Podcast content, production, editing and sound design by Anton Helman
Podcast written summary & blog post by Raymond Cho; edited by Anton Helman
Cite this podcast as: Helman, A. Morgenstern, J. Sommer, L. Shenvi, C. Cheskes, S. Mohindra, R. Khatib, N. Sampsel, K. EM Quick Hits 44 – Fluids in Pancreatitis, Nasal Fractures, Delirium, DOSE VF, Intimate Partner Violence. Emergency Medicine Cases. November, 2022. https://emergencymedicinecases.com/em-quick-hits-november-2022/. Accessed November 30, 2023.
Fluids in Acute Pancreatitis – WATERFALL Trial
Background: ED management of acute pancreatitis has traditionally focused on aggressive fluid resuscitation; however, recent evidence suggests potential harm in this approach
Clinical question: Does moderate vs. aggressive fluid resuscitation in acute pancreatitis decrease progression to moderate/severe pancreatitis?
Methods/Outcomes: The WATERFALL trial is a randomized control trial of 249 patients with the control group receiving a ringer’s lactate (RL) bolus of 20 cc/kg followed by 3.0 cc/kg/hr, and the intervention group receiving 10 cc/kg bolus if hypovolemic or no bolus if euvolemic followed by 1.5 cc/kg/hr. Primary outcome was progression to moderate-to-severe acute pancreatitis, and primary safety endpoint was fluid overload.
Results: 17.3% in the moderate and 22.1% in the aggressive fluid group progressed to moderate/severe pancreatitis (aRR 1.30, 95% CI 0.78-2.18)
The trial was stopped early as interim analysis showed a high incidence of fluid overload in the aggressive fluid group (20.5% vs. 6.3%, aRR 2.85, 95%CI 1.36-5.94)
Author conclusions: Early aggressive fluid resuscitation resulted in a higher incidence of fluid overload without improvement in clinical outcomes
Commentary: In the fluid management of acute pancreatitis, less is more. Use small boluses (e.g., 500 cc RL), and reassess after each bolus; note that this trial applies only to patients with mild pancreatitis and ensure your patient meets this inclusion criteria before abandoning IV fluid resuscitation altogether.
Other causes: pain, urinary/fecal retention, missing hearing or vision aids
Update 2022:A systematic review examining patients aged 65 or older who received neuroimaging at the time of ED assessment for delirium, confusion, or altered mental status found that 15.6% of these patients had an abnormal CT head. Anticoagulation did not have a significant pooled odds ratio for an abnormal CT (OR 1.18, 95% CI 0.43-3.25), but neurological deficit did have a significant pooled odds ratio for abnormal CT (OR 110.2, 95% CI 30.5-340.1). Abstract
Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med. Mar 2009;16(3):193-200. http://www.ncbi.nlm.nih.gov/pubmed/21496140
Shenvi, C., Kennedy, M., Austin, C. A., Wilson, M. P., Gerardi, M., & Schneider, S. (2020). Managing delirium and agitation in the older emergency department patient: The ADEPT tool. Annals of Emergency Medicine, 75(2), 136-145. https://doi.org/10.1016/j.annemergmed.2019.07.023
DOSE VF Trial – Best of University of Toronto Emergency Medicine
Treatment-refractory ventricular fibrillation (VF) is a common problem with seemingly limited options as medications in our toolbox do not confer survival benefit
Survival within 3 shocks is ~30%, but drops significantly after shocks 4-10 to ~12.5%
Alternative strategies in refractory VF include a vector change (VC) of defibrillation pads from anterior-lateral (AL) position to anterior-posterior (AP) position, and double sequential external defibrillation (DSED). These strategies have been traditionally applied as a last-ditch effort, but this will predictably fail as too much time has passed since the onset of cardiac arrest.
This study aims to evaluate the efficacy of the early application of DSED and VC defibrillation compared to standard defibrillation in treatment-refractory VF in out-of-hospital cardiac arrest.
Cluster-randomized control trial with 6 paramedic services.; all patients received three successive defibrillation attempts with pads in standard AL position and if they remained in VF, were randomized to standard AL defibrillation (n = 136), VC defibrillation (n = 144), and DSED (n = 125).
Inclusion criteria: Refractory VF after 3 consecutive standard defibrillations
Exclusion criteria: < 18 years of age, DNR, traumatic arrest, drowning
Enrolment was stopped early (n = 405) due to the feasibility concerns during the ongoing COVID-19 pandemic
Primary outcome: survival to hospital discharge
Secondary outcomes: termination of VF, return of spontaneous circulation, modified Rankin Scale ≤ 2
Survival to hospital discharge for standard, VC, and DSED was 13.3%, 21.7%, and 30.4% respectively (p = 0.009)
Termination of VF
Modified Rankin score ≤2
Overall, DSED was superior to standard management in all primary and secondary outcomes, and VC was superior to standard management in VF termination and survival to hospital discharge but not neurologically intact survival
The sensitivity analysis showed that the effect size of VC treatment is likely not reflective of true effect size, and higher rate of crossover back to standard treatment, which likely biased results
All studies that show a new technique tend to show higher benefits than subsequent studies
Several paramedic training and monitoring factors, including the emphasis on and monitoring of high-quality CPR and standardized training in DSED, may have influenced the results
Blinding was impossible for the intervention; this limitation was minimized with monitoring of CPR quality, medications given, PCI, demographics (shown to be balanced across all three arms), and data assessors were blinded to the intervention
Considerations in the application of DSED/VC in refractory VF
Defibrillator damage in DSED: theoretical damage can happen if both defibrillators are activated simultaneously to the millisecond; however, as they are being activated in sequence in DSED, there is almost no risk of damage if technique is applied correctly
Immediate use of DSED/VC (rather than waiting for 3 standard shocks): not recommended as conversion and survival is already quite good in early VF arrest
Pad placement for double sequential defibrillation. Image courtesy of Dr. Mark Ramzy (@MRamzyDO)
Bottom Line: Double-sequential external defibrillation (and vector change in lower-resourced settings) is ready for prime time pending guideline recommendations. Use these strategies early in cardiac arrest immediately after 3 standard shocks have been delivered.
Cheskes, S., Verbeek, P. R., Drennan, I. R., McLeod, S. L., Turner, L., Pinto, R., Feldman, M., Davis, M., Vaillancourt, C., Morrison, L. J., Dorian, P., & Scales, D. C. (2022). Defibrillation strategies for refractory ventricular fibrillation. New England Journal of Medicine. https://doi.org/10.1056/nejmoa2207304
Cheskes, S., Dorian, P., Feldman, M., McLeod, S., Scales, D. C., Pinto, R., Turner, L., Morrison, L. J., Drennan, I. R., & Verbeek, P. R. (2020). Double sequential external defibrillation for refractory ventricular fibrillation: The DOSE VF pilot randomized controlled trial. Resuscitation, 150, 178-184. https://doi.org/10.1016/j.resuscitation.2020.02.010
Intimate Partner Violence
38% of murders of all women worldwide are related to IPV, 44% of women murdered by their intimate partner visited the ED in the past year, and ED physicians only identified 5% of IPV cases
IPV should be recognized as having similar presentations as non-accidental trauma or child abuse
IPV should be considered in patients with multiple visits for the same presentation, chronic pain, mental health concerns, substance use disorders
Universal screening is encouraged in the ED (i.e., all genders, age groups, etc.)
Treat IPV-related injuries similarly to that of other accidental traumas
Refer all consenting patients to a specialized IPV treatment center
In documenting IPV-related charts, avoid legal words and use clear, factual statements