Grand Rounds Recap 12.7.22
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Pulmonary hypertension w/ Dr. jean Elwing
In patients with RH failure, pericardial effusions should not be drained, as it often constricts the RV enough to maintain their position on the starling curve
Diagnosis of RHF is clinical, although the condition is defined by PAWP and PVR
Assess the wedge pressure (is this left-sided or right-sided failure?
What is the patient’s mortality?
Disease progression, functional status, etc
PAH: this is a disease of the pulmonary vasculature, with heart failure as a result. Disease is irreversible at the point at which the patient develops hypertrophy of the pulmonary vasculature
Medications:
endothelin receptor pathway
parenteral prostanoids (i.e. IV epoprostenol)
Excellent mortality benefit
new biologics
“Triple therapy” refers to the use of a PDE-5 inhibitor, an ERA and intravenous epoprostenol
Vasodilation, inhibit vascular proliferation and reduce the load on the right heart: the endothelin, nitric oxide and prostacyclin (PGI2) pathways
This targets wall stress, coronary perfusion, afterload reduction
Decompensated CTEPH management
Would need transfer to a PH center (for possible ECMO for bridge to therapy)
Pulmonary angioplasty (although this carries a high risk of death with pulmonary artery rupture)
Causes of death: RV failure, sudden death, sepsis
Older males may not respond well to standard oral therapies
Hyponatremia portends poor prognosis
Decreased TAPSE also associated with increased mortality
In Hospital Mortality linked to:
SBP <100 (much more than patients with left heart failure with hypotension)
Hyponatremia
Renal dysfunction
Principles of Critical Care Management of Right HEart Failure
Optimize fluid balance
Reverse precipitating events
Optimize oxygenation/lung protection
Optimize cardiac output
Control contributing factors (acidemia, anemia, infections, arrhythmia)
Optimize perfusion pressure
Reduce RV afterload
Causes of precipitated disease:
Sepsis
Cardiac arrhythmia
Pneumonia
Unplanned withdrawal of vasodilator therapy
Unplanned pregnancy
Purulent pleural effusion
Unplanned withdrawal of diuretics
Atrial Arrhythmias
Poorly tolerated in PAH patients
Associated with poorer survival in PAH
Right heart is more dependent on atrial kick
Difficult to manage
BB and CCB are negative inotropes, can be deleterious
Recommendations
Digoxin or amiodarone
Low threshold for cardioversion
Optimizing Fluid Balance
Neck vein distension, dilated IVC on TTE
Cautious diuresis
If uncertain about IVF in hypotensive patients
Consider small crystalloid infusion slowly and observe response (250cc-observe CVP, CO, BP)
Bolus can stretch RV and cause bradycardia-therefore decreasing CO
Oxygenation and Ventilation
Maintain SpO2 >92%
Correct anemia
CPAP or NIPPV preferred (avoid intubation if possible)
If intubation is necessary:
Pretreat w/ catecholamines prior to sedation
Lung protective strategy
TV 6 cc/kg IBW and Pplat <30 cmH2O
Minimum PEEP necessary
CO2 is a potent vasoconstrictor. Don’t forget to bag these patients and provide ventilatory support during the apneic period if intubation is deemed necessary
Propofol has been shown to have worse outcomes on induction (etomidate is a reasonable choice)
RV is poorly tolerant of afterload
In acute RV failure, RV stroke volume decreases with increasing afterload
Patients with RV failure typically only perfuse their coronaries in diastole (and therefore are poorly tolerant of hypotension, which can lead to decreased CPP and cardiac ischemia)
Pulmonary vasodilators
iNO
iEpo
IV epoprostenol
Inhaled iloprost
IV sildenafil (causes a lot of hypotension)
Single Dose Sildenafil in ARDS has been shown to increase shunt and hypoxemia
Vasopressors
Very important to maintain sufficiency BP to adequately perfuse the RV
Vasopressors elevate MAP by inducing systemic vasoconstriction
No data on which vasopressors are superior
Inotropes
Increase contractility (but rarely used in isolation), may have systemic vasodilatory effects which can worsen hypotension
No consensus on drug of choice in setting of PH-induced RHF
Dobutamine, low dose dopamine, Norepi, milrinone, levosimendan
Avoid Systemic Vasodilators in RHF
Smooth muscle relaxers: NTG, nitroprusside, hydralazine
Calcium channel blockers
VA ECMO
Bypasses RV
Can provide weeks of support
Patients can remain awake and extubated
Upper body configuration may allow for physical therapy
Bridge to transplant
Atrial septostomy
Severe class IV, Creation of a PFO to overload the RV (not possible if significant hypoxia given that shunting will worsen hypoxemia)
Can’t do it if RAP >20 (you will shunt too much)
RVAD
increased flow through the pulmonary circulation will likely cause shearing and result in hemoptysis
When to refer for double lung transplantation
Functional decline, worsening CO after optimal therapy
Invasive monitoring can help with initial diagnosis and long term monitoring, but in the short terms, less invasive studies like TTE and monitoring of UOP can be beneficial
CPR may not be be helpful in patients who suffer cardiac arrest from RHF due to PAH
They are likely already on maximal medical therapy, and their pathology is not reversible
Helpful to discuss goals of care early when they are admitted for decompensation
Summary
Characterize, identify, and correct reversible factors
Cardiac echo and PA catheter helpful
Maintain organ perfusion, optimize fluid volume, avoid hypoxemia
Prostacyclins are potent vasodilators, inhaled route promising
Inhaled NO also useful, but limitations
PDE-5 inhibitors may have role
ECMO offers rescue therapy for some
Morbidity and mortality are still very high
Airway grand rounds w/ Dr. adan
Nomenclature
Avoid use of the term “D blade,” as this does not specify the size and is not reflective of our current equipment (please specify size 3 or 4 of the hyperangulated blades)
Cart in SRU2
Blades, Rigid stylets, Ducanto suction catheter, iGels, NP suction and pediatric OG tubes (for iGel decompression port)
Preferred paralytic is succinylcholine in trauma patients (per protocol created in conjunction with trauma)
Dosing (based on total body weight):
Induction
Etomidate 0.3 mg/kg
Ketamine 1.5 mg/kg
Propofol 1.5mg/kg (less preferred 2/2 hypotension in the event of drug shortages)
Midazolam 0.2-0.3 mg/kg (less preferred 2/2 hypotension in the event of drug shortages)
Neuromuscular blockade
Succinylcholine 1.5 mg/kg
Rocuronium 1.5 mg/kg (max 150mg)
“7 P’s”
-preparation
-preoxygenation
-physiologic optimization
-paralysis with induction
-positioning
-Placement with proof
-Postintubation management
CRASH
-increased O2 consumption
-RV failure
-acidosis (metabolic)
-risk of desaturation
-hypotension
Current Stats for the Academic Year July 2022-Present:
259 Intubations (144 medical, 103 trauma)
84% DASH-1A
91% first pass success
Airway Literature:
Engagement of the glossoepiglottic fold in SGVL view
Showed improvement in CL 1 and 2a by 9% when hyoepiglottic ligament was engaged
RCT showing glidescope hyperangulated blade combined with “cheap seats view” was associated with faster and easier tracheal intubation when compared with a full glottic view
Time to intubate 36 vs 27 seconds, favoring cheap seats view
No change in first pass success rates
Occlusion myocardial infarction w/ Dr. Stephen Smith
STEMI-NSTEMI Paradigm (The No False Negative Paradox)
OMI Features:
Hyperacute T waves
Pathologic Q waves
Terminal QRS distortion
Reciprocal STD and/or reciprocal TWI
Subtle STE not meeting criteria, but with other features
ANY amount of STD in V1-V4
Any STE in inferior leads with any STD/TWI in aVL
Ratio of these T wave changes in relation to the QRS complex is incredibly important
T/QRS ratio >0.36 is acute
Smith Modified Sgarbossa Criteria
(1 and 2 are unchanged)
3. Discordant STE of 1 >/= and ST/S ratio of >/=20-25%
PseudoSTEMI patterns
LBBB, paced rhythm
LVH
Old inferior MI w/ persistent STE (inferior aneurysm) vs acute inferior OMI
Myocarditis
Takotsubo
Pericarditis
LAD
De winter pattern
Large symmetric T waves compared to QRS
Hyperacute T waves
Tower over the R wave
Large compared to QRS
Bulky T wave
Broader upstroke
QS wave (no R wave)
Dr. Smith’s Subtle Anterior STEMI Equation/Formula
Components
Bazett-corrected QT interval
QRS amplitude in lead V2
R wave amplitude in lead V4
ST segment elevation 60 ms after the J point in lead V3
Subtle Anterior STEMI 4-Variable Calculation = 0.052 x (Bazett-corrected QT interval, ms) - 0.151 x (QRS amplitude in lead V2, mm) - 0.268 x (R wave amplitude in lead V4, mm) + 1.062 x (ST segment elevation 60 ms after the J point in lead V3, mm)
Scores ≥18.2 are likely to be anterior STEMI (83.3% sensitivity, 87.7% specificity, and 85.9% diagnostic accuracy).
Scores <18.2 are likely to be benign early repolarization.
Formula excluded: Q waves, lack of concavity, terminal QRS distortion
Subtle STEMI app will walk you through this
This formula can be used to change your index of suspicion
Beware dynamic EKG changes (i.e. changes in T wave morphology, even if these are normalizing)
R3 Taming the Sru: Burn and inhalational injuries w/ Dr. Milligan
Consider concomitant traumatic injuries in burn patients
Inhalational injury increases burn mortality by 20x
What factors predict the need for emergent intubation?
High TBSA (>/=27%)
Respiratory distress
Indications
TBSA >40%
Full thickness facial burns
Altered mental status
Stridor
Hypoxia
Succinylcholine
Safe in burns up to 24-48 hours from injury
Carbon Monoxide Exposure
Incomplete combustion of carbon sources
Normal range is <3-5% in nonsmokers and <10% in smokers
Headache, n/v, but could progress to AMS, LOC and seizure
Continue treatment with 100% FiO2 until symptoms resolve and COHb is <10%
Can utilize NC + NRB in a nonintubated patient
Indications for hyperbaric O2 therapy include:
COHb >25% (>15% if pregnant, because FtHb has higher affinity for CO)
LOC or persistent AMS
End organ dysfunction
Data on efficacy of hyperbaric O2 therapy remains unclear
Be cognizant that at some centers, the patient will be unaccompanied, and that the chamber takes several minutes to pressurize and depressurize, so this may be at play if the patient is unstable
Cyanide Toxicity
Can give cyanokit
Needs to be diluted (gently mix, administer over 15 mins)
Can redose once
Will change the color of urine and can affect colorimetric assays for weeks
Volume Resuscitation
2-4cc/kg xTBSA = 24h volume
50% given over the first 8h, and then remaining 50% over the next 16 hrs
Lund & Browder Chart
Different charts for adult and pediatric
Burn Description/Classification
1st, superficial vs deep partial, full
Sterile dry dressing is acceptable for initial
Escharotomy
Circumferential burns are at higher risk of compartment syndrome, but do not necessitate need for escharotomy
Local transfer centers
Pediatric Burns in the Cincinnati Area:
Nationwide Children’s in Columbus
Shriners Children’s in Dayton
R4 Clinical capstone: “Why ultrasound is practice-changing” w/ Dr. broadstock
TEE in Cardiac Arrest
Common views for emergency physician use in resuscitation include the midesophageal four chamber, bicaval, midesophageal long axis, and transgastric short axis
Allows for continuous assessment of cardiac function, and can be used during cardiac arrest to guide resuscitation. Its applications include optimization of chest compression placement (area of maximal compression), identification of fine arrhythmias, and guide procedures
TEE use influences management
In cases of cardiac arrest and resuscitation in the ED, TEE has been shown to provide diagnostic influence in 78-97% of cases (Arntfield 2016, Teran 2019)
In the ICU setting, one study demonstrated that TEE changed management in 80% of cases (Arntfield 2020)
Pulse checks were shown to be shorter with the use of TEE (9s) vs manual pulse checks (11s), and much shorter when compared to TTE (19s) (Fair 2019)
Patients found to have area of maximal compression (AMC) over the LVOT were also found to have lower rates of ROSC compared with those with proper AMC on TEE with OR 0.06. (Teran 2022)
When TEE was taught and incorporated into an academic ED, the median # of uses was 10 over 42 months (including ~75% non-ultrasound trained attendings) (Reardon 2022)
Ultrasound improves your diagnostic efficiency
Initial impressions are more accurate for patients with dyspnea with the use of ultrasound (Mantuani 2016)
Ultrasound provides a faster time to ultimate diagnosis for patients with dyspnea (Zanobetti 2019)
Ultrasound can generate revenue
RVUs can be generated by performing and interpreting PoCUS
For example, an e-FAST is billed as a limited TTE, limited abdominal ultrasound, and limited chest ultrasound
RVU’s for ultrasound can be a large component of a provider’s billable work
Ultrasound can help offset healthcare costs and are a suitable substitute for CT scan in the appropriate patient population
Nephrolithiasis (Wong 2018)
Sensitivity 70.2%
Sensitivity 75.4%
Greater than moderate hydronephrosis, specificity is 94%
Multispecialty consensus statements (Moore 2019)
For suspected uncomplicated kidney stone and adequate pain relief, even without prior history of kidney stone, CT can be avoided in younger patients (approximately 35 years old) with a presentation typical for kidney stone.
In middle-aged patients (approximately 55 years old), CT may be avoided if there is a prior history of kidney stone.
POCUS first approach is appropriate in these cases
Use of POCUS-first evaluation of urolithiasis for patients who meet Choosing-Wisely criteria can save resources on unnecessary CT utilization (Frederick 2022)
$25.5 million
203,000 CT scans
205,000 ED bed-hours
