Category: Critical Care
Keywords: amiodarone, lung toxicity, ARDS, infection, critical care (PubMed Search)
Posted: 12/20/2011 by Haney Mallemat, MD
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Amiodarone-induced lung toxicity (ALT) is a serious and sometimes fatal complication of amiodarone use.
Symptoms range from mild (e.g., dyspnea with exertion) to acute respiratory distress syndrome and risk of death.
ALT is secondary to either release of toxic oxygen radials that are directly toxic to the lung or the reaction is secondary to an indirect immunologic reaction.
Risk factors for ALT: use > 2 months, dose > 400mg/day, advanced age, or pre-existing lung injury
ALT is typically a diagnosis of exclusion so suspect ALT through a detailed history; physical exam and radiology are non-specific. Lung biopsy is the only confirmatory test.
Treat ALT by discontinuing the drug, steroids, and supportive care. In rare cases where amiodarone cannot be safely discontinued (i.e., life-threatening arrhythmia), dosage should be reduced and steroids added immediately.
Generally, ALT is reversible with a good prognosis.
Mahajan, V. et al Amiodarone induced acute interstitial pneumonitis.BMJ Case Rep. 2009;2009.
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Category: Critical Care
Posted: 12/13/2011 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
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The Crashing Patient with PAH
Rubenfire M, Bayram M, Hector-Wood Z. Pulmonary hypertension in the critical care setting: classification, pathophysiology, diagnosis, and management. Crit Care Clin 2007;23: 801-834.
Category: Critical Care
Posted: 12/6/2011 by Haney Mallemat, MD
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Up until recently, a tight-fitting mask was one of the only ways to deliver non-invasive positive-pressure ventilation.
High-flow nasal cannulas (HFNC) have been adapted from use in neonates to adults to deliver continuous positive airway pressure (CPAP).
HFNC provides continuous, high-flow (up to 60 liters), and humidified-oxygen via nasal cannula providing positive pressure to the pharynx and hypopharynx. Patients tolerate it well and it is less claustrophobic than tight-fitting masks.
HFNC does not generate the same amount of pressure as CPAP so it may be best utilized as an intermediate step between low-flow oxygen (i.e., traditional nasal cannula) and non-invasive positive pressure ventilation with tight-fitting masks.
Check with your respiratory department if these devices are locally available.
Kernick, j. What is the evidence for the use of high flow nasal cannula oxygen in adult patients admitted to critical care units? A systematic review. Aust Crit Care. 2010 May;23(2):53-70. Epub 2010 Mar 5.
Parke, R. A preliminary randomized controlled trial to assess effectiveness of nasal high-flow oxygen in intensive care patients. Respir Care. 2011 Mar;56(3):265-70. Epub 2011 Jan 21.
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Category: Critical Care
Posted: 11/29/2011 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
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Hypotension in the PAH Patient
Rubenfire M, Bayram M, Hector-Wood Z. Pulmonary hypertension in the critical care setting: classification, pathophysiology, diagnosis, and management. Crit Care Clin 2007;23: 801-834.
Category: Critical Care
Keywords: hypotension, shock, ultrasound, hi map (PubMed Search)
Posted: 11/22/2011 by Haney Mallemat, MD
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Determining the exact etiology of hypotension / shock can sometimes be difficult in the Emergency Department.
The Rapid Ultrasound for Shock / Hypotension (RUSH) exam is a sequential, 5 step-protocol (typically requiring less than 2 minutes) that can be used to determine the cause(s) of hypotension.
The mnemonic for the exam is “HI MAP”, and is easy to remember because a "HI MAP" is our goal with hypotensive patients.
H - Heart (parasternal and four-chamber views)
I - Inferior Vena Cava (for volume responsiveness)
M - Morrison’s pouch (i.e., FAST exam) and views of thorax (looking for free fluid)
A - Aortic Aneurysm (ruptured abdominal aneurysm)
P - Pneumothorax (i.e., Tension PTX)
Refer to the link for a more detailed discussion and podcast from the creators of this exam: emcrit.org/rush-exam
Category: Critical Care
Posted: 11/15/2011 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
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Hypertensive Emergency Pearls
Marik PE, Rivera R. Hypertensive emergencies: an update. Curr Opin Crit Care 2011; 17:569-80.
Category: Critical Care
Keywords: tamponade, critical care, intubation, positive pressure, PEA arrest (PubMed Search)
Posted: 11/8/2011 by Haney Mallemat, MD
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Positive-pressure ventilation (e.g., mechanical ventilation) increases intrathoracic pressure potentially reducing venous return, right-ventricular filling, and cardiac output.
Pericardial tamponade similarly causes hemodynamic compromise through increased pericardial pressure which reduces right-ventricular filling and cardiac output.
When mechanically ventilating a patient with known or suspected pericardial tamponade the mechanisms above may be additive, causing cardiovascular collapse and possibly PEA arrest.
For the patient with known or suspected pericardial tamponade consider draining the pericardial effusion prior to intubation or delaying intubation until absolutely necessary.
If intubation is unavoidable, consider maintaining the intrathoracic pressure as low as possible (by keeping the PEEP and tidal volumes to a minimum) to ensure adequate cardiac filling and cardiac output.
Ho, A. et. al. Timing of tracheal intubation in traumatic cardiac tamponade: A word of caution. Resuscitation, 80(2), 272–274.
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Category: Critical Care
Posted: 11/1/2011 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
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Mechanical Ventilation in Patients with Pulmonary HTN
Category: Critical Care
Keywords: xigris, activated protein C, sepsis, multi-organ failure, resuscitation (PubMed Search)
Posted: 10/25/2011 by Haney Mallemat, MD
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On October 25, 2011, Eli Lilly announced a voluntary-recall of activated drotrecogin alfa (Xigris) following a recent trial (PROWESS-SHOCK), which demonstrated no survival benefit when using the drug when compared to placebo.
Activated drotrecogin alfa is a recombinant form of human activated protein C previously recommended for adults with severe sepsis and a high-risk of death (APACHE II > 25 or multi-organ failure); it is included in the 2008 International Sepsis Guidelines (Grade 2b recommendation).
The PROWESS-SHOCK trial reported an all-cause mortality rate of 26.4% in the drotrecogin alfa group compared with 24.2% in the placebo group; this difference was not statistically significant.
Interestingly, the study also found that severe bleeding (the drug's main side-effect) was found to be 1.2% in the activated drotrecogin alfa group compared to 1.0% for the placebo group (also non-significant) suggesting it does not increase the risk of bleeding as it had previously been reported.
Hospitals should revise their sepsis guidelines based on this recent news.
www.medscape.com/viewarticle/752169?sssdmh=dm1.728719&src=nl_newsalert
Dellinger, R. P., et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Critical Care Medicine, 36(1), 296–327. doi:10.1097/01.CCM.0000298158.12101.41
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Category: Critical Care
Posted: 10/18/2011 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
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SAH and Electrolyte Disorders
Wartenberg KE. Critical care of poor-grade subarachnoid hemorrhage. Curr Opin Crit Care 2011; 17:85-93
Category: Critical Care
Keywords: listeria, food borne illness, cns infection (PubMed Search)
Posted: 10/11/2011 by Haney Mallemat, MD
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Lisiteria Monocytogenes is typically transmitted from ingestion of contaminated food such as unpasteurized milk or cheese, raw foods, and recently cantaloupes; transmission from veterinary exposure, infected soil and water have also been reported.
Listeria has a predilection for the central nervous system (CNS) causing several infections including meningioencephalitits, brain or spinal abscess, cerebritis (infection of brain parenchyma), and rhomboencephalitis (encephalitis of the brainstem).
Risk factors include immunosuppression, advanced age, newborns, and pregnancy.
There is no clinical way to distinguish CNS infection with Listeria from other pathogens, therefore blood and cerebrospinal fluid (CSF) culture is required.
CSF analysis demonstrates pleocytosis, elevated protein, and low glucose. CSF gram stain has a low sensitivity (~33%), but consider Listeria in the differential if "diptheroid-like" bacteria are reported on gram stain.
Ampicillin is the drug of choice and should be continued for at least three weeks (sometimes longer). Adding gentamycin is sometimes recommended for synergy in severe infection.
Mylonakis E, Hohmann EL, Calderwood SB. Central nervous system infection with Listeria monocytogenes. 33 years' experience at a general hospital and review of 776 episodes from the literature. Medicine (Baltimore). Sep 1998;77(5):313-36.
http://emedicine.medscape.com/article/220684-overview
http://www.cdc.gov/listeria
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Category: Critical Care
Posted: 10/4/2011 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
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Fever and ICH
Flower O, Smith M. The acute management of intracerebral hemorrhage. Curr Opin Crit Care 2011; 17:106-14.
Category: Critical Care
Keywords: Epinephrine, adrenaline, cardiac arrest, return of spontaneous circulation, ROSC, critical care, ICU, saline (PubMed Search)
Posted: 9/27/2011 by Haney Mallemat, MD
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· The use of epinephrine in cardiac arrest is currently standard of care.
· Several observational and non-randomized trials have demonstrated the efficacy of epinephrine in cardiac arrest, but there has never been a randomized double-blind placebo-controlled trial in humans.
· A recently published Australian trial randomized cardiac patients (of any type) to receive either 1 mg of epinephrine (n=272) or 0.9% normal saline (n=262); the primary end-point was survival to hospital discharge. Secondary end-points were pre-hospital return of spontaneous circulation (ROSC) and neurological outcomes at hospital discharge.
· Significantly more patients had pre-hospital ROSC in the epinephrine group (regardless of the underlying rhythm), however, there was no statistically significant difference in survival to discharge (the primary outcome) between groups.
· This randomized double-blinded placebo-controlled trial raises many new and interesting questions about epinephrine, but more study is needed before changing current practice.
Jacobs IG, et al. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomized double-blind placebo-controlled trial. Resuscitation 2011;82:1138-1143.
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Category: Critical Care
Posted: 9/20/2011 by Mike Winters, MBA, MD
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Spontaneous Bacterial Peritonitis
Al-Khafaji A, Huang DT. Critical care management of patients with end-stage liver disease. Crit Care Med 2011; 39:1157-66.
Category: Critical Care
Keywords: Procedures, Arterial lines, Axillary, hemodynamic monitoring (PubMed Search)
Posted: 9/13/2011 by Haney Mallemat, MD
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Radial and femoral arteries are common sites for arterial-line placement, but are not without complications (e.g., Radial artery: malfunction with positioning and Femoral artery: contamination and infection); an alternative site to consider is the axillary artery.
The axillary artery's superficial location and large size make it a desirable choice for cannulation.
The "anatomical-landmark" and "palpation" methods have been the traditional techniques of axillary arterial cannulation, however these methods may be difficult for to a variety of reasons (e.g., obesity, anasarca, arterial disease, etc.)
Ultrasound allows visualization of the axillary artery and avoids unintended injury to structures in close proximity (e.g., brachial plexus, pleura, axillary vein, etc.); please see figures 1 and 2 in the referenced Sandhu article and http://www.youtube.com/watch?v=Z31YiyV7cNQ.
A recent study (Killu, 2011) found that ultrasound increases success rates when compared to the traditional landmark approach.
Killu, K. et al. Utility of Ultrasound Versus Landmark-Guided Axillary Artery Cannulation for Hemodynamic Monitoring in the Intensive Care Unit. ICU Director; 2011. 2(3), 54–59.
Sandhu, N. The Use of Ultrasound for Axillary Artery Catheterization Through Pectoral Muscles: A New Anterior Approach. Anesthesia and analgesia. 2004; 562–565.
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Category: Critical Care
Posted: 9/6/2011 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
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Fungal Sepsis in the Critically Ill
Lepak A, Andes D. Fungal sepsis: Optimizing antifungal therapy in the critical care setting. Crit Care Clin 2011; 27:123-147.
Category: Critical Care
Keywords: ultrasound, tracheal intubation, esophageal intubation, critical care, airway (PubMed Search)
Posted: 8/30/2011 by Haney Mallemat, MD
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Multiple methods of confirming endotracheal tube placement exist, however quantitative waveform capnography is the most reliable method. Unfortunately this may not be immediately available at all medical centers.
Recent studies demonstrate that bedside ultrasound may assist in the detection of proper endotracheal tube placement.
The T.R.U.E. (Tracheal Rapid Ultrasound Exam) was demonstrated to be 99% sensitive, 94% specific, 99% PPV, and 94% NPV during intubation.
The basic exam involves placing a high-frequency linear-array probe on the anterior neck above the sternal notch and identifying the trachea and esophagus during intubation.
The following video is an example of what you DO NOT want to see during an intubation: http://www.youtube.com/watch?v=LvfThxhQ93A
Chou, H. et al. Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube placement during emergency intubation. Resuscitation. Jun 2011
Werner SL,et al. Pilot study to evaluate the accuracy of ultrasonography in confirming endotracheal tube placement. Ann Emerg Med 2007;49:75–80.
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Category: Critical Care
Posted: 8/23/2011 by Mike Winters, MBA, MD
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Re-expansion Pulmonary Edema After Chest Tube Placement
Hsu KF, et al. Re-expansion pulmonary edema after insertion of chest tube for pneumothorax. J Trauma 2011;70(3):761.
Category: Critical Care
Keywords: bougie, cricothyrotomy, trauma, critical care, intubation, failed airway (PubMed Search)
Posted: 8/16/2011 by Haney Mallemat, MD
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The open cricothyrotomy technique is taught as the trauma airway standard when one “cannot intubate and cannot ventilate” however, it is not without difficulty and limitations. The B.A.C.T. (Bougie-Assisted Cricothyrotomy Technique) may improve the procedure by using a bougie to assist.
Steps for the B.A.C.T. (as described in the paper):
1. Stabilize the larynx with the thumb and middle finger, then identify the cricothyroid membrane.
2. Make a transverse stabbing incision with a scalpel through both skin and cricothyroid membrane.
3. Insert tracheal hook at the inferior margin of the incision and pull up on the trachea.
4. Insert a bougie through the incision with curved tip directed towards the feet
5. Pass 6-0 endotracheal tube or Shiley over bougie into trachea.
Advantages of a bougie:
1. Thin and easy to insert into incision
2. Tactile feedback from tracheal rings confirms proper placement
3. Ensures that stoma will not be lost during procedure
EMRAP.tv has a great video of Dr. Darren Braude demonstrating the procedure;
http://bit.ly/nB3BMG
Hill, C., et al. Cricothyrotomy Technique Using Gum Elastic Bougie Is Faster Than Standard Technique: A Study of Emergency Medicine Residents and Medical Students in an Animal Lab. Academic Emergency Medicine17(6), 666–669.
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Category: Critical Care
Posted: 8/9/2011 by Mike Winters, MBA, MD
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When may an ED thoracotomy be futile?
Moore EE, Knudson M, Burlew CC, Inaba K, et al. Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective. J Trauma 2011;70:334-9.