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
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
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
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
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
IV vitamin C is not recommended in septic shock
Update 2023:A multicenter randomized controlled trial including 1563 patients with sepsis-induced hypotension refractory to initial treatment with 1-3L of IV fluids comparing a restrictive fluid strategy (prioritizing vasopressors and low intravenous fluid volumes) and a liberal fluid strategy (prioritizing higher volumes of intravenous fluid before vasopressor use) found that death from any cause before discharge home by day 90 was not significantly different between the two groups (14.0% vs 14.9% respectively, estimated difference -0.9%, 95% CI -4.4 to 2.6, P=0.61) (CLOVERS trial). Abstract
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
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
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)
Bougie vs. Endotracheal Tube and Stylet on First-Attempt Intubation
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
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.
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
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
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
Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.