Grand Rounds Recap 01.13.2021

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Journal club WITH Drs. Laurence, Urbanowicz, and wolochatiuk


Double sequential external defibrillation for refractory ventricular fibrillation: The DOSE VF pilot randomized controlled trial. Cheskes et al.

  • What is the safety and feasibility of a randomized controlled trial assessing:

    • Vector change defibrillation

    • Double sequence defibrillation 

    • Dual sequence compared to standard defibrillation for patients with refractory ventricular fibrillation

  • Design & Population: 

    • Four Canadian paramedic services, in both urban and rural regions

    • All patients aged 18 years and older who experienced a cardiac arrest 

    • Excluded traumatic arrests, patients with DNR orders, cardiac arrest secondary to hypothermia, suspected overdose, hanging, drowning 

    • Refractory ventricular fibrillation - defined as having failed three defibrillation attempts with pads in the anterior-lateral position

  • Strengths & Limitations: 

    • Strengths: 

      • Pragmatic study design limited selection bias

      • Allowed for efficient data collection and identification of problems in advance of the larger RCT

      • Acknowledged realistic constraints of having a second defibrillator through their intention-to-treat analytic approach. 

    • Limitations: 

      • Decreased enrollment in the standard defibrillation arm 

      • Non-inclusion of shocks administered by fire departments prior to paramedic arrival for approximately 28% of patients

    • Results/Conclusions:

      • The study design and interventions were feasible with 89% of patients getting the assigned therapy 

      • 77% of patients getting the assigned therapy by the fourth shock, which was the earliest possible time of intervention. 

      • There were no safety complaints

      • ROSC was obtained in:

        • 25% of the standard defibrillation group 

        • 39% of the VC group

        • 40% of the DSED group

      • However, caution must be used when digesting these statistics

      • Since this pilot study was not intended to evaluate these endpoints primarily

Effectiveness of Sodium Bicarbonate Administration on Mortality in Cardiac Arrest Patients: A Systematic Review and Meta-analysis

Wu et al.

  • The use of sodium bicarbonate (SB) during cardiac arrest has been cautioned against in the 2010 iteration of the ACLS guidelines

    • It is still commonly used in clinical practice

    • Re-evaluated the literature

  • Systemic analysis and meta-analysis of 6 eligible studies 

  • Evaluating nontraumatic, adult, cardiac arrest patients 

  • Comparing effect of SB administration on rates of ROSC and survival to discharge

  • 6 observational included in final meta-analysis involving 18,406 total patients. 

  • Results: 

    • No significant difference: 

      • In rates of ROSC

      • Survival to hospital discharge 

  • Limitations: 

    • Variability in treatment locations (ED only vs. ED/prehospital/in hospital)

    • Does not take into consideration patient comorbidities or other potential confounders

      • Pre-existing metabolic derangements, targeted temperature management, post-ROSC management, etc.

  • Take Home:

    • This meta-analysis serves to highlight the need for caution in approaching arrest management as a of one-size-fits-all resuscitation

      • Use SB only in clinical situations where it may be specifically indicated

      • Consensus of discussion was there is rational use of SB in known metabolic acidosis that have known adequate compensation

    • Lends weight to the ongoing ACLS recommendation against routine use of sodium bicarbonate in cardiac arrest. 

Beta-blockade for the treatment of cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia: A systematic review and meta-analysis

Gottlieb et al.

  • This is a meta-analysis of the data that exists on beta blocker therapy vs control for refractory VF/VT arrest. 

  • This patient demographic is important given the poor outcomes of arrest patients in refractory shockable rhythms that do not respond to ACLS. 

  • Using a fairly comprehensive literature search:

    • Reviewed almost 3,000 abstracts

    • Narrowed it down to 3 observational studies with an n of 115. 

  • Using pooled data: 

    • A significant difference in:

      • Both temporary and sustained ROSC

      • Survival to admission

      • Survival to discharge

      • Favorable neurologic outcome

    • Unfortunately, the small number of patients has the potential to skew or magnify results.

    • One of the articles included in the meta-analysis involved some heterogeneity in terms of beta blocker used

Airway grand rounds WITH Dr. Carleton

Case 1: Female coming in from rehab for altered mental status, tachycardia, hypotension

  • PMH of NASH, CKD, Obesity

  • Resuscitated with fluids from EMS, shock index was still 1.7 on arrival

  • VBG shows a metabolic acidosis that is being compensated with a pCO2 of 20

    • This worsens on worsening VBGs

  • Continued resuscitation with declining mental status and appears to be tiring out

    • Levo and bicarb gtts started

  • Airway? No difficulties with oxygenation or ventilation and still protecting. Clinical course? 

    • Induction agents: 

      • Are cardiodepressant and many are vasoplegic when patient is maximally stressed

    • Hypoxia is a negative inotrope and arrhythmogenic

    • Acidosis is a negative inotrope, arrhythmogenic, reduces the effectiveness of catecholamines, insulin, other hormones

    • Positive intrathoracic pressure reduces preload and CO

  • Pre-Intubation Optimization

    • Mitigate adverse effects: underlying illness, laryngoscopy/RSI drugs/ Mech Vent

    • Peri-Intubation Hypotension:

      • Hypotension and need for pressors prior to intubation are the 2 leading predictions for peri-intubation death

      • SI>0.8, OR of 55 for peri-intubation death

      • If present then will have 30% in hospital mortality

      • To prevent it:

        • Treat the cause

        • Volume resuscitate

        • Pressors as needed

        • Consider push-dose epi prior to induction

        • Choose your induction agent wisely

          • Use a reduced dose

          • Ketamine: great but not perfect

            • If catecholamine are depleted its direct cardiodepressant effect may predominate over indirect sympathetic effects

            • Single dose in ill patients: hemodynamic indices will reduce between 30-70% (1980 study)

        • Prevent/treat hypoxia

        • Prevent/treat acidemia

        • Pseudo-NIPPV: attempt to match or improve the minute ventilation: put them on ventilator with BiPAP to measure it 

          • Follow EtCO as surrogate for PaCO2, provided pressure support, PEEP, 100% prior to intubation

          • Start at Resp Rate of 0 and turn to 12 when RSI is initiated

          • When paralysis is complete, match prior rates and put TV on to match minute ventilation

          • Will bicarb help? 

            • Only if they can blow of the CO2 generated, don’t let them hypoventilate!

  • Consider delaying intubation in physiologically fragile patients until mitigation measures are executed

Case 2: Older woman who was weak at home for a week and then found in a puddle of blood

  • Labs show anemia, coagulopathy, lactate of 13, anion gap of 21, 

  • Sats improved after suctioning and bagging - doing well with iGel in place

  • Large resuscitation: product and other to help improve pre-intubation optimization

  • Airway Decontamination:

    • SALAD 1: lead with suction catheter, displace tongue anteriorly, glottis and upper esophagus are cleared, move catheter to left of blade and park in the esophagus, then intubate and suction ETT w/ spaghetti sucker, ventilate

    • SALAD 2: park 7.0 ETT into the upper esophagus, inflate balloon then Salad 1

    • Yankauer vs DeCanto Catheter: 

      • Yankauer is good for blood and thin liquids: tip is 3.8mm diameter (this is the limiting size)

      • Decanto: tip is 6.7mm diameter, so the limiting factor is our suction tubing of 5.1 diameter

      • Shapes mirror a Mac 4 and D-blade: should be held with angled part facing anteriorly

      • Create a large suction device: attach suction tubing to an ETT (>6.5)

    • Anticipate the need for airway decontamination

    • Use largest catheter available 

    • SALAD 1 technique offers the best solution 

Case 3: Female in status epilepticus - intubation is planned for inability to protect airway

  • Difficult to make the tube pass anteriorly enough, bagged

  • Bougie attempted but still couldn’t pass anteriorly enough, bagged

    • Bougie is meant to solve the inability to see, not inability to pass

  • D-blade with rigid stylet: fails due to inability to pass but succeeds after vigorous BURP

  • Improving the intubating conditions: when view is good but tube wont go

    • Positioning - bring tragus to the jugular notch

    • Tip position: Mac blades are vallecula devices, the tip must be in the depth of the vallecula

      • If used as a Miller - then the intubating conditions may be worse and harder to pass the tube

    • Physical maneuvers / BURP

    • Rigid stylet

      • Bougie: this doesn’t work for difficult tube passage

    • Modified ramp - it goes up to the AO joint and allows the patients head to extend more - will improve the first pass success rate and time to intubation

      • 2020 study in BMC Anesthesiology

      • Improves upon the standard ramp

  • Embrace mediocrity! - an OK view is ok with a VL 

  • The best view may not give the best intubating conditions when using a VL

    • Deliberately relax laryngoscopy and tolerate a lesser view

    • A CM 2b view may provide easiest ETT passage when using VL

History and future of EM WITH visiting professor Dr. Schmitz

 1700-1800: majority of care was provided at home by the matriarch, if you were VERY sick you called a doctor

  • Surgeries even were performed at home

1736: Charity hospital opens in New Orleans, then Bellevue opened 

  • These were mostly homeless shelters, providing care and food all for free

  • Run through the churches

1873-1909: significantly increased the number of hospitals - families moved around and less family unit

  • Specialization occurred

1946: Congress passes Hill-Burton act - $3 trillion to build hospitals

1965: Medicare - providing care to people >65, allowing access to care

Technology changed significantly too - didn’t fit into the black bag

Emergency Room was a room and was started in the basement often

  • A bell was rung to get into the ER

  • Staffed by medical students or interns, a “good learning opportunity” with minimal supervision

  • Pontiac Michigan: attending should run the emergency department, it was anyone who is available though (Dermatology, surgery, family medicine)

  • James Mills in 1960s - just worked full time in the ED

    • Recruited 3-4 more physicians to run

    • 1961 became the first democratic group

    • Happened in Lansing as well and across the country to take care of acute unscheduled care

  • John Wiegenstein: a group should be created

  • ACEP in 1968 with 36 people in attendance

    • Plenty of people didn’t think that we had a set of knowledge

    • Peter Rosen: a strong personality to challenge the surgeons

    • Judy Tintinali - another strong personality and great female role model, but must commit to the learning and the practice

    • Bruce Janiak - was the first resident in the country and came to UC though it was not recognized or accredited 

Prehospital care- came from Vietnam 

  • 1950-70s were converted Hearses as first EMS vehicles 

    • Fought over the dead people, they were the ones who paid, when on scene

  • 1973 EMS bill 

  • TV shows helped change the perception of the ER 

  • High volume of trauma: news cameras were in the ED in Denver during the weekends

Creating a recognized specialty 

  • ABMS - fought to make us a specialty

  • First attempt lost 100-5, no peer reviewed data and no unique body of knowledge

    • Collected a unique body of knowledge

  • 1973 became the 23rd specialty and in 1980 the first ABEM exam was sat for (600)

Anyone anywhere anytime

  • Boarding and overcrowding became bad and bad outcomes (dying in the waiting room)

    • Was a problem for the county hospitals, privates could say no and go on diversion

  • Art Kellermann: took the problem to congress and showed them the problem of diversion

    • 1986: EMTALA was passed - cant turn patients away based on inability to pay

    • Truly makes anyone anywhere anytime

  • No funding behind EMTALA - must provide care no matter if they can pay

    • Our patient population over the whole system: 

      • ⅓ have private insurance, ⅓ are medicaid (pays 10 cents on $1), ⅓ are self-pay/medicare/other 

      • ⅔ of our patients do not pay the true cost of care. 

      • Therefore the private insurance are charged more to help make up the difference

  • Insurance denials: making determinations about what is or is not an emergency afterwards

    • Prudent lay-person standard: is it reasonable to get checked out in the ED

  • 2010: ACA - codified the prudent layperson - reasonable chief complaint should be covered by the insurance. 10 essential benefits

    • things that must be covered (included emergency care)

    • Helped increase access and coverage

  • The cost of healthcare has increased significantly, about 20% of our budget goes to healthcare

    • Costs going up: people are living longer, chronic diseases are more prevalent

  • Mergers and acquisitions - systems are being created

    • To decrease costs by merging

    • Hospitals are still closing due to costs

    • Lost number of health insurers, and will make up 80% of the private market in some places

      • Is bigger better? 

  • MACRA: was paid based on volume and complexity of the patient

    • Changes: are more focused on quality, doesn’t incentivize saving money, only tests

    • Judged and reimbursed based on quality of care

    • In the ED, outcomes are influenced by way more than what we do in the ED

      • Disease progression, social determinants of health, health problems (smoking)

Growth in the residency programs in EM

  • Work force studies: In 2002 5000 EDs present in the country and has decreased over time 

    • 27000 EDP with 144 residencies in 2002

    • 45000 EDP with 208 residencies in 2016

    • Rural EDs lack EPs

  • 2018: 60K people practicing in the EM, 60% are board certified, 15% other physicians (mostly rural), 25% were APPs

  • Annals 2020: 70K EDPs, no DOs (due to lack of data) 

    • 49K clinically active EDP: 28% women, 92% urban or suburban, 81% Board certified

    • less other docs

  • Patients seen by the APPs is about 25%, half of these are seen w/ and EDP

  • A lot of places are very saturated, but the middle of America is only at 20-30% of demand

    • 1 in 5 Americans live in rural America

    • Worse outcomes for many reasons: higher degree with risk taking behavior, hundreds of miles away from a specialty care, espcially in time sensitive diseases

    • How to get people to work in Rural areas? They pay more...but still cant get people there

      • Often it's the people that grew up there

      • Tried opening a medical school in the rural area to create rural docs with 8 students

        • 3 of the 8 stayed

      • Barriers: funding for rural EM rotations, loan repayment programs, signing bonuses, improved access to specialists, CME

Reasons for Optimism:

  • We are not a room-we are a specialty 

  • Companies are working to help remote health care of rural area

  • EM Physicians are all over media - we are the mavericks to help us navigate the storm of 2020

  • We are the politicians, CEOs, the FDA, and every level of leadership

    • In the COVID-19 response with President-Elect Biden’s team

  • ACEP is suing anthem to show that we will not roll over on the retroactive denials of ED visits

  • Health information exchange

    • In the last 5-10 years we have seen significant data sharing to help track patients records 

    • New pricing and payment models

      • Hybrid model: Free standing ER with UC too, this helps triage patients on arrival. 

        • Helps with price transparency 

  • Legislative solutions: continue to advocate for fair payment

  • Surprise medical billing is finally coming to an end - insurance companies will have more transparency 

r4 Case follow up WITH dr. hughes

ED Crowding is linked to morbidity and mortality 

  • Decades of this being a problem

  • #1 cause is ED boarding

    • Crowding is a supply/demand mismatch

    • Boarding is time from accepted admission to going upstairs

  • 2004 retrospective study: does ED crowding change door to needle time to tPA?

    • 7 min absolute increase, and OR of 1.4 of delay

  • 2007 do prolonged ED stays >8 hours lead to lower quality of care and worse outcomes?

    • Less likely to get guideline recommended therapies

    • 1.23 OR of reinfarction during the hospitalization

  • 2011 retrospective cohort - does ED boarding >2 hours increased mortality and hospital length of stay?

    • 2% increase in mortality if boarding >12 hours (absolute and adjusted for all comorbidities)

    • 3 day increase in hospital LOS if boarding for >24 hours

Why handoffs should scare you

  • An insufficient level of handoff training is currently mandate or available for EM residents

  • Tips for improving handoff communication:

    • Remove unnecessary handoffs: don’t pick up at the end of your shift

    • Limit distractions

    • Provide succinct overview

    • Communicate outstanding tasks - errors of omission and things forgotten

    • Make info readily available - have the EHR up and available 

      • Should take 30 mins of your shift to prep for 

    • Encourage questions

    • Account for all patients

    • Signal a clear moment of transition

Fussy but afebrile child WITH Cincinnati Children’s PEM Fellows

What is normal crying?

  • At what age do infants hit their peak amount of time per day crying? 

    • 2nd month of life

  • At this peak age how many hours on average does a healthy infant cry?

    • 2-3 hours

  • 1991 paper:

    • 61% of patients had serious underlying pathology in crying infant

    • Best thing to find the diagnosis:

      • 76% of dx were made on physical exam

  • 2009 paper: 

    • Afebrile fussy children whether or not there was a serious dx

    • 5% have serious dx - UTI and clavicle fx, ALL, intussusception 

    • What study did the authors find most useful in absence of clinical signs or history:

      • Urine studies

    • H&P was most helpful:

      • Diagnosis made in 66% of participants 

How do you approach the eval of fussy afebrile child?

  • Start with a history then through physical exam (including vital signs)

  • Mnemonic: ITCRIES

    • Infection: UTI, cellulitis, diaper rashes

    • T: Trauma - NAT and accidental - do a tertiary and take a history

    • C: cardiac - SVT, myocarditis, birth history, weight loss

    • R: reaction/reflux

    • I: intussusception 

    • E: eyes - periorbital cellulitis, FB, infant glaucoma (dull red reflex), abrasions 

    • S: Surgical: hair tourniquets, torsion, volvulus