Category Archives: Acute Med

Acute care of the medically sick adult

Acute Med, All Updates, ICU, Resus

Unilateral pulmonary oedema worse

A few years ago in the Emergency Department I managed a sick hypotensive, hypoxic 20-something year old with a unilateral lung white-out and air bronchograms as pneumonia/septic shock. He died subsequently of refractory pulmonary oedema on the ICU, where the diagnosis of acute pulmonary oedema due to severe aortic stenosis was delayed. Post mortem findings showed pulmonary oedema but no pneumonia. A kind radiologist told me the chest x-ray would certainly have fitted with pneumonia. After this case I learned to echo sick hypotensive patients in the ED.
Circulation reports 869 cardiogenic pulmonary oedema patients, of which 2.1% had unilateral pulmonary oedema (UPE). In patients with UPE, blood pressure was significantly lower (P<=0.01), whereas noninvasive or invasive ventilation and catecholamines were used more frequently (P=0.0004 and P<0.0001, respectively). The prevalence of severe mitral regurgitation in patients with bilateral pulmonary edema and UPE was 6% and 100%, respectively (P<0.0001). In patients with UPE, use of antibiotic therapy and delay in treatment were significantly higher (P<0.0001 and P=0.003, respectively). In-hospital mortality was 9%: 39% for UPE versus 8% for bilateral pulmonary edema (odds ratio, 6.9; 95% confidence interval, 2.6 to 18; P<0.001). In multivariate analysis, unilateral location of pulmonary edema was independently related to death.
Prevalence, Characteristics, and Outcomes of Patients Presenting With Cardiogenic Unilateral Pulmonary Edema
Circulation. 2010 Sep 14;122(11):1109-15

Acute Med, All Updates, Resus

Pneumonia scores equivalent

Got a favourite assessment tool for classifying the severity of community acquired pneumonia? Two systematic reviews showed no significant differences in performance between Pneumonia Severity Index (PSI) and various versions of CURB (CURB, CURB-65, and CRB-65).
An accompanying editorial* opines that CRB-65 is the simplest tool and can easily be remembered. It also discusses some of the more subtle strengths and weaknesses of the tools.
Severity assessment tools for predicting mortality in hospitalised patients with community-acquired pneumonia. Systematic review and meta-analysis
Thorax. 2010 Oct;65(10):878-83

Value of severity scales in predicting mortality from community-acquired pneumonia: systematic review and meta-analysis
Thorax. 2010 Oct;65(10):884-90
*Severity scores for CAP. ‘Much workload for the next bias’
Thorax 2010 Oct;65:853-855

Acute Med, All Updates, ICU, PHARM, Resus, Trauma

EZ-IO outperformed B.I.G

A small randomised trial of adult emergency department patients showed faster insertion and higher success rates with the EZ-IO compared with the Bone Injection Gun (B.I.G). This is in keeping with my own experience and that of several services I have worked for.

EZ-IO

Bone Injection Gun

Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: A prospective, randomized study
Resuscitation. 2010 Aug;81(8):994-9

Acute Med, All Updates, Resus, Ultrasound

Pulmonary embolism echo

Academic Emergency Medicine has a free article on sonographic detection of submassive pumonary embolism, with three video clips.
One of the videos shows a nice demonstration of the McConnell sign (RV mid-segment dilation with apical sparing), which has been reported to be specific for (sub)massive PE. According to this article however, it has been reported that the McConnell sign is present in two thirds of patients with RV infarction and is only 33% specific for PE. Continuous wave Doppler helps differentiate RV infarction from submassive PE by demonstrating an increased tricuspid regurgitation RA-RV pressure gradient in submassive PE and a normal or low gradient in RV infarction.
The full article is available here

Acute Med, All Updates, Guidelines, ICU, Resus

New ICH Guidelines

A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association on the management of spontaneous intracerebral haemorrhage has been published in Stroke. The full text is available here.
In summary:
Medical Treatment for ICH

  • Patients with a severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets, respectively
  • Patients with ICH whose INR is elevated due to oral anticoagulants (OAC) should have their warfarin withheld, receive therapy to replace vitamin K–dependent factors and correct the INR, and receive intravenous vitamin K. Prothrombin Complex Concentrates have not shown improved outcome compared with FFP but may have fewer complications compared with FFP and are reasonable to consider as an alternative to FFP.
  • rFVIIa does not replace all clotting factors, and although the INR may be lowered, clotting may not be restored in vivo; therefore, rFVIIa is not routinely recommended as a sole agent for OAC reversal in ICH
  • Although rFVIIa can limit the extent of hematoma expansion in noncoagulopathic ICH patients, there is an increase in thromboembolic risk with rFVIIa and no clear clinical benefit in unselected patients. Thus rFVIIa is not recommended in unselected patients. Further research to determine whether any selected group of patients may benefit from this therapy is needed before any recommendation for its use can be made.
  • The usefulness of platelet transfusions in ICH patients with a history of antiplatelet use is unclear and is considered investigational
  • Patients with ICH should have intermittent pneumatic compression for prevention of venous thromboembolism in addition to elastic stockings
  • After documentation of cessation of bleeding, low-dose subcutaneous low-molecular-weight heparin or unfractionated heparin may be considered for prevention of venous thromboembolism in patients with lack of mobility after 1 to 4 days from onset
    • Blood Pressure

    • Until ongoing clinical trials of BP intervention for ICH are completed, physicians must manage BP on the basis of the present incomplete efficacy evidence. Current suggested recommendations for target BP in various situations are listed in an accompanying table and may be considered
    • In patients presenting with a systolic BP of 150 to 220 mmHg, acute lowering of systolic BP to 140 mm Hg is probably safe

    Inpatient Management and Prevention of Secondary Brain Injury

    • Initial monitoring and management of ICH patients should take place in an intensive care unit with physician and nursing neuroscience intensive care expertise
    • Glucose should be monitored and normoglycemia is recommended

    Seizures and Antiepileptic Drugs

    • Clinical seizures should be treated with antiepileptic drugs
    • Continuous EEG monitoring is probably indicated in ICH patients with depressed mental status out of proportion to the degree of brain injury
    • Patients with a change in mental status who are found to have electrographic seizures on EEG should be treated with antiepileptic drugs
    • Prophylactic anticonvulsant medication should not be used

    Procedures/Surgery

    • Patients with a GCS score of ≤8, those with clinical evidence of transtentorial herniation, or those with significant IVH or hydrocephalus might be considered for ICP monitoring and treatment. A cerebral perfusion pressure of 50 to 70 mmHg may be reasonable to maintain depending on the status of cerebral autoregulation
    • Ventricular drainage as treatment for hydrocephalus is reasonable in patients with decreased level of consciousness

    Intraventricular Hemorrhage Recommendation

    • Although intraventricular administration of recombinant tissue-type plasminogen activator in IVH appears to have a fairly low complication rate, efficacy and safety of this treatment is uncertain and is considered investigational

    Clot Removal

    • For most patients with ICH, the usefulness of surgery is uncertain. Specific exceptions to this recommendation follow
    • Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible. Initial treatment of these patients with ventricular drainage alone rather than surgical evacuation is not recommended
    • For patients presenting with lobar clots ≥30 mL and within 1 cm of the surface, evacuation of supratentorial ICH by standard craniotomy might be considered
    • The effectiveness of minimally invasive clot evacuation utilizing either stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain and is considered investigational
    • Although theoretically attractive, no clear evidence at present indicates that ultra-early removal of supratentorial ICH improves functional outcome or mortality rate. Very early craniotomy may be harmful due to increased risk of recurrent bleeding

    Outcome Prediction and Withdrawal of Technological Support

    • Aggressive full care early after ICH onset and postponement of new DNR orders until at least the second full day of hospitalization is probably recommended. Patients with preexisting DNR orders are not included in this recommendation. Current methods of prognostication in individual patients early after ICH are likely biased by failure to account for the influence of withdrawal of support and early DNR orders. Patients who are given DNR status at any point should receive all other appropriate medical and surgical interventions unless otherwise explicitly indicated.

    Prevention of Recurrent ICH

    • In situations where stratifying a patient’s risk of recurrent ICH may affect other management decisions, it is reasonable to consider the following risk factors for recurrence: lobar location of the initial ICH, older age, ongoing anticoagulation, presence of the apolipoprotein ε2 or ε4 alleles, and greater number of microbleeds on MRI
    • After the acute ICH period, absent medical contraindications, BP should be well controlled, particularly for patients with ICH location typical of hypertensive vasculopathy
    • After the acute ICH period, a goal target of a normal BP of <140/90 (<130/80 if diabetes or chronic kidney disease) is reasonable
    • Avoidance of long-term anticoagulation as treatment for nonvalvular atrial fibrillation is probably recommended after spontaneous lobar ICH because of the relatively high risk of recurrence. Anticoagulation after nonlobar ICH and antiplatelet therapy after all ICH might be considered, particularly when there are definite indications for these agents. Avoidance of heavy alcohol use can be beneficial. There is insufficient data to recommend restrictions on use of statin agents or physical or sexual activity

    Rehabilitation and Recovery

    • Given the potentially serious nature and complex pattern of evolving disability, it is reasonable that all patients with ICH have access to multidisciplinary rehabilitation. Where possible, rehabilitation can be beneficial when begun as early as possible and continued in the community as part of a well-coordinated (seamless) program of accelerated hospital discharge and home-based resettlement to promote ongoing recovery

    Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association
    Stroke published online Jul 22, 2010

    Acute Med, All Updates

    Balloon pump before PCI? Nah.

    High risk patients benefit from pre-operative intra-aortic balloon counterpulsation (IABP) prior to coronary artery bypass surgery. Would the same apply to patients undergoing percutaneous coronary intervention (PCI)?
    A multicentre randomised controlled trial was conducted on over 300 patients with severe LV dysfunction and extensive coronary disease. The intervention was elective insertion of IABP before PCI. The composite primary end point of death, acute myocardial infarction, cerebrovascular event, or further revascularization at hospital discharge was not reduced in the intervention group.
    These results do not support a strategy of routine IABP placement before PCI in all patients with severe left ventricular dysfunction and extensive coronary disease.
    Elective Intra-aortic Balloon Counterpulsation During High-Risk Percutaneous Coronary Intervention
    JAMA. 2010;304(8):867-874

    Acute Med, All Updates, Resus

    ACE-inhibitor related angioedema

    The pathophysiology of angiotensin-converting enzyme inhibitor (ACEi)–induced angioedema most likely resembles that of hereditary angioedema, ie, it is mainly mediated by bradykinin-induced activation of vascular bradykinin B2 receptors. It was hypothesised that the bradykinin B2 receptor antagonist icatibant might therefore be an effective therapy for ACEi-induced angioedema. This month’s Annals of Emergency Medicine reports research assessing its effciacy in a small series of patients, with a retrospective comparison against steroid and antihistamine therapy.
    The eight patients with acute ACEi-induced angioedema were treated with a single subcutaneous injection of icatibant. First symptom improvement after icatibant injection occurred at a mean time of 50.6 minutes and complete relief of symptoms at 4.4 hours. In the historical comparison group treated with methylprednisolone and clemastine (an antihistamine / anticholinergic), the mean time to complete relief of symptoms was 33 hours. Some of these patients received a tracheotomy (3/47), were intubated (2/47), or received a second dose of methylprednisolone (12/47).
    Therapeutic Efficacy of Icatibant in Angioedema Induced by Angiotensin-Converting Enzyme Inhibitors: A Case Series
    Ann Emerg Med. 2010;56(3):278-82

    Acute Med, All Updates, ICU, Resus

    UK Capacity Assessment Mnemonic

    GPs Drs Hoghton & Chadwick have produced a bioethical mnemonic ‘CURB BADLIP’, for all healthcare professionals in England, Scotland, and Wales for use in patients aged 18 or over in an emergency:

    C—communicate. Can the person communicate his or her decision?
    U—understand. Can the person understand the information being given?
    R—retain. Can the person retain the information given?
    B—balance. Can the person balance, or use, the information?
    B—best interest. If there is no capacity can you make a best interest decision?
    AD—advanced decision. Is there an advanced decision to refuse treatment?
    L—lasting power of attorney. Has lasting power of attorney been appointed?
    I—independent mental capacity advocate. Is the person without anyone who can be consulted about best interest? In an emergency involve an independent mental capacity advocate
    P—proxy. Are there any unresolved conflicts? Consider involving the local ethics committee or the court of protection appointed deputy.

    Assessing patient capacity: Remember CURB BADLIP in the UK
    BMJ 2010 340: c1285

    Acute Med, All Updates, Guidelines, ICU, Resus

    Delirium guidelines

    The UK’s National Institute for Health and Clinical Excellence (NICE) has produced guidelines on delirium.
    Delirium (sometimes called ‘acute confusional state’) is a common clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course.
    Some snippets from the guideline include:

    • If indicators of delirium are identified, carry out a clinical assessment based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria or short Confusion Assessment Method (short CAM) to confirm the diagnosis.
    • In critical care or in the recovery room after surgery, CAM-ICU should be used. A healthcare professional who is trained and competent in the diagnosis of delirium should carry out the assessment.
    • If there is difficulty distinguishing between the diagnoses of delirium, dementia or delirium superimposed on dementia, treat for delirium first.
    • If a person with delirium is distressed or considered a risk to themselves or others and verbal and non-verbal de-escalation techniques are ineffective or inappropriate, consider giving short- term (usually for 1 week or less) haloperidol or olanzapine.

    The CAM-ICU assessment tool is demonstrated in the video below, which is found along with other helpful delirium resources at http://www.icudelirium.co.uk

    NICE Guidance: Delirium: diagnosis, prevention and management