Topics in this EM Quick Hits podcast
Brit Long on Surviving Sepsis Campaign: 2021 Updates (0:38)
Nour Khatib on rural medicine case: angle closure glaucoma (11:59)
Reuben Strayer on bougie vs endotracheal tube and stylet on first-attempt intubation (20:51)
Justin Hensley on management of frostbite (31:35)
Sarah Foohey on the hot and altered patient (39:50)
Andrew Petrosoniak on central cord syndrome (47:47)
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Podcast production, editing and sound design by Anton Helman
Podcast content, written summary & blog post by Raymond Cho, edited by Anton Helman
Cite this podcast as: Helman, A. Long, B. Khatib, N. Strayer, R. Hensley, J. Foohey, S. Petrosoniak, A. EM Quick Hits 36 – Surviving Sepsis, Angle Closure Glaucoma, Bougies, Frostbite, Hot/Altered Patient, Central Cord Syndrome. Emergency Medicine Cases. March 2022. https://emergencymedicinecases.com/em-quick-hits-march-2022/. Accessed [date].
Surviving Sepsis Campaign: 2021 Updates relevant to EM
Screening for Sepsis
- New guidelines recommend against using qSOFA as a single screening agent
- Commentary: NEWS score is likely a better single screening tool that is easy to use and can be done at triage
Resuscitation
- Fluids
- Guidelines now only suggest rather than recommend using 30 cc/kg of IV crystalloid within the first 30 minutes of resuscitation
- Balanced crystalloids such as Plasmalyte and Lactated Ringer’s recommended as a first line over normal saline
- Vasopressors
- In most patients, norepinephrine is the first-line vasopressor, followed by vasopressin, then epinephrine
- In patients with cardiac dysfunction, use norepinephrine as first line then dobutamine or epinephrine alone
- In septic shock resistant to vasopressors, guidelines now support using IV hydrocortisone
- Monitoring resuscitation
- Use dynamic parameters (e.g. passive leg raise, stroke volume/pulse pressure variation, ultrasound) rather than using static parameters
- Point-of-care ultrasound can be used to assess volume status (IVC, B-lines, cardiac activity)
- For patients in septic shock, target a MAP of 65 mmHg
- Adjunctive markers: use capillary refill, lactate to guide resuscitation
- Antimicrobial therapy
- In patients with possible sepsis without shock, consider investigating for other causes for up to 3 hours before starting antimicrobial therapy (adjusted from 1 hour from previous guidelines)
- Choice of antimicrobials in the empiric phase
- High risk of multi-drug resistant organisms: 2 agents with gram negative coverage
- Low risk of multi-drug resistant organisms: 1 agent with gram negative coverage
- High risk of MRSA: provide coverage for MRSA (eg. vancomycin)
- No risk factors for MRSA: no routine MRSA coverage
- Other
- IV vitamin C is not recommended in septic shock
Airway and ventilation
- High-flow nasal cannula (HFNC): in sepsis-induced hypoxemic respiratory failure, HFNC is recommended over non-invasive positive pressure ventilation
- Intubation: low tidal volume strategy and upper plateau pressure of 30 cm H2O; in ARDS, consider using higher PEEP
- V-V ECMO can be considered if conventional mechanical ventilation fails
Episode 122 Sepsis and Septic Shock – What Matters from EM Cases Course with Sara Gray
- Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-e1143.
- Evans L, Rhodes A, Alhazzani W, et al. Executive Summary: Surviving Sepsis Campaign: International Guidelines for the Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021 Nov 1;49(11):1974-1982.
Rural Medicine Case: Angle Closure Glaucoma
Background
- Raised intra-ocular pressure due to impaired aqueous humour flow from posterior chamber
- This pushes the iris forward, closing the angle between the iris and the cornea
Clinical Presentation and Diagnosis
- Risk factors: medications that dilate the pupil (anticholinergics, TCAs, antiparkinsonian drugs, etc.), family history of glaucoma, hyperopic eyes, recent eye surgery
- Diagnosis: at least 2 of following symptoms – acute onset ocular pain with nausea and vomiting, intermittent blurring of vision with halo around lights, photophobia, vision loss
- Plus: at least 3 of following signs – intraocular pressure > 21 (typically >40), conjunctival injection, corneal epithelial edema, fixed mid-dilated pupil, shallow anterior chamber on slit lamp exam
Management and medications to consider
- Consult ophthalmology (definitive management is laser iridotomy)
- Pilocarpine 1-2 drops q15min for 2 doses (miotic)
- Timolol 0.25-0.5% 1 drop (beta blocker)
- Apraclonidine drops (alpha adrenergic agonist)
- Acetazolamide 500 mg IV x 1
- Mannitol 20% 1.25-2 g/kg IV x 1
- Reassess IOP q15min in the early phases
- Tintinalli J E, Cline D, Ma O John, et al. Tintinalli’s Emergency Medicine Manual 7/E. McGraw Hill Professional; 2012.
- Cargnelli S, Krywenky, A. Acute angle closure glaucoma review. (2016, October 8). CanadiEM. https://canadiem.org/medical-concepts-acute-angle-closure-glaucoma/
Bougie vs. Endotracheal Tube and Stylet on First-Attempt Intubation
Papers:
Driver et. al. (2018). Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation. JAMA. Single-centre emergency department trial (BEAM Trial) at Hennepin County Medical Center.
Driver et. al. (2021). Effect of use of a bougie vs endotracheal tube with stylet on successful intubation on the first attempt among critically ill patients undergoing tracheal intubation. JAMA. Multi-centre trial at 7 emergency departments and 8 ICUs (BOUGIE Trial).
Clinical Question: does use of a tracheal tube introducer (“bougie”) increase the incidence of successful intubation on the first attempt, compared with use of an endotracheal tube with stylet?
Primary outcome: first-attempt intubation success in patients with at least one difficult airway characteristic
Results
- BEAM Trial (n = 757): first-attempt intubation success in patients was higher in the bougie group (98%) than in the endotracheal tube and stylet group (87%) (95% CI, 8-20%)
- BOUGIE Trial (n = 1102): there was no significant difference in first-attempt intubation success between the bougie group (80.4%) and the stylet group (83.0%) (95% CI, -7.3 to 2.2%, P = 0.27)
- Commentary: when the operator is experienced at using the bougie with a standard-geometry blade (i.e. emergency physicians at Hennepin County Medical Center), first-pass intubation success is very high. If the operator does not routinely use bougies, they do not confer a first-pass intubation success advantage
Advantages of bougie
- Better view of bougie passing through the cords; therefore, less likely to place the ETT in the esophagus
- Alternative ways to assess placement before placing ETCO2 monitor: feeling tracheal rings and being held up at the carina when advancing the bougie
Disadvantages of bougie
- Poor success with Grade 4 view (rare); when confronted with Grade 4 view consider alternative techniques
Respiratory Care, June 2014 Vol 59 No 6
Bottom Line: the bougie confers higher first-attempt intubation only when the operator is experienced using it. Use it regularly rather than only as a rescue device.
George Kovacs’ talk “What You Don’t Know About Bougies” from EM Cases Summit 2021 FOAMed
- Driver, B. E., Prekker, M. E., Klein, L. R., Reardon, R. F., Miner, J. R., Fagerstrom, E. T., Cleghorn, M. R., McGill, J. W., & Cole, J. B. (2018). Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation. JAMA, 319(21), 2179.
- Driver, B. E., Semler, M. W., Self, W. H., Ginde, A. A., Trent, S. A., Gandotra, S., Smith, L. M., Page, D. B., Vonderhaar, D. J., West, J. R., Joffe, A. M., Mitchell, S. H., Doerschug, K. C., Hughes, C. G., High, K., Landsperger, J. S., Jackson, K. E., Howell, M. P., & Robison, S. W. (2021). Effect of use of a bougie vs endotracheal tube with stylet on successful intubation on the first attempt among critically ill patients undergoing tracheal intubation. JAMA, 326(24), 2488.
Management of Frostbite
First, manage hypothermia: rapid rewarming is most important
- Rewarm patient to a core temperature of 35°C before treating frostbite
- Remove all wet or constrictive clothing
CritCases 12 Accidental Hypothermia
Local Thawing
- Extremities: place in water with temp 37-39°C for 20-30 minutes
- Face: apply moistened compresses soaked in warm water
- Do not rewarm if there is any chance of refreezing
- Analgesia: be mindful that rewarming is very painful, so consider parenteral analgesia
- Local wound care: topical aloe vera cream, consider draining nonhemorrhagic bullae (in consultation with surgery), but leave hemorrhagic bullae alone; avoid antibacterial ointments
- Compartment syndrome: maintain high suspicion
Systemic Care
- In all patients
- Ibuprofen 12 mg/kg BID (2.4 g/d max)
- Tetanus prophylaxis
- If you think there is a chance of deep injury, consider using tPA and/or iloprost
- 3rd degree or higher: IV iloprost 2 ng/kg per min infusion, 6 h/d, for 5 days
- 4th degree: tPA 3 mg IV bolus then 1 mg/hr and heparin within 12 hours of rewarming
Iloprost protocol for frostbite
Quick Hit 27 on iloprost for frostbite
- Hallam, M., Cubison, T., Dheansa, B., & Imray, C. (2010). Managing frostbite. BMJ, 341(nov19 1), c5864-c5864. https://doi.org/10.1136/bmj.c5864
- Handford, C., Buxton, P., Russell, K., Imray, C. E., McIntosh, S. E., Freer, L., Cochran, A., & Imray, C. H. (2014). Frostbite: A practical approach to hospital management. Extreme Physiology & Medicine, 3(1). https://doi.org/10.1186/2046-7648-3-7
- Poole, A., & Gauthier, J. (2016). Treatment of severe frostbite with iloprost in Northern Canada. Canadian Medical Association Journal, 188(17-18), 1255-1258. https://doi.org/10.1503/cmaj.151252
The Hot and Altered Patient
- Foohey, S. (2021, December 1). The Hot and Altered Patient. First10EM. https://first10em.com/fooheysfigures-diagnostic-approaches/
Central Cord Syndrome: Hyperextension injury of the c-spine with upper extremity weakness and a benign CT c-spine that is easy to miss
- This is an incomplete spinal cord syndrome (meaning there is some sensory and/or motor function below the level of the injury that may be only in the saddle/sacral region) so check these on physical examination
- It is a clinical diagnosis with upper extremity weakness (typically weakness in hands>arm>shoulder) greater than lower extremity weakness (findings may be subtle so a careful assessment of power is essential); in a minority of cases, there is some bowel/bladder dysfunction.
- The 3 predominant phenotypes are
- Elderly patients who have a low energy fall sustaining a hyperextension mechanism,
- High energy trauma (often MVC) that causes hyperextension in a younger patient or
- Patients with a fracture/dislocation of the c-spine
- CT is the test of choice in the ED and a CT-angiogram of the carotids should be considered as well; CT typically shows no fracture/dislocation and only degenerative disc disease; it is important to maintain a high index of suspicion regardless of the CT findings, even if the CT is normal; typically full spine MRI is done as an inpatient
- Ameer et al. Central Cord Syndrome. Dec 29, 2021. https://www.ncbi.nlm.nih.gov/books/NBK441932/
- Badhiwala et al. The case for revisiting central cord syndrome. Spinal Cord, 2020. 58:125-127. https://www.nature.com/articles/s41393-019-0354-5
- Nowak et al. Central Cord Syndrome. J Am Acad Orthop Surg 2009; 17:756-765.
None of the authors have any conflicts of interest to declare
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