Search
81-100 of 354 results by Mike Winters
Dynamic LVOT Obstruction
- Recent literature has indicated that dynamic LVOT obstruction can occur in critically ill patients without hypertrophic cardiomyopathy. In fact, a recent study found that this condition may be present in many patients with septic shock.
- Risk factors for LVOT obstruction include any condition that decreases afterload, decreases preload, or increases heart rate.
- Consider LVOT obstruction when your ultrasound demonstrates close approximation of the lateral wall and septum plus systolic anterior motion of the anterior mitral leaflet.
- The treatment of patients with dynamic LVOT obstruction includes:
- Increasing preload with aggressive IVFs
- Increasing afterload (phenylephrine may be a good choice)
- Avoiding inotropes
- Decreasing heart rate (often with esmolol)
Show References
Oxygen-ICU Trial
- Recent observational trials have demonstrated an association between hyperoxia and worse outcomes in select critically ill patient populations.
- The Oxygen-ICU Trial was just published online in JAMA, and was an RCT to assess whether a conservative protocol for oxygen supplementation could improve outcomes in critically ill ICU patients compared with usual care.
- A total of 236 patients were randomized to the conservative oxgyen group (PaO2 target 70-100 mm Hg, SpO2 94-98%), whereas 244 were randomized to the usual care group (PaO2 up to 150 mm Hg, SpO2 97-100%).
- The results demonstrated that ICU mortality was lower in patients treated witih a conservative oxygen strategy, with an absolute risk reduction of 8.6%.
- Take Home Point: Be careful with the tiration of oxygen therapy and avoid hyperoxia in many of your critically ill patients.
Show Additional Information
Show References
Pitfalls with PLR
- The passive leg raise (PLR) test has become a popular method to assess volume responsiveness in critically ill patients.
- PLR mobilizes a volume of approximately 150-300 mL and can be used in spontaneously breathing patients, those receiving positive pressure ventilation, or those with various arrhythmias.
- In order to properly perform the PLR, you must have a method to monitor cardiac output. (See previously pearl on 7/26/16).
- Pitfall: Simply monitoring arterial blood pressure alone is not a sufficient method to assess a positive PLR.
- Pitfalls:Risks of performing a PLR include increased intracranial pressure, reduced cerebral blood flow, and decreased pulmonary compliance.
Show References
Ketamine for RSE?
- Up to 43% of patients with status epilepticus may progress to refractory status epilepticus (RSE).
- Propofol, midazolam, and barbituates are often recommended for patients with RSE.
- Importantly, all of these medications may be limited by hypotension and respiratory depression.
- Ketamine is emerging as adjuvant therapy for patients with RSE.
- The loading dose of ketamine ranges from 0.5 to 3 mg/kg, followed by a maintenance infusion of 0.3 to 4 mg/kg/h.
Show References
Zika Virus-associated GBS
- Zika virus has been shown to trigger Guillain-Barre Syndrome (GBS) at a rate similar to Campylobacter jejuni infections.
- In patients with Zika virus-associated GBS, neurologic deterioration has been rapid, with approximately 33% of patients developing respiratory distress.
- For patients who have required intubation, the duration of mechanical ventilation and length of ICU stay has been very long.
- Consider Zika virus-associated GBS in patients with muscle weakness, facial palsy, or paresthesias in the setting of a travel or exposure history to the virus.
Show References
Predicting Fluid Responsiveness with ETCO2
- It is well known that almost 50% of critically ill patients do not respond to fluid resuscitaiton. For those that do not respond, indiscriminate fluid administration may be harmful.
- There is increasing emphasis on the use of dynamic markers of fluid responsiveness, namely passive leg raise (PLR), pulse pressure variation, respirophasic changes in the IVC, and many others.
- ETCO2 can also be used to assess fluid responsiveness in mechanically ventilated patients with no spontaneous respiratory effort.
- An increase in ETCO2 of at least 5% with a PLR has been shown to outperform arterial pulse pressure as a measure of fluid responsiveness.
Show References
Fentanyl and the Neurologically Injured Patient
- Emergency providers routinely care for neurologically injured patients, such as those with a SAH or TBI.
- Many of these patients will require airway management. In these patients, it is important to minimize any increase in ICP, as this can adversely effect cerebral perfusion pressure.
- When intubating the neurocritical care patient, consider a dose of fentanyl (2 to 5 mcg/kg) prior to intubation. This has been shown to decrease the sympathomimetic response to laryngoscopy.
Show References
LVADs and RV Failure
- Acute RV failure can be seen in up to 10% of patients after LVAD implantation.
- The treatment of RV failure in the LVAD patient consists of the following:
- Fluids: avoid aggressive fluid administration, as this can displace the septum and impair LVAD function
- Inotropes: consider early initiation of dobutamine, milrinone, or epinephrine to augment RV function
- Vasopressors: target a MAP higher than 60 to 70 mmHg to maintain RV perfusion pressure
- If intubated, avoid hypoxia, hypercarbia, high PEEP, and high ventilator pressures. These can increase pulmonary vascular resistance and further worsen RV function.
Show References
Heat Stroke
- Heat stroke is critical illness defined as a core body temperature greater than or equal to 40oC and altered level of consciousness.
- Mortality from heat stroke can be as high as 30%.
- Numerous methods exist to rapidly cool patients below 39oC.
- Of these methods, ice-water immersion cools patients the fastest and is highly effective in young patients with exertional heat stroke.
- There is currently insufficient evidence to routinely recommend antipyretic agents, intravascular cooling devices, body cavity lavage, or the use of ice packs in the groin/axilla/neck. In addition, dantrolene is not recommended in the treatment of heat stroke.
Show References
Situations Where ECMO Will Likely Fail
- As many EDs and ICUs begin to develop protocols for the use of ECMO, it is important to note select conditions when this therapy is unlikely to be succesful.
- Chronic respiratory or cardiac disease with no hope of recovery
- OHCA with prolonged no blood flow
- Severe aortic regurgitation
- Type A aortic dissection
- Refractoroy septic shock with preserved LV function
- Stem cell transplant patients
- Advanced age with ARDS
- Prolonged pre-ECMO mechanical ventilation (> 7 days)
- Center inexperienced with ECMO
Show References
Can NIV be Used in ARDS?
- Mechanical ventilation can cause lung injury and increase patient morbidity and mortality.
- Noninvasive ventilation (NIV) is well-known to decrease intubation rates and improve patient outcome in select disease states (i.e., COPD, acute CHF).
- For patients with acute respiratory distress syndrome (ARDS), NIV may reduce the work of breathing by opening collapsed alveoli, increasing FRC, and improving oxygenation.
- To date, there are only a few RCTs that have evaluated the use of NIV in ARDS.
- Unfortunately, these trials have failed to demonstrate improved patient outcome or decreased intubation rates in patients with ARDS.
- Clinical Bottom Line: Intubate patients with ARDS who are difficult to oxygenate with standard oxygen therapy.
Show References
Cerebral Venous Thrombosis
- Approximately 25% of patients with cerebral venous thrombosis (CVT) will experience neurologic deterioration.
- This is most commonly due to an increase in ICP that results in transtentorial herniation.
- While heparin remains the treatment of choice for CVT, consider the following alternative strategies in the acutely decompensating patient:
- Endovascular thrombolysis
- Mechanical thrombectomy
- Decompressive hemicraniectomy
Show References
Sepsis-3
- After nearly 2 decades, the definitions for sepsis and septic shock have been updated.
- Key findings from the Task Force convened by SCCM and ESICM include:
- Sepsis
- Definition: life-threatening organ dysfunction due to a dysregulated host response to infection
- ICU patients: organ dysfunction is defined as an increase of 2 points or more in the Sequential Organ Failure Assessment (SOFA) score
- ED patients: 2 or more of the following new qSOFA (quickSOFA) score may identify patients with increased mortality
- SBP less than or equal to 100 mm Hg
- RR greater than or equal to 22
- Altered mental status
- Septic Shock
- Definition: a subset of patients with sepsis and profound circulatory, cellular, and metabolic abnormalities
- Clinical Criteria:
- Persistent hypotension requiring vasopressors to maintain MAP greater than or equal to 65 mm Hg despite adequate volume resuscitation
- Lactate greater than or equal to 2 mmol/L
- The term "severe sepsis" is no longer used
- Sepsis
Show References
Shock Index
- The shock index (SI) is calculated as the ratio of heart rate to systolic blood pressure and is often used in the assessment of critically ill patients.
- A SI > 0.8 has been shown to be an independent predictor of post-intubation hypotension during emergency airway management.
- Kristensen and colleagues performed a retrospective review in a single-center in Denmark to evaluate the ability of SI to predict 30-day mortality.
- In over 110,000 patients, they found a weaker association of SI with 30-day mortality in patients > 65 years of age, those taking a beta-blocker or calcium channel blocker, or those with a history of hypertension.
- Notwithstanding, a SI > 1 was a significant predictor of mortality across all patient populations and should be considered a warning of serious illness.
Show References
Acute Chest Syndrome
- Acute chest syndrome (ACS) accounts for the most common cause of ICU admission and the most common cause of death in sickle cell patients.
- Important pearls for ACS include:
- Chlamydophila pneumonia is the most common bacterial cause of ACS in adults, whereas Mycoplasma pneumonia is the most common bacterial cause in children.
- CXR abnormalities may be absent early in disease.
- Children are more likely to have middle lobe disease, in contrast to adults who often have lower lobe involvement.
- Acute RV failure is a well recognized complication of ACS - use ultrasound to evaluate the RV and be careful with fluids.
Show References
Mechanical Ventilation for Septic Patients in Resource-Limited Settings
- An international team of physicians just published a series of recommendations for ventilatory support of septic patients in resource-limited settings.
- Pearls from these recommendations include:
- Elevate the head of the bed to 30o - 45o
- Consider tidal volumes of 5 - 7 ml/kg PBW in all patients
- Use minimum levels of PEEP ( 5 cm H2O) in all patients with sepsis and acute respiratory failure (unless the patient has moderate to severe ARDS)
- Lower FiO2 to target SpO2 > 88% or PaO2 > 60 mm Hg
- Use lung ultrasound to evaluate pulmonary edema when CXR is not available
- Consider using SpO2 to FiO2 (S/F) as an alternative to P/F when blood gas analyzers are not available
Show References
Pain Management in the Critically Ill Patient
- Pain is common, often underappreciated, and routinely undertreated in our critically ill patients.
- Poorly treated pain has been shown to adversely affect both short- and long-term outcomes.
- Key pearls when treating pain in the critically ill:
- Vital signs should not be used in isolation to assess pain
- Use a validated assessment tool to objectively quantify pain (i.e., Critical Care Pain Observation Tool)
- An analgosedation strategy (analgesics before sedative medications) has been shown to decrease duration of mechanical ventilation and decrease ICU LOS
- Opioids have no maximum or ceiling dose. The appropriate dose is that which controls pain with the fewest side effects.
Show References
Hyperoxia in the Critically Ill
- Oxygen is liberally administered to many critically ill patients, thereby exposing them to supranormal arterial oxygen levels.
- Hyperoxia results in the formation of reactive oxygen species, which adversely affect the pulmonary, vascular, cnetral nervous, and immune systems.
- Though the optimal PaO2 remains unknown, recent evidence indicates that hyperoxia is associated with increased mortality in post-cardiac arrest, CVA, acute coronary syndrome, and traumatic brain injury patients.
- Take Home Point: Carefully titrate oxygen to the lowest tolerable level to meet the patient's needs.
Show References
Is It Really ARDS?
- Recent literature suggests that the incidence of ARDS in intubated ED patients may be as high as 10%.
- The Berlin Definition of ARDS includes the acute onset of bliateral opacities (CXR or chest CT) that is not fully explained by pulmonary edema or fluid overload.
- Emergency physicians and Intensivists are well versed in lung-protective ventilator settings for patients with ARDS.
- However, several diseases can appear simliar to ARDS and may require different ventilator strategies and treatments.
- In the absence of clinical risk factors for ARDS (e.g., sepsis, trauma), consider the following in your differential:
- Idiopathic pulmonary fibrosis
- Interstitial pneumonitis
- Granulomatosis with polyangitis (Wegener's)
- Diffuse alveolar hemorrhage
- Goodpasture's syndrome
Show References
Blood Pressure Management in Severe Preeclampsia
- Severe preeclampsia (preeclampsia + at least one severe complication) accounts for almost 40% of deaths in obstetrical ICU admissions.
- Systolic arterial hypertension is the most important predictor of morbidity in patients with severe preeclampsia.
- First-line agents to reduce blood pressure in severe preeclampsia are nicardipine and labetalol.
- Hydralazine is no longer recommended as first-line therapy.
- Magnesium is used as an anticonvulsant and should not be considered an antihypertensive.