Intraabdominal infections leading to sepsis can come from cholecystitis, small bowel perforation, gastric perforation, left sided colonic diverticulitis, right sided diverticulitis and appendicitis. When to initiate source control and antibiotics is controversial. These authors propose breaking patient populations into three groups:
From this they propose algorithms to treat these intraabdominal infections such as (note the different approach to right and left diverticulitis):
This article looks at source control as it relates to intrabdominal sources for sepsis. Key take aways are:
Those at high risk of morbidity and mortality from intraabdominal infection associated sepsis include:
Mild–moderate immune deficiency: Elderly (according to the age and general status of the patient), Malnourished, Diabetic, Burns, Trauma, Uremic, Active malignancy, not on chemotherapy, HIV with CD4+ count >200/mm3, Splenectomized, Severe immune deficiencyAIDS HIV with CD4+ count <200/mm3, Transplant (solid organ, bone marrow), High-dose steroids (more than 20 mg/day prednisone), Malignancy on chemotherapy, Neutrophil count <1,000/mm3
High-risk population (medical or surgical causes)Low serum albumin concentration Older age Obesity Smoking Diabetes mellitus Ischemia secondary to vascular disease or irradiation Prolonged or delayed/late procedures
Comparing prescribing patterns from early 2000s to late 2010s in the National Hospital Ambulatory Medical Care Survey, these authors found we continue to under prescribe pain medications to non-white patients for traumatic injuries.
A prospective cohort of South Korean patients over 65 years admitted from the ED with critical illness had Clinical Frailty Scale (CFS) performed on them. Those with a high CFS had increased 3 month mortality. CFS helps us prognosticate morbidity and mortality in our older critically ill patients.
In 252 mild traumatic brain injury patients seen at 3 level I centers that were given the Rivermead Post Concussion Symptoms Questionnaire within 24 hours of arrival, 3 month post concussive symptoms were significantly correlated with their score on the questionnaire. This questionnaire take 3 minutes to complete. This may be helpful in prognosticating who will have post-concussive symptoms and who will need additional follow up.
In reviewing the limited literature available, the authors found that fascia iliaca blocks did not improve mortality but did improve hospital length of stay, decreased opiate use, and decreased delirium rates. More research is needed, however this tool should be added to our multimodal pain control toolbox.
This group looked at 88 patients intubated for penetrating neck injury and found 95% received neuromuscular blocking agents, 73% were intubated using a bougie, and 95% were intubated on first pass.
The authors concluded; “Rapid sequence intubation with bougie use was an effective default approach to definitive airway management in ED patients with penetrating neck trauma.”
These authors followed 250 consecutive trauma activation patients over a one year period. In hospital elevated blood pressure and glucose level correlated with a new diagnosis of hypertension and diabetes respectively over that 1 year time line. Some of these patients also had a new diagnosis of HIV, substance use disorder and hepatitis C. Using their contact with the health system due to trauma can be a way to screen for undiagnosed medical problems such as diabetes and hypertension. Assuring outpatient follow up for these patients will have an effect on their long term morbidity and mortality.
In a German study comparing one EMS jurisdiction which used IV paracetamol (acetaminophen) in combination with nalbuphine (Nubian, opiate agonist/antagonist) to another jurisdiction which used piritramide (synthetic opioid similar to fentanyl) for prehospital traumatic pain, the combination worked better to decrease pain on a numerical scale. There were no differences in typical safety measures.
The use of an antagonist/agonist theoretically could precipitate withdrawal in non-opiate naive patients and could influence in hospital analgesic choices. The literature on this is mixed.
This study offers further evidence of the efficacy of multi-modal pain control, the feasibility of paramedics using IV paracetamol and the possibility of using rapid onset opioid agonist/antagonist in the prehospital setting.
A scoping review of literature involving norepinephrine use during cardiac arrest associated with a shockable rhythm found:
-evidence in animal and signal in human trials of improved myocardial and cerebral blood flow
-a suggestion of less re-arrest
There is not enough evidence comparing epinephrine to norepinephrine however this would be an excellent area of research with a theoretical advantage to norepinephrine.
In the newly released American Heart Association guidelines on CPR and cardiovascular care, they state there is no evidence that mechanical compression devices show improvement in survival when compared to manual CPR. They do not recommend routine use of mechanical devices except when high quality CPR can not be maintained or when healthcare personnel safety is impacted such as during transport to the hospital.
Surely there will be more to follow on this topic.
These authors looked at survival to discharge pre and post-implementation of a single dose epinephrine protocol for out of hospital cardiac arrest as it relates to age ranges. They found that older patients had a survival rate of 12% in the single dose protocol compared to 6% in the multidose protocol. Younger and middle aged patients had no difference in survival pre and post-implementation. At least in older adults, epinephrine does not seem to offer much benefit when given more than one time during cardiac arrest.
The authors conducted a pre- and post-implementation study after five North Carolina county EMS agencies switched to single dose epinephrine during out of hospital cardiac arrest treatment from the traditional multidose (every 3-5 minutes) protocol. They looked at 1 year before and 1 year after implementation. They found no difference in survival to discharge from the hospital in the two groups but there was less return to spontaneous circulation in the single dose group.
Another paper emphasizing care for brain injured patients should include:
-pre-intubation preoxygenation to avoid hypoxia
-pre-intubation avoid extremes in blood pressure (hypotension kills)
-use hemodynamically neutral induction agents such as ketamine or etomidate
-post intubation target eucapnia on the ventilator. (do not aim for low CO2)
-post intubation maintain adequate sedation to avoid increased intercranial pressure
This study looked at older patients admitted to the hospital with a diagnosis of one of the following: RSV infection, UTI, influenza, fracture. Those patients with RSV had longer stays, higher mortality, higher ICU length of stay and interestingly more cardiovascular complications up to one year after hospitalization. Further evidence we should be testing for RSV in our ill older patients and encouraging vaccination.
These authors used information available from both the medical record as well as from a survey instrument given in the emergency department to created this fall risk score. A score over 6 had a 63% sensitivity and 75% specificity of predicting future falls.
In a retrospective observational study comparing patients both on and not on antithromotics (DOAC/warfarin or anti platelets) who presented with a GI bleed these authors found:
“Patients with anticoagulant therapy more often present with a lower source of GI bleeding than both those on antiplatelet medications and those with no antithrombotics. Overall patients on anticoagulants are also less likely to present with hematemesis, even with a later confirmed upper GI bleeding. Furthermore, results indicate that the need for endoscopic interventions and transfusions are dependent on initial presenting symptoms but not affected by antithrombotic therapy at admission.”
This paper reminds us older patients have higher mortality and worse outcomes overall if their injury includes a head injury. Any mechanism that results in head injury, including fall from standing, has a higher potential for death, disability, and long term cognitive decline in older patients. Triaging these patients to trauma centers can lead to better outcomes. The difficulty is knowing which patients to send to trauma centers vs. emergency departments. The authors write:
"clinicians should consider transporting to a trauma center in geriatric patients with head trauma, if feasible. However, given the frequency with which head injury occurs, transportation to a trauma center for all patients with head trauma is likely to overwhelm EMS systems and hospitals. Unfortunately, the existing literature does not delineate the subset of patients whose condition will benefit from this evaluation . Given these considerations, we recommend EMS clinicians consider abnormal mental status, presence of anti-coagulation, and loss of consciousness as considerations to transport to a trauma center in cases where the need for trauma center evaluation is not clear.”
Reenforcing the recent pearl on geriatric trauma patient care, here is the National Association EMS Physicians statement on prehospital care.
"EMS clinicians should use age-adjusted, physiologic criteria to guide decisions to transport geriatric trauma patients to the most appropriate level of trauma center available in the community.
Geriatric trauma patients should be promptly evaluated for pain and should receive analgesic interventions in a timely manner. Analgesic medications should be dosed following weight-based guidance and should be administered with consideration of potential drug interactions and age-related changes in drug metabolism and side effects.
EMS clinicians should consult advance care planning documents, e.g., Physician Orders for Life-Sustaining Treatment (POLST), when available, to guide care in emergency scenarios, including management of traumatic injuries.
While older patients are at higher risk for spinal injuries, including lumbar and cervical spine fractures, traditional spinal motion restriction practices may not be suitable for older patients due to age-related anatomic changes in spinal alignment and increased risk for cutaneous pressure-related injuries. EMS clinicians should exercise judgment to determine when and how to best achieve spinal motion restriction if spinal injury is suspected in geriatric trauma patients."
This retrospective study looking at a readmission database for patients greater than 65 years categorized 10,000 patients into non-frail, pre-frail and frail based on the five-factor modified frailty index. They found no difference in recurrent diverticulitis among the groups but did find:
“frailty was a predictor of mortality on index hospitalization (adjusted odds ratio, 1.99; p < 0.001) and readmissions (adjusted odds ratio, 3.05; p < 0.001)…frail patients are at increased risk of mortality once they develop diverticulitis. Optimal management for frail patients with diverticulitis must be defined to improve outcomes.”
Once again, assessing your patient's frailty can help you predict outcomes and have meaningful discussions with patients and their families.
