At this point in time our desire to continue to provide a useful, educational and fun-filled emergency medicine newsletter each month is our top priority. Considering this, as well as our severe lack of skillz with websites/blogs, we are going to cease further updates on this blog and concentrate solely on the newsletter. However, our current and past news letters will always be available here at thesharpend.org as well as author instructions above (hint, hint). We hope to get the blog up and running again one day. If any whiz out there were would like to help out with the blog, we would love to hear from ya.
The Sharp End Crew
To the right is a possible algorithm using clinical judgment, some decision instruments, and a D-dimer to evaluate for possible PEs. It is intentionally vague but still something to think about.
The most important part of any algorithm is the clinical judgment required to decide which patients need the algorithm applied. If you really think your patient may have a PE then you can start using this (or similar) clinical algorithms to help you correctly diagnose the patient and avoid unnecessary testing.
It surprises me, but not everybody has heard of the PERC rule or understands the Wells Criteria. Each can be used in addition to clinical judgment on patients who you think might have a PE but may not need a D-dimer to rule out PE, they also serve as a great checklist to help remind you of the risk factors for PE.
The SMOs have been discussing the best way to work up suspected PEs and we haven’t yet reached a consensus, which means that, unless you are sure a D-dimer is going to help you, discuss it with your SMO before ordering it.
PS: For the detailed discussion that led to this figure, check out this video.
We have observed that most people here don’t use a stylet when they intubate in the ED. Although this is common in anesthetics (I suppose it is easier on the cords), every “difficult airway”resource I’ve ever encountered recommends using a bent stylet or a bougie to increase first pass success.This article, The complexites of tracheal intubation with direct laryngoscopy and alternative intubation devices, by the ED difficult airway guru Rich Levitan goes through the geometric complexities of a difficulty intubation and is worth a close review. Additionally, he has an awesome series on using a laryngoscope in Emergency Physicians Monthly that has some great reminders on “Tube Delivery Issues.”
Either way, next time you’re trying to “deliver the tube” try it with a straight-to-cuff styletted tube with a 35º bend at the cuff. Just to try in out – see how it feels to cram with a little stiff angle on your dangle.
Our Sydney friends just published a great trio of observational studies in this August’s EMA. The first paper, titled Procedural Sedation Practices in Australian EDs presented data on how eleven Australian EDs used procedural sedation and analgesia (PSA). They prospectively enrolled 2623 adults and children who received ED PSA. The mean age was 39 y/o. Shoulders (27%), wrists (16%), lower legs (13%), and hips (6.5%) were the most common procedures. Most patients (51%) had been NPO for less than 6 hours. Less than half received pre-procedural medication (morphine 34%, fentanyl 12%). The most common sedative was propofol (38%), midazolam (10%), and ketamine (7.5%). Patients who were considered inappropriate for ED PSA and those who just received nitrous oxide were not included.
The second paper, titled Risk Factors for Sedation-related Events During Procedural Sedation in the ED. They reported that about (17.6%) of the time there was an “event.” These “events” were classified as a temporary airway obstruction (12.7%), hypoventalation (6.4%), desaturation (3.7%), or vomiting (1.6%) that required an intervention.
A single (0.05%) case resulted in clinically important adverse outcome. This was a 83 y/o woman sedated for a prosthetic hip reduction who had been fasting for 24 hours. She was premedicated with 2.5mg of morphine and then deeply sedated with 50µg of fentanyl and 50mg of propofol. She then stopped breathing, obstructed her airway, and desaturated. Although no vomiting was observed, she required intubation and ICU admission. The CXR indicated aspiration. That’s a bad day at the office.
Increasing age and deeper sedation were associated with an airway event. Ketamine appeared to be protective. Anti-emetics and fasting status was not associated with airway “event” rates. This supports most of the previous evidence showing that extended (greater than 2 hour) pre-sedation fasting times are not associated with an increased risk of vomiting and/or aspiration.
The third paper Factors associated with failure to successfully complete a procedure during ED sedation describes the 5.8% of ED PSA failures. Larger patients (>100kg) and hip and finger reductions were associated with increased risk of failure. Ketamine had the lowest failure rate (but this was likely due to its use on peds).
What’s the take-home? PSA is generally safe, but be extra careful on the older types. I’m also going to continue my practice of doing the standard stuff (pre-PSA history and exam, preparing airway stuff, selecting and titrating the appropriate meds to the procedure, etc.), ALWAYS using end-tidal CO2 to detect obstruction and hypoventilation early, and am always prepared to quickly provide a jaw thrust. I’m also going to start using more ketamine on adults. And finally, this paper just adds to my previous view that non-fasting status is not a contraindication to PSA.
Breathing a sigh of relief as you successfully intubated your patient you decide to skulk out of the room and leave ICU to do the rest of the boring stuff.
NOOOOOOOOOOOOOOO! Unless you want your patient rising off the bed like a zombie from a Michael Jackson video and ripping everything out you put in, you need a good post-intubation plan.
Post-Intubation patients are in pain b/c they have a piece of rigid plastic jammed down their throats and because we do a lot of not-so-much-fun stuff to them in the ED. Give them a bolus of fentanyl or morphine as soon as you complete the intubation whilst you arrange post-intubation care.
Our usual preference at MMH is to reach for the propofol infusion and long acting paralytics, but is this the right thing to do? A recent trial published in the Lancet titled A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomized trial looked at no sedation in mechanically ventilated patients and found patients treated with analgesia rather than sedation spent less days ventilated and had lower rates of VAP.
This brings up the question “should we be starting a fentanyl or morphine infusion in isolation or in addition to a propofol infusion?” Check out Scott Weingard’s thoughts on EMCRITpodcast.
My suggestions are:
These drugs are short acting and easily titratable and should obviate the need for long acting paralytics, reduce the dosage and therefore side effects of sedative agents. Infusions are preferable to boluses as we tend to forget to repeat the bolus!
Post-intubation care doesn’t end at just analgesia and sedation FAST HUGS IN BED is an excellent mnemonic for remembering post sedation cares.
Which ones of those cute little kids are we supposed to irradiate? This perplexing question is one of the reasons I moved from the land of my-kid-needs-every-test-in-the-hospital-and-my-cousin’s-a-lawyer patients to the Kiwiland of reasonable, trusting, I’ve-never-needed-a-lawyer patients. While most of us are aware that head CTs can cause cancer in somewhere from 1:1000 to 1:1500 of children, and many of us think that they may suppress intellectual development, ALL of us want to avoid missing something that we can fix.
A paper titled Clinical decision rules for children with minor head injury: a systematic review, compares several decision aids. It showed that a whole alphabet soup of aids (NEXUS II, UCD, Chalice, and PECARN) all had sensitivities of around 98% for traumatic brain injury.
98% sensitivity sounds pretty good, but I’m interested in correctable TBIs. The rule published in Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study by the Paediatric Emergency Care Applied Research Network (PECARN) was 100% (95% CI 0.72-1.00) sensitive for detecting injuries that required neurosurgical intervention.
This study took place in 25 North American EDs and evaluated 42,412 (97% with GCS of 15) patients with head trauma. It excluded all the severe trauma (GCS <14), and all the “trivial injury mechanisms defined by ground-level falls or walking or running into stationary objects, and no signs or symptoms of head trauma other than scalp abrasions and lacerations” and patients with pre-existing neurological conditions or bleeding disorders.
It is important to use this decision aid only to help inform clinical decision making. It was designed only tell you who we can safely AVOID CT scanning. They are much worse on predicting who you should CT. The specificity was only 0.58%, which is almost certainly worse than physician judgment.
If a child has a GCS of 15, mild to moderate mechanism, non-severe other injuries, no LOC, no signs of a skull fracture, no severe vomiting, and no severe headache, they almost certainly DON’T need a CT. The inverse is not true. If a child has some of the aforementioned characteristics that means they need a DOCTOR. They need an evaluation, responsible observation, and may occasionally need a radiologist.
If you need help remembering decision aids, check out www.mdcalc.com
Just the Tip-
Who’s new in the neighborhood?
Dabigatrin (Pradaxa®) is a new anti-coagulant (direct thrombin inhibitor) that can be used instead of warfarin. If a potential bleeder is taking it: be afraid.
It doesn’t change the INR, so it can really sneak up on you. If you’re suspicious send coags (write “on dabigatrin/time of last dose”). A normal to mildly elevated INR, a prolonged aPPT and a elevated echis ratio means they are anticoagulated.
Surgical homeostasis is still important, and dialysis is the only proven reversal agent, but IVF, RBCs, FFPs, Plts, Tranexamic acid, PCC, Cryo, and/or Factor VII may help. Contact hematology early.
How many times have you heard “vital signs are vital”. Well. the authors of a new study published in the Journal of Trauma would like to remind us of this fact once again. In their paper, Just One Drop: The Significance of a Single Hypotensive Blood Pressure Reading During Trauma Resuscitations, they point out that transient hypotension during prehospital care or in the surgical ICU has been determined to be predictive of severe injury and poor outcome. Despite these reports, a single, isolated hypotensive blood pressures (BP) during trauma resuscitations are often ignored .
The study was prospective observational study at a single level I trauma center with an 145 adult patients (54% with blunt mechanism of injury) who had at least one SBP measurement <110 during initial trauma care.
Cut-point analysis determined that a single SBP reading <105 best predicted the need for immediate therapeutic intervention. Although 38.1% patients with isolated SBP <105 measurements underwent immediate therapeutic operative or endovascular procedures, only 10.4% (p <0.001) with isolated SBP ≥105 required these procedures. Patients were ~12.4 times more likely to undergo immediate therapeutic intervention than those with a single SBP ≥105.
While this was a small single-centre study, it does have a valuable take home point. Single, isolated hypotensive BP measurements during trauma resuscitations should not be ignored or dismissed. A single low reading may be a good clue to impending shock and indicate a need for aggressive management as well as possible surgical intervention.
PS: Remember, size matters! Make sure your BP cuff is the correct size for the patient.
Pop Quiz: Which is more accurate?
Actually, multiple studies have shown them to be about equivalent