UMEM Educational Pearls

Category: EMS

Title: Supraglottics may not be SUPERglottic for E-CPR patients

Keywords: cardiac arrest, ECMO, E-CPR, mechanical ventilation (PubMed Search)

Posted: 4/3/2024 by Benjamin Lawner, MS, DO
Click here to contact Benjamin Lawner, MS, DO

BACKGROUND:
The ideal strategy for out of hospital ventilation is a matter of long standing debate and clinical controversy. To date, improved out of hospital outcomes have been associated with non invasive (BVM) and supraglottic airway (SGA) management strategies. A recent, prospective trial featured in Resuscitation offers a slightly different perspective. The trial enrolled 420 adult patients with refractory out of hospital cardiac arrest due to a shockable rhythm. The study looked at outcomes for patients who received endotracheal intubation (ETI)  or supraglottic airway placement. Importantly, the study involved a high volume cannulation center and  codified screening criteria for eCPR including:  a) ongoing arrest despite 3 shocks, b) treatment with amiodarone, c) mechanical CPR and d) anticipated time to arrival at ECMO cannulation center of <30 minutes. 

OUTCOMES:
Compared to patients in the SGA group, patients receiving ETI demonstrated: 

  • Significantly higher Pa02
  • Significantly lower PaC02
  • Significantly higher pH 
  • No significant differences in lactic acid level 
  • Improved neurological outcomes (CPC score)

In accordance with the study institution's cannulation criteria, more patients in the SGA group were deemed ineligible for ECMO. 

BOTTOM LINE:
In this single center study, patients who received ETI as a primary strategy for out of hospital airway management were more likely to meet ECMO eligibility critera and exhibit improved oxygenation and ventilation.

While this is not necessarily a practice changing article, it illustrates the complexities inherent in out of hospital cardiac arrest management. EMS has largely transitioned from a “scoop and run” cardiac arrest strategy to a plan that emphasizes treat in place. For patients who may benefit from E-CPR, additional research is indicated to shed light on best out of hospital resuscitation (and airway management)  practices.

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Category: Critical Care

Title: It's only a little fluid - does it matter what kind I choose?

Keywords: IV Fluid, balanced solutions (PubMed Search)

Posted: 4/3/2024 by Mark Sutherland, MD (Updated: 6/21/2024)
Click here to contact Mark Sutherland, MD

Multiple studies have suggested differences in patient outcomes with balanced solutions (e.g. plasmalyte) vs unbalanced solutions (e.g. normal saline) when large volumes are administered.  But what about when giving smaller volumes of fluid?  Does it matter which one you choose?

A recent study by Raes et al in the Journal of Nephrology looked at urine and serum effects of administering 1L of normal saline, vs 1L of plasmalyte, to ICU patients needing a fluid bolus.  Chloride levels, strong ion difference (SID), and base excess were all significantly different between the two groups.  There was no difference in blood pressure or need for vasopressors.  As best I can tell, other clinically significant differences such as kidney injury were unfortunately not reported.

Bottom Line: When giving small (e.g. 1L) volumes of IVF, there ARE real physiologic differences seen between balanced and unbalanced solutions.  Whether these differences translate to patient-oriented or clinically significant outcomes remains unclear.

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Category: Ultrasound

Title: Ultrasound Artifacts: The April Fool's of Ultrasound

Keywords: POCUS; Ultrasound Artifacts (PubMed Search)

Posted: 4/1/2024 by Alexis Salerno, MD (Updated: 6/21/2024)
Click here to contact Alexis Salerno, MD

Ultrasound artifacts can sometimes be helpful, but sometimes they can be misleading. 

For example:

1)Does this patient have a gallstone?

No, this is edge artifact! This is due to the ultrasound signals refracting off the side of the gallbladder wall.

  1. Does this patient have sludge?

No, this is side lobe artifact! This is due to a bright reflector outside of the central beam of the ultrasound signal that the machine mistakenly places with in the center of the beam. Side lobe artifact can occur near fluid filled masses such as the gallbladder and bladder. 

  1. Is there tissue above the liver?

No, this is mirror artifact!! This is due to ultrasound signals bouncing off a highly reflective surface such as the diaphragm.  The ultrasound machine misinterprets the time delay from the reflected ultrasound signal as a structure deeper in the image.



This retrospective population cohort study looked at  first time ED visits for adolescents and young adults comparing those with visits related to alcohol to those not related to alcohol. Patients in the alcohol related visit group had  a threefold increased one year mortality rate.  Cause of death was trauma, poisoning by drug and alcohol. Risk factors include being male, age 20-29, history of mental health and having a visit for withdrawal.  

Adolescents and young adults presenting to an emergency department for an alcohol related complaint are high risk for one year mortality and deserve intervention and appropriate referral.

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Category: Misc

Title: Palliative Care in the Emergency Department

Posted: 3/26/2024 by Heidi Teague, MD (Emailed: 3/30/2024) (Updated: 3/30/2024)
Click here to contact Heidi Teague, MD

Advancements in complex illness management have led to an increasing number of patients surviving longer, with subsequent development of end-stage organ disease, cancer, and dementia. EDs are encountering patients with more complex medical needs who present with challenging complaints such as functional loss, bounce-back visits for uncontrolled symptoms, and caregiver fatigue. ACEP underscored the importance of advancing access to palliative care in 2013 and is one of its top five measures in the Choosing Wisely campaign, aimed at minimizing unwarranted and excessive medical interventions. Proactive symptom management, including promptly addressing pain, dyspnea, nausea, and other distressing symptoms, as well as goals of care conversations, and early referral to hospital and outpatient palliative services can enhance patient and caregiver comfort and quality of life.

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Standard practice regarding various pediatric fractures has started to shift over the last several years, often to less restrictive means of treatment. Torus (buckle) fractures of the distal radius are one of the most common pediatric fractures and tend to heal very well with minimal intervention. 

The FORCE study (FOrearm fracture Recovery in Children Evaluation), a multicenter study out of the UK, was conducted to compare rigid immobilization (splinting) to a soft bandage used as needed per family discretion for treatment of these fractures. There was no different in outcomes of self-reported pain, function, quality of life, complications, or school absences. UK orthopedic guidelines have been updated to reflect a recommendation against rigid immobilization as well as against any need for specialist follow-up. American guidelines are slower to follow suit, but in recent years have transitioned to an approach of a removable brace. 

Take Home: Pediatric torus fractures of the distal radius likely do not require immobilization and can be managed with self-limited activity instead. Practice in the US is in flux, but it is reasonable to manage with a removable brace or soft dressing as well as pediatrician follow up.

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Category: Misc

Title: Research Pearl - FINER Criteria for New Studies

Posted: 3/12/2024 by Michael Witting, MD (Emailed: 3/28/2024) (Updated: 3/28/2024)
Click here to contact Michael Witting, MD

Considering starting a research project? Apply the FINER criteria:

Feasible

                  Do you have the resources to study this? Enough patients? Support?

Interesting

                  Does it interest you enough to devote your time to it? Does it interest colleagues?

Novel

                  Would it provide new findings, or confirm, refute, or extend prior findings?

Ethical

                  Can you think of a way to ethically study it?

Relevant

                  Consider possible outcomes of your research. Could the study advance care or policy?

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Category: Administration

Title: Patient Experience

Keywords: Administration, Patient Experience, Microaggression, Discrimination (PubMed Search)

Posted: 3/27/2024 by Mercedes Torres, MD (Updated: 6/21/2024)
Click here to contact Mercedes Torres, MD

Do microaggressions and discrimination impact the patient experience in your ED?  How can we address this?

This article is one of few studies to address this topic specifically in the ED. Authors used quantitative (discrimination scale) and qualitative (follow-up interviews) methods to answer this question in two urban academic EDs.  

Common themes from patient responses provide food for thought and action in this regard:

  • Clinician behaviors: Positive behaviors included frequent communication, reassurance, privacy, respect, and validation of concerns. Empathy and eye contact were also mentioned.
  • Healthcare team actions: Positive interactions with clinicians reassured confidence in the emergency care visit and willingness to return for future health care.
  • Environmental pressures in the ED: Participants often noted long wait times and busy staff when describing negative ED experiences.
  • Hesitancy to Complain: Patients were hesitant to identify staff members, did not feel that the complaint would be acted on, and worried that their medical care would suffer if they brought up their concerns.

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Bag-Valve-Mask Ventilation During OHCA

  • Current OHCA resuscitation guidelines recommend a 30:2 strategy of CPR with BVM ventilations.
  • Idris and colleagues performed a secondary analysis of the Resuscitation Outcomes Consortium CCC clinical trial to determine the incidence of BVM ventilation during a 30:2 CPR strategy and assess the association of detectable ventilations with patient outcomes.
  • In 1,976 patients, the authors found that only 40% of patients had detectable ventilations (> 250 ml) in more than half of CPR pauses.
  • For those patients with detectable ventilations in more than 50% of pauses, there was an association with increased survival to hospital admission, increased survival to hospital discharge, and increased survival with favorable neurologic outcome.
  • The current study highlights the importance of proper BVM ventilation during OHCA resuscitation and the opportunity to improve performance of this vital skill.

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Category: Trauma

Title: A benzodiazepine sparing protocol for alcohol withdrawal in trauma patients

Keywords: Alcohol, withdrawal, trauma, protocol, sparing (PubMed Search)

Posted: 3/24/2024 by Robert Flint, MD (Updated: 6/21/2024)
Click here to contact Robert Flint, MD

This study compared  admitted trauma patients with alcohol withdrawal or those at risk of withdrawal before and after a  benzodiazepine sparing protocol (using clonidine and gabapentin) was initiated. They found a lower daily CIWA score and significantly less lorazepam use in the benzodiazepines sparing group. This sparing protocol appears to be safe and effective.

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The OPAL trial attempted to investigate the effectiveness of opioids in the acute management of neck and back pain.

346 adults presenting to the Emergency department or primary care provider with 12 weeks or less of lower back pain, neck pain or both (of at least moderate intensity).

51% male. 49% female.

Location: Sydney, Australia

All participants received guideline care (advice to stay active, reassurance of a positive prognosis, avoidance of bed rest, and, if required, other non-opioid analgesics).

Patients were then randomly assigned to an opioid (oxycodone, up to 20 mg PO qD) or and an identical placebo, for up to 6 weeks*.

         *Trial used a combination oxycodone/naloxone to reduce risk of opioid induced constipation and assist with blinding.

         *Trial used a modified release formulation that could be dosed q12h rather than q4-6h to increase adherence.

*Recommended regimen was oxycodone 5mg every 12 hours, with titration as necessary, max dose 20mg total per day. 

*Trial physicians were able to individualize the prescription to suit the patient’s needs. 

* Mean prescribed dose was approx. oxycodone 10mg total daily.

*Most patients only treated for 2 weeks

Primary outcome: Pain severity at 6 weeks

Results: Mean pain score at 6 weeks was identical between groups.

Trend towards faster recovery in the placebo group in the first 2 weeks.

Take home: Consider the likely benefit vs harm of prescribing opioids for acute back and neck pain in the ED.

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Category: EMS

Title: What can we learn from suicide related cardiac arrests?

Keywords: Suicide, EMS, prevention, causes (PubMed Search)

Posted: 3/20/2024 by Jennifer Guyther, MD (Updated: 6/21/2024)
Click here to contact Jennifer Guyther, MD

7,365 suicide related cardiac arrests were included in this study that included a several year study period in Queensland Australia.  Cardiac arrests where resuscitation was attempted by EMS and where circumstances were concerning for suicide were included.  ROSC rates were 28.6% with survival at 30 days being only 8%.  30-day survival for medical cardiac arrests in this jurisdiction was 16.4%.  Overdose and poisoning had the best survival rate (19.9%), while hanging and chemical asphyxia were the worst (7.3 and 1.1% respectively).

Bottom line: Survival rates for suicide related out of hospital cardiac arrest were worse compared to other causes of medical arrest.  Suicide prevention should become a focus with emphasis on early identification and treatment of people at high risk of suicide.  While EMS is well trained on the management of cardiac arrest, training should also emphasize suicide risk assessment and identification.

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Category: Critical Care

Title: Which Vasopressor Should You Use to Manage Shock After Cardiac Arrest?

Keywords: ROSC, OHCA, cardiac arrest, shock, vasopressors, norepinephrine, noradrenaline, epinephrine, adrenalin (PubMed Search)

Posted: 3/19/2024 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

Post-arrest shock is a common entity after ROSC. There is support for the use of continuous norepinephrine infusion over epinephrine to treat shock after ROSC, due to concerns about increased myocardial oxygen demand and associations with higher rates of rearrest [1,2] and mortality [2,3] with the use of epinephrine compared to norepinephrine, and increased refractory shock with use of epinephrine infusion after acute MI [4].

An article in this month’s AJEM compared norepinephrine and epinephrine infusions to treat shock in the first 6 hours post-ROSC in OHCA [5].  With a study population of 221 patients, they found no difference in the primary outcome of incidence of tachyarrhythmias, but did find that in-hospital mortality and rearrest rates were higher in the epinephrine group. 

Bottom Line: Absent definitive evidence, norepinephrine should probably be the first pressor you reach for to manage post-arrest shock, especially if there is strong suspicion for acute myocardial infarction.

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Category: Trauma

Title: Use of hospice for discharge in geriatric trauma patients

Keywords: Geriatric trauma, outcome, hospice (PubMed Search)

Posted: 3/17/2024 by Robert Flint, MD (Updated: 6/21/2024)
Click here to contact Robert Flint, MD

This was a database study of nearly 2 million trauma patients over age 65 who were discharged looking at all levels of trauma centers. The authors found:

“Dominance analysis showed that proportion of patients with Injury Severity Score of >15 contributed most to explaining hospice utilization rates (3.2%) followed by trauma center level (2.3%), proportion White(1.9%), proportion female (1.5%), and urban/rural setting (1.4%).”

 Level one centers had the lowest level of discharge to hospice. The authors felt: “As the population ages, accurate assessment of geriatric trauma outcomes becomes more critical. Further studies are needed to evaluate the optimal utilization of hospice in end-of-life decision making for geriatric trauma.”

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This study is out of the American University of Beirut, Lebanon, and courtesy of our own Mazen El Sayed!

Many patients of Muslim faith will observe fasting during the month of Ramadan, with no food, water, oral of IV medication taken from sunrise to sunset

This study showed a lower daily ED volume than during non Ramadan months, however did show a higher length of stay during Ramadan.

It also found an increase in mortality rates during Ramadan (OR 2.88) and 72 hour ED bounce-backs (OR 1.34)

Be sensitive and aware of the needs of your patients of Muslim faith during this holy month of fasting.

Ramadan Kareem

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The gold standard for confirming ETT position is a chest xray, but this can often be delayed while the patient is stabilized. Many physicians will estimate ETT insertion depth to be 3x the ETT size, but this is based on selection of the correct tube.  There are several other published formulas, including the PALS guidelines [age in years/2 + 12] which applies to children older than one year.  In 1982, there was an article published that cited the formulas of [Height (cm) x 0.1 +5] or [Weight(kg)/5 + 12].

This was a retrospective study where the ideal position of cuffed ETT (from the front teeth) was determined by looking at post intubation xrays of 167 patients between 28 days and 18 years.  The individual optimal ETT insertion depth was plotted against age, weight and height for all children.  This study showed that there is not a fully linear relationship between age, height or weight which is a flaw of all of these formulas.  Calculations using the patients’ weight performed the worst.  Age based and height formulas performed the best.

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MYTH: Bactrim cannot be used as monotherapy for nonpurulent skin and soft tissue infections.

Not True!

Organisms of concern: Streptococcus spp.

Here’s why:

  • Sulfamethoxazole-Trimethoprim (Bactrim) disrupts folic acid synthesis & utilization.
  • This prevents the biosynthesis of the nucleic acid thymidine by bacteria and causes them to die. 
  • Some species of Strep, including S. pyogenes, are able to utilize exogenous sources of thymidine to continue their life cycle. 
  • Guess what? The laboratory media that was originally used to test Strep spp. susceptibility to Bactrim contained thymidine - therefore the bacteria were able to use it and did not die!
  • When tested using thymidine-depleted media, all 370 S. pyogenes isolates tested were highly susceptible to Bactrim!

TRUTH: Bactrim CAN be used as monotherapy for nonpurulent skin and soft tissue infections.

Prepared by Rianna Fedora, PharmD on 2/26/24

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Attachments

SMX-TMP Myth Buster Inservice-65f3561ae6df0.pdf (58 Kb)



Background: There is no clear guidelines regarding whether norepinephrine or epinephrine would be the preferred agent to maintain hemodynamic stability after cardiac arrest. In recent years, there has been more opinions about the use of norepinephrine in this situation.

Settings: retrospective multi-site cohort study of adult patients who presented to emergency departments at Mayo Clinic hospitals in Minnesota, Florida, Arizona with out-of-hospital-cardiac arrest (OHCA). Study period was May 5th, 2018, to January 31st, 2022

Participants: 18 years of age and older

Outcome measurement: tachycardia, rate of re-arrest during hospitalization, in-hospital mortality.

Multivariate logistic regressions were performed.

Study Results:

  • The study included 221 patients, 151 patients received norepinephrine infusion vs. 70 patients received epinephrine infusion.
  • The maximum dose of epinephrine = 0.28 mcg/kg/min vs. 0.15 mcg/kg/min for norepinephrine.
  • The Odds for clinically significant tachyarrhythmia was the same between both groups (OR 1.34, 95% CI 0.6802.62, P=0.40).
  • Epinephrine infusion was associated with higher odds of in-hospital mortality (OR 6.21, 95% CI 2.37–16.25, P <0.001)
  • Epinephrine infusion was associated with higher odds of re-arrest ( OR 5.77, 95% CI 2.74–12.18, P < 0.001)

Discussion:

It was retrospective study that uses electronic health records. Thus, other important factors from the pre-hospital settings might not be accurate.

On the other hand, the patient population came from multiple hospitals with varying practices so the patient population is more generalizable.

Conclusion

Although the rate of tachyarrhythmia was not different between patients receiving norepinephrine vs. epinephrine after ROSC. This study would add more data to the current literature that norepinephrine might be more beneficial for patients with post-cardiac arrest shock.

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What happens if you have a patient who steps on a nail? How can you make this procedure easier for you and the patient? 

– Use a Posterior Tibial Nerve Block! !

To Perform This Procedure:

  • Have the patient lay on a stretcher and externally rotate their hip and have their knee flexed.
  • Clean the area  
  • Use a linear probe with a sterile probe cover on
  • Place the probe with the marker towards the patient’s right, just above the medial malleolus and positioned posteriorly.
  • Identify the posterior tibial nerve next to the posterior tibial artery and center the probe on the nerve
  • Use a 22–30-gauge needle in an out of plane technique, slowly inject about 5 cc of anesthetic, making sure you are just above the nerve and not in the artery.

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This secondary analysis of the NEXUS head injury data found patients over 65:

-sustained more significant injuries than younger pts

-presented more frequently with occult injuries

-when they required neurosurgery intervention only 16% went home, 32% were discharged to rehab facility and 41%  died

-mechanism of injury was most commonly fall from standing

-mortality rates were highest for fall from ladder and auto vs. pedestrian injuries

The authors concluded: “Older blunt head injury patients are at high risk of sustaining serious intracranial injuries even with low-risk mechanisms of injury, such as ground-level falls. Clinical evaluation is unreliable and frequently fails to identify patients with significant injuries. Outcomes, particularly after intervention, can be poor, with high rates of long-term disability and mortality.”

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