar cellulitis symptoms overlap. Physical examination is approximately 75% sensitive and 50% specific for identifying PTA. CT and aspiration or drainage are considered the gold standard for diagnosis. Unfortunately, there are limited guidelines from ACEP, SAEM, and AAO-HNS regarding the optimal diagnostic approach for patients with PTA. Moreover, POCUS can be used to augment clinical assessment, and the results may obviate the need for advanced imaging. However, It is unclear how well POCUS performs in ruling in or ruling out the diagnosis of PTA. 

Article:  Kim DJ et al. Test characteristics of ultrasound for the diagnosis of peritonsillar abscess: A systematic review and meta-analysis. Acad Emerg Med. 2023 Jan 10. Epub ahead of print. PMID: 36625850.

Question: How well does the US perform in diagnosing PTA compared to CT, needle aspiration, or Incision and Drainage?

What They Did:

• The systematic review was performed in accordance with the PRISMA-DTA guidelines
• Searched multiple databases, including Ovid MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Central Register of Controlled Trials, Latin American and Caribbean Health Sciences Literature database, and Web of Science from 1960 to 2020. A repeat search was completed in May 2021 & November 2022.
• Two investigators independently assessed and screened all studies for eligibility. 
• Two reviewers independently assessed study quality using the QUADAS-2 tool
• Authors were contacted for any missing or unreported data. 
• Any disagreements resolved through discussion and third-party adjudication when necessary. 
• The trial was registered wIth PROSPERO (CRD42021224241)

Inclusion Criteria:

• Studies that evaluated the test characteristic of ultrasound in diagnosing PTA compared to the reference standard of CT or the aspiration or drainage of pus.
• Retrospective, prospective, and RCTs

Exclusion Criteria:

• Case Reports
• Case series with 10 or fewer patients
• Protocol papers
• Narrative reviews
• Articles not written in English

Outcomes: 

Primary Outcome: Diagnostic accuracy of ultrasound for diagnosing a peritonsillar abscess

Subgroup Analysis:

• Operator type (radiology vs. POCUS)
• Scanning technique (intraoral vs. transcervical)

Results:

Study Selection:

• Authors identified 339 studies and screened 192 abstracts after removing duplicates.
• 33 studies selected for full review
• Of those 33 studies, 17 of those met criteria for inclusion
• Of the 18 studies, 1 was an RCT, 14 were prospective cohort studies, and 3 were retrospective cohort studies
• Total of 812 patients of whom 541 had PTA from 17 studies.
• Overall all included studies had some unclear risk or high risk of bias based on the QUADAS-2 assessment. 

Sensitivity & Specificity of US for Diagnosis of PTA:

Strengths:

• Utilized multiple databases to identify a large number of studies
• Excluded studies with less evidentiary strength
• Used established guidelines, including PRISMA-DTA, and registered with PROSPERO to reduce reporting biases
• Multiple statistical analyses were performed to account for possible factors that would contribute to bias (heterogeneity summary using I2 statistics; QUADAS-2 risk of bias assessment)
• Sound and transparent methodology 
• Included studies from multiple countries 
• Investigators compared ultrasound to an appropriate independent reference standard (in this case, CT vs drainage)
• Participating patients constituted a representative sample of those presenting with PTA
• Heterogeneity (I2) was low and < 50%

Limitations:

• Training & qualification of the sonographers not specified in 13 studies
• Based on the QUADAS-2 tool for quality assessment, all of the included studies were found to be of high or unclear risk of bias
• Most of the studies contained small sample sizes, and only one study had a sample size estimate.
• Low generalizability- studies took place in multiple settings, including ENT, ED, and radiology departments
• Excluded non-English papers
• Did not report on investigator agreement of Kappa for included studies 
• Did not search reference lists of included studies for additional papers
• 53% of enrolled patients came from 2 studies
• More than half the patients enrolled in the included studies had a PTA, which seems high and suggests non-consecutive enrollment and selection bias
• Only one included trial was an RCT
• Confidence intervals were wide, and point estimates were heavily disparate

Discussion:

Bias:

• Based on a positive LR of 3.51, the post-test probability of having a PTA given a positive US is approximately 80%. 
• However, there is a tremendous amount of bias in the included studies. Furthermore, we have no confidence in the results rendering the numbers meaningless. We need high-quality evidence to provide a definite conclusion.

Does CT Change Management:

• Peritonsillar infections, including uncomplicated cellulitis, phlegmon, and small and large abscess, exist on a spectrum. Likewise, patients can have many symptoms, including mild tonsillar erythema and swelling or more ominous symptoms like muffled voices, drooling, and trismus. However, clinicians treat many patients without drainage.
• An extensive systematic review with more than 30,000 patients found no difference in the odds of treatment failure for patients with PTA managed with medical intervention alone or surgically (Forner 2020). However, in a small retrospective study of 214 patients, investigators found that abscesses >2cm in size were more likely to fail antibiotic treatment (Urban 2018). Furthermore, another small retrospective study found that approximately 30% of patients with CT-diagnosed PTA lacked purulence on drainage attempts (Eliason 2023). 
• In some patients, the presence of CT confirmed abscess might not change management. In these patients, a diagnostic US may be enough to confidently forgo CT imaging, as many will improve with medical therapy alone.

First, Do No Harm!

• We are often uncomfortable with uncertainty and may feel compelled to order a CT scan on patients with PTA. However, CT imaging is not infallible and carries the potential for false negatives and false positives, and beyond statistics, CT imaging is not harmless. The neck and thyroid are particularly vulnerable to radiation (Tipnis et al.). Additionally, potential increases in resource utilization, healthcare expense, and ED length of stay are also essential considerations. Ultrasound has become an extended part of our physical exam. While operator dependent, the dynamic ability of POCUS augments bedside diagnosis and can assist with drainage. Furthermore, we can still perform a CT scan if the US proves inconclusive. In short, there is little downside to utilizing US as an adjunct for PTA diagnosis and management.

Author’s Conclusion: “Ultrasound is an acceptable alternative to computed tomography and incision and drainage for establishing diagnosis of peritonsillar abscess. It has high sensitivity for ruling out PTA but it demonstrates only moderate specificity for ruling in the diagnosis.”

Clinical Bottom Line:

This systematic review and meta-analysis adds to the growing body of evidence in favor of utilizing US for diagnosing PTA. However, there simply is not enough high-quality evidence to provide a definite conclusion. Many questions remain, but in our opinion, the benefits provided by US outweigh any drawbacks. We recommend US as an adjunct diagnostic tool for managing patients with suspected PTA. If inconclusive, order a CT scan.

References:

1. Forner D, Curry DE, Hancock K, MacKay C, Taylor SM, Corsten M, Trites JR, Rigby MH. Medical Intervention Alone vs Surgical Drainage for Treatment of Peritonsillar Abscess: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2020 Nov;163(5):915-922. Epub 2020 Jun 2. PMID: 32482146.
2. Tipnis SV, Spampinato MV, Hungerford J, Huda W. Thyroid Doses and Risks to Adult Patients Undergoing Neck CT Examinations. AJR Am J Roentgenol. 2015 May;204(5):1064-8. PMID: 25905942.
3. Urban MJ, Masliah J, Heyd C, Patel TR, Nielsen T. Peritonsillar Abscess Size as a Predictor of Medical Therapy Success. Ann Otol Rhinol Laryngol. 2021 May 12:34894211015590. Epub ahead of print. PMID: 33980073.
4. Eliason MJ, Wang AS, Lim J, Beegle RD, Seidman MD. Are Computed Tomography Scans Necessary for the Diagnosis of Peritonsillar Abscess? Cureus. 2023 Feb 9;15(2):e34820.. PMID: 36919070

For More Information, Check Out:

• Kimberly Fender. POCUS for Peritonsillar Abscess. Ultrasound G.E.L. Podcast Blog. Published on October 25, 2021. Accessed on December 3, 2021. Available at https://www.ultrasoundgel.org/117.
• Friedman, MD, L., & Adhikari, MD, MS, FACEP, S. (2020, August 18). ACEP Sonoguide/ENT. Retrieved April 5, 2023, from https://www.acep.org/sonoguide/advanced/ent/

Guest Post By:

Alanna Dompkowski, MD
PGY-3, Chief Emergency Medicine Resident
Nuvance Health, Poughkeepsie, New York
Email: alanna.dompkowski@nuvancehealth.org

Melissa Hazlitt, MD
Student Ultrasound Director
Department of Emergency Medicine
Nuvance Health, Poughkeepsie, New York
Email: melissa.hazlitt@nuvancehealth.org

Marco Propersi, DO FAAEM
Vice-Chair/Associate Medical Director
Assistant Residency Program Director
Department of Emergency Medicine
Vassar Brothers Hospital, Poughkeepsie, New York
Twitter: @marco_propersi

Post-Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie), Anand Swaminathan, MD (Twitter: @EMSwami)

The post How Good is Ultrasound at Diagnosing PTA? appeared first on REBEL EM - Emergency Medicine Blog.

REBEL Core Cast 99.0 – Bundle Branch Blocks

Click here for Direct Download of the Podcast

Definition: Interruption of the normal conduction system leading to aberrant conduction and an abnormal QRS morphology

Anatomy: At the AV node, conduction splits into the right and left bundle branches.  The left bundle branch is composed of anterior and posterior branches.

Right Bundle Branch Block (RBBB)

Physiology

• Normally, the right bundle depolarizes the right ventricle (RV)
• In a RBBB, the right bundle does not activate. The right ventricle is instead depolarized by spread of impulse from the left bundle, through the left ventricle (LV) and then to the RV
• This pattern of electrical spread creates an aberrant QRS morphology
• Depolarization vector produces delayed R waves in leads V1-3 and delayed S waves in the lateral leads.

RBBB Criteria

• Rhythm is supraventricular in origin
• QRS duration > 110 msec (some criteria state > 120 msec)
• Terminal R wave in lead V₁ giving an RSR’ morphology (i.e. “Rabbit Ears”)
• Wide terminal S wave in leads I, aVL, V5 and V₆
• Axis is normal.

Note: A partial RBBB, defined as a RBBB morphology with a QRS < 100 msec, can be pathologic (i.e. in right heart strain) or a normal variant (seen in up to 10% of the general population)

Left Bundle Branch Block (LBBB)

Physiology

• The left bundle is composed of two fascicles (the left anterior and the left posterior fascicle)
• Normally, the left bundle depolarizes the left ventricle
• In a LBBB, the left bundle does not activate. The left ventricle is, instead, depolarized by spread of impulse from the right bundle through the RV and then to the LV.
• This pattern of electrical spread creates an aberrant QRS morphology
• The left bundle has two fascicles (anterior and posterior) and either (or both) can have a conduction abnormality

LBBB Criteria

• Rhythm is supraventricular in origin
• QRS duration > 120 msec
• QS or rS morphology in lead V₁ + V₂
• Broad, dominant monomorphic R wave in lead I, aVL, V5 and V₆

Fascicle Blocks

Left Anterior Fascicular Block (LAFB aka left anterior hemi-block)

• Blocking the left anterior fascicle results in LV depolarization via the left posterior fascicle which inserts into the infero-septal wall of the LV
• Produces small R waves in II, III, aVF
• Produces tall R waves in left-sided leads and deep S waves in the inferior leads
• LAFB EKG Criteria
  • Left axis deviation (QRS up in I, down in II + aVF)
  • Slight prolongation of the QRS complex (but < 120 msec)
  • Small q waves and  large R waves (qR complexes) in leads I and aVL
  • Small r waves and large S waves (rS complexes) in leads II, III + aVF
• Causes of LAD
  • LAFB
  • LBBB
  • LV Hypertrophy
  • Inferior MI
  • Ventricular ectopy
  • Paced rhythm
  • WPW

Left Posterior Fascicular Block (LPFB aka left posterior hemi-block)

• Blocking the left posterior fascicle results in LV depolarization via the left anterior fascicle which inserts into the upper, lateral wall of the LV
• LPFB is much less common than LAFB and the LAFB typically occurs with a RBBB (bifascicular block)
• LPFB EKG Criteria
  • Right axis deviation (RAD) (QRS up in III + aVF, down in I)
  • Slight prolongation of the QRS complex (but < 120 msec)
  • qR complexes in leads II, III + aVF
  • rS complexes in leads I + aVL
  • No evidence of RV hypertrophy
  • No evidence of other cause of right axis deviation
• Causes of RAD
  • LPFB
  • Old lateral myocardial infarction
  • Acute pulmonary hypertension (e.g. pulmonary embolism)
  • Chronic pulmonary hypertension
  • Sodium channel blocking drugs
  • Hyperkalemia
  • Right ventricular hypertrophy
  • Misplaced leads

Post Created By: Anand Swaminathan MD, MPH

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

The post REBEL Core Cast 99.0 – Bundle Branch Blocks appeared first on REBEL EM - Emergency Medicine Blog.

Background: Previous observational studies published in 2015 (Geri 2015)(Vyas 2015) indicated that early cardiac catheterization in patients with out-of-hospital cardiac arrest (OHCA) might improve mortality and result in more favorable neurological outcomes. The TOMAHAWK (Desch 2021), COACT (Abella 2019), and PEARL (Lemkes 2019) trials examined patients with OHCA without ST elevation with a shockable rhythm, and investigators found no difference in delayed versus emergency angiogram. However, there are no clear guidelines for management in post-cardiac arrest patients without ST-segment elevations on ECG.

Clinical Question: In patients who suffer an OHCA without ST-segment elevation on the post-resuscitation ECG, will early coronary angiogram (CAG) vs. delayed CAG improve outcomes?

Article: How-Berlemont C, Lamhaut L, Diehl J, et al. Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest: Results of the Randomized, Multicentric EMERGE Trial. JAMA Cardiol. Published online June 08, 2022. PMID: 35675081

What They Did:

• National, multicenter, randomized control, open-label parallel trial performed at 22 centers in FrancePatients enrolled from January 19, 2017 –  November 23, 2020.
• Assigned survivors of an OHCA without ST-segment elevation on ECG 1:1 ratio to either emergency (direct transfer) or delayed (48 to 96 hours) for CAG
• Meta-analysis was done with three RCT trials TOMAHAWK (Desch 2021), COACT (Abella 2019), and PEARL (Lemkes 2019) trials.

Inclusion criteria: 

• > 18 years old who had an OHCA with the return of spontaneous circulation (ROSC)
• No obvious non-cardiac related etiology
• Admitted to hospital with an intensive care unit and 24/7 interventional cardiology

Exclusion criteria:

• <18 years of age
• In-hospital cardiac arrest
• Patients without ROSC
• ST-segment elevation on the post-resuscitation ECG
• Suspected non-cardiac etiology
• Presence of comorbidities with life expectancy of < 1 year
• Pregnancy
• Adults subject to legal protection (guardianship or curatorship)

Intervention: 

• Emergent CAG: Patients were transferred directly to the catheterization lab where a CAG was performed at the hospital.

Comparator:

• Delayed CAG: Patients were admitted to the ICU, and CAG was performed after 48-96 hours.

Primary Outcomes: 

• The 180-day survival rate with Cerebral Performance Category (CPC) < 2

Cerebral Performance Category:

• CPC 1: Good cerebral performance. Conscious, alert, able to work, might have a mild neurological or psychological deficit
• CPC 2: Moderate cerebral disability. Conscious, sufficient cerebral function for independent activities of daily life. Able to work in a sheltered environment
• CPC 3: Severe cerebral disability. Conscious, dependent on others for daily support because of impaired brain function. Ranges from ambulatory state to severe dementia or paralysis.
• CPC 4: Coma or vegetative state. Any degree of coma without the presence of all brain death criteria. Unawareness, even if one appears awake (vegetative) without interacting with the environment, may have spontaneous eye-opening and sleep/ awake cycles. Cerebral unresponsiveness
• CPC 5: Brain death. Apnea, areflexia, EEG silence, etc.

Secondary Outcomes:

• Shock, ventricular tachycardia, and/or fibrillation within 48 hours after hospital admission.
• Changes in left ventricular ejection fraction from baseline (at admission) and 180 days.
• Major Neurologic Sequelae
  • CPC scale 3 and 4  assessed in the intensive care unit at discharge, 90 days, 180 days.
• All-cause mortality
• Hospital LOS

Results: 

• 338 Randomized → 59 excluded for various reasons
• 279 randomized to delayed or early CAG
• 141 patients allocated to emergency CAG → 138 included in ITT analysis
  • 126 received intervention
    • 15 died before catheterization
  • 89 died by 3 months follow up
  • 1 died at 6 months follow up
• 138 patients allocated to delayed CAG → 137 included in ITT analysis
  • 51 patients received allocated intervention
  • 87 did not receive intervention
    • 61 patients died before the intervention
    • 23 had catheterization before 48 h
    • 92 died by 3 months follow up

Critical Results:

• Primary Outcome:
  • No statistically significant difference in 180-day survival rates with CPC 1 or 2
  • 34.1% (47 of 141) in the emergency CAG group
  • 30.7% (42 of 138) in the delayed CAG group
  • HR, 0.87; 95% CI, 0.65–1.15; P= 0.32
• Secondary Outcomes:
  • No statistically significant difference in overall 180-day survival rates
  • 36.2% (51 of 141) in the emergency CAG group
  • 33.3% (46 of 138) in the delayed CAG group
  • HR, 0.86; 95% CI, 0.64–1.15; P= 0.31
  • No statistically significant difference in any secondary outcomes

Strengths:

• Investigators asked heavily debated, and patients centered questions
• Primary and secondary outcomes were patient-oriented
• Inclusion of multiple centers increases the external validity
• Centralized electronic randomization process
• Wider non-shockable rhythm was analyzed as the previous study focused only on shockable rhythm
• Investigator performed an intention-to-treat analysis

Limitations:

• Study performed in a single country. Results may not be generalizable.
• The study was stopped early due to a lack of enrollment.
• Investigators did not achieve their target sample size making the study underpowered.
• The enrolled cohort appears to be a convenience sample. It’s unclear how many patients sustained a cardiac arrest but were not enrolled, indicating the presence of selection bias.
• There are differences within the demographic:
  • More women in the delayed group
  • Delayed group had higher witnessed arrest and bystander CPR
  • Delayed group had more non-shockable rhythms
• Protocol violations were common. Only 51 of 138 patients randomized to the delayed CAG received the allocated intervention.
• Open-label study introducing the potential for co-intervention bias: Providers were aware of study allocation by nature of the treatment (CAG). 
  • Providers could have provided more aggressive medical management to one group.
• There is very little information on the methodology of the meta-analysis.

Discussion:

• The study was stopped early due to insufficient enrollment. Investigators enrolled approximately 280 patients out of 970 planned. Studies stopped early can overestimate results. While the study provides interesting data, it’s underpowered, and we cannot draw firm conclusions. The study findings are similar to those reported in TOMAHAWK (Desch 2021), COACT (Abella 2019), and PEARL (Lemkes 2019) trials.
• Additionally, the trial had several biases. Firstly, the enrolled cohort appears to be a convenience sample. It’s unclear how many patients had an OHCA and were not enrolled. Next, the trial was open-label, and all care team members knew the allocation arm. Moreover, there is relatively little information regarding patient management outside the study intervention. Clinicians could potentially have managed one group more aggressively than the other. Next, 61 patients in the delayed CAG arm did not get catheterization due to hemodynamic instability, severe brain damage, or because they died before CAG, which introduces survivorship bias. Lastly, there are some differences in the demographics between the groups. The delayed group had a higher incidence of non-shockable rhythms. Could these demographic differences contribute to the outcomes?
• Meta-analyses have complex statistical rigor and methodology. The addition of the trial results to a meta-analysis seems haphazard. We know relatively little information about the search timeline, the number of reviewers, the agreement of reviewers, the use of bias assessment tools, or other common standards used in meta-analyses.

Authors’ Conclusion:  “In this randomized clinical trial, for patients who experience an OHCA without ST-segment elevation on ECG, a strategy of emergency CAG was not better than a strategy of delayed CAG with respect to 180-day survival rate and minimal neurologic sequelae.”

Clinical Bottom Line:

We agree with the author’s conclusion. There was no difference in outcomes in the data presented. The findings are similar to other recent studies. However, this study was markedly underpowered, making it difficult to draw firm conclusions. Based on the totality of the evidence, there is no indication for emergent cardiac catheterization in patients with OHCA without ST elevations.

For More on This Topic, Checkout:

MIRACLE2 Risk Score for Early Prediction of Neurologic Outcome in Out-of-Hospital Cardiac Arrest

TTM2: Hypothermia vs Normothermia for Out-of-Hospital Cardiac Arrest

References:

1. Geri, G., Dumas, F., Bougouin, W., Varenne, O., Daviaud, F., Pène, F., Lamhaut, L., Chiche, J.-D., Spaulding, C., Mira, J.-P., Empana, J.-P., & Cariou, A. (2015). Immediate percutaneous coronary intervention is associated with improved short- and long-term survival after out-of-hospital cardiac arrest. Circulation: Cardiovascular Interventions, 8(10). PMID: 26453685
2. Vyas, A., Chan, P. S., Cram, P., Nallamothu, B. K., McNally, B., & Girotra, S. (2015). Early coronary angiography and survival after out-of-hospital cardiac arrest. Circulation: Cardiovascular Interventions, 8(10). PMID: 26453686
3. Desch, S., Freund, A., Akin, I., Behnes, M., Preusch, M. R., Zelniker, T. A., Skurk, C., Landmesser, U., Graf, T., Eitel, I., Fuernau, G., Haake, H., Nordbeck, P., Hammer, F., Felix, S. B., Hassager, C., Engstrøm, T., Fichtlscherer, S., Ledwoch, J., … Thiele, H. (2021). Angiography after out-of-hospital cardiac arrest without st-segment elevation. New England Journal of Medicine, 385(27), 2544–2553. PMID: 34459570
4. Abella, B. S., & Gaieski, D. F. (2019). Coronary angiography after cardiac arrest — the right timing or the right patients? New England Journal of Medicine, 380(15), 1474–1475. PMID: 30883048
5. Lemkes, J. S., Janssens, G. N., van der Hoeven, N. W., Jewbali, L. S. D., Dubois, E. A., Meuwissen, M., Rijpstra, T. A., Bosker, H. A., Blans, M. J., Bleeker, G. B., Baak, R., Vlachojannis, G. J., Eikemans, B. J. W., van der Harst, P., van der Horst, I. C. C., Voskuil, M., van der Heijden, J. J., Beishuizen, A., Stoel, M., … van Royen, N. (2019). Coronary angiography after cardiac arrest without st-segment elevation. New England Journal of Medicine, 380(15), 1397–1407. PMID: 32876654

Guest Post By:

M. Ahmad Khan, MD
PGY-3, Emergency Medicine Resident
Nuvance Health, Poughkeepsie, New York
Email: khan.a@outlook.com

Marco Propersi, DO FAAEM
Vice-Chair/Associate Medical Director
Assistant Residency Program Director
Department of Emergency Medicine
Vassar Brothers Hospital, Poughkeepsie, New York
Twitter: @marco_propersi

Post-Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie), Anand Swaminathan, MD (Twitter: @EMSwami)

The post The EMERGE Trial: Emergency vs Delayed Catheterization in Survivors of Out-of-Hospital Cardiac Arrest appeared first on REBEL EM - Emergency Medicine Blog.

Background Information:

Obtaining definitive control of the airway, when indicated, is the responsibility of the emergency medicine physician. Traditionally patients were managed on the ventilator with lung volumes of 10 – 15 ml/kg. However, that practice is long-outdated and patients managed on lower tidal volumes (6 ml/kg) were found to have decreased mortality.¹ This practice of lower tidal volumes has been termed “lung protective ventilation” (LPV) and is now the standard of care for patients receiving mechanical ventilation. Ventilator-associated lung injury and inflammation can occur even during short-term mismanagement can worsen patient outcomes.² Finally the settings initiated early in a patient’s care are often carried forward unchanged into their hospital and ICU stay. Over the past few years, there has been an increase in emergency department (ED) volumes and lengths of stay. The result of this ED capacity strain and less than ideal patient to staff ratios has led to delays in interventions, treatments and care adjustments. Thus it is imperative that the emergency physician be familiar with post-intubation ventilator management include the use of LPV. The authors of this retrospective observational study sought to investigate what system factors, if any, serve as obstacles to the implementation of standard-of-care LPV on critically ill ED patients admitted to the intensive care unit (ICU), particularly those at risk for acute respiratory distress syndrome (ARDS).

Paper: Owyang CG, et al. The effect of emergency department crowding on lung-protective ventilation utilization for critically ill patients. J Crit Care. 2019 Aug; PMID: 30954692

Clinical Question:

What is the impact of system factors in the implementation of standard-of-care LPV in critically ill ED patients admitted to the ICU?

What They Did:

• Retrospective, observational cohort study in a single high-volume academic hospital
• The ED had a 5 bed area used for ongoing management and resuscitation of patients who clinically deteriorate while boarding or while actively undergo a workup in other sections of the ED. Patients admitted to the ICU and/or patients requiring mechanical ventilation are cohort to these 5 beds.
• The 5-bed area of critically ill patients is staffed by an ED attending and upper level ED resident who simultaneously care for patients in other sections of the ED. The typical nursing to patient ratio is 1:3 with a shared respiratory therapist for the entire ED.
• The default ventilator order set is pre-filled for a tidal volume of 500mL. This could be overwritten with alternative settings by the ordering ED provider
• Crowding metrics obtained at 5-minute intervals and averaged over the ED stay.
• Patients were stratified by acuity using the Mortality Probability Model III.
  • This model uses 16 variables to predict ICU mortality by using specific variables to determine a patient’s acuity within 1 hour of admission to the ICU.³ Among these variables are: tachycardia, SBP <90 and time to intubation after arrival.
• Patients at risk for ARDS were stratified by the Lung Injury Prevention Score (LIPS) which predicts the probability of developing ARDS and subsequent mortality.⁴
  •  Using factors such as shock, pneumonia, and sepsis this score allows an accurate prediction of developing ARDS.
• Reason for intubation, severity of illness, ARDS risk score, and ventilator settings were extracted from the electronic medical record (EMR).

Inclusion Criteria:

• Adult emergency department patients 18 years or older
• Intubated by EMS in the field or ED providers
• Requiring continuous mechanical ventilation

Exclusion Criteria:

• Intubated in the inpatient service
• Intubated for a procedure or in the operating room
• Patients on chronic mechanical ventilation
• Expired prior to ICU admission
• Those not on volume control mode of ventilation

Outcomes:

Primary

• Final ED mechanical ventilator tidal volume settings of LPV (<8 cc/kg) or non-LPV (>8 cc/kg)

Results:

• Controlling for age, gender, body mass index (BMI), increased active ED patients and higher acuity were associated with lower LPV utilizations.
• Ventilator adjustments to non-TV settings were associated with improved odds of LPV adherence.

Critical Results:

• On average, initial TV settings were too high.
• 66% of patients were initiated on the default setting for the ventilator and settings not adjusted. In fact, any TV change in the ED was very minimal.
• The likelihood of departing the ED on LPV settings was not affected by severity of illness nor the risk of ARDS
• 30.5% of patients left the ED on TV settings of 450 mL and 36.1% of patients left the ED on TV settings of 500 mL

Strengths:

• Total ED census data obtained at 5-minute intervals allowed for calculation of how ED crowding affected LPV usage. Prior studies have used annual census or shift level crowding. Thus allowed for evaluation on how the physicians workload affects their usage of LPV.
• First ED-based study to evaluate how operational effects such as crowding can affect patient care in the form of LPV
• Included ARDS criteria relating to the usage of LPV in the ED allowing evaluation as to whether patients with ARDS were more likely to receive LPV settings.
• Data was automatically captured in the EMR so that accurate information was able to be extracted for the study.
• Consecutive enrollment avoided sampling bias

Limitations:

• Retrospective observational study at a single academic center limits external validity (ie. generalizability)
• Over reliance on electronic data capture may have predisposed to a misclassification bias
• Unclear which provider was responsible for ventilator changes
• Under-recognition of ARDS in the ED

Discussion:

• Patients who are intubated in the ED are less likely to be placed on LPV than in the ICU. This is a critical error that leads to poorer outcomes for patients in need of critical care. According to the paper this problem is made worse not by overall census but by the number of active patients a provider has that will eventually be admitted. The strain of making diagnostic decisions eventually becomes exhausted and LPV is overlooked.
• As volumes increase of patients actively being worked up is paired with those who need eventual admission, there is a higher task burden which creates a significant barrier to adequate critical care delivery.
• More concerning is that a patient with a higher severity of illness or at higher risk for ARDS did not receive more diligent attention even in a dedicated resuscitation area
• An important point to note is that it was unclear which provider made ventilator changes. There may have very well been a policy where only RTs can make changes to a ventilator after an order was placed to ensure accurate documentation. Unfortunately, its not clear whether the documentation came from RTs or ED providers.
• Females and patients with increased BMI are at increased risk of not being placed on LPV. This problem is evident by the fact that patients are not being routinely placed on settings reflecting their ideal body weight. Accurate measurements including height can be quickly obtained in triage. This information could then easily be converted to demonstrate the patient’s ideal body weight and thus enabling the physician to make accurate decisions regarding a patient’s ideal tidal volume post intubation.
• A significant portion of patients were placed on the default ventilator settings without changes to the ventilator. This demonstrates that ventilator settings were rarely adjusted to patient weight. Adjustments to non-tidal volume settings correlates to increased usage of LPV.

Author’s Conclusions:

ED patients remain on suboptimal tidal volume settings with infrequent ventilator adjustments during the ED stay. Hospitals should focus on both systemic factors and bedside physician and/or respiratory therapist interventions to increase LPV utilization in times of ED boarding and crowding for all patients.

Our Conclusion:

It is difficult to generalize this study as it is limited to one hospital and its practice. A large problem with this trial is the default ventilator setting in the order set was a TV of 500mL. An even bigger problem is that RTs and ED providers were not adjusting the ventilator to ideal body weight thus setting up patients to less likely receive LPV, especially if in an ED with a high census. More pertinent and relevant takeaway messages have to do with staffing and operations. Critically ill ED patients should be paired with a 2:1 patient to nurse ratio. Ventilator order sets or bundles should be based on ideal body weight as their default setting. Liberating ventilator adjustments to ED providers in addition to RTs could help improve ventilator management regardless of patient location or strain on the ED.

Clinical Bottom Line:

This single center retrospective study highlights important barriers to placing patients on LPV in the ED which include high census, incorrect default ventilator settings in an order set, insufficient staffing, under-recognition of ARDS, policies restricting which providers can adjust the ventilators and the lack of ventilator protocols, all of which have the potential to improve patient outcomes in a regardless of patient location or strain of the ED.

REFERENCES:

1. Acute Respiratory Distress Syndrome Network et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000 May 4; PMID: 10793162
2. Harvey CE, et al. Initiation of a lung protective strategy in the emergency department: Does an emergency department-based ICU make a difference? Crit Care Explor. 2022 Feb 8;. PMID: 35156050
3. Higgins TL et al. Prospective validation of the intensive care unit admission Mortality Probability Model (MPM0-III). Crit Care Med. May 2009. PMID: 19325480
4. Gajic O, et al. Early identification of patients at risk of acute lung injury: evaluation of lung injury prediction score in a multicenter cohort study. Am J Respir Crit Care Med. 2011 Feb 15; Epub 2010 Aug 27. PMID: 20802164
5. Heimberg DH, et al. Quality Improvement Intervention associated with Improved Lung Protective Ventilation Settings in an Emergency Department. Spartan Med Res J. 2022 Feb 24;7(1):29603. doi: 10.51894/001c.29603. PMID: 35291703

Guest Post By:

Karl Bischoff, MD
PGY-2, Emergency Medicine Resident
RWJBH Community Medical Center, Toms River, NJ
Twitter: @KarlJayB

Mark Ramzy, DO
Emergency Medicine Attending and Critical Care Intensivist
Clinical Assistant Professor of Emergency Medicine
RWJBH Community Medical Center, Toms River, NJ
Twitter: @MRamzyDO

For More Thoughts on This Topic Checkout:

EMCRIT: MDCalc for the perfect tape-measure intubation
EMCRIT: The Case of an Ugly Truth
First10EM: Emergency Airway Management Part 5: Post intubation care

Post-Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

The post Impact of Emergency Department Crowding on Lung Protective Ventilation appeared first on REBEL EM - Emergency Medicine Blog.

Background information: Alcohol has potentiating effects on the inhibitory GABA neurotransmission system and inhibitory effects on the excitatory glutamate neurotransmission system. Chronic alcohol use causes changes to preserve homeostasis, and when the stimulus is removed, alcohol withdrawal results due to decreased inhibition via the GABA system and increased excitation via the glutamate system. Treatment options for alcohol withdrawal include benzodiazepines such as lorazepam, diazepam, or chlordiazepoxide, gabapentin, and phenobarbital (Buell et al.). Tolerance to alcohol can also result in cross-tolerance to benzodiazepines and to a lesser degree barbiturates. Benzodiazepines and phenobarbital are positive allosteric modulators of GABA, and phenobarbital also blocks glutamate signaling. However, the main benefit of phenobarbital is that in down-regulation of GABA-A receptors alpha subunits that occurs in chronic alcohol use, benzodiazepines cannot bind, whereas phenobarbital binds directly to the ion channel and can function without the GABA-A receptors alpha subunit. Phenobarbital can be used as a monotherapy or in combination with benzodiazepines to treat alcohol withdrawal (Hawa et al.).

REBEL Cast Ep115 – Phenobarbital vs Lorazepam in Alcohol Withdrawal

Clinical question: Is a phenobarbital-based or lorazepam-based alcohol detoxification protocol associated with a lower hospital length of stay compared to Ativan for alcohol withdrawal?

Paper: Hawa F et al. Phenobarbital Versus Lorazepam for Management of Alcohol Withdrawal Syndrome: A Retrospective Cohort Study. Cureus. 2021. PMID: 33728215

What They Did:

• Retrospective cohort study (n=606) of patients admitted to three hospitals in Michigan for alcohol withdrawal between 2016 and 2018

Inclusion Criteria:

• Aged 18-100 years
• Admitted for alcohol intoxication or withdrawal treated with a CIWA-AR driven protocol
• CIWA-AR = Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised

Exclusion Criteria:

• Admitted directly to the ICU
• Pregnant patients
• Prisoners
• Patients who were transferred
• Patients who received an addiction medicine consultation

Primary Outcome:

• Hospital length of stay

Secondary Outcomes:

• Alcohol-related 30-day readmission
• All-cause 30-day readmission
• 30-day emergency department visits
• ICU transfers

Results:

Table 1: Selected clinical characteristics with and without propensity scoring for demographic and clinical variables.

Overall, the group that received phenobarbital had a higher initial CIWA score than the group that received lorazepam. The group that received phenobarbital had a higher maximum CIWA score, but the difference was not significantly significant. The difference in initial blood-alcohol levels were not statistically significant between the groups.

The primary outcome, hospital length of stay, was significantly shorter both before and after propensity score adjustment for the phenobarbital group. The 30-day emergency department readmission rate and all-cause 30-day readmission were significantly lower only when adjusted for propensity scores.

Table 2: Primary and secondary outcomes with and without propensity scoring for demographic and clinical variables.

Strengths:

• Although this was not a randomized controlled trial, propensity scoring was used to adjust for variables that may have influenced physician selection of a lorazepam or phenobarbital protocol. The authors appropriately intended for this study to be a pilot observational study and did not complete a prospective randomized controlled trial to test for non-inferiority due to sample size limitations.
• A broad range of variables were included that potentially influences treatment decisions and/or outcomes.
• The protocols used in the study were using symptom-driven medications. Although symptom-triggered protocols require experienced staff and close monitoring, in previous studies the outcomes are associated with lower benzodiazepine doses and shorter lengths of stay in the hospital (Sachdeva et al.).

Limitations:

• More information would have been helpful regarding the statistical methods regarding propensity scores. The study only mentioned that propensity-score weighting was used instead of propensity-score matching (i.e., 1:1 matching using propensity score, which typically discards some patients who do not have matches) (Olmos et al.).
• The group that received phenobarbital had a higher maximum CIWA score than the group that received lorazepam, which could mean that phenobarbital was not as effective as lorazepam, although this is potentially confounded by patients who were transferred to the ICU were excluded from the study. Although CIWA has subjective components, when a patient has a CIWA in the 20s ICU transfer should be considered.
• The study only examined symptom-triggered phenobarbital based on CIWA-Ar scoring, and it is unclear if there was front-loading, as phenobarbital (and benzodiazepines) sometimes are administered. This is beyond the scope of the paper but has been examined in other literature (Rosensen et al.)
• The protocol at this hospital system was that all patients admitted to the ICU were started on a phenobarbital protocol, so the unadjusted score could reflect that sicker patients were started on the phenobarbital protocol based on variables that were not measured in the analysis.
• The study does not address crossover, i.e., did some patients fail benzodiazepine treatment while inpatient and then get started on phenobarbital? Phenobarbital is also used in practice as a benzodiazepine-sparing adjunct in treating alcohol withdrawal.
• The study did not include emergency department treatment in categorizing the patients, e.g., was there any crossover between treatment in the emergency department and treatment after admission?
• Hospital C had 0 patients in the phenobarbital group (58 in the lorazepam group), which leads to concern about selection bias, i.e., were all the patients who the physicians would have started on phenobarbital sent to the ICU and thus excluded from the study?
• The protocols in the hospitals in the study included phenobarbital and lorazepam IV, p.o., and IM, and the physician was able to choose the method of administration. One of the main benefits of phenobarbital is the 30-minute peak serum concertation when administered IV.

Discussion

• Two randomized clinical trials exist for emergency department patients at this time:
• A randomized, double-blind, placebo-controlled trial of emergency department patients (n=102) with alcohol withdrawal in the emergency department were treated with a loading dose of 10mg/kg phenobarbital versus placebo (Rosenson et al.) resulted in decreased ICU admissions (8% in the phenobarbital loading group versus 25% in the placebo group). Both groups received symptom-triggered lorazepam per institutional protocol. This study differed in that the phenobarbital administration was administered in a symptom-triggered protocol as opposed to a bolus.
• A randomized, blinded clinical trial (Hendey et al.) of symptom-triggered phenobarbital versus symptom-triggered lorazepam in the emergency department (n=44). The phenobarbital arm received 260mg IV followed by 130mg IV PRN with no medications if discharged, and the lorazepam arm received 2mg doses followed by a chlordiazepoxide (Librium) taper if discharged. There was found to be no significant difference in CIWA scores at 48 hours between the two groups (p=0.6). A potential benefit in the phenobarbital group is that no medications were prescribed at discharge.
• This study evaluated phenobarbital in the setting of a symptom-triggered protocol. A symptom-triggered protocol has been demonstrated to have improved outcomes when compared to a fixed taper when using benzodiazepines for alcohol withdrawal. However, a potential downside of symptom-triggered phenobarbital is that phenobarbital is sometimes underdosed. Large randomized clinical trials are warranted to provide further information regarding phenobarbital as an adjunct to benzodiazepine symptom-triggered management, phenobarbital using a loading dose, and phenobarbital monotherapy, among other topics.

Authors’ Conclusion:

“Phenobarbital may be a reasonable alternative to lorazepam in management of AWS patients admitted to general medical units. When taking into account the BZDs-related adverse events including oversedation, encephalopathy, agitation, and increased risk of rebound withdrawal symptoms, phenobarbital may represent a reasonable alternative with a potential for improved outcomes.”

Our Conclusion:

Although not the subject of this study, across multiple medical conditions, lower hospital lengths of stay are associated with lower morbidity and mortality as well as lower healthcare costs. Hospital length of stay is an important metric to take into consideration when starting someone on a protocol for alcohol detoxification in the emergency department. This topic will need to be revisited pending an RCT being completed currently (Filewood et al.) on a loading dose of phenobarbital versus placebo in addition to symptom-triggered benzodiazepine treatment in both study arms.

Clinical Bottom Line: Consider phenobarbital when starting treatment for alcohol withdrawal for patients who meet admission criteria.

References:

1. Hawa F, Gilbert L, Gilbert B, Hereford V, Hawa A, Al Hillan A, Weiner M, Albright J, Scheidel C, Al-Sous O. Phenobarbital Versus Lorazepam for Management of Alcohol Withdrawal Syndrome: A Retrospective Cohort Study. Cureus. 2021 Feb 11;13(2):e13282. doi: 10.7759/cureus.13282. PMID: 33728215.
2. Buell D, Filewod N, Ailon J, Burns KEA. Practice patterns in treating severe alcohol withdrawal: a multidisciplinary, survey. J Intensive Care Med. 2019;23: 885066619847119.31122170
3. Mo Y, Thomas MC, Karras GE Jr. Barbiturates for the treatment of alcohol withdrawal syndrome: A systematic review of clinical trials. J Crit Care. 2016 Apr;32:101-7. doi: 10.1016/j.jcrc.2015.11.022. Epub 2015 Dec 8. PMID: 26795441.
4. Filewod N, Hwang S, Turner CJ, Rizvi L, Gray S, Klaiman M, Buell D, Ailon J, Caudarella A, Ginocchio GF, Santos M, Sandhu G, Dewhurst N, Sequeira K, Burns KEA. Phenobarbital for the management of severe acute alcohol withdrawal (the PHENOMANAL trial): a pilot randomized controlled trial. Pilot Feasibility Stud. 2022 Jan 22;8(1):14. doi: 10.1186/s40814-021-00963-4. PMID: 35065662.
5. Sachdeva A, Chandra M, Deshpande SN. A comparative study of fixed tapering dose regimen versus symptom-triggered regimen of lorazepam for alcohol detoxification. Alcohol Alcohol. 2014 May-Jun;49(3):287-91. doi: 10.1093/alcalc/agt181. Epub 2014 Jan 8. PMID: 24407777.
6. Olmos, Antonio and Govindasamy, Priyalatha (2015) “A Practical Guide for Using Propensity Score Weighting in R,” Practical Assessment, Research, and Evaluation: Vol. 20, Article 13. https://doi.org/10.7275/jjtm-r398.
7. Rosenson J et al. Phenobarbital for Acute Alcohol Withdrawal: A Prospective Randomized Double-Blind Placebo-Controlled Study. J Emerg Med 2013. PMID: 22999778.
8. Hendey GW, Dery RA, Barnes RL, Snowden B, Mentler P. A prospective, randomized, trial of phenobarbital versus benzodiazepines for acute alcohol withdrawal. Am J Emerg Med. 2011 May;29(4):382-5. doi: 10.1016/j.ajem.2009.10.010. Epub 2010 Mar 25. PMID: 20825805.

For More on this Topic Checkout:

• EmCrit: “Alcohol withdrawal,” Josh Farkas
• Tox and Hound: “Fear and loathing in alcohol withdrawal,” Jeff Lapoint

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

The post REBEL Cast Ep115 – Phenobarbital vs Lorazepam in Alcohol Withdrawal appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points

1. AVNRT is a common tachydysrhythmia that results from a reentrant loop within the AV node.
2. Unstable patients with AVNRT should be considered for immediate synchronized electrical cardioversion.
3. Stable patients with AVNRT can have a trial of vagal maneuvers followed by chemical cardioversion with adenosine or verapamil and synchronized electrical cardioversion if that fails.
4. Serum troponins should not routinely be obtained.

REBEL Core Cast 98.0 – AVNRT

Click here for Direct Download of the Podcast

Definition: A regular, narrow-complex rhythm with a ventricular rate that is typically > 160 bpm. Atrioventricular nodal reentrant tachycardia (AVNRT) results from the presence of a reentry circuit in the AV node. This circuit conducts down the bundle of His (resulting in a narrow QRS) and generates retrograde conduction into the atria (inverted P waves buried within the QRS).

AVNRT is also referred to as paroxysmal supraventricular tachycardia (PSVT) or simply supraventricular tachycardia (SVT). However, it is important to understand that SVT is an umbrella term that refers to all tachydysrhythmias that originate above the ventricles including atrial fibrillation and atrial flutter, for example.  When describing a supraventricular tachycardia that is due to a re-entrant circuit in the AV node specifically, it is better to use the term AVNRT as opposed to SVT in order to avoid confusion.

Differential to Consider (for Regular, Narrow Complex Tachydysrhythmias)

1. Sinus Tachycardia
2. AVNRT
3. Orthodromic Atrioventricular Reentrant Tachycardia (AVRT)
4. Atrial Flutter with 2:1 block

Common EKG Findings

• Narrow-complex, regular rhythm with a rate that often exceeds the theoretical maximal heart rate (220 – age) for that patient.
• Rhythm strip (or monitor): The rhythm is exquisitely regular. Sinus tachycardia and atrial flutter will have some minor variation in rate while AVNRT will not.
• ST depressions are commonly seen in AVNRT and can be diffuse (see EKG 1). These depressions are often rate related and of unknown significance.

AVNRT with Aberrancy

• Although AVNRT typically has a narrow-complex, some patients may demonstrate a wide-complex if the patient has aberrant conduction (baseline right or left bundle branch block or rate related bundle branch block).
• It can be difficult to differentiate AVNRT with aberrancy from ventricular tachycardia (VT). A number of algorithms have been constructed for this purpose, including the Brugada criteria, but none are perfect. Amal Mattu’s ECG Blog has an excellent review of AVNRT vs. VT and REBEL EM reviews the sensitivity and specificity of various algorithms.
• When in doubt, regular, wide-complex tachydysrhythmias should be treated as VT as this is the safest approach. [cross link to vt post]

Immediate Management: The primary goal is to convert the patient back to sinus rhythm.

Basics: ABCs, IV, O₂ and Cardiac Monitor

Directed Management

• Establish patient stability
  • Unstable: Evidence of end-organ (brain, heart) malperfusion or hypotension. This may manifest as altered mental status, severe lightheadedness, severe shortness of breath or chest pain.
  • If the patient is unstable, proceed directly to electrical cardioversion
  • If the patient is stable, you may pursue non-pharmacological therapy with vagal maneuvers, electrical cardioversion or chemical cardioversion
• Vagal Maneuvers
  • Definition: maneuvers that increase stimulation of the vagal nerve resulting in increased vagal tone breaking the reentrant circuit
  • Examples
    • Carotid massage
      • Massage of the carotid sinus at the angle of the mandible
      • Caution
        • Do not perform bilateral carotid massage as this can markedly decrease blood flow to the brain
        • This maneuver is relatively contraindicated in elderly patients or those in whom you hear a bruit over the carotid as there is a theoretical risk of breaking off a carotid artery plaque and causing a stroke.
    • Valsalva maneuvers
      • Have patient bear down as if they are having a bowel movement
      • Have patient blow as hard as they can into a straw
      • Syringe technique
      • Postural Modification
        • Success rate: 43% vs. 17% (standard Valsalva) (Appleboam 2015)
        • Details of technique found at the St. Emlyn’s blog
• Electrical Cardioversion
  • Synchronized cardioversion is indicated for unstable patients with AVNRT
  • Synchronized cardioversion can also be strongly considered in stable patients with AVNRT
  • Dose: 100-200 J
  • Perform procedural sedation and analgesia if the patient’s hemodynamics allow
• Chemical Cardioversion
  • Adenosine
    • A naturally occurring purine nucleoside
    • Causes abrupt slowing of all AV conduction (anterograde and retrograde)
    • Dose: 6 mg fast IV push. If unsuccessful, dose can be doubled to 12 mg
    • Onset of action: 5-20 seconds
    • Duration of effect: 30 – 40 seconds
    • Key Point: because of adenosine’s short half-life, it must be given through a proximal peripheral IV (antecubital or closer) and as a rapid IV push. An alternate administration approach can be found on ALiEM.
  • Verapamil (Non-dihydropyridine Calcium Channel Blocker)
    • Class IV antidysrhythmic agent that slow Ca²⁺ channels and thus, slow conduction at the AV node and suppresses the SA node.
    • Multiple studies comparing verapamil to adenosine demonstrate equal efficacy of either agent with verapamil causing more hypotension (Delaney 2011, Hood 1992)
    • Dose: 0.07 mg/kg (most studies gave 5 mg over 2-5 minutes).  Dose can be repeated
    • Should not be given to pediatric patients as there are reports of profound hypotension and circulatory collapse
  • Cardiac troponin is commonly elevated in patients with AVNRT but is often not associated with coronary artery disease (Ben Yedder 2011, Carlberg 2011)

Disposition:

• Most adult patients with AVNRT can be discharged after termination of the tachydysrhythmia.
• Pediatric patients should be considered for admission and further cardiology evaluation.
• Patients with frequent recurrences should be sent to a electrophysiologist for follow up.

Take Home Points

1. AVNRT is a common tachydysrhythmia that results from a reentrant loop within the AV node.
2. Unstable patients with AVNRT should be considered for immediate synchronized electrical cardioversion.
3. Stable patients with AVNRT can have a trial of vagal maneuvers followed by chemical cardioversion with adenosine or verapamil and synchronized electrical cardioversion if that fails.

Resources

• REBEL EM: SVT with Aberrancy Versus VT
• Amal Mattu’s ECG Case of the Week: August 26th, 2013
• ALiEM: Tricks of the Trade: Valsalva Maneuver By Using a 10cc Syringe
• Larry Mellick: Treating SVT with Adensoine
• ALiEM: Trick of the Trade: Combining Adenosine with the Flush

References

1. Brugada P et al. A new approach to the diagnosis of regular wide complex tachycardia. Circulation 1991; 83: 1649-59. PMID: 2022022
2. Appleboam A et al. Postural mdodification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised trial. Lancet 2015. PMID: 26314489
3. Delaney B, Loy J, Kelly AM. The relative efficacy of adenosine versus verapamil for the treatment of stable paroxysmal supraventricular tachycardia in adults: a meta-analysis. Eur J Emerg Med. 2011; 18(3): 148-52. PMID: 20926952
4. Hood MA, Smith WM. Adenosine versus verapamil in the treatment of supraventricular tachycardia: a randomized double-crossover trial. Am Heart J. 1992; 123(6):1543-9. PMID: 1595533
5. Ben Yedder N et al. Troponin elevation in supraventricular tachycardia: primary dependence on heart rate. Can J Cardiol 2011; 27(1): 105-9. PMID: 21329868
6. Carlberg DJ et al. Serum troponin testing in patients with paroxysmal supraventricular tachycardia: outcome after ED care. Am J Emerg Med 2011; 29(5): 545-8. PMID: 20825871
7. Yealy D, Kosowsky JM: Dysrhythmias, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 79: p 1034-63.

Post Created By: Anand Swaminathan MD, MPH

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

The post REBEL Core Cast 98.0 – AVNRT appeared first on REBEL EM - Emergency Medicine Blog.

Background: Traumatic cardiac arrest in the prehospital setting carries an extremely high mortality rate. Nevertheless, mortality of prehospital traumatic cardiac arrest (TCA), and survivability with good neurologic outcome, remain the gold standards of trauma care in and out of the hospital and are effectively the criterion by which we measure outcomes in the trauma literature. In recent years, emergency response systems have made significant efforts to study, standardize, and improve the management of prehospital TCA in the field with the hopes of improving its survivability.

In this systematic review and meta-analysis, researchers aim to establish an accurate prehospital TCA mortality rate and explore associations between survivability and the many factors contributing to prehospital TCA management.

Article: Vianen NJ et al. Prehospital traumatic cardiac arrest: a systematic review and meta-analysis. Eur J Trauma Emerg Surg. 2022 Aug;48(4):3357-3372. Epub 2022 Mar 25. Erratum in: Eur J Trauma Emerg Surg. 2022 May 5. PMID: 35333932 

Objectives:

1. What is the pooled mortality rate for prehospital TCA? 
2. Does the inclusion of patients pronounced dead on scene and the presence of a physician-based EMS organization affect the pooled mortality rate and survival with favorable neurologic outcomes for prehospital TCA?
3. Are any pre- or intra-arrest factors prognostic of prehospital TCA mortality?

What They Did:

• Two researchers performed a systematic review and meta-analysis following the PRISMA and CHARMS guidelines
• They collected articles using Embase, Medline ALL via Ovid, Web of Science Core Collection, and Google Scholar published between 1995-2020.
• The search contained terms for (1) prehospital cardiac arrest or prehospital advanced life support, and (2) injuries and trauma.
• The references on all selected articles were then used to identify additional studies. 
• Two authors independently screened all articles and collected data; discrepancies were solved via discussion between the two authors. 
• An additional division was performed, separating studies from countries or regions with prehospital physician-based EMS systems vs those without.

Inclusion Criteria:

• Articles written in English, French, German, or Dutch
• Studies with reported outcomes of interest for prehospital TCA

Exclusion Criteria:

• Any study with >10% pediatric patients
• Military studies or those using combat patients
• Studies only focusing on a single treatment or intervention
• Animal studies
• Studies whose full text was unavailable
• Studies published before 1995
• Conference papers and unindexed journals

Results:

• The search yielded 2957 articles 
  •  2865 were excluded based on title or abstract
• 92 articles were screened for full-text review 
  • 56 additional articles were excluded
• 36 articles remained for inclusion
  • All 36 articles met quality and bias standards
  • Papers included data from 51,722 patient
• Overall pooled TCA mortality and neurological outcome: 
  • 36 studies
  • 96.2% (95%CI 95.0-97.2)
• Overall pooled favorable neurologic outcome: 
  • 13 studies
  • 43.5% (95%CI 32.3-55.0)
• Prognostic Factors for TCA Mortality:
  • Non-shockable initial rhythm was the only statistically significant prognostic factor and only in the study cohorts, including prehospital deaths. 
  • RR 1.12 (95% CI 1.03-1.21; p=0.006)

Strengths:

• Performed an exhaustive literature search encompassing major databases, and the sources of each paper were also searched for completeness.
• Used established guidelines via the PRISMA and CHARMS checklists.
• Literature search and review strategy is thorough and reproducible.
• Assessed the quality of papers using Newcastle-Ottawa Quality Assessment Scale.
• Assess bias using the RevMan Risk of Bias Tool.
• Used a patient-centered search query.
• Inclusion/Exclusion criteria and definitions were very specific.
• Authors included their search terminology, allowing for reproducibility.
• Resultant data contained a large sample size from various countries and healthcare systems in multiple languages.

Limitations:

• Patient populations in some of the included studies likely overlap, allowing some patients to be counted multiple times.
• The investigators did not contact authors or subject matter experts.
• The investigators did not include un-indexed journals or gray literature.
• A third party did not arbitrate discrepancies in article selection.
• The agreement rate between the authors was not reported.
• Of the included articles, only one was a randomized controlled trial, and only two were prospective trials.
• The weight of the included studies was only reported for the subgroup analysis in Figure 7.
• Subgroup analysis on EMS system type and favorable neurologic status were less powered and had much wider CI ranges, making the data much less definitive.
• Subcategory data on EMS system type is still extremely variable, given the range of included EMS systems and regions. It would be difficult to draw direct conclusions on a prehospital physician’s impact on traumatic cardiac arrest without much more data.
• Inconsistency and lack of reporting prehospital intracardiac arrest factors limited this study’s ability to draw any conclusions on prognostic factors.
• The only statistically significant factor intra-arrest was the first ECG rhythm, which only had an odds ratio of 1.12, which is relatively low.

Discussion:

Dead On Scene:

• The 96.2% mortality rate and 43.5% rate of favorable neurologic outcomes in survivors are consistent with prior studies in recent years. (Grasner 2011; Zwingmann 2012) Their data pools overlap considerably with previous studies; it would have been concerning if the data differed significantly.
• Intuitively, studies that exclude patients dead on scene should have much higher survivability rates and favorable neurologic outcomes. By selectively removing patients who have already achieved the worst possible outcome, those remaining will undoubtedly have better outcomes.
• Studies including patients dead on scene are more epidemiologically useful, as the data likely represent true survivability and neurologic outcomes of patients involved in prehospital TCA. In contrast, data from studies that exclude prehospital deaths may be more useful to tease out intra-arrest factors leading to apparently improved outcomes.

Pre-Hospital Physician-Based EMS:

• The data indicate a substantial reduction in morbidity and mortality when prehospital physicians are available. However, as the authors point out, there are many confounding variables. 
• Could we attribute the discrepancy to better triage where only patients thought to have a better chance of survival had prehospital physician deployment? Or, could the distinction be due directly to the usage of advanced prehospital medicine and intervention by the EMS physicians? However, we might expect on-scene advanced trauma resuscitation to prolong prehospital time sizably. 
• Many studies suggest that increased time spent on scene correlates with worse outcomes for trauma (Stiell 2008) and all-cause incidence (Isenberg 2005) across all levels of prehospital care. 
• Lastly, data collection is often limited, and many important factors are unreported. Could factors such as downtime before the arrival of EMS, time in the field, time in transit to the hospital, and trauma center vs. non-trauma center destination account for the discrepancy? These factors vary considerably between regions, countries, and even local EMS agencies. Further clarification of these uncertainties may be pivotal and warrant future exploration. 

Heterogenous Population:

•  Heterogeneity (I2) was high between the cohorts. Therefore, we may be uncomfortable pooling the results of studies with vastly different pathologies, and as a result, it is questionable whether a meta-analysis is appropriate.
• The authors attempt to delineate intra-arrest prognostic factors that could explain survivability. They analyzed eight independent factors, and “shockable first ECG rhythm” was the only statistically significant factor, and only in the studies including prehospital death, with a RR of 1.12 (95% CI 1.03-1.21; p=0.006).
• Likewise, other studies in both traumatic and nontraumatic cardiac arrest (Tran 2020) report comparable findings. 
• However, the data do not provide a deeper understanding or allow for creating an actionable plan for the resuscitation of TCA patients. More research is needed to define what factors could provide significant insights into the survivability of prehospital TCA patients.

Author’s Conclusion: “In conclusion, prehospital TCA is associated with a high mortality rate, with approximately one in twenty patients surviving to discharge. When interpreting results from studies on this subject, factors such as the in- or exclusion of patients that have deceased on-scene and the type of prehospital EMS system (physician-based) should be considered. Apart from the first monitored ECG rhythm, this study found no other prognostic factors available to differentiate between survivors and non-survivors.”

Clinical Bottom Line:

Prehospital TCA has a high mortality and low favorable neurologic outcomes. Before extrapolating data from prehospital studies, it is essential to discern whether patients declared dead on the scene were included, as the results can vary widely. Furthermore, a physician-based EMS system may or may not impact prehospital TCA mortality and favorable neurologic outcomes in survivors. But, further study is needed to identify precisely how physicians benefit TCA patients. Lastly, shockable first ECG rhythm remains a prognostic factor in prehospital TCA, and more data is needed to identify additional intra-arrest factors.

References:

1. Grasner JT, et al. Cardiopulmonary resuscitation traumatic cardiac arrest—there are survivors. An analysis of two national emergency registries. Crit Care. 2011;15(6):276. PMID: 22108048
2. Zwingmann J, Mehlhorn AT, Hammer T, Bayer J, Südkamp NP, Strohm PC. Survival and neurologic outcome after traumatic out-of-hospital cardiopulmonary arrest in a pediatric and adult population: a systematic review. Crit Care. 2012 Jul 6;16(4):R117. PMID: 22770439
3. Stiell IG, Nesbitt LP, Pickett W, Munkley D, Spaite DW, Banek J, Field B, Luinstra-Toohey L, Maloney J, Dreyer J, Lyver M, Campeau T, Wells GA; OPALS Study Group. The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. CMAJ. 2008 Apr 22;178(9):1141-52. PMID: 18427089
4. Isenberg DL, Bissell R: Does advanced life support provide benefits to patients?: A literature review. Prehospital Disaster Med. 2005, 20: 265-70. PMID: 16128477
5. Tran A, et al. Pre-arrest and intra-arrest prognostic factors associated with survival following traumatic out-of-hospital cardiac arrest—a systematic review and meta-analysis. Resuscitation. 2020;153:119–35. PMID: 32531405

Further Reading:

1. Beck B, et al. Trends in traumatic out-of-hospital cardiac arrest in Perth, Western Australia from 1997 to 2014. Resuscitation. 2016;98:79–84. PMID: 26620392
2. Farrell MS, Emery B, Caplan R, Getchell J, Cipolle M, Bradley KM. Outcomes with advanced versus basic life support in blunt trauma. Am J Surg. 2020 Sep;220(3):783-786. PMID: 32000980
3. Fernando SM, Tran A, Cheng W, Rochwerg B, Taljaard M, Vaillancourt C, Rowan KM, Harrison DA, Nolan JP, Kyeremanteng K, McIsaac DI, Guyatt GH, Perry JJ. Pre-arrest and intra-arrest prognostic factors associated with survival after in-hospital cardiac arrest: systematic review and meta-analysis. BMJ. 2019 Dec 4;367:l6373. PMID: 31801749
4. Liberman M, Mulder D, Lavoie A, Denis R, Sampalis JS. Multicenter Canadian study of prehospital trauma care. Ann Surg. 2003 Feb;237(2):153-60. PMID: 12560770
5. Liberman M, Roudsari BS: Prehospital trauma care: what do we really know?. Curr Opin Crit Care. 2007, 13: 691-6. 10.1097/MCC.0b013e3282f1e77e. PMID: 17975392
6. Lockey D, Crewdson K, Davies G. Traumatic cardiac arrest: who are the survivors? Ann Emerg Med. 2006;48(3):240–4. PMID: 16934644
7. Ryynänen, OP., Iirola, T., Reitala, J. et al. Is advanced life support better than basic life support in prehospital care? A systematic review. Scand J Trauma Resusc Emerg Med 18, 62 (2010). PMID: 21092256

Guest Post By:

Dan Wolf, MD
PGY-1, Emergency Medicine Resident
Vassar Brothers Hospital, Poughkeepsie, New York
E-mail: daniel.wolf@nuvancehealth.org

Marco Propersi, DO FAAEM
Vice-Chair, Emergency Medicine
Vassar Brothers Hospital, Poughkeepsie, New York
Twitter: @marco_propersi

Post-Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie), Anand Swaminathan, MD (Twitter: @EMSwami)

The post Prehospital Traumatic Cardiac Arrest: A Systematic Review and Meta-analysis appeared first on REBEL EM - Emergency Medicine Blog.

Background: Acute alcohol intoxication is often identified early in a patient’s visit by behavioral changes accompanied by slurred speech, ataxia, nystagmus, or the smell of alcohol. However, evaluating and managing patients with acute alcohol intoxication in the emergency department can be challenging. Patients may be agitated or altered, hindering their initial evaluation and diagnostic workup. The situation is more dangerous given the high incidence of chronic disease, critical illness, and acute trauma. (Klein 2018)

Despite the high risk of pathology and decompensation, many patients with presumed alcohol intoxication can be evaluated and discharged without any labs or imaging. However, because of the high morbidity and mortality associated with alcohol use, patients presenting with presumed intoxication should receive a thorough and methodical evaluation with a low threshold for further workup. 

After your primary ABCs assessment, consider “D” for dextrose and check for occult hypoglycemia. Once a patient has been deemed stable, and you have addressed ABCD, begin your assessment.

Taking a History:

If your patient cannot participate in an interview due to intoxication or chemical sedation, the initial assessment will rely heavily on the physical exam. However, if (or when) the patient can talk with at least limited participation, run through a checklist of items.

• Suicidal Ideation and Homicidal Ideation (SI/HI): Alcohol use is a risk factor for suicide attempts (Suokas 1995), and individuals presenting with acute intoxication should be evaluated for SI. (Pompili 2010) However, >65% of patients who endorse suicidal ideation when intoxicated no longer endorse suicidal ideation once sober. It is reasonable to wait to consult psychiatry until clinical sobriety is achieved. (Keyes 2022)
• Auditory and Visual Hallucinations (AH/VH): The differential diagnosis for hallucinations is broad and includes medical pathology, psychiatry pathology, and transient causes such as acute drug intoxication. (Prerost 2014) In a patient with chronic alcohol use, hallucinations should prompt consideration of acute intoxication, alcoholic hallucinosis, or delirium tremens (DT). While DT is accompanied by vital sign abnormalities and findings consistent with severe alcohol withdrawal, alcoholic hallucinosis may present in a more stable patient. It may be mistaken for acute intoxication, psychiatric illness, or other occult pathology. Consider a psychiatric consult (and labs needed for psychiatric admission) or check blood work if there is a concern for concomitant underlying medical pathology as a cause of hallucinations.
  
• Trauma: Discoordination and a decreased pain response predispose individuals to trauma with lack of insight into their injuries. Brain atrophy and liver dysfunction with decreased clotting factors put patients at high risk of intracranial hemorrhage. Any report of trauma should prompt evaluation with imaging.
• Pain / Additional Complaints: Alcohol can weaken the immune system with only moderate use, predisposing individuals to pneumonia, soft tissue infections, and sepsis. (Barr 2016, Trevejo-Nunez 2015) Patients are at high risk of bleeding from the GI tract due to clotting factor impairment or devastating hemorrhage from esophageal varices in the setting of portal hypertension. (Osna 2017) Alcohol can contribute to pancreatitis, CKD, epilepsy, and countless other conditions. Have a low threshold to work up additional complaints. 
  
• Alcohol use before arrival: If an altered patient denies alcohol use, this should prompt immediate concern for alternative underlying pathologies such as electrolyte abnormalities, uremia, hyperammonemia, infection, or intracranial pathology. If there is a strong clinical suspicion of alcohol use, but a patient denies drinking, it is reasonable to send an alcohol level. However, a positive alcohol level does not exclude underlying pathology. If the diagnosis of isolated acute alcohol intoxication is not patently obvious, patients should undergo a broad workup.

The Physical Exam:

The most crucial part of the assessment of a patient with acute alcohol intoxication is the physical exam. It should resemble a trauma evaluation, including a thorough primary and secondary exam with full exposure. Ensure that the patient has stable vitals, appears comfortable, and is not diaphoretic (which could be concerning for withdrawal, cardiac event, or underlying medical pathology). 

• Airway, breathing, and circulation: Assess and reassess the ABCs and evaluate for an intact airway, including a clear oropharynx without active emesis or excessive secretions, normal respiratory rate with bilateral breath sounds, and good pulses.
• Assess for head and neck trauma: A 2014 study out of NYU/Bellevue Hospital found that 39% of patients who frequented the emergency department with acute alcohol intoxication had a moderate to severe brain injury over a three-year period. (Hamilton 2014) Patients with alcohol intoxication have an extremely high risk of intracranial pathology, and the threshold for obtaining head imaging should be very low. Any facial or scalp lacerations, abrasions, ecchymosis, or deformities should prompt imaging.  Assess for blood in the nares or signs of basal skull fracture, including battle signs, raccoon eyes, or hemotympanum. Do a pupillary exam and ensure pupils are mid-range, equal, round, and reactive to light. 
• The extremities and torso: Ensure that a patient, at minimum, moves all four extremities to noxious stimuli, has good distal pulses, and has a normal passive range of motion. Check that clavicles are intact and that there are no obvious rib fractures or spinal step-offs. Remove all clothing and do a full skin exam. Look for skin ecchymosis, abrasions, lacerations, erythema, temperature differentials, petechiae, or lower extremity edema. Work up appropriately.
• Wernicke’s Encephalopathy (WE): WE is present in over 12% of patients with alcohol use disorder (AUD) (Donnino 2007) and is misdiagnosed in up to 80% of patients (Sechi 2007), and carries a mortality rate of 10-17%. (Sanvisens 2017) Consideration of WE when conducting a physical exam can be lifesaving. The diagnosis can be made if a patient is malnourished (as many patients with AUD are) and has any persistent unexplained finding of ocular symptoms (i.e., nystagmus or sixth nerve palsy), ataxia or mental status change. (Caine 1997) For high suspicion for WE, initiate high dose thiamine (500mg IV TID) and admit for treatment.

Reassessment:

After the initial history and physical exam, reassess the patient roughly every hour. Be fast but thorough. Recheck ABCs. Look for a new battle sign, developing flank ecchymosis, or other evolving pathology. Importantly, ensure the patient follows an expected clinical course for acute intoxication. Document at each reassessment and always have a low threshold to add on a CTH or labs if the patient is not progressing appropriately.

Generally, patients are ready for discharge when their workup is complete, and they are “clinically sober.”  Clinical sobriety involves being: 

• AOx4 (person, place, time, circumstance)
• able to hold a conversation with minimal prompting, and
• able to walk with an independent steady gait.

Patients must also have a benign physical re-exam, have no additional complaints, and be able to tolerate PO. Note that a patient who drinks daily might be “clinically sober” even when their alcohol level is still elevated. However, in certain practice settings, patients are likely to drive upon discharge. In these cases, it is important to ensure that a patient has a safe discharge plan that does not involve driving while legally intoxicated. Also, be cognizant that getting an alcohol level might be tied to a specific length of stay.  As always, document clinical sobriety before discharge.

References:

1. Klein L, Cole J, Driver B, Battista C, Jelinek R, Martel M. Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication. Annals of Emergency Medicine. 2018 Mar;71(3):279-288. PMID: 28844504
   
2. Suokas J, Lonnqvist J. Suicide attempts in which alcohol is involved: a special group in general hospital emergency rooms. Acta Psychiatr Scand. 1995 Jan;91(1):36-40. PMID: 7754784
3. Pompili M, Serafini G, Innamorati M, Dominici G, Ferracuti S, Kotzalidis GD, Serra G, Girardi P, Janiri L, Tatarelli R, Sher L, Lester D. Suicidal behavior and alcohol abuse. Int J Environ Res Public Health. 2010 Apr;7(4):1392-431. Epub 2010 Mar 29. PMID: 20617037
4. Keyes D, Talarico P, Hardin B, Molter A, Lee H, Valiuddin H, Moore B. Suicidal ideation and sobriety: Should acute alcohol intoxication be taken into account for psychiatric evaluation? Alcohol Clin Exp Res. 2022 Jul;46(7):1306-1312. Epub 2022 Jun 9, PMID: 35581530
5. Prerost FJ, Sefcik D, Smith B. Differential Diagnosis of Patients Presenting with Hallucinations. Osteopathic Family Physician. 2014 Mar;6(2). 
6. Barr T, Helms C, Grant K, Messaoudi I. Opposing effects of alcohol on the immune system. Prog Neuropsychopharmacol Biol Psychiatry. 2016 Feb 4;65:242-51. Epub 2015 Sep 14. PMID: 26375241
7. Trevejo-Nunez G, Kolls JK, de Wit M. Alcohol Use As a Risk Factor in Infections and Healing: A Clinician’s Perspective. Alcohol Res. 2015;37(2):177-84. PMID: 26695743
8. Osna NA, Donohue TM Jr, Kharbanda KK. Alcoholic Liver Disease: Pathogenesis and Current Management. Alcohol Res. 2017;38(2):147-161. PMID: 28988570
9. Hamilton BH, Sheth A, McCormack RT, McCormack RP. Imaging of frequent emergency department users with alcohol use disorders. J Emerg Med. 2014 Apr;46(4):582-7. Epub 2014 Jan 10. PMID: 24412058
10. Donnino MW, Vega J, Miller J, Walsh M. Myths and misconceptions of Wernicke’s encephalopathy: what every emergency physician should know. Ann Emerg Med. 2007 Dec;50(6):715-21. Epub 2007 Aug 3. PMID: 17681641
11. Sechi G, Serra A. Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet Neurol. 2007 May;6(5):442-55. PMID: 17434099.
12. Sanvisens A, Zuluaga P, Fuster D, Rivas I, Tor J, Marcos M, Chamorro AJ, Muga R. Long-Term Mortality of Patients with an Alcohol-Related Wernicke-Korsakoff Syndrome. Alcohol Alcohol. 2017 Jul 1;52(4):466-471. PMID: 28340112.
13. Caine D, Halliday GM, Kril JJ, Harper CG. Operational criteria for the classification of chronic alcoholics: identification of Wernicke’s encephalopathy. J Neurol Neurosurg Psychiatry. 1997 Jan;62(1):51-60. PMID: 9010400

Guest Post By:

Lara Silverman, MD
PGY-3, Emergency Medicine Resident
Mount Sinai Hospital, New York, New York

Trevor Pour, MD
Assistant Professor of Emergency Medicine
Assistant Program Director of Emergency Medicine
Mount Sinai Hospital, New York, New York

Post-Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie), Anand Swaminathan, MD (Twitter: @EMSwami) and Marco Propersi, DO (Twitter: @marco_propersi)

The post Managing the Patient with Alcohol Intoxication appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points:

• Assess patients with floaters or flashers for retinal or vitreous detachment. Rapid diagnosis and emergency referral improves outcomes of ophthalmologic interventions.
• CRAO is a stroke of the eye; patients should be considered for a complete stroke work up.

The post REBEL Core Cast 97.0 – Acute Vision Loss II appeared first on REBEL EM - Emergency Medicine Blog.