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
Category Archives: Resus
Life-saving medicine
Give all sick patients oestrogen?
A thought provoking article in Critical Care Medicine outlines basic science, animal, and human studies that suggest oestrogen may have a protective effect in a wide range of critical illnesses from cardiac arrest to trauma to stroke. It urges clinical trials of sex hormones, some of which are underway. Regarding traumatic brain injury, the authors state: “To date, studied interventions to treat the effects of secondary injury, such as induced hypothermia or sedative-hypnotic coma, have had disappointing results… Clearly, EMS (or emergency department) infusion of a single IV bolus of estrogen, a therapy shown in the laboratory to be a strong, direct, easy-to-deliver antioxidant, antiapoptotic, and anti-inflammatory intervention, has a much better chance of decreasing the severity of injury.”
Bold? Let’s see if studies such as this one show this intervention to be so beneficial.
Rationale for routine and immediate administration of intravenous estrogen for all critically ill and injured patients
Critical Care Medicine. 38(10):S620-S629, October 2010
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.
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
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
Peripheral vasoactive infusions
It is often recommended that vasoactive agents are infused via central lines because of the risk of infiltration and tissue injury. The Children’s Hospital Boston transport team describe transport of 73 infants and children who were treated during interhospital transport with vasoactive medications via a peripheral intravenous line.
Median transport time was only 38 minutes (range 3[!!]-216) and median age was 1 (birth to 19) .
Dopamine monotherapy was given in 66 patients, adrenaline (epinephrine) monotherapy in 2, dobutamine plus phenylephrine in 1, dopamine and epinephrine in 3, and dopamine, dobutamine, and epinephrine in 1 patient.
In this retrospective study no patients developed infiltration or other complications related to peripheral vasoactive agents during interfacility transport. Eleven of the 73 patients, however, did develop infiltrates related to vasoactive infusion after arrival at the accepting institution; all infiltrates involved only minimal blanching and/or erythema, and all resolved without significant intervention and caused no lasting tissue injury. The risk of infiltration rose with increasing medication dose and duration of use.
Interesting that noradrenaline (norepinephrine) wasn’t used. This study is interesting but the overwhelming predominance of dopamine makes it hard to extrapolate this to European or Australasian practice.
The Use of Vasoactive Agents Via Peripheral Intravenous Access During Transport of Critically Ill Infants and Children
Pediatr Emerg Care. 2010 Aug;26(8):563-6
rFVIIa did not reduce trauma mortality
An industry sponsored placebo-controlled multicentre randomised controlled trial has shown no mortality reduction from recombinant activated Factor VII (rFVIIa) in patients with trauma.
rFVIIa acts physiologically by enhancing clot formation in the presence of tissue factor expressed on injured or ischemic vascular subendothelium. It also acts pharmacologically, binding directly to activated platelets, increasing thrombin burst, and promoting the formation of a stable hemostatic plug.
Blunt and/or penetrating trauma patients aged 18 years to 70 years were eligible if they had continuing torso and/or proximal lower extremity bleeding after receiving 4 units of RBCs despite standard hemostatic interventions. There was no 30 day mortality reduction, although fewer blood products were transfused from dosing to 24 hours in the rFVIIa group.
No significant difference was seen in the safety profile of rFVIIa compared with placebo.
The CONTROL trial was terminated early (573 of 1502 patients) after an interim analysis suggested a high likelihood of futility in demonstrating the primary endpoint in the blunt trauma population.
Results of the CONTROL Trial: Efficacy and Safety of Recombinant Activated Factor VII in the Management of Refractory Traumatic Hemorrhage
Journal of Trauma-Injury Infection & Critical Care September 2010 69(3):489-500
Pneumoperitoneum
This video from the Trauma Association of Canada shows sonographic detection of intraperitoneal free air
[quicktime]http://www.traumacanada.org/media/pneumoperitoneum_video.mov[/quicktime]
Bronchiolitis – not much works
A review article on bronchiolitis reminds us that there is little evidence to support any specific therapies. Bronchodilators, steroids, adrenaline (epinephrine), CPAP, heliox, mucolytics and leukotriene antagonists are all reviewed. Of these, inhaled 3% saline as a mucolytic has some promise in that studies show it to reduce length of stay in admitted patients by one day. CPAP has been shown to reduce pCO2 but evidence of further benefit may have been limited by a lack of adequately powered studies.
Current Therapies in Bronchiolitis
Pediatr Emerg Care. 2010 Apr;26(4):302-7
Alternative toothless mask position
An alternative position for holding the facemask when bag-mask ventilating edentulous patients is described and evaluated. 49 patients with inadequate seal and air leak during two-hand positive-pressure ventilation had significantly improved ventilation as measured by reduced air leak and increased expiratory volume when the caudal end of the mask was repositioned above the lower lip while maintaining neck extension.
Face mask ventilation in edentulous patients: a comparison of mandibular groove and lower lip placement
Anesthesiology. 2010 May;112(5):1190-3
Taming the Ketamine Tiger
A paper of great interest for those of us who spend a lot of time teaching the use of ketamine describes its history from initial synthesis in the early 1960s. Ketamine pioneer Edward F. Domino, M.D describes how it was first given to humans in 1964: ‘Our findings were remarkable! The overall incidence of side effects was about one out of three volunteers. Frank emergence delirium was minimal. Most of our subjects described strange experiences like a feeling of floating in outer space and having no feeling in their arms or legs.‘
Domino goes on to list interesting anecdotes in ketamine’s history, like how his wife came up with the term ‘dissociative anaesthetic’ and how physicians and their partners experimenting with ketamine in the 1970s tried communicating with dolphins, fell in love, and froze to death in a forest. The pharmacology of ketamine is described along with its effects on pain and even depression.
Taming the ketamine tiger.
Anesthesiology. 2010 Sep;113(3):678-84 Free Full Text