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 18, 2019

Background: With CMS core measures requiring timely use of antibiotics in patients with fever and suspected sepsis, many patients receive antibiotics up front that may ultimately end up having another non-bacterial etiology as the cause of their fever.  On the one hand overuse of antibiotics can increase bacterial resistance, healthcare costs, and potential side effects. On the other hand, withholding antibiotics from patients with bacterial infections can increase morbidity and mortality. The authors of this trial wanted to determine whether a procalcitonin-guided algorithm could be used to reduce antibiotic regimens in the ED.

March 11, 2019

Background: Based on the Surviving Sepsis Campaign, hemodynamic resuscitation of sepsis patients is done by repeating serum lactic acid levels every 2 – 4 hours until normalization. The issue with this strategy is that there are other things that may elevate lactate levels other than sepsis and hypoperfusion.  Another, potentially useful marker to guide hemodynamic resuscitation could be capillary refill time.  Its easy-to-use, requires no resources, and costs nothing.  To answer this question the ANDROMEDA-SHOCK randomized controlled trial tried to evaluate the use of a peripheral perfusion-targeted resuscitation strategy during septic shock in adults.

February 28, 2019

Background: Standard management of septic shock has included, IV fluids until optimal intravascular volume is achieved, appropriate early antibiotics, and source control.  Typically, only after all these measures have been undertaken is vasopressor infusion initiated if a MAP of ≥65mmHg is not achieved. There have been some animal and human studies that have advocated for early norepinephrine administration in septic shock improving hemodynamics and mortality.  The issue, with these trials is that they were retrospective which means these studies suffer from the limitations of this type of methodology (i.e. convenience sampling, recall bias, confounding, and ultimately cannot determine causation, only association).