Re-expansion Pulmonary Edema After Chest Tube Placement
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
When may an ED thoracotomy be futile?
Pregnancy causes many physiologic changes, which may be challenging during trauma resuscitations. A few pearls on the ABC’s:
Airway
Breathing
Circulation
Blood Pressure in the Critically Ill Obese Patient
Heat stroke is hyperthermia (>41.6 Celsius / 106 Fahrenheit) plus neurologic findings (e.g., altered mental status, seizures, coma, etc.); it also causes systemic inflammation response syndrome (i.e., cytokine release), coagulation disorders (e.g., thrombosis in end organs) and tissue abnormalities (e.g., acute kidney injury and rhabdomyolysis)
Two classifications exist:
Treatment includes:
Despite the most aggressive therapy, up to 30% survivors may have permanent neurologic or multi-organ system dysfunction months to years after recovery
Hemodynamic Optimization in the Post-Arrest Patient
Hepato-Renal Syndrome
Cancer patients admitted to ICUs with AKI or who develop AKI during their ICU stay have increased risk of morbidity and mortality. AKI in cancer patients is typically multi-factorial:
Causes indirectly related to malignancy
Septic, cardiogenic, or hypovolemic shock (most common)
Nephrotoxins:
Aminoglycosides
Contrast-induced nephropathy
Chemotherapy
Hemolytic-Uremic Syndrome
Causes directly related to malignancy
Tumor-lysis syndrome
Disseminated Intravascular Coagulation
Obstruction of urinary tract by malignancy
Multiple Myeloma of the kidney
Hypercalcemia
Because AKI increases the already elevated morbidity and mortality in these patients, prevention (e.g., using low-osmolar IV contrast, avoiding nephrotoxins), early identification (e.g., strict attention to urine output and renal function), and aggressive treatment (e.g., early initiation of renal replacement therapy) is essential.
AKI in the Critically Ill Cancer Patient
Bleeding associated with uremia is a spectrum, from mild cases (e.g., bruising or prolonged bleeding from venipuncture) to life-threatening (e.g., GI or intracranial bleed). The exact pathologic mechanisms are not understood, but are likely multi-factorial (e.g., dysfunctional von Willebrand’s Factor (vWF) and factor VIII, increased NO, etc.)
Besides dialysis, treatments for uremic bleeding include:
Cardiovascular Complication of ESLD
TIP: Suspect when abdominal pain presents 10-14 after chemotherapy (when PMNs are lowest).
Acute Liver Failure (ALF)
Although oral metronidazole is indicated for mild to moderate Clostridium difficile associated diarrhea, oral vancomycin should be considered first-line therapy in critically-ill patients with moderate to severe disease. Vancomycin dosing should begin at 125mg PO q6 and increased to 250mg q6 if poor enteral absorption exists. Consider adding metronidazole IV if either reduced enteral absorption or severe disease exists.
Recently, fidaxomicin has been shown to be non-inferior to oral vancomycin in the treatment of mild to moderate C. difficile. While promising, the study population was not critically-ill and extrapolation should be avoided.
Gastrointestinal Changes of Obesity that Complicate Critical Illness
A mortality benefit from combination antimicrobial therapy has not been clearly demonstrated in sepsis. However, when only the most severely-ill patients (i.e., septic shock) are considered in subgroup analysis, there appears to be a mortality benefit to using two antimicrobials against a suspected organism.
Combination antimicrobial therapy may reduce mortality through three mechanisms.
Always obtain appropriate cultures before initiating therapy. Although identification and susceptibility of the organism may take some time, eventually narrowing antimicrobial therapy to monotherapy in the ICU is still recommended.
Combination Antimicrobial Therapy for Gram (+) Bacteremia
Vancomycin is often started empirically for gram-positive and MRSA coverage. Although effective and generally well-tolerated, emerging resistance and side-effect profiles limit its use in some patients. Two alternatives are Linezolid and Daptomycin.
Linezolid
Daptomycin
Emergency Medicine physicians are gaining experience with non-invasive ventilation (i.e., Bi-level ventilation and continuous positive-pressure ventilation) in managing respiratory distress and failure. Although NIV is commonly used across a variety of pathologies, the best data exists for use with COPD exacerbation and cardiogenic pulmonary edema (CHF, not an acute MI)
Although other indications for NIV have been studied, the data is less robust (eg., smaller study size, weak control groups, etc.). If there are no contraindications, however, many experts still support a trial of NIV in the following populations:
Failure to clinically improve during a NIV trial should prompt invasive mechanical ventilation.
