March 28, 2019

Pulse Checks Background: In an older study published in Resuscitation 1998 [1], ED physicians, ICU physicians, and nurses tried to identify a carotid pulse in a healthy male volunteer with normal blood pressure. 43.1% of the health professionals required >5 seconds to detect the carotid pulse and another 4.3% required >10 seconds.  Something I have advocated for in cardiac arrest is the death of pulse checks, as our fingers are poorly sensitive for detecting which patients have a pulse in a shock state.  A visible rhythm on the monitor, along with the absence of a pulse with digital palpation, does not always indicate the presence of true pulseless electrical activity (PEA).  Our reflexive action when we don’t feel a pulse is to begin CPR and give 1mg epinephrine which may not be beneficial in these patients.  Patients in profound shock don’t necessarily need cpr and 1mg of epinephrine, they need augmentation of cardiac output with either push dose pressors or hemodynamically driven epinephrine drips.  Now another study published in Resuscitation looked to compare the efficiency of cardiac ultrasonography (CUSG), doppler ultrasonography (DUSG) and manual pulse palpation to check the pulse in cardiac arrest patients [2].

March 25, 2019

Background: TXA is a synthetic lysine derivative that binds with the lysine site on plasminogen and inhibits fibrinolysis.  TXA is not a new drug. Studies from the late 1960s and early 1970s have shown reduced bleeding and need for transfusions in many surgical and medical settings.  Fast forward to today and we are finding all kinds of uses for TXA other than trauma including post-partum hemorrhage, epistaxis, hemoptysis, gastrointestinal hemorrhage, and many more.

March 23, 2019

The management of the critically hemorrhaging trauma patient has seen a large amount of change over last decade, from bringing care far forward to the field to early use of blood products to civilian translation and application tourniquets to name a few. The reality unfortunately is that there is still a subgroup of patients who continue to suffer early mortality from hemorrhage, primarily because they are bleeding in the torso.  This is particularly challenging for both prehospital and in-hospital clinicians to manage as these areas do not allow control through direct compression. Enter resuscitative endovascular balloon occlusion of the aorta (REBOA) – a technique that builds on principles from vascular surgery and sees the placement of a balloon catheter into the aorta via the femoral artery.  Acting as an internal tourniquet, it temporarily occludes flow to the bleeding vessel thus providing circulatory support and precious time to get the patient to definitive care. With the alternative being death from hemorrhage, REBOA came as a breath of fresh air – a minimally invasive means of achieving hemorrhage control in these extremely sick patients. There were innovators and early adopters and reports of fantastic saves – patients were surviving who would never have survived before. 

March 21, 2019

Background: Rapid Sequence Intubation (RSI)  is a common procedure performed by both emergency clinicians and intensivists. Although the procedure is complex, the major pieces are pre-oxygenation, administration of a sedative agent in close proximity with a paralytic, laryngoscopy and placement of an endotracheal tube without the provision of any ventilations during the process. The avoidance of bag-mask ventilations (BMV), or any positive pressure breaths, rests on the belief that those breaths can distend the stomach and lead to regurgitation and aspiration. For this to happen, the force of the breath must exceed the pressure of the lower esophageal sphincter (~ 20 mm Hg). Critically ill patients presenting with airway compromise cannot be guaranteed to have a fasting state, regurgitation and aspiration is a major concern.

However, there’s another side to this. Many of our patients who are critically ill have intrapulmonary shunting; portions of the lung are atelectatic, filled with fluid, blood, or pus and not being oxygenated though they are being perfused. Blood running through these portions of the lung will be deoxygenated and will lower the overall O2 content of blood entering the systemic circulation after mixing with blood coming from ventilated regions. This shunting at least partially explains why we see patients rapidly desaturating during intubation. Positive pressure can recruit atelectatic portions of the lung that are not involved in gas exchange thus decreasing the physiologic shunt and increasing the patient’s oxygen reserve.

Despite decades of experience with RSI we continue to look for better approaches since the procedure still poses serious risks to the patient. Recent modifications that have seen wide adoption include using the bed-up-head-elevated (BUHE) position, suction assisted laryngoscopy for airway decontamination (SALAD) and bougie first intubation, though there are many more. Now, a publication in the NEJM makes us question the core principle of BMV during RSI.

March 20, 2019

Take Home Points on Oncologic Emergencies:

  1. Hyperviscosity Syndrome happens when elevated WBCs or severe hyperproteinemia cause high serum viscosity and micro-circulatory problems in patients with Waldenstrom’s macroglobulinemia, multiple myeloma or acute leukemia. Be suspicious of this syndrome in these patient’s when they present with the classic triad of mucosal bleeding, visual disturbances, and neurological symptoms or with any end organ failure.
  2. Tumor Lysis Syndrome results from high turnover of malignant cells resulting in severe metabolic derangements including hypocalcemia, hyperkalemia, hyperphosphatemia, hyperuricemia, AKI, metabolic acidosis. Be suspicious of this in patients presenting with edema, hematuria, fatigue, weakness, altered mental status or symptoms that go along with specific metabolic derangement, particularly if they recently received chemotherapy, radiation or high dose steroids.