Grand Rounds Recap - 8/20/14

An Update on CHF w/ Dr. Fermann

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The phenotype of acute presentation of heart failure can be dramatically different. Consider the difference between the hypotensive patient who has very poor cardiac output now in cardiogenic shock requiring pressors (these have a very poor outcome), the normotensive patient who has slowly become retained fluid, and the acutely hypertensive patient who presents in extremis (who actually does quite well even though they are so sick on arrival).

Mainstays of therapy for each include:

  • Hypotensive patient: aggressive vasopressor and inotrope use. Some fluid bolus can be used but these patients are usually do not benefit from additional preload.
  • Normotensive patient: these patients benefit from aggressive diuresis and do not require signficant afterload reduction. ADHERE registry suggested that lower doses of lasix (<160mg in first 24hrs) did better than those who received >160mg with multiple end points (ICU days, mortality, AKI, etc). DOSE trial showed no real difference multiple end points when comparing q12 bolus dosing versus continuous lasix gtt and low intensity dosing (home oral diuretic dose) compared to high intensity dosing (2.5x home oral dose). New recommendations from Academic Emergency Medicine recommend adding a thiazide diuretic early if initial lasix dose is not providing adequate urine output. Tip: the addition of a thiazide diuretic puts your patient at high risk of acute electrolyte abnormalities. 
  • Hypertensive patient: these patients benefit more from afterload reduction. When you use a nitroglycerin gtt be aggressive early. It is okay to provide a SL bolus (400mcg) while getting the gtt set up but then be sure to stay aggressive with your gtt dose (50-100mcg/min to start). The standard starting dose of 10mcg/min is not enough.

Additional drugs currently being studied (at our institution): Serelaxin is a synthetic peptide seen in the physiology of pregnancy that showed improvement in dyspnea and 180 day mortality in Phase III trial. (RELAX-2 is ongoing). Ularitide is an atrial natriuretic peptide (study is TRUE-HF). Clevidipine is a calcium channel blocker (read: negative inotrope) that likely works to provide cardiac relaxation in patients with acute HF but preserved EF (PRONTO trial). Angiotensin receptor blocker (TRV 027) is the BLAST-AHF study.

Lastly, some of these patients can go home (probably after an observation stay) to help with acute symptoms and avoid recurrent hospitalization. Note that even after hospitalization the mortality of AHF is ~5% within 30 days.


Electrical Injuries with Dr. Plash

"Lightning hits tree" by Unknown, author of the article is Barbara Watson - http://www.erh.noaa.gov/er/lwx/lightning/va-lightning.htm. Licensed under Public domain via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Lightning_hits_tree.jpg#mediaviewer/File:Lightning_hits_tree.jpg

"Lightning hits tree" by Unknown, author of the article is Barbara Watson - http://www.erh.noaa.gov/er/lwx/lightning/va-lightning.htm. Licensed under Public domain via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Lightning_hits_tree.jpg#mediaviewer/File:Lightning_hits_tree.jpg

There are 3 groups of patients at highest risk: adventurous toddlers, risky adolescents, and utility workers. 

  • Low Voltage injuries (<1000V) can increase exposure time by causing muscle tetany so the patient can't let go. High incidence of deep burns with very little superficial findings. Electrical currents that pass through the thorax >70V can cause Vfib or respiratory arrest. Always get an EKG on presentation. If the patient has no cardiac symptoms and a normal EKG they are not going to develop a delayed arrythmia.
  • High Voltage Injuries (>1000V) can cause whole-body muscle spasm resulting in fractures of bones including vertebrae. Vocab word of the day: opisthotonic posture is the arched-back posture from the very strong paraspinal muscle spasm. Treat all of these patients like trauma patients. You can also see prolonged respiratory depression due to stunning of the medulla. Aggressive resuscitation is warranted and can be successful as these patients did not die from ischemic heart disease, so good CPR can work!

Physician Wellness with Dr. Cousar

Burnout = a psychological syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment. Wellness is not simply the absence of burnout, but there is probably a spectrum between wellness and burnout. 

 In general physicians have much higher symptoms of burnout (38% vs 28% and are dissatisfied with work-life balance (40% vs 23%) when compared to the general population. Specifically, EM has very high rates of burnout and dissatisfaction. 

Focus on financial wellness (get insured, make a plan to pay down your debt with a professional, and put money away http://whitecoatinvestor.com/ , physical wellness (any activity is good activity, choose something you enjoy), spiritual/mental wellness (your family, your beliefs, your vacations matter).


Visiting Professor Lecture Series 

Out of Hospital Endotracheal Intubation: Where Are We? With Dr. Henry Wang from UAB

Intubation has been a mainstay of paramedicine for 25 years but the landscape of EMS has changed. Prehospital airways are always difficult (read: there is no easy airway in the back of an ambulance) yet paramedics are offered less training (usually required to have only 5 intubations in training) and some studies suggest an average paramedic gets approximately 1 intubation per year in practice. A study of 800 paramedic students suggested that you probably need 15-20 intubations to reach a 90% success rate. Skill proficiency requires baseline training + regular application and while simulation is good "plastic does not recreate the mush of live structure" - Levitan.

Poor outcomes identified with prehospital endotracheal intubation range from worsened neurologic outcome in TBI, increased mortality in TBI, prolonged oxygen desaturations with resultant bradycardia, prolonged chest compression interruptions, and misplacement rates as high as 25-30%. 

While this does not mean that we have to stop intubating, we need to have a healthy respect for intubation and consider alternative options like supra-glottic airways (where significant research is ongoing).


Twins and Triplets: Scientific Lessons from Resuscitation Research with Dr. Wang

Some of the most compelling scientific lessons don't come from a single trial but rather the interpretation of multiple trials with differing results.

Questions to ask yourself about every article you read: What journal published it? Who wrote it? Where did it take place? What was the objective? What was the design? What were the outcomes? Was was the intervention? What analytic techniques were used? What were the results? What was the sales pitch? What were the limitations? What were the take-away messages? 

Things to keep in mind when comparing trials: 

  • Small changes in study population, incidence of disease, or intervention may have profound impacts on the results.
  • Sometimes a research protocol which incorporates several controlled variables into the intervention group (ie bundle of treatment) makes it hard to identify the piece that actually made a difference.
  • Over time, secular trends change. ie: Maybe the mortality was lower because since the last trial was published we have improved our care of these patients
  • Star pupils can bust the curve: a single site in a multisite trial that vastly differs compared to the others can alter the final results of the trial.