Grand Rounds Recap 1/6

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Emergency KT Protocol - The Pharmacology of RSI with Drs. Dang and Renne

Who do we RSI? What do we use? We can be better than etomidate and succ and the protocol in development will drill into the details - here is an overview:

  • The most clinically useful categorization of RSI candidates is probably based on hemodynamics
  • Hemodynamically unstable patients can be classified as “shock" based on myriad criteria and/or clinician gestalt while patients in whom the adrenergic surge of laryngoscopy could potentiate their pathology (e.g., increased ICP, aortic dissection, active ACS, or hypertensive crisis, etc.) can be classified as “high risk hypertension” for patients with increased ICP
  • The hemodynamic classification of a patient determines his/her track down the pathway, but their classification can shift at any point based on clinician discretion (i.e., a well-resuscitated shock patient may later be considered “stable” and managed accordingly) 

Optimization

  • It is imperative that shock patients be adequately resuscitated prior to RSI to the extent permitted by their respiratory state and airway protection; depending on the suspected etiology for shock, this may include any or all of: crystalloids, PRBCs/FFP/TXA/platelets, pressors, etc.
  • “High risk hypertension” patients need protection from the potentially dangerous adrenergic surge of laryngoscopy; the best solutions for this are those that mitigate MAP excursions and the best studied candidates are lidocaine, fentanyl, and esmolol
  • Evidence on lidocaine is not particularly compelling, with most human studies showing limited benefit and its main support deriving from animal studies or human studies without appropriate clinical circumstances or endpoints (e.g., ICP rise associated with endotracheal suction, not intubation)
  • Fentanyl and esmolol both blunt MAP rise with laryngoscopy in several appropriately-powered studies; esmolol has the added effect of limiting HR excursion but this may not be optimal in all patients and esmolol is sometimes more logistically difficult to acquire
  • The strongest recommendation for allcomers based on the combination of evidence and practicality is an implied fentanyl 3 mcg/kg, with studies showing 2 mcg/kg is too low a dose to be effective and the potential risk of hypotension at higher doses; esmolol 2 mg/kg is also an option is if readily available and in appropriate patients

Induction

  • Etomidate has been demonstrated to have adrenal suppression, however in critically ill patients no increase in mortality has been demonstrated when compared to other induction agents.
  • Ketamine has been shown to have both sympathetic stimulation and negative ionotropic cardiac effects. Negative cardiovascular effects have been seen in:
    • Prolonged critically ill patients (ie septic and catecholamine depleted)
    • Larger or repeated doses of ketamine (Study repeated doses of 2 mg/kg with negative ionotropic effect seen with second dose)
  • In shock patients, etomidate and ketamine are the induction agents of choice with the least hemodynamic effects.  However, beware of sympatholysis in shock patients, as ALL induction agents can cause hypotension.
  • Consider dosing lower in states of shock.
    • Theoretically, a reduced dose of ketamine in shock can maintain hemodynamics and prevent sympatholysis, while still providing dissociation.
    • Etomidate may be unreliable in reduced doses. Swine in hemorrhagic shock required higher doses of etomidate. Contrasted to propofol, which required a 1/10th of the standard dose to achieve sedation.
  • In high risk hypertensive patients (ie Increased ICP, aortic dissection, myocardial infarction, hypertensive crises/PRES, increased intraocular pressure) avoid ketamine due to sympathetic stimulation. However, ketamine has not been shown to increase ICP in recent studies.  

Paralysis

  • We recommend rocuronium over succinylcholine, except in cases where short duration of paralysis is preferred (ie status asthma, severe acidosis (ie DKA), and evaluation of neuro exam).
  • Studies comparing rocuronium dosed 1-1.2 mg/kg compared to succinylcholine dosed at 1-1.5 mg/kg demonstrated no difference time to intubate, intubating conditions, or success.
  • A probability based study suggest larger doses of rocuronium (1.85 – 2.33 mg/kg) have a higher likelihood of creating “perfect” intubating conditions.
  • Rocuronium has a dose dependent duration of action.
  • Rocuronium has a longer safe apnea time compared to succinylcholine.
  • Succinylcholine has more contraindications and adverse effects compared to rocuronium.
  • In states of shock, increase dose of paralytic.
  • Potential game changer with recently FDA approved sugammadex, rocuronium reversal agent, for use in the United States. 

Analgosedation

  • Every patient who undergoes RSI deserves post-intubation analgosedation
  • Start with analgesia first and add sedation to achieve RASS goal
  • The conundrum lies in proper analgosedation for the patient in shock, who deserve the same comfort measures as their normotensive counterparts but carry the risk of further hemodynamic deterioration; we see this not infrequently with those placed on propofol drips for lack of a better option
  • One valid option for truly shocked patients (i.e., those persistently unstable even after resuscitation/optimization) is a ketamine drip (2.5 -10 ug/kg/min)
  • This has efficacy in numerous studies with varying evidence levels from 2 - 4 and appears to be overall quite safe both from a hemodynamic and psychiatric perspective
  • From an EBM perspective, a comprehensive, prospective, randomized control trial on postintubation ketamine drips is lacking though the existing pool of literature is encouraging; they appear to have a role in profoundly and persistently  shocked patients wherein the hemodynamic benefits most certainly outweigh the risks of only partial certainty and literature support
  • In practice, the military and international red cross (as well as anesthesia at several institutions) have been using these ketamine drips for decades and continue to do so
  • In our shop, these drips come up from pharmacy; while awaiting their arrival or in resource-limited settings (e.g., Air Care), ketamine boluses 0.5 mg/kg q10 mins function as adequate bridges to the drip
  • Regardless of hemodynamic status, ketamine drips should be considered in bronchospasm for its bronchodilatory benefits and should probably be avoided in cardiogenic shock patients due to its adrenergic side effects

Southwest Ohio Protocol Update with Dr. Lardaro

The following is based on the publically available SW Ohio 2016 Protocol

Major Updates

Suspected CHF management if hypertensive with severe symptoms

  • SLNG 1-2 doses of normotensive
  • Nitro paste added modality
  • Remember both can precipitate hypotension and to evaluate the patient for paste

Prehospital Pediatric Steroids

  • May be given pre-hospital so make sure to ask your squads


Fentanyl

  • No longer requires medical control for acute severe pain with SBP > 100


Determination of death

  • Rigor mortis. Lividity. Decomposition. Injury incompatible - decap, burn beyond recognition or active Do Not Resuscitate (DNR) Order

Termination of Resuscitation Efforts

  • Good contact between paramedic and medical control
  • Airway control (BVM, SGD, ETT)
  • 20 minutes of resuscitative efforts and 30 minutes for < 16 years old
  • Never had signs of life (movement)
  • The ongoing rhythm cannot be shockable (VFib, VTach)
  • Everyone must agree on the termination
  • Electrocution, hypothermia and lightening strikes should be transported

There will always be unique scenarios  (high etCO2, temporary ROSC, etc) that do not fall into the protocol or be found in the evidence - this is where that clinical judgement comes in.

Traumatic Arrest

Needle Decompression if there is evidence of trauma to the torso

Initial resuscitation should involve fluid resuscitation

Get on monitor and assess rhythm

  • PEA < 40 - Terminate resuscitation
  • PEA > 40 - Give fluids, repeat needle decompression if applicable, transport to trauma center
  • VFib/VTach - Defibrillation, needle decompressions if applicable, fluids and transport
  • All pregnant traumatic arrests require transport

Opiate Overdose

  • Basic airway maneuvers first while giving reversal agent
  • 0.4mg - Intranasal preferred (1ml/nostril x 2), or IM or IV up to 10 mg until clinical reversal
  • Patients are able to refuse if they are an adult, behaving normally, not actively intoxicated, repeat back the risks of refusing transport

Clinical Pathologic Case with Drs. Miller and Powell

  • The ‘accidental overdose’ patients get sick too; often with confounding features that require careful analysis and thinking outside pattern recognition.
  • Thyroid storm represents the severe end of the spectrum of thyrotoxicosis. While the presentation can vary, it classically presents with tachycardia, fever, AMS, diaphoresis, hepatobiliary dysfunction, and evidence of heart failure
  • Defined by the Burch-Wartofsky Score which takes into consideration thermoregulation, hepatic-GI system, heart failure, cardiovascular dysfunction, CNS effects
  • Almost always has precipitating event. If discovered without a known precipitating event (trauma, surgery, pregnancy) evaluate for MI, DKA, infection etc
  • Treated with symptom control with beta blockers (propranolol 1 mg/min IV q15 min up to 10 mg IV), steroids (dexamethasone 2 mg IV), and thioamides (Methimazole 30 mg po)

XRay of the shoulder and clavicle with Dr. Soria

Please see Dr. Soria's online module and post here

Time Management for the Academic Physician with Drs. Miller and Stettler

Time is what you can't give back - so use it and give it wisely. The more projects we have, the more we are pressed and planning is the key to prevent chaos... We asked two of our department efficiency gurus to give us some tips

As you progress towards an academic career your time in the ED will decrease but your clinical time but assuredly, you will fill them - time to do some accounting:

  • 168 hours / week
  • ~56 hours / week clinically
  • 49 hours / week sleep
  • 63 hours of discretionary time left - that's 9 hours a day for all the rest (family, ADLs, social, spiritual, physical health, etc. etc). This number seems high but goes quickly and you must make the most of the time you have.

Discipline is the key to undermining the distraction of multi-tasking

  • Task switching is what we excel at in Emergency Medicine
  • Bring that into your daily life
    • Eliminate your distraction (Email notification, overnight notifications, open doors, etc)
    • Schedule your calendar to block out dedicated time
    • Avoid physical distractions of 'you got 5 minutes?' - open door policy works when it is meant to be but can be distracting

Investment Costs vs Opportunity Costs

  • Investment costs look at what you have to put in to perform a task
  • Opportunity costs evaluate what you would be missing by not engaging in a task or engaging in another
  • Your assignment of value is how you balance the two - people could evaluate the same objective measures and arrive at different costs - this is the hardest part of determining your priorities

Tips

  • When task prioritizing  - focus of the priority - not the task. Don't schedule an hour answering email - focus of the emails that have important content and focus on the involved projects instead
  • Give back to someone other than yourself and your work - reminds you what you are working for and what you value

Sports Medicine with Drs. Dailey and Burley

Our sports medicine colleagues shared some pearls on common injuries and ED management.

Quadriceps Tendon Rupture

  • Partial tears can be managed with straight leg immobilization, but in the case they require surgical intervention they need prompt surgical evaluation within 2-3 days.

Patellar Tendon Rupture

  • Normally associated with repeated knee irritation and will typically result in a high riding patella. Requires prompt surgical repair.

Scapholunate Dislocation

  • Clenched fist XR view can help widen the gap and highlight the injury - when in doubt with focal tenderness split and follow up imaging.

Lunate Dislocation

  • Associated with a scaphoid fracture, and this is often missed by EM and radiology.

Lisfranc fracture or dislocation

  • Typically from axial load or crush injury
  • Require weighted films and may need comparison to other side. Even CT may miss diastasis if unweighted view.
  • If you have suspicion of it, should keep them non weight bearing with a posterior splint until followup.

Sudden Cardiac Death in Athletes

  • Incidence in collegiate athletes can be as high as 1:6000 in a population of African American males playing collegiate basketball. Role of EKG is controversial because of concern for false positives and the unnecessary disqualifications and expense to athletes.
  • Syncope during exertion is far more concerning than syncope post exertion.
  • In the US we are working to establish criteria for EKG interpretation in athlete physicals. See the Seattle Criteria and associated training module.