Sydney HEMS physician Dr Brian Burns talks about the prehospital care of trauma in this 20 minute audio podcast recorded at SMACC 2013
Further talks from the SMACC conference are available for free download on iTunes.
Here are the accompanying slides:
Category Archives: Resus
Life-saving medicine
The non-intubation checklist
Scenario:
A 79 year old previously well female presents with loss of consciousness, having been found unresponsive by her daughter who saw her well one hour previously.
Examination reveals a GCS of E1V2M3 = 6 and reactive pupils with no lateralising signs. She is hypertensive. A VBG reveals a normal glucose and sodium and a pCO2 of 60 mmHg (7.9 kPa).
The emergency physician’s plan is to intubate and get a CT scan of her brain. This is explained to the daughter.
A no-brainer? You’d think so.
A 79 year old previously well female presents with loss of consciousness, having been found unresponsive by her daughter who saw her well one hour previously.
Examination reveals a GCS of E1V2M3 = 6 and reactive pupils with no lateralising signs. She is hypertensive. A VBG reveals a normal glucose and sodium and a pCO2 of 60 mmHg (7.9 kPa).
The emergency physician’s plan is to intubate and get a CT scan of her brain. This is explained to the daughter.
A no-brainer? You’d think so.
A consistent issue that recurs during discussions with UK emergency medicine colleagues is that of having to rely on anaesthesia and/or ICU colleagues for intubation of their patients in the ED. The pain comes not from disagreeing about who does the procedure or what drugs to use, but rather on the decision to intubate.
The refusal to intubate can stall or halt a resuscitation plan, delay care, result in risky transfers to the imaging suite, and even deny potential outcome-improving therapy (for example post-ROSC cooling). It can undermine team leadership and disrupt the team dynamic.
There are often different ways to ‘skin a cat’ and it is frequently helpful to invite the opinion of other critical care specialists. However, it is clear from multiple discussions with frustrated EM colleagues that the decision not to intubate is often influenced by non-clinical factors, most often ICU bed availability. Other times, it appears to be that the ‘gatekeeper’ to airway care (and to ICU beds) does not share the same appreciation of the clinical issues at stake. Examples here include the self-fulfilling pessimism post-ROSC based on inappropriate assignment of predictive value to neurological signs, and the assumption of non-treatable pathology in elderly patients presenting with coma.
The obvious solution to this is that the responsibility for managing the ‘A’ of ABC should not be delegated to non-emergency medicine personnel. Sadly, this is not achievable 24/7 in all UK departments right now for a number of awkward reasons.
So what’s a team leader to do when faced with a colleague’s refusal to intubate? The best approach would be to gently and politely persuade them to change their mind by stating some clinical facts that enable a shared mental model and agreed management plan, and to ensure the most senior available physicians are participating in the discussion.
Sometimes that fails. What next? Here’s a suggestion. This is slightly tongue-in-cheek but take away from it what you will.
It is imperative that the individual declining intubation appreciates the gravity of his or her decision. They must not be under the impression that they’ve done you (and the patient) a favour by giving their opinion after an ‘airway consult’. They have declined a resuscitative intervention requested by the emergency medicine team leader and should appreciate the consequences of this decision and the need to document it as such.
Perhaps say something along the lines of:
‘I see we haven’t managed to agree on this. We’ll just need you to complete the non-intubation form please for our quality improvement process. This will also help prevent your point being forgotten or misunderstood if we’re unlucky enough to face any complaints or litigation. I can fill it in on your behalf but I suspect you’d want to represent yourself as accurately as possible when documenting such a bold decision’
And here’s the form. It is provocative, cheeky, and in no way should really be used in its current form:
Thenar eminence based medicine
A recent study showed superior effectiveness of one bag-mask ventilation style over another in novice providers. The technique recommended is the thenar eminence grip, in which downward pressure is applied with the thenar eminences while the four fingers of each hand pull the jaw upwards toward the mask.
Interestingly, in their crossover study in which the thenar emininence (TE) technique was compared with the traditionally taught ‘CE’ technique, they demonstrated a ‘sequence effect’. If subjects did TE first, they maintained good tidal volumes when doing CE. However if they did CE first, they achieved poor tidal volumes which were markedly improved when switching to TE.
The authors suggest: “A possible explanation for this sequence effect is that the TE grip is superior. When one used the TE grip first, he or she was more likely to learn how a good tidal volume “feels” and then more likely to apply good technique with the EC grip.“.
Some of us have been practicing and teaching this technique for a while. None have put it better than the brilliant Reuben Strayer of EM Updates in this excellent short video:
Emergency Ventilation in 11 Minutes from reuben strayer on Vimeo.
Efficacy of facemask ventilation techniques in novice providers
J Clin Anesth. 2013 May;25(3):193-7
STUDY OBJECTIVE: To determine which of two facemask grip techniques for two-person facemask ventilation was more effective in novice clinicians, the traditional E-C clamp (EC) grip or a thenar eminence (TE) technique.
DESIGN: Prospective, randomized, crossover comparison study.
SETTING: Operating room of a university hospital.
SUBJECTS: 60 novice clinicians (medical and paramedic students).
MEASUREMENTS: Subjects were assigned to perform, in a random order, each of the two mask-grip techniques on consenting ASA physical status 1, 2, and 3 patients undergoing elective general anesthesia while the ventilator delivered a fixed 500 mL tidal volume (VT). In a crossover manner, subjects performed each facemask ventilation technique (EC and TE) for one minute (12 breaths/min). The primary outcome was the mean expired VT compared between techniques. As a secondary outcome, we examined mean peak inspiratory pressure (PIP).
MAIN RESULTS: The TE grip provided greater expired VT (379 mL vs 269 mL), with a mean difference of 110 mL (P < 0.0001; 95% CI: 65, 157). Using the EC grip first had an average VT improvement of 200 mL after crossover to the TE grip (95% CI: 134, 267). When the TE grip was used first, mean VTs were greater than for EC by 24 mL (95% CI: -25, 74). When considering only the first 12 breaths delivered (prior to crossover), the TE grip resulted in mean VTs of 339 mL vs 221 mL for the EC grip (P = 0.0128; 95% CI: 26, 209). There was no significant difference in PIP values using the two grips: the TE mean (SD) was 14.2 (7.0) cm H2O, and the EC mean (SD) was 13.5 (9.0) cm H2O (P = 0.49).
CONCLUSIONS: The TE facemask ventilation grip results in improved ventilation over the EC grip in the hands of novice providers.
Making Things Happen from SMACC 2013
The talks from SMACC 2013 – the best critical conference ever (so far) – are being made available.
Here’s my talk on Making Things Happen.
Video:
An audio only version is available here:
References from the talk and the slide set are available here
For more SMACC talks susbscribe via iTunes or keep an eye on the Intensive Care Network site
RSI haemodynamics in the field
The noxious stimulus of laryngoscopy & tracheal intubation can precipitate hypertension, tachycardia, and intracranial pressure elevation, risking exacerbation of brain injury or haemorrhage. Physicians from an English Helicopter Emergency Medical Service examined the response of heart rate and blood pressure to prehospital rapid sequence intubation (RSI). While a retrospective study, the haemodynamic data were prospectively recorded and documented using standard monitor printouts, and time of intubation could be accurately determined by the onset of capnography recordings. Their standardised system documents blood pressure recordings every three minutes. Etomidate and suxamethonium were used for RSI.
They report their findings:
A hypertensive response occurred in 79% (70/89) of patients. MAP exceeded the upper limit of estimated intact cerebral autoregulation (150 mmHg) in 18% (16/89) of cases and 9% (8/89) of patients had a greater than 100% increase in MAP and/or SBP. A single hypotensive response occurred. A tachycardic response occurred in 58% (64/110) of patients and bradycardia was induced in one.
Of note, 97 of the 115 patients had injuries that included head trauma.
The authors note that opioids are often co-administered during in-hospital RSI and that this may offset the haemodynamic stimulation, while possible increasing the complexity of the procedure in the prehospital environment. They have modified their pre-hospital anaesthesia standard operating procedure to include the use of an opioid and will report the associated outcomes and complication rates ‘in due course’.
This is interesting and important stuff, and something we should all be looking at in our respective prehospital critical care services.
The haemodynamic response to pre-hospital RSI in injured patients
Injury. 2013 May;44(5):618-23
[EXPAND Abstract]
BACKGROUND: Laryngoscopy and tracheal intubation provoke a marked sympathetic response, potentially harmful in patients with cerebral or cardiovascular pathology or haemorrhage. Standard pre-hospital rapid sequence induction of anaesthesia (RSI) does not incorporate agents that attenuate this response. It is not known if a clinically significant response occurs following pre-hospital RSI or what proportion of injured patients requiring the intervention are potentially at risk in this setting.
METHODS: We performed a retrospective analysis of 115 consecutive pre-hospital RSI’s performed on trauma patients in a physician-led Helicopter Emergency Medical Service. Primary outcome was the acute haemodynamic response to the procedure. A clinically significant response was defined as a greater than 20% change from baseline recordings during laryngoscopy and intubation.
RESULTS: Laryngoscopy and intubation provoked a hypertensive response in 79% of cases. Almost one-in-ten patients experienced a greater than 100% increase in mean arterial pressure (MAP) and/or systolic blood pressure (SBP). The mean (95% CI) increase in SBP was 41(31-51) mmHg and MAP was 30(23-37) mmHg. Conditions leaving the patient vulnerable to secondary injury from a hypertensive response were common.
CONCLUSIONS: Laryngoscopy and tracheal intubation, following a standard pre-hospital RSI, commonly induced a clinically significant hypertensive response in the trauma patients studied. We believe that, although this technique is effective in securing the pre-hospital trauma airway, it is poor at attenuating adverse physiological effects that may be detrimental in this patient group.
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Awake intubation
I had some fun today getting intubated.
We used the Ambu aScope 2 and the Greater Sydney Area HEMS equipment and approach to airway management. I didn’t receive an antisialogogue or any analgesia or sedation.
The big learning point for me was how hard it was to anaesthetise the posterior part of my nasal cavity and nasopharynx. I thought the worst part would be any stimulation of my vocal cords or trachea with lidocaine or instrumentation, but this really was fine. Nebulised 2% lidocaine (the strongest concentration we have), atomised lidocaine (using a mucosal atomiser), and co-phenylcaine spray weren’t sufficient. I can see why people use pastes or gel to maintain mucosal contact while the lidocaine takes effect, but we don’t have those (yet). The best solution came from hooking up oxygen tubing to an iv cannula via a three way tap. Oxygen was run through at 2 l/min and lidocaine injected via the the three way tap. This enabled an atomised spray to be directed right onto the area concerned, and made the insertion of the nasotracheal tube more tolerable – although still unpleasant.
The fact I could be intubated awake with reasonable topicalisation suggests most patients should tolerate it perhaps after even an analgesic dose of ketamine, eg. 30-40 mg in an adult. I suspect full dissocation would not be required, which is good for cooperation (“stick your tongue out sir”). I appreciate there are better agents, such as remifentanil or dexmedetomidine, but my area of interest is the retrieval setting – where I have neither the luxury of using these agents nor that of calling for anaesthetic back up.
Thanks to HEMS physicians Emily Stimson, Nirosha De Zoysa, Felicity Day, Chloe Tetlow, and Fergal McCourt for making it fun and safe.
Here’s the video:
Twitter has been helpful in gathering some advice, particularly from @DocJohnHinds:
Predicting volume responsiveness
One of the current Holy Grails of ED critical care is to find a reliable measure of fluid responsiveness in those patients with impaired organ perfusion, such as those with severe sepsis. This would enable us to identify those patients whose cardiac output would be improved by fluid therapy, and avoid subjecting ‘non-responders’ to the risks associated with fluid overload. Thanks to the uptake of early goal-directed therapy in sepsis, under-resuscitation is now much less common in the ED. However a growing evidence base reveals the dangers of over-resuscitation. We have a responsibility to optimise fluid therapy as best we can with the equipment we have, according to the latest evidence.
Inferior Vena Cava Ultrasound
Some tests of fluid responsiveness rely on the effect of respiration-induced changes in pleural pressure on the circulation. Inferior vena cava (IVC) size and degree of inspiratory collapse correlate with central venous pressure (CVP), but CVP is not a reliable predictor of volume status or responsiveness. Skinny, collapsing IVCs detected on ultrasound suggest volume responsiveness, but the lack of this finding does not exclude fluid responsiveness. IVC size and measurement can be affected by patient position, probe position, and a variety of health states from athleticism to increased abdominal pressure.
Pulse Pressure Variation
Respiratory pulse pressure variation derived from an arterial line trace in mechanically ventilated patients who are adequately sedated and receiving large tidal volumes can predict fluid responsiveness too. Variability in tidal volume, the presence of spontaneous breathing activity in a ventilated patient, and cardiac dysrhythmia can all confound the usefulness of this method.
End expiratory occlusion
Another test in mechanically ventilated patients is the end expiratory occlusion test. A positive pressure inspiratory breath cyclically decreases the left cardiac preload. Occluding the circuit at end-expiration prevents this cyclic impediment in left cardiac preload and acts like a fluid challenge. A 15 second expiratory occlusion is performed and an increase in pulse pressure or (if you can measure it) cardiac index predicts fluid responsiveness with a high degree of accuracy. The patient must be able to tolerate the 15 second interruption to ventilation without initiating a spontaneous breath.
Passive Leg Raise
Passive leg raising (PLR) involves measuring cardiac output (or its surrogate, velocity-time integral, or VTI) before and after tilting the semirecumbent patient supine and raising the legs to 45 degrees. This ‘autotransfuses’ blood from the lower limbs to the core and acts as a reversible fluid challenge. An increase in VTI identifies fluid responders. It would be nice if a PLR-induced increase in blood pressure revealed the answer, but BP does not reliably inform us of changes in cardiac output.
All these tests have limitations. Pulse pressure variation fails in patients with low respiratory system compliance, such as is found in ARDS(1). End-expiratory occlusion and PLR work in low respiratory system compliance, but the former still requires mechanical ventilation, and the latter requires a means of estimating cardiac output or a surrogate – oesophageal Doppler, the velocity-time integral measured by transthoracic echocardiography, and femoral artery flow (measured by arterial Doppler) have all been used. Non-invasive cardiac output monitors that are not operator dependent exist, such as the NICOM(TM) bioreactance device. Bioreactance cardiac output measurement is based on an analysis of relative phase shifts of an oscillating current that occurs when this current traverses the thoracic cavity. Its advantages are that it is noninvasive, it does not require endotracheal intubation or an arterial line, and it provides a good estimate of stroke volume in patients with atrial fibrillation.
A recent study evaluating the combination of PLR with NICOM(TM) bioreactance monitoring revealed that another tool could indicate volume responsiveness: an increase in carotid blood flow after PLR, as measured by carotid Doppler flow imaging(2). A threshold increase in carotid Doppler flow imaging of 20% for predicting volume responsiveness had a sensitivity and specificity of 94% and 86%, respectively. This was studied in a heterogenous group of hemodynamically unstable patients, suggesting applicability to the kind of patients who present to the ED, although numbers were small so more validation is required.
End-tidal carbon dioxide
End-tidal carbon dioxide (ETCO2) levels depend on cardiac output. Increasing cardiac output with a fluid challenge or PLR increases ETCO2,as long as ventilatory and metabolic conditions remain stable. In a recent small study, a PLR-induced increase in ETCO2 ≥ 5 % predicted a fluid-induced increase in cardiac index ≥ 15 % with sensitivity of 71 % (95 % confidence interval: 48-89 %) and specificity of 100 (82-100) %(3). The maximal effects of PLR on CI and ETCO2 were observed within 1 min.
So what can I use?
In summary, differentiating fluid responders from non-responders in the ED remains a challenge. The method used depends on available equipment and expertise, and whether the patient is spontaneously breathing or mechanically ventilated. The NICOM(TM) shows great promise but until your department can afford one, ultrasound is the way to go; small collapsing IVCs suggest fluid responders. Learning to measure a VTI on transthoracic echo or carotid Doppler flow will help you assess the response to a PLR in spontaneously ventilating patients. If they’re mechanically ventilated, then looking for an ETCO2 rise after PLR could be a simpler alternative.
Fluid responsiveness assessment – options in the Emergency Department
Inferior Vena Cava Ultrasound
Helpful if skinny / large degree of respirophasic collapse – suggests fluid responsive – ventilated or spontaneous breathing
Passive Leg Raise
Good in ventilated or spontaneous breathing patients; need to measure cardiac output or a surrogate, such as VTI (echo), NICOM(TM), carotid Doppler flow, or ETCO2 (if ventilation and metabolic status constant)
Pulse Pressure Variation
Requires full mechanical ventilation; no good if low respiratory compliance / disturbed heart-lung interaction
End expiratory occlusion
Requires mechanical ventilation and patient tolerance of 15 seconds of apnoea. Acts like a passive leg raise so need a measure of cardiac output or surrogate
Inferior Vena Cava Ultrasound
Helpful if skinny / large degree of respirophasic collapse – suggests fluid responsive – ventilated or spontaneous breathing
Passive Leg Raise
Good in ventilated or spontaneous breathing patients; need to measure cardiac output or a surrogate, such as VTI (echo), NICOM(TM), carotid Doppler flow, or ETCO2 (if ventilation and metabolic status constant)
Pulse Pressure Variation
Requires full mechanical ventilation; no good if low respiratory compliance / disturbed heart-lung interaction
End expiratory occlusion
Requires mechanical ventilation and patient tolerance of 15 seconds of apnoea. Acts like a passive leg raise so need a measure of cardiac output or surrogate
I look forward to more studies on these modalities, and to trying some of them in the resus room at every available opportunity.
1. Passive leg-raising and end-expiratory occlusion tests perform better than pulse pressure variation in patients with low respiratory system compliance
Crit Care Med. 2012 Jan;40(1):152-7
[EXPAND Abstract]
OBJECTIVES: We tested whether the poor ability of pulse pressure variation to predict fluid responsiveness in cases of acute respiratory distress syndrome was related to low lung compliance. We also tested whether the changes in cardiac index induced by passive leg-raising and by an end-expiratory occlusion test were better than pulse pressure variation at predicting fluid responsiveness in acute respiratory distress syndrome patients.
DESIGN: Prospective study.
SETTING: Medical intensive care unit.
PATIENTS: We included 54 patients with circulatory shock (63 ± 13 yrs; Simplified Acute Physiology Score II, 63 ± 24). Twenty-seven patients had acute respiratory distress syndrome (compliance of the respiratory system, 22 ± 3 mL/cm H2O). In nonacute respiratory distress syndrome patients, the compliance of the respiratory system was 45 ± 9 mL/cm H2O.
MEASUREMENTS AND MAIN RESULTS: We measured the response of cardiac index (transpulmonary thermodilution) to fluid administration (500 mL saline). Before fluid administration, we recorded pulse pressure variation and the changes in pulse contour analysis-derived cardiac index induced by passive leg-raising and end-expiratory occlusion. Fluid increased cardiac index ≥ 15% (44% ± 39%) in 30 “responders.” Pulse pressure variation was significantly correlated with compliance of the respiratory system (r = .58), but not with tidal volume. The higher the compliance of the respiratory system, the better the prediction of fluid responsiveness by pulse pressure variation. A compliance of the respiratory system of 30 mL/cm H2O was the best cut-off for discriminating patients regarding the ability of pulse pressure variation to predict fluid responsiveness. If compliance of the respiratory system was >30 mL/cm H2O, then the area under the receiver-operating characteristics curve for predicting fluid responsiveness was not different for pulse pressure variation and the passive leg-raising and end-expiratory occlusion tests (0.98 ± 0.03, 0.91 ± 0.06, and 0.97 ± 0.03, respectively). By contrast, if compliance of the respiratory system was ≤ 30 mL/cm H2O, then the area under the receiver-operating characteristics curve was significantly lower for pulse pressure variation than for the passive leg-raising and end-expiratory occlusion tests (0.69 ± 0.10, 0.94 ± 0.05, and 0.93 ± 0.05, respectively).
CONCLUSIONS: The ability of pulse pressure variation to predict fluid responsiveness was inversely related to compliance of the respiratory system. If compliance of the respiratory system was ≤ 30 mL/cm H2O, then pulse pressure variation became less accurate for predicting fluid responsiveness. However, the passive leg-raising and end-expiratory occlusion tests remained valuable in such cases.
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2. The use of bioreactance and carotid doppler to determine volume responsiveness and blood flow redistribution following passive leg raising in hemodynamically unstable patients
Chest. 2013 Feb 1;143(2):364-70
[EXPAND Abstract]
BACKGROUND: The clinical assessment of intravascular volume status and volume responsiveness is one of the most difficult tasks in critical care medicine. Furthermore, accumulating evidence suggests that both inadequate and overzealous fluid resuscitation are associated with poor outcomes. The objective of this study was to determine the predictive value of passive leg raising (PLR)- induced changes in stroke volume index (SVI) as assessed by bioreactance in predicting volume responsiveness in a heterogenous group of patients in the ICU. A secondary end point was to evaluate the change in carotid Doppler fl ow following the PLR maneuver.
METHODS: During an 8-month period, we collected clinical, hemodynamic, and carotid Doppler data on hemodynamically unstable patients in the ICU who underwent a PLR maneuver as part of our resuscitation protocol. A patient whose SVI increased by . 10% following a fluid challenge was considered a fluid responder.
RESULTS: A complete data set was available for 34 patients. Twenty-two patients (65%) had severe sepsis/septic shock, whereas 21 (62%) required vasopressor support and 19 (56%) required mechanical ventilation. Eighteen patients (53%) were volume responders. The PLR maneuver had a sensitivity of 94% and a specificity of 100% for predicting volume responsiveness (one false negative result). In the 19 patients undergoing mechanical ventilation, the stroke volume variation was 18.0% 5.1% in the responders and 14.8% 3.4% in the nonresponders ( P 5 .15). Carotid blood fl ow increased by 79% 32% after the PLR in the responders compared with 0.1% 14% in the nonresponders ( P , .0001). There was a strong correlation between the percent change in SVI by PLR and the concomitant percent change in carotid blood fl ow ( r 5 0.59, P 5 .0003). Using a threshold increase in carotid Doppler fl ow imaging of 20% for predicting volume responsiveness, there were two false positive results and one false negative result, giving a sensitivity and specificity of 94% and 86%, respectively. We noted a significant increase in the diameter of the common carotid artery in the fluid responders.
CONCLUSIONS: Monitoring the hemodynamic response to a PLR maneuver using bioreactance provides an accurate method of assessing volume responsiveness in critically ill patients. In addition, the study suggests that changes in carotid blood fl ow following a PLR maneuver may be a useful adjunctive method for determining fluid responsiveness in hemodynamically unstable patients.
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3. End-tidal carbon dioxide is better than arterial pressure for predicting volume responsiveness by the passive leg raising test
Intensive Care Med. 2013 Jan;39(1):93-100
[EXPAND Abstract]
PURPOSE: In stable ventilatory and metabolic conditions, changes in end-tidal carbon dioxide (EtCO(2)) might reflect changes in cardiac index (CI). We tested whether EtCO(2) detects changes in CI induced by volume expansion and whether changes in EtCO(2) during passive leg raising (PLR) predict fluid responsiveness. We compared EtCO(2) and arterial pulse pressure for this purpose.
METHODS: We included 65 patients [Simplified Acute Physiology Score (SAPS) II = 57 ± 19, 37 males, under mechanical ventilation without spontaneous breathing, 15 % with chronic obstructive pulmonary disease, baseline CI = 2.9 ± 1.1 L/min/m(2)] in whom a fluid challenge was decided due to circulatory failure and who were monitored by an expiratory-CO(2) sensor and a PiCCO2 device. In all patients, we measured arterial pressure, EtCO(2), and CI before and after a fluid challenge. In 40 patients, PLR was performed before fluid administration. The PLR-induced changes in arterial pressure, EtCO(2), and CI were recorded.
RESULTS: Considering the whole population, the fluid-induced changes in EtCO(2) and CI were correlated (r (2) = 0.45, p = 0.0001). Considering the 40 patients in whom PLR was performed, volume expansion increased CI ≥ 15 % in 21 “volume responders.” A PLR-induced increase in EtCO(2) ≥ 5 % predicted a fluid-induced increase in CI ≥ 15 % with sensitivity of 71 % (95 % confidence interval: 48-89 %) and specificity of 100 (82-100) %. The prediction ability of the PLR-induced changes in CI was not different. The area under the receiver-operating characteristic (ROC) curve for the PLR-induced changes in pulse pressure was not significantly different from 0.5.
CONCLUSION: The changes in EtCO(2) induced by a PLR test predicted fluid responsiveness with reliability, while the changes in arterial pulse pressure did not.
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Upstairs vs Downstairs: an EPIC Conundrum
A new breed, and new terminology
Scott Weingart MD and colleagues have published a discussion paper [1] outlining the role of emergency physicians who have completed additional critical care training – ED intensivists – and the potential benefits these individuals might bring to patients, emergency departments, and their emergency physician colleagues.
The paper also introduces a glossary of new terms which might help clarify future discussion of this practice area:
Emergency medicine critical care a subspecialty of emergency medicine dealing with the care of the critically ill both in the ED and in the rest of the hospital
EP intensivist a physician who has completed a residency in emergency medicine and a fellowship in critical care
ED critical care emergency medicine critical care practiced specifically in the ED
ED intensivist (EDI) EPIs who practice ED critical care as a portion of their clinical time
Resuscitationists EPs who have additional knowledge, training, and interest in the care of the critically ill patient
EDICU a unit within an ED with the same or similar staffing, monitoring, and capability for therapies as an ICU
RED-ICU a hybrid resuscitation area and EDICU allowing a department to adopt the ED intensive care model with minimal cost and no changes to the physical plant
Potential benefits of ED-intensivists – and associated adequately staffed areas within ED that facilitate ongoing critical care delivery – include:
Full intensive care provided to patients unable to be moved to ICU (usually due to bed unavailability)
Development of protocols and care pathways that allow other EPs to deliver enhanced critical care
Gaining of advanced skills for ED nurses
Removal of need for ICU bed for conditions that can be improved in a few hours (eg. some overdoses, DKA, acute pulmonary oedema)
Cost saving due to decreased ICU stay (if the above ‘short term critical care’ patients are admitted to ICU, ward bed unavailability can make it difficult to discharge them from ICU)
Additional airway skills in ED (and training around that)
Improved invasive and non-invasive ventilatory management (and training) in ED
Gaining of ED experience in ventilator weaning and extubation
Gaining of ED experience in haemodynamic monitoring, vasoactive support, and even mechanical circulatory support (balloon pumps and ECMO)
Improved sepsis care
Improved post-cardiac arrest care
Improved trauma management
Greater exposure to invasive procedures
Improved end of life care
Better critical care exposure for trainees
Improved ED-ICU communication and shared protocols
Scott’s whole mission is about bringing ‘upstairs care downstairs’, and educating others to do that, at which he is a true master. No doubt he will singlehandedly have inspired a large cohort of emergency physicians to train in critical care. Examples of ED intensivists and their roles are listed here on the EMCrit site.
Emergency physician intensivists in the Old Country
As an ‘ED-intensivist’ myself, I do believe many of those advantages can be realised. In the UK when I originally trained in both EM and ICM there was a small number of similarly trained individuals and we collectively called ourselves ‘EPIC’ – ‘Emergency Physicians in Intensive Care’.
Our shared energy and enthusiasm led to a dedicated conference in 2011 and it’s possible that our proselytizing combined with publications like Terry Brown’s ‘Emergency physicians in critical care: a consultant’s experience‘[2] may have made some small contribution to the subsequent explosion in interest in dual accreditation in EM & ICM in the UK.
Disappearing upstairs
When I moved to Australia in 2008 I was excited to hear that emergency docs now made up the largest proportion of dual trained new intensivists. When I asked a leading member of this group whether he saw any role for an ‘EPIC’ community in Australia I was surprised and disappointed with the response:
‘Nice idea but I don’t see the point. I can’t think of anyone who dual trained who’s still working in emergency medicine’
So it seems those who were in the best position to bring upstairs care downstairs had all disappeared upstairs. Many will admit it’s not just because they find critical care more interesting than emergency medicine; the combination of a significantly higher income (through private practice) with better working conditions plays a significant role.
There are other opportunities in Australia for emergency physicians to practice critical care. Prehospital & retrieval medicine services undertake interhospital critical care transport of patients from small and often remote facilities where all of the first few hours of intensive care must be delivered by retrieval teams in often challenging environments with limited personnel and equipment. In some cases it’s these retrieval physicians who are able to fulfil the role of ED-intensivist in their own EDs.
Integrated critical care models and SuperDoctors
Another Australian example is the ‘integrated critical care’ model pioneered in some regional centres in rural New South Wales where emergency physicians with critical care training aim to provide seamless care to patients in the prehospital, ED, ICU and ward environments. I was lucky enough to do some locum shifts in one of these centres – Tamworth – where the service is delivered by some of the most highly skilled and dedicated physicians I’ve ever met. Check out their registrar job ad for a flavour of their work. This model was described in a 2003 publication[3] by my Sydney HEMS colleague Craig Hore which lists its features as follows:
Features of integrated critical care
Multiskilled critical-care specialists trained and experienced in the various aspects of critical care in rural hospitals.
Multidisciplinary critical-care teams that provide:
A more seamless interface between the various phases of critical care and between its respective disciplines;
A rapid response to, and a continuum of care for, critically ill and injured patients;
Clinical leadership in evaluating and managing critically ill and injured patients, both in the hospital (including the emergency department, critical-care unit and hospital wards) and in the community (including retrievals, and support for ambulance crews, peripheral hospitals and general practitioners); and
Training of medical students, medical staff, nursing staff and allied health professionals to recognise and provide a systematic approach to critical illness and injury.
Team members who are empowered to work beyond perceived traditional boundaries, but within the realms of their clinical expertise and credentials, to enable the best use of available resources.
So it appears the benefits to patients, hospitals, and team skills of ED-intensivists have been espoused for some years in the Anglo-Australian setting, and different practice models evolve to best serve local need.
Resuscitating the resuscitationists
Is it time to revive EPIC? I chased up my UK buddies who co-founded it, and here are extracts from their replies (note ‘CCT’ refers to certificate of completion of training – the UK equivalent of specialist accreditation or board certification):
“Interesting to hear that most Aussies leave EM, my experience of [our regional] trainees is the opposite; of 4 EM / ITU dual CCT over last 5 years, I’m the only one still doing a little bit of CCM, the rest have all ended up in full time EM posts, despite all doing periods of locum consultant work in CCM. (Although, after last 4 winter months of UK EM, I’m beginning to appreciate that I backed the wrong horse! (In the wrong country!!))”
“Having recently dropped ICU/ED 40/60 mix for full time ED i think those gravitating to ICU have a point – an error on my part. The ED represents much more intense work with fewer staff and a work load that far far exceeds resources. As such time to deliver care falls and skills with it. I have just spend 5 weeks [overseas]. I spent time with several directors who pointed out they no longer look to the UK for high quality ED docs as they manage depts as opposed to caring for patients, lack critical care skills and lack the experience to review and manage patients as they improve or deteriorate – a sad state of affairs indeed.”
“I would like to see EPIC back in force and do see an increasing role. around 1 in 4 of our trainees here are looking to joint qualify and we have 3 in their last 2 years. two are currently looking for posts but struggling to find any with a 50-50 mix and are been told to choose one or the other both by prospective ED and ICU employers.”
“I am concerned that dual trained folk here will, like in Australia gravitate to ICU. Whether that is a reflection of where EM is currently in the UK or a personal reflection I’m not sure. Where as I still have days in the ED where I come home and think ‘best job in the world’ these are overshadowed by the stresses of trying to deliver quality care in a failing system. My impression is that urgent care in the UK may well implode soon as ever decreasing workforce meets an over increasing work load. Inevitable closures of units will speed up this process. I currently have a 50/50 ICM/ED job split but that might change to become more ICU.”
“The ED/ICU community in the UK is growing and it wlll be interesting to see the effect of the ICM CCT has on this. There is sadly still a paucity of ED/ICU jobs in the UK and we probably missed a trick with the trauma centres.”
“It would be great to re-create EPIC to make it a real player for the future.”
So it appears emergency physician intensivists are growing in number, but employment prospects in both specialties are not guaranteed. If we are to recruit them to work as ED intensivists (ie. providing critical care in the ED) we have a challenge in making such posts attractive and sustainable. Emergency medicine in the UK is suffering at the moment, and we’ll have to work hard to stop those who are dual trained from disappearing upstairs.
Your comments on this are invited. Should there be more critical care- trained EPs? Shouldn’t ALL EPs have the right critical care skills to manage the first few hours of critical care? Can you call yourself an emergency physician and not be a ‘resuscitationist’? Where do retrievalists fit into this spectrum? How do we help motivate those who are dual trained to stay in the ED for some of their time? Is there a need for a body like EPIC to guide those who are considering dual training, and to provide recommendations to employers and physicians on models of care and job planning? I would love to get more of an international perspective on this issue.
1. ED intensivists and ED intensive care units
Am J Emerg Med. 2013 Mar;31(3):617-20
Full text link available from here
2. Emergency physicians in critical care: a consultant’s experience
Emerg Med J. 2004 Mar;21(2):145-8
Full text link available from here
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There is a growing interest in the interface between emergency medicine and critical care medicine. Previous articles in this journal have looked at the opportunities and advantages of training in critical care medicine for emergency medicine trainees. In the UK there are a small number of emergency physicians who also have a commitment to critical care medicine. This article describes a personal experience of such a job, looking at the advantages and disadvantages. Depending upon future developments in the role of emergency medicine in the UK, together with the proposed expansion in critical care medicine, such posts may become more common.
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3. Integrated critical care: an approach to specialist cover for critical care in the rural setting
Med J Aust. 2003 Jul 21;179(2):95-7
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Critical care encompasses elements of emergency medicine, anaesthesia, intensive care, acute internal medicine, postsurgical care, trauma management, and retrieval. In metropolitan teaching hospitals these elements are often distinct, with individual specialists providing discrete services. This may not be possible in rural centres, where specialist numbers are smaller and recruitment and retention more difficult. Multidisciplinary integrated critical care, using existing resources, has developed in some rural centres as a more relevant approach in this setting. The concept of developing a specialty of integrated critical-care medicine is worthy of further exploration.
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Another argument for ED thoracotomy
A team from Los Angeles (including the great Kenji Inaba) has published a study on penetrating cardiac wounds in the pediatric population[1]. This is one of the largest studies on this thankfully rare event.
The outcome was poor which may be due to the high proportion of patients arriving at hospital without signs of life (SOL).
What I like about the paper is the discussion of their liberal policy for the use of resuscitative ED thoracotomy:
…we do not rely heavily on prehospital data regarding the precise timing of loss of SOL. Thus, at the discretion of the attending trauma surgeon, every penetrating injury to the chest with SOL lost during patient transport will be considered for ED thoracotomy.
In cases when a perfusing cardiac rhythm is regained, the patient will receive all operative and critical care support as standard of care. If the patient progresses to brain death, aggressive donor management will be implemented in accordance with consent obtained by the organ procurement organization.
In a recent publication, we observed two pediatric patients who underwent ED thoracotomy that subsequently became organ donors after brain death was declared [2]. A total of nine organs were recovered for transplantation. This contemporary outcome measure is of paramount importance in the current era of significant organ shortage.
When such aggressive resuscitative procedures are attempted on arrested trauma patients, there is a temptation to justify inaction on the grounds of futility or the risk of ‘creating a vegetable’. This paper reminds us that other outcome benefits may arise from attempted resuscitation even if the patient does not survive.
These benefits include the saving of other lives through organ donation. In addition to this, there is the opportunity for family members to be with their loved one on the ICU, to hold their warm hand for the last time, to hear the news broken by a team they have gotten to know and trust, to enact any spiritual or religious rites that may provide a source of comfort and closure, and to be there during withdrawal of life sustaining therapies after diagnosis of brain stem death. That will never be pleasant, but on the bleak spectrum of parental torture it may be better than being told the devastating news in the ED relatives’ room by a stranger they’ve never met but will remember forever.
The ED thoracotomy may at the very least remove any doubt that everything that could have been done, was done.
1. Penetrating cardiac trauma in adolescents: A rare injury with excessive mortality
Journal of Pediatric Surgery (2013) 48, 745–749
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Background Penetrating cardiac injuries in pediatric patients are rarely encountered. Likewise, the in-hospital outcome measures following these injuries are poorly described.
Methods All pediatric patients (<18years) sustaining penetrating cardiac injuries between 1/2000 and 12/2010 were retrospectively identified using the trauma registry of an urban level I trauma center. Demographic and admission variables, operative findings, and hospital course were extracted. Outpatient follow-up data were obtained through chart reviews and cardiac-specific imaging studies.
Results During the 11-year study period, 32 of the 4569 pediatric trauma admissions (0.7%) sustained penetrating cardiac injuries. All patients were male and the majority suffered stab wounds (81.2%). The mean systolic blood pressure on admission was 28.8±52.9mmHg and the mean ISS was 46.9±27.7. Cardiac chambers involved were the right ventricle (46.9%), the left ventricle (43.8%), and the right atrium (18.8%). Overall, 9 patients (28.1%) survived to hospital discharge. Outpatient follow-up echocardiography was available for 4 patients (44.4%). An abnormal echocardiography result was found in 1 patient, demonstrating hypokinesia and tricuspid regurgitation.
Conclusions Penetrating cardiac trauma is a rare injury in the pediatric population. Cardiac chambers predominantly involved are the right and left ventricles. This injury is associated with a low in-hospital survival (<30%).
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2. Organ donation: an important outcome after resuscitative thoracotomy
J Am Coll Surg. 2010 Oct;211(4):450-5
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BACKGROUND: The persistent shortage of transplantable organs remains a critical issue around the world. The purpose of this study was to investigate outcomes, including organ procurement, in trauma patients undergoing resuscitative emergency department thoracotomy (EDT). Our hypothesis was that potential organ donor rescue is one of the important outcomes after traumatic arrest and EDT.
STUDY DESIGN: Retrospective study at Los Angeles County and University of Southern California Medical Center. Patients undergoing resuscitative EDT from January 1, 2006 through June 30, 2009 were analyzed. Primary outcomes measures included survival. Secondary outcomes included organ donation and the brain-dead potential organ donor.
RESULTS: During the 42-month study period, a total of 263 patients underwent EDT. Return of a pulse was achieved in 85 patients (32.3%). Of those patients, 37 (43.5%) subsequently died in the operating room and 48 (56.5%) survived to the surgical intensive care unit. Overall, 5 patients (1.9%) survived to discharge and 11 patients (4.2%) became potential organ donors. Five of the 11 potential organ donors had sustained a blunt mechanism injury. Of the 11 potential organ donors, 8 did not donate: 4 families declined consent, 3 because of poor organ function, and 1 expired due to cardiopulmonary collapse. Eventually 11 organs (6 kidneys, 2 livers, 2 pancreases, and 1 small bowel) were harvested from 3 donors. Two of the 3 donors had sustained blunt injury and 1 penetrating mechanism of injury.
CONCLUSIONS: Procurement of organs is one of the tangible outcomes after EDT. These organs have the potential to alter the survival and quality of life of more recipients than the number of survivors of the procedure itself.
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Cricoid can worsen VL View
It is known that cricoid pressure can hinder laryngoscopic view of the cords during direct laryngoscopy. Using a Pentax-AWS Video laryngoscope, these authors have demonstrated that cricoid pressure can also worsen glottic view during video laryngoscopy.
Videographic Analysis of Glottic View With Increasing Cricoid Pressure Force
Ann Emerg Med. 2013 Apr;61(4):407-13
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BACKGROUND:Cricoid pressure may negatively affect laryngeal view and compromise airway patency, according to previous studies of direct laryngoscopy, endoscopy, and radiologic imaging. In this study, we assess the effect of cricoid pressure on laryngeal view with a video laryngoscope, the Pentax-AWS.
METHODS: This cross-sectional survey involved 50 American Society of Anesthesiologists status I and II patients who were scheduled to undergo elective surgery. The force measurement sensor for cricoid pressure and the video recording system using a Pentax-AWS video laryngoscope were newly developed by the authors. After force and video were recorded simultaneously, 11 still images were selected per 5-N (Newton; 1 N = 1 kg·m·s(-2)) increments, from 0 N to 50 N for each patient. The effect of cricoid pressure was assessed by relative percentage compared with the number of pixels on an image at 0 N.
RESULTS: Compared with zero cricoid pressure, the median percentage of glottic view visible was 89.5% (interquartile range [IQR] 64.2% to 117.1%) at 10 N, 83.2% (IQR 44.2% to 113.7%) at 20 N, 76.4% (IQR 34.1% to 109.1%) at 30 N, 51.0% (IQR 21.8% to 104.2%) at 40 N, and 47.6% (IQR 15.2% to 107.4%) at 50 N. The number of subjects who showed unworsened views was 20 (40%) at 10 N, 17 (34%) at 20 and 30 N, and 13 (26%) at 40 and 50 N.
CONCLUSION: Cricoid pressure application with increasing force resulted in a worse glottic view, as examined with the Pentax-AWS Video laryngoscope. There is much individual difference in the degree of change, even with the same force. Clinicians should be aware that cricoid pressure affects laryngeal view with the Pentax-AWS and likely other video laryngoscopes.
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