Accidental Tracheostomy Decannulation

Written by: Chezlyn Patton, MD (NUEM ‘27) Edited by: Keara Kilbane, MD (NUEM ‘25)
Expert Commentary by: Matt McCauley, MD (NUEM ‘21)

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Introduction

Tracheostomy is a common procedure in the US with over 110,000 trachs placed annually (1). Complications occur at a rate of approximately 40-50%, however most complications are minor, with only 1% being catastrophic (1). Of these devastating complications, 90% occur within the first 10 days of placement. Overall approximately 15% of tracheostomies will be decannulated accidentally, and in a critical care setting, 50% of airway related deaths were associated with accidental tracheostomy decannulation (1, 2). 

One way to approach a decannulated tracheostomy tube could be with the acronym, IRMI; Investigate, Recannulate, Monitor, and Intubate (if you must). 

Investigate: How long ago was the tracheostomy tube placed? How long has it been out? What is the size of the trach? Is it cuffed or uncuffed? Why was the trach placed initially? 

1. Cuffed vs. uncuffed: Is there a pilot balloon present? If yes, that indicates the trach is a CUFFED tracheostomy tube. 

2. Size of tracheostomy tube: ALWAYS labeled on the neck flange. 

Figure 1: Size of trach tube identification on flange. Borrowed from https://tracheostomyeducation.com/tracheostomy-tubes/.

Figure 2: Tracheostomy tube parts labeled, borrowed from ©Linda L. Morris and M. Sherif Afifi, https://www.trachresource.com/table-of-contents/

Recannulate:  Oxygenate from above with non-rebreather or by blow by oxygen over the tracheostomy stoma if the patient is spontaneously breathing. If they are in respiratory distress or not spontaneously breathing, bag-valve-mask (BVM) oro-nasopharyngeal or over the stoma. You can use a pediatric mask to fit over the stoma or a LMA. Ensure to occlude the stoma if BVM from above or close the mouth if BVM from the stoma to prevent air leakage. Note, if the patient is ventilator dependent, you need a CUFFED tracheostomy tube. Obtain one tracheostomy tube of appropriate size, and a tube that’s a size down, as a stoma may begin to close the longer it’s out. For stomas less than 10 days old, grab a fiberoptic scope, as these will require recannulization under direct visualization. This is to minimize the risk of creating a false passage.

Figure 3: Depiction of creation of false passage through subcutaneous tissue when replacing tracheostomy tube. Borrowed from: Morris, L.L., Whitmer, A., & McIntosh, E. (2013). Tracheostomy care and complications in the intensive care unit. Critical care nurse, 33 5, 18-30 .

Otherwise, you can place blindly for the initial insertion. Ensure the obturator is placed inside the outer cannula tracheostomy tube prior to insertion, as it blunts the hard edge of the tracheostomy tube that can damage the membranous wall of trachea. If you meet any resistance, size down immediately, as the stoma has likely started to heal (even with a matured tracheostomy). Then remove the obturator and inflate the cuff to maintain placement (3,4).

Monitor: Once the trach tube is reinserted, it is important to monitor for appropriate placement and gas exchange. Continuous capnography is the gold standard for this. Additionally, the tube should be confirmed to be in the trachea through direct fiberoptic visualization of the trachea and carina. Be sure  to assess for complications such as creation of a false lumen, which could manifest as subcutaneous emphysema (5). 

Intubate if you must: If faced with a scenario where the tracheostomy tube cannot be passed through the stoma, and your patient is developing respiratory distress, you can intubate your patient orotracheally if they have a patent upper airway. The only exception to this is a patient who has had a laryngectomy, as those patients cannot be intubated orally and are obligate neck stoma breathers (6).

References

1.Bontempo, Laura J., and Sara L. Manning. "Tracheostomy emergencies." Emergency Medicine Clinics 37.1 (2019): 109-119.

2. Cheung, Nora Ham-Ting and Lena M. Napolitano. “Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes.” Respiratory Care 59 (2014): 895 - 919.

3. Rajendram, R., and N. McGuire. "Repositioning a displaced tracheostomy tube with an Aintree intubation catheter mounted on a fibre-optic bronchoscope." BJA: British Journal of Anaesthesia 97.4 (2006): 576-579.

4. Shah RK, Lander L, Berry JG, et al. Tracheotomy outcomes and complications: a national perspective. Laryngoscope 2012;122(1):25–9

5. Riley, Christine M.. “Continuous Capnography in Pediatric Intensive Care.” Critical care nursing clinics of North America 29 2 (2017): 251-258 .

6. McGrath B, Bates L, Atkinson D, et al, National Tracheostomy Safety Project. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia 2012;67(9):1025–41.

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Expert Commentary

Thank you for this concise summary of tracheostomy management. While most of the immediate complications of tracheostomy will occur in the ICU, these patients still frequent our emergency department with and without tracheostomy related emergencies. Despite this, patients with tracheostomy can be intimidating there is a general lack of knowledge about tracheostomy among healthcare professionals in general and emergency medicine trainees in specificity.1,2 

As you have outlined, understanding both the chronicity of the tracheostomy as well as the indication for the procedure are key history when managing a displaced tube. A patient who underwent tracheostomy for failure to liberate for the ventilator likely has a patent upper airway while one placed following an ENT surgery likely poses a significant challenge for orotracheal intubation! Obtaining this history (and handing off this key information when transitioning care) can be lifesaving. Significant care should be taken when replacing a tracheostomy through an immature stoma, the usual cited maturity date being 10 to 14 days old. These should always be replaced over a fiber-optic scope with visualization of the tracheal rings and carina prior to cuff inflation and ventilation by BVM or ventilator. Failure to do so can result in severe pneumomediastinum, pneumothorax, subcutaneous emphysema, and respiratory arrest if placement into a false tract is not recognized3 . Replacement of a tracheostomy tube into a mature tract can be done blindly with an obturator in place but care should also be taken if there are any signs of trauma or bleeding. When in doubt, play it safe and obtain fiber optic visualization!  

While trach replacement can be stressful under the wrong circumstances, patients with tracheostomy tubes can present with enumerable other emergencies. As with any high stress situation in resuscitation, it helps to fall back onto our ABCs, airway being of principle importance here. The immediate assessment of any patient with a tracheostomy tube in extremis should be focused on a singular question: can I ventilate the patient through this tube? In order for a patient to be effectively bagged or ventilated through a tracheostomy tube three things must be true. The tube must be patent and endotracheally placed, the tube must be cuffed, and the cuff must be inflated. Patency can be quickly assessed with passage of a flexible suction catheter. If this is unsuccessful, removal of the inner cannula (if present) and replacement with a fresh inner cannula can often resolve obstruction by secretions.  If obstruction is unable to resolve, you should oxygenate from above while preparing to replace the tracheostomy tube as you have elegantly outlined.  

The presence of a cuffed tube will be indicated by the presence of a pilot balloon, no reading of numbers or brand names needed! Finally, cuff inflation can be confirmed by palpation of the pilot balloon and assessing for any speech production or gurgling hear though the mouth. If the patient can phonate then the balloon is not properly inflated! If gentle inflation of the cuff does not resolve the air leak assume a ruptured cuff and replace the tracheostomy.  

Tracheostomy tube care and emergencies can be very intimidating but this procedure is a valuable tool for ICU and ventilator liberation. As emergency physicians, we need to be familiar with the nuances of these devices so we can safely manage the airway just as we would any sick patient. 

References

1. Whitcroft KL, Moss B, Mcrae A. ENT and airways in the emergency department: national survey of junior doctors’ knowledge and skills. J Laryngol Otol. 2016;130(2):183-189. doi:10.1017/S0022215115003102 

2. Darr A, Dhanji K, Doshi J. Tracheostomy and laryngectomy survey: do front-line emergency staff appreciate the difference? J Laryngol Otol. 2012;126(6):605-608; quiz 608. doi:10.1017/S0022215112000618 

3. Long B, Koyfman A. Resuscitating the tracheostomy patient in the ED. Am J Emerg Med. 2016;34(6):1148-1155. doi:10.1016/j.ajem.2016.03.049 

Matt McCauley, MD

Assistant Professor, Division of Critical Care  

UW BerbeeWalsh Department of Emergency Medicine  

Associate Medical Director  

UW Organ and Tissue Donation 

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Patton, C. Kilbane, K. (2024, Apr 15). Accidental Tracheostomy Decannulation. [NUEM Blog. Expert Commentary by McCauley, M]. Retrieved from http://www.nuemblog.com/blog/tracheostomy-decannulation

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Molar Pregnancy

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Written by: Conner Morton, MD (NUEM ‘26) Edited by: August Grace (NUEM ‘24)

Expert Commentary by: Dana Loke, MD, MS

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Expert Commentary

Thank you to Drs. Morton and Grace for this excellent infographic highlighting molar pregnancy and its relevance to Emergency Medicine providers. While rarer than other pregnancy issues seen in the Emergency Department, molar pregnancy is an important diagnosis for Emergency Medicine providers to be able to recognize, understand, and treat. As listed in the above post, symptoms of molar pregnancy can be similar to viable pregnancy and its complications, so it is important to obtain a timely ultrasound in any patient with unknown pregnancy location or if considering molar pregnancy. While molar pregnancy is not a difficult diagnosis to make as long as an ultrasound is done, it is important to be wary of its complications and treat appropriately. This includes monitoring vitals, specifically in consideration of hemorrhage and pre-eclampsia, with resuscitation and transfusion as needed. Consultation with OB/GYN should occur in the Emergency Department for immediate next steps, which will include procedural management. When updating the patient about the diagnosis and next steps, make sure to sensitively explain that molar pregnancy is nonviable. Lastly, make sure to complete a comprehensive review of systems and physical exam; molar pregnancy is associated with choriocarcinoma, which is known to spread widely and aggressively throughout the body. 

Dana Loke, MD, MS

Assistant Professor

Emergency Medicine

University of Wisconsin-Madison

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Morton, C. Grace, A. (2024, Apr 1). Molar Pregnancy. [NUEM Blog. Expert Commentary by Loke, D. Retrieved from http://www.nuemblog.com/blog/molar-pregnancy

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TXA in the Trauma Bay

Written by: Jilan Shimberg, MD (NUEM ‘26) Edited by: Rafael Lima, MD (NUEM ‘23)
Expert Commentary by: Matthew R Levine, MD

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Expert Commentary

Unlike many of the treatments and interventions we use in the Emergency Department and the trauma bay, tranexamic acid (TXA) has rather robust studies to guide usage. Like many interventions, however, even when there are studies with large numbers of patients and positive results, there are still barriers towards implementation. TXA is no different.

Working at a Level 1 Trauma Center and frequently interacting closely with the trauma surgeons through the Trauma Quality Management Committee, I often follow their lead when it comes to promising trauma innovations through the years such as TXA, REBOA, permissive hypotension, and so on. What I have observed is that our trauma surgeons tend to believe that there is benefit to properly timed TXA in the right trauma patients and that we do not use it enough. Yet use of TXA in trauma at our hospital has not been protocoled.

Why not? Some possibilities:

1. Someone usually (but not always) thinks to give it to patients who would benefit despite there not being a protocol (thanks ED pharmacists!).

2. The patients who need it most also need something else even more – source control of hemorrhage. Anything that slows or distracts from that may be counterproductive. It may not seem like a simple TXA infusion would delay anything. But keep in mind the multiple lines sick trauma patients may need and the often already chaotic nature of “the bay” getting the sickest patients the tubes, meds, lines, products, studies, and, ultimately, proper disposition during their “golden hour”. The nurses have many tasks, to say the least. But maybe this is an argument for why use of TXA should just be protocolized.

I bounced this off of our trauma section head to make sure I was not misrepresenting their thoughts. As a result, we are looking into protocolling its use. Thanks NUEM Blog!

Matthew Levine, MD

Associate Professor of Emergency Medicine

Department of Emergency Medicine

Northwestern Memorial Hospital

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Shimberg, J. Lima, R. (2024, Mar 11). TXA in the Trauma Bay. [NUEM Blog. Expert Commentary by Levine, M]. Retrieved from http://www.nuemblog.com/blog/txa-trauma

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Breastfeeding Pharmacy: Analgesics

Written by: Courtney Premer-Barragan, MD, PhD (NUEM ‘25)
Edited by: Adam Payne, MD (NUEM ‘24)
Expert Commentary by: Kelsea Caruso, PharmD

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Expert Commentary

“Pump and dump” is definitely the easy way out for the emergency medicine provider, but this practice can have detrimental effects on the baby and on the mother. There is a false pretense that many medications are harmful to the breastfeeding infant, but this is not the case. The other consideration to have when thinking about medication use in breastfeeding is the medication effects on the mother’s lactation and the medication impact on breast milk production.

Ibuprofen by far has the most supporting evidence for use in breastfeeding women and this is a reasonable first line agent for treating many types of pain. Ketorolac is used frequently immediately after delivery and limited amount of drug is excreted in colostrum, but more may be excreted as milk supply increases thus increasing the risk of bleeding in the infant. Aspirin is excreted into breastmilk, and long-term use of high doses may cause bleeding along with metabolic abnormalities in the infant. That said, long-term use of low dose aspirin is likely safe.

If opioids are required for pain control, fentanyl is a reasonable choice for immediate pain control. Combination hydrocodone and acetaminophen is also an option when oral pain medications need to be utilized. The jury is (sort of) out on if oxycodone is safe during breastfeeding, and the baby should be monitored closely if oxycodone is selected for pain management.

Local anesthetics are very poorly absorbed by the infant, but still remain diligent about checking the specific maximum recommended dose for adults. My favorite database to find information on medications in lactation is LactMed, a database funded by the NIH. It is always safest to check this database before prescribing a medication to a lactating patient.

Kelsea Caruso, PharmD

Clinical Pharmacist

Department of Emergency Medicine

Northwestern Memorial Hospital

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Premer-Barragan, C. Payne, A. (2023, Jul 31). Breastfeeding Pharmacy Analgesics. [NUEM Blog. Expert Commentary by Caruso, K]. Retrieved from http://www.nuemblog.com/blog/breastfeeding-pharm-analgesics

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Breastfeeding Pharmacy: Antibiotics

Written by: Courtney Premer-Barragan, MD, PhD (NUEM ‘25)
Edited by: Ben Kiesel, MD (NUEM ‘23)
Expert Commentary by: Kelsea Caruso, PharmD

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Expert Commentary

Emergency Medicine practitioners may be quick to recommend patients to “pump and dump” when on antibiotics, but this can have downstream detrimental effects on the baby and on the mother. With the numerous indications for antibiotics, including some dealing with breastfeeding itself, it is imperative that EM providers recognize that most antibiotics are considered safe.

Most beta-lactam antibiotics are considered safe in breastfeeding women and can be used to treat many infections. Depending on the type of infection, anaerobic coverage may be warranted. Case reports have documented the potential for metronidazole to cause Candida infections and diarrhea in the infant. Clindamycin has the highest potential to cause GI issues in the breastfed infant. If these medications are indicated, it is best to have a risk-benefit discussion with the patient about the best option.

Tetracyclines have historically been feared in breastfeeding mothers due to the potential for bone deposition and staining of the dental enamel. As more literature has reviewed their safety, tetracyclines are considered safe for short term use, but limit courses to fewer than 21 days. Tetracycline absorption is also inhibited by calcium, which is contained in breast milk, so the amount actually absorbed by the infant should be low.

My favorite database to find information on medications in lactation is LactMed, a database funded by the NIH. Always the safest bet is to check this database before prescribing a medication to a lactating patient.

Kelsea Caruso, PharmD

Clinical Pharmacist

Department of Emergency Medicine

Northwestern Memorial Hospital

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Premer-Barragan, C. Payne, A. (2023, Jul 25). Breastfeeding Pharmacy Antibiotics. [NUEM Blog. Expert Commentary by Caruso, K]. Retrieved from http://www.nuemblog.com/blog/breastfeeding-pharm-antibiotics

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COVID-19 and Mental Health

Written by: Evelyn Huang, MD (NUEM ‘24) Edited by: Julian Richardson (NUEM ‘21)
Expert Commentary by: Tyler Black, MD, FRCPC

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COVID-19 has been difficult for everyone. Deaths, isolation, loss of work, and countless other hardships abound. With this, comes the concern for mental health crises. In a survey from June 2020, 11% of adults reported thoughts of suicide in the past 30 days [1]. It can be hypothesized that the pandemic has increased suicide rates. However, does this bear out in the literature? As frontline workers, and oftentimes the only interaction that patients have with the healthcare system, it is particularly important that we identify the impact of COVID-19 on the mental health of the patients that we see every day.

In Japan, researcher used a cross-sectional study to analyze national suicide rates during the COVID-19 pandemic. They found that suicide rates in 2020 were increased in October and November for men and in July through November for women when compared to 2016-2019. Increases in suicide rates were more pronounced with men and women that are younger than 30 [2]. This supports the idea that suicide rates increased as a result of the pandemic, especially with the younger population.

However, the trends in the United States are different. A study conducted in the US looked at suicide rates in Massachusetts from March to May 2020. Excluding data from pending death investigations, they found that the incident rate for suicide death was 0.67 per 100,000 person-months for the pandemic period as compared to 0.80 in the corresponding period in 2019. The researchers point to a sense of shared purpose, connections via video platforms, anticipated government aid, and mental health awareness campaigns as possible explanations for the stable rate of suicide deaths [3]. Another study looked at United States suicide related searches during the beginning of the pandemic. Researchers found that internet searches for suicide decreased during the early stages of the COVID pandemic (March to July 2020). While this may be surprising, there is literature that shows that catastrophic events can be associated with increased social support and reduce suicidal outcomes [4]. However, as the pandemic lengthens, more research is needed to see the trends in the data.

The next question is whether the same trend of decreased suicidality also applies to the pediatric population. A pediatric emergency department in Texas looked at the resulted of their routine suicide risk screenings for patients aged 11-21. They found a significantly higher rate of suicidal ideation in March and July 2020 and a higher rate of suicide attempts in February, March, April, and July 2020 when compared to the same months in 2019 [5]. It has also been cited that prior to the pandemic, suicide was the 10th leading cause of death in the United States, but the 2nd leading cause of death among people aged 12-17 [1]. This makes our interactions with the pediatric population even more important and argues for suicide risk screening for every patient.

Looking historically, there are differing trends for different global catastrophes. One researcher found that World War I did not influence United States suicide rates, whereas the great Influenza Epidemic increased suicide rates [6]. Another study looked at suicide rates in Hong Kong during the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003. They found an increase in older adult suicide in April 2003 when compared to 2002. These researchers cited loneliness and disconnectedness in the older community as a possible explanation [7]. While there are many different factors that go into increased suicidality, trends seen in the past can help guide policy and actions today.

Research is still needed to look at the current trends of suicide rates. The question is whether suicide rates will change as the pandemic continues to lengthen and the sense of shared purpose wanes and social isolation continues. The mental health of our patients is likely to be impacted long after the pandemic ends.

A study conducted in California found that emergency department patients presenting with deliberate self-harm or suicidal ideation had an increased risk of suicide or other mortality during the first year after their initial presentation in the emergency department [8]. This is a troubling trend, but also presents an opportunity for improvement. As emergency physicians, it is also important that we keep vigilant and take the time to talk about mental health. A common fear is that asking about suicide will prompt suicidal ideation, but research has shown that this is not the case [9]. There are several suicide screening tools that can be used in the ED, such as the Suicide Assessment 5‐step Evaluation and Triage (SAFE‐T) and American College of Emergency Physicians ICAR2E [9]. What is important is to ask, because patients will often reveal things to us that they do not mention to their loved ones. Build suicide screenings into your general practice, watch out for risk factors, and support those that are seek help.

References

1. Panchal, Nirmita, et al. The Implications of COVID-19 for Mental Health and Substance Use. Kaiser Family Foundation, 10 Feb. 2021, www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/.

2. Sakamoto H, Ishikane M, Ghaznavi C, Ueda P. Assessment of Suicide in Japan During the COVID-19 Pandemic vs Previous Years. JAMA Netw Open. 2021;4(2):e2037378. doi:10.1001/jamanetworkopen.2020.37378

3. Faust JS, Shah SB, Du C, Li S, Lin Z, Krumholz HM. Suicide Deaths During the COVID-19 Stay-at-Home Advisory in Massachusetts, March to May 2020. JAMA Netw Open. 2021;4(1):e2034273. doi:10.1001/jamanetworkopen.2020.34273

4. Ayers JW, Poliak A, Johnson DC, et al. Suicide-Related Internet Searches During the Early Stages of the COVID-19 Pandemic in the US. JAMA Netw Open. 2021;4(1):e2034261. doi:10.1001/jamanetworkopen.2020.34261

5. Hill RM, Rufino K, Kurian S, Saxena J, Saxena K, Williams L. Suicide ideation and attempts in a pediatric emergency department before and during COVID-19. Pediatrics. 2020; doi: 10.1542/peds.2020-029280

6. Wasserman IM. The impact of epidemic, war, prohibition and media on suicide: United States, 1910-1920. Suicide Life Threat Behav. 1992 Summer;22(2):240-54. PMID: 1626335.

7. Cheung YT, Chau PH, Yip PS. A revisit on older adults suicides and Severe Acute Respiratory Syndrome (SARS) epidemic in Hong Kong. Int J Geriatr Psychiatry. 2008 Dec;23(12):1231-8. doi: 10.1002/gps.2056. PMID: 18500689.

8. Goldman-Mellor S, Olfson M, Lidon-Moyano C, Schoenbaum M. Association of Suicide and Other Mortality With Emergency Department Presentation. JAMA Netw Open. 2019;2(12):e1917571. doi:10.1001/jamanetworkopen.2019.17571

9. Brenner, J. M., Marco, C. A., Kluesner, N. H., Schears, R. M., & Martin, D. R. (2020). Assessing psychiatric safety in suicidal emergency department patients. Journal of the American College of Emergency Physicians Open, 1(1), 30-37.

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Expert Commentary

This review is a comprehensive summary of the challenges and nuances of suicide epidemiology. Though it goes against the narrative many hold, in the United States we have preliminary but reliable data for suicides two years into the pandemic, we have not seen an increase in suicide rate in any age group (Figure 1) [1,2]. This reassuring news is tempered by the knowledge that prior to the pandemic, a decade-long trend of increasing suicide rates has maintained, and children, adults, and older adults are much more likely to die of suicide now in America than they were in 2010 [3].

Figure 1. Odds ratio for suicide, by age groups (A = under 18 years; B = 18 to 64 years; C = above 64 years). Years are grouped to match with the onset of the pandemic (March 2020), such that each data point represents April of that year to the following March (instead of the typical January to December presentation). The comparator for each year’s odds of suicide is a sum of the odds between April 2017 and March 2020. The shaded vertical lines represent the 95% confidence interval for odds ratio, and they are hidden behind the markers for the adult group due to the small confidence interval. 

Whenever considering suicide risk, it is crucial to remember that there are not direct links between suicidal thinking, suicide attempts or visits to the emergency department, and deaths by suicide. Up to 60% of people die of suicide on their first attempt, and the vast majority (95%) of people who attempt suicide do not die of suicide, so while it is important to see the danger in suicidal presentations to emergency department, it is crucial to be aware of the challenges in predicting who will live and who will die by suicide and focus on a person-centered approach to understanding an individual’s risk and protective factors[4, 5].

I applaud the authors for encouraging all clinicians to consider suicide risk in all patients and to become comfortable with routine screening. This may never demonstrate a reduction in suicide rates in rigorous research, but we have ample evidence that having open, genuine discussions about psychological, social, and health problems regarding suicide risk is beneficial to the patients we care for [6].

References

1. Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 1999-2020 on CDC WONDER Online Database, released in 2021. Data are from the Multiple Cause of Death Files, 1999-2020, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/ucd-icd10.html on Dec 1, 2022.

2. Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Provisional Mortality on CDC WONDER Online Database. Data are from the final Multiple Cause of Death Files, 2018-2020, and from provisional data for years 2021-2022, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/mcd-icd10-provisional.html on Dec 1, 2022

3. Centers for Disease Control and Prevention. (2022, June 28). Suicide data and statistics. Centers for Disease Control and Prevention. Retrieved December 1, 2022, from https://www.cdc.gov/suicide/suicide-data-statistics.html

4. Bostwick, J. M., Pabbati, C., Geske, J. R., & McKean, A. J. (2016). Suicide attempt as a risk factor for completed suicide: Even more lethal than we knew. American Journal of Psychiatry, 173(11), 1094–1100.

5. Hawton, K., Lascelles, K., Pitman, A., Gilbert, S., & Silverman, M. (2022). Assessment of suicide risk in mental health practice: shifting from prediction to therapeutic assessment, formulation, and risk management. The Lancet Psychiatry.

6. Dazzi, T., Gribble, R., Wessely, S., & Fear, N. T. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence?. Psychological medicine, 44(16), 3361-3363.

Tyler Black, MD, FRCPC

Assistant Clinical Professor

Department of Psychiatry

The University of British Columbia

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Huang, E. Richardson, J. (2023, Jan 2). COVID-19 and Mental Health. [NUEM Blog. Expert Commentary by Black, T]. Retrieved from http://www.nuemblog.com/blog/covid-mental-health

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EMTALA and Patient Transfers

Written by: Mike Tandlich, MD (NUEM ‘24) Edited by: David Feiger, MD (NUEM ‘22)
Expert Commentary by: Michael Schmidt, MD

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Expert Commentary

While EMTALA was first enacted to address issues with “patient dumping”, it has had broad influence on how patients are treated, dispositioned, and transferred in emergency department and hospital settings. In addition, EMTALA law has taken on almost mythic proportions among healthcare workers and administrators, likely due to high-profile cases, the fear of potential violation of the law and subsequent penalties, the potential for it to bolster civil malpractice claims, misunderstanding of it by healthcare personnel, and variability in interpretation by regulatory bodies.

Emergency physicians are often called upon to make decisions as the default expert in EMTALA for patients presenting for emergency care or in fielding hospital transfer calls. Unfortunately, on-call specialty physicians involved in the acceptance of transfers, and even hospital transfer centers, may not have a good understanding of the statue. As such, emergency physicians who are not versed in EMTALA can put both the hospital and themselves at risk.

The infographic by Dr. Tandlich gives an excellent summary of EMTALA. In addition, it is imperative that hospitals and emergency departments establish clear processes and appropriate documentation for EMTALA-related situations. More specifically, important concepts to consider include:

• When conducting a medical screening exam (MSE), approach it as a process with consistent implementation for all patients and understand this often includes more than just a physical exam

• When accepting transfers from outside hospitals, do not solely rely on on-call physicians to make the decisions

• When transferring patients to outside hospitals, make clear the reasoning, the patient status, and the risks and benefits

It behooves emergency physicians, emergency department staff, and transfer centers to understand the basic concepts around EMTALA. Overall, the best advice is to do that which is in the best interest of the patient, as this will usually lead to the right decision.

Michael Schmidt, MD

Chief of Staff

Department of Emergency Medicine

Northwestern Memorial Hospital

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Tandlich, M. Feiger, D. (2022, Oct 31). EMTALA. [NUEM Blog. Expert Commentary by Schmidt, M]. Retrieved from http://www.nuemblog.com/blog/emtala-transfers

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Health Insurance Basics

Written by: Evelyn Huang, MD (NUEM ‘24) Edited by: Vytas Karalius, MD, MPH (NUEM ‘22)
Expert Commentary by: Cedric Dark, MD, MPH

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Health Insurance: The Basics Every Doctor Should Know

A Brief History of Insurance in the U.S.

• In 1929, teachers in Dallas contracted with Baylor University Hospital to have monthly payments in exchange for up to 21 days of inpatient care a year. By 1937, there were 26 similar plans that all combined to form the Blue Cross network. In the 1930s, physicians also formed a network of insurance plans known as Blue Shield [1].

• During World War II, wage controls prevented employers from raising salaries. As a result, they started to offer health insurance. The IRS added that employers and employees did not have to include these costs in their taxable income [1].

• In 1944, President Franklin Roosevelt called for an “Economic Bill of Rights” that included the right to medical care that was never passed. President Truman proposed national health insurance for all Americans that was unpopular due to anti-communist sentiment [1, 2].

• In 1965, Medicare and Medicaid were created. In 1972, Medicare was extended for people under 65 who had long-term disabilities and/or end-stage renal disease [2].

• In 2010, the Patient Protection and Affordable Care Act (ACA) was passed [2].

Medicare Basics

As of 2019, Medicare covers approximately 61.4 million people [4]. Medicare is federally-run and has four parts:

• Part A: inpatient services, nursing care, home health

• Part B: outpatient services, ED visits

• Part C: “Medicare Advantage,” enrolling in Medicare benefits through private insurers

• Part D: prescription medications

Medicaid Basics

As of 2019, Medicaid covers approximately 75.8 million people and includes low-income adults, pregnant, and children [4]. Medicaid is unique from Medicare in that it is state-run with set federal regulations. The Affordable Care Act expanded eligibility to households with income up to 138% of the federal poverty level [2]. To date, 39 states including DC have adopted this expansion and 12 states have not, as seen in the map below [5].

Medicaid also includes the Children’s Health Insurance Program (CHIP) for children living in households that are under 200% of the federal poverty level and is state-run [2]. As of 2019, CHIP covers approximately 7.2 million children [4].

Patients that come to the emergency room are also able to apply for emergency Medicaid if they are currently uninsured. The details of this vary from state to state.

The Affordable Care Act

Signed into law 2010, the Patient Protection and Affordable Care Act had three main goals: expanding healthcare coverage, decreasing health care costs, and improving health care delivery.

• Expanding healthcare coverage

  • Medicaid expansion

  • Individual mandate (discussed in “Private Insurance Basics”)

  • Requirements for employers to offer health insurance plans

  • Dependent coverage for children up to age 26

  • Removed insurance exclusions for patients with pre-existing conditions

• Decreasing health care costs

  • Tax credits for small business employers that purchase health insurance for employees

  • Creation of health insurance exchanges

  • Insurance market rules, such as limiting deductibles and prohibiting lifetime limits of coverage

  • Discounts for prescription drugs for patients covered by Medicare

• Improving health care delivery

  • National quality improvement strategies

  • Required health plans to cover preventative services

  • Bonus payments for primary care physicians

  • Grants for wellness programs

  • Required chain restaurants to disclose nutritional content

For more information on the ACA, visit this website.

Private Insurance Basics

The ACA enacted an individual mandate, which required Americans to have health insurance or face a tax fee. However, the individual mandate penalty was repealed starting in 2019. Private insurance can be purchased individually, through an exchange/marketplace (third-party markets created by the ACA) or is provided by employers [2].

The ACA also set up 10 essential health services that must be covered with insurance plans. This includes hospitalizations, ambulatory services, lab tests, prescriptions, and emergency services [7].

There are different types of private health insurances, and it is important to have a basic knowledge of this when caring for your patients [9]:

• HMO (Health Maintenance Organization): you choose a primary care physician (PCP) that is in-network, you will need a PCP referral for any specialists, no out-of-network care is covered

• PPO (Preferred Provider Organization):  you can choose in-network providers (typically lower cost) or out-of-network providers, no referral needed for specialists

• EPO (Exclusive Provider Organization): does not cover out-of-network providers, but do not need a referral for specialists

• POS (Point of Service): you have a PCP that is in-network and that must give you a referral to see a specialist, but you can also access out-of-network options for a higher cost

• Catastrophic plan: only available for people under 30 or with a hardship exemption (affordability exemption), low premium and high deductible, theoretically only used for serious illness

Insurance plans on the marketplace also have different metal tiers to their plans. As you go up in tiers, the insurance company pays more when you get healthcare, with a higher associated monthly premium. If someone utilizes a lot of health care, a higher tier choice is better [8].

• Bronze: lowest premium, higher cost that you must pay when obtaining care, high deductible

• Silver: moderate premium, moderate cost when obtaining care

• Gold: high premium, low cost when obtaining care, low deductible

• Platinum: highest premium, lowest cost when obtaining care, low deductible

Insurance Definitions You Should Know

• Premium: monthly payment to insurance company regardless of whether you use the insurance

• Deductible: how much you pay for health services before insurance starts to pay

  • Plans with lower premiums typically have higher deductibles

  • Usually, you will still need to pay copays and coinsurance if you reach your deductible until you meet your out-of-pocket maximum

• Out-of-pocket maximum: after this level, insurance will pay for 100%

  • Includes deductible, copay, and coinsurance

  • The ACA established that policies must include an out-of-pocket maximum

    • For 2020: $8,150 for an individual and $16,300 for a family [9]

• Copay(ment): fixed payment for specific service or medication

  • E.g. You pay $20 every time you see your PCP

• Coinsurance: Percentage of cost that you pay before the out-of-pocket maximum

  • E.g. You pay 20% every time you see your PCP

Part of medical care is knowing that there is an associated cost with every test and treatment that we use. Medical insurance is essential to this, and it is important to know the basic ideas and language surrounding insurance, so that we can better serve our patients.

References

1.     Moseley III GB. The U.S. Health Care Non-System, 1908-2008. AMA Journal of Ethics. 2008;10(5):324-331.

2.     Schlicher N, Haddock A. Emergency Medicine Advocacy Handbook. 5th ed. Irving: Emergency Medicine Residents’ Association; 2019:1-8.

3.     What's Medicare?. Medicare.gov. https://www.medicare.gov/what-medicare-covers/your-medicare-coverage-choices/whats-medicare. Accessed August 18, 2020.

4.     CMS Fast Facts. Cms.gov. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMS-Fast-Facts. Published 2020. Accessed August 18, 2020.

5.     Status of State Medicaid Expansion Decisions: Interactive Map. KFF. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/. Published 2020. Accessed August 18, 2020.

6.     Summary of the Affordable Care Act. KFF. https://www.kff.org/health-reform/fact-sheet/summary-of-the-affordable-care-act/. Published 2013. Accessed November 10, 2020.

7.     Norris L. Obamacare's essential health benefits. healthinsurance.org. https://www.healthinsurance.org/obamacare/essential-health-benefits/. Published 2020. Accessed August 18, 2020.

8.     The 'metal' categories: Bronze, Silver, Gold & Platinum. HealthCare.gov. https://www.healthcare.gov/choose-a-plan/plans-categories/. Published 2020. Accessed September 8, 2020.

9.     Lalley C. Health insurance basics: The 101 guide to health insurance. Policygenius.com. https://www.policygenius.com/health-insurance/learn/health-insurance-basics-and-guide/. Published 2020. Accessed August 18, 2020.

10.  Out-of-pocket maximum/limit. HealthCare.gov. https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/. Published 2020. Accessed August 18, 2020.

Expert Commentary

Every year, I instruct our medical students and residents on the “Anatomy & Physiology of the United States Health Care System” using a historical journey from the first Blue Cross plan in Dallas crafted for schoolteachers until the modern era of the Affordable Care Act. Along the way, we have added in a piecemeal fashion to our nation’s health care system such that seniors and low-income Americans have coverage carved out for them. Everyone else is reliant upon employer insurance for coverage or must purchase for themselves. Because of our country’s surprisingly involvement in financing health care for its citizens – over 36 percent is paid by the federal government – some commentators have declared the U.S. is an “insurance company with an army.”

While national health expenditures and financing our system are big picture items everyone in the health care sector should understand, we must also understand the small details that are most relevant to patients, such as common terminology regarding their insurance types and the payments they are required to pay at the point of service.

Cedric Dark, MD, MPH

Assistant Professor

Department of Emergency Medicine

Baylor College of Medicine

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Huang, E. Karalius, V. (2022, Oct 10). Health Insurance Basics. [NUEM Blog. Expert Commentary by Dark, C]. Retrieved from http://www.nuemblog.com/blog/health-insurance-basics

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Other Posts You May Enjoy

Debriefing in the ED

Written by: Diana Halloran (NUEM ‘24) & Andrew Long (NUEM ‘25) Edited by: Nick Wleklinski (NUEM ‘22)
Expert Commentary by: John Bailitz, MD

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Introduction

The Emergency Department is a challenging work environment for a variety of reasons. It is not surprising that unpredictable work hours mixed with frequent interactions with patients undergoing physical and emotional trauma can cause spillover into the personal lives of ED staff. However, in the recent years there has been an increasing body of literature that highlights the challenges that we face as ED personnel. 

The American Heart Association even recommends a “hot” debrief for every cardiac arrest attended by a healthcare professional. We know debriefing has concrete and tangible advantages. Previous studies have shown that debriefing immediately after an event can improve individual and team performance by 20-25%, issues can be identified for interventions, and mental health and emotional trauma can be addressed. It is well-documented that ED physicians have historically high rates of burnout compared to other specialties as well as a high incidence of post-traumatic stress disorder (PTSD) compared to the general population. PTSD is 2 times more prevalent in physicians (14.8%), with EM resident physicians falling in the range from 11.9%-21.5%.

As a field, we are now starting to design and implement interventions to preserve our own mental wellbeing. In fact, debriefing has been shown to be one method for managing PTSD. One article described an initiative that implemented an immediate (also known as “hot”) debrief protocol immediately following all cardiac arrests during which 90% of participants felt they benefited psychologically, and 100% felt it improved their clinical practice. In this post, we will give a brief overview of a landmark study in the ED debrief literature, which advocates for a “hot” debrief model in resuscitation cases using the STOP5 model.

Study Analysis

This study published in 2019 designed, tested, and developed the STOP5 model to facilitate safer patient care, team development, and quality improvement within the Emergency Department. The STOP5 model, the first widespread debriefing tool, was designed as a “hot debrief”: “an interactive and structured team dialogue that takes place either immediately or very shortly after a clinical case”. Any team member of the resuscitation may lead the hot debrief.

Figure 1: The STOP5 Model Debriefing Framework (proposed by CA Walker et al 2020)

After an initial check-in the team moves to a group discussion and follows the STOP framework above: Summarize the case, Things that went well, Opportunities to improve, and Points to action and responsibilities. Inclusion criteria for these hot debriefing cases were major traumas, deaths in resuscitation, and any cases upon request by any staff member. No potential resuscitation cases were formally excluded.

After 18 months the ER staff was re-surveyed to ascertain STOP5 rating scores, the number of staff involved in the debriefs, any possible benefits or barriers to team performance, and if staff believed there should be more or less hot debriefing in the ER. In this 18-month review all STOP5 debriefs were rated “good” to “excellent”, suggesting the debriefing was highly valued. 98% of respondents believed that there should continue to be more hot debriefs in the emergency department. In a 12-month review there were 10 process and equipment changes (“hard outcomes”) as a direct result of the STOP5 hot debriefs and 14 additional opportunities for improvement. The hot debrief allowed for concrete actions to be taken about these issues and for a dedicated plan of action for correction. These hard outcomes identified issues such as those listed below which allowed for concrete solutions for all the identified problems.

• Shortage of resuscitation room equipment

• Drug stocking issues

• Drug preparation/infusion regime for vital but rarely used medications difficult for staff to find

• Faulty equipment (doors, machines)

Reported barriers to enacting hot debriefs include time constraints, workload, low staff confidence in leading the debrief, or absence of team members (consultants who might have left the department, change of shift). For these reasons hot debriefing is still not standard practice. However, a hot debrief such as STOP5, with a concrete checklist, is an inexpensive and quick way to enhance team performance, improve patient care, and assist with emotional trauma and mental check-ins for the team. Debriefing is a valuable and important aspect of our medical career. We hope to bring more of a focus to debriefing within our institution by beginning to enact the STOP5 based hot debriefing after clinical events.

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Expert Commentary

Whether working in a community or academic Emergency Department, recurrent extraordinary cases threaten the well-being of the clinical team during that shift and after. Although resources often exist for individual employee assistance after a difficult shift has ended, few interventions have been described to help the team regroup and recover during that particular shift. Furthermore, department level morbidity and mortality conferences or hospital level quality assurance reviews focus more on the technical case details and less on team wellness.

With the primary purpose of quickly restoring team performance and wellness, hot debriefs at NUEM provide the opportunity for our ED teams to have a structured yet brief meeting immediately after an extraordinary case. Using STOP5, team leaders have a step-by-step plan to quickly yet effectively help every clinician on the team properly mentally frame the case, share gratitude, and then identify and assign opportunities for immediate improvement. Building on life support courses and residency training, specific education on the STOP5 framework quickly prepares senior clinicians to lead hot debriefs. Utilizing change management principles to identify and address logistical barriers helps to create a culture that supports immediate debriefing. Successful strategies in our NUEM ED include protocols to pause new inflow and cover existing patient demands, designating meeting spaces, adding positive program reminders to clinical areas and recurring meetings, and tracking and celebrating program success.

References

1.    Get With The Guidelines - Resuscitation Clinical Tools. (2021, August 16). Www.Heart.Org. https://www.heart.org/en/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-resuscitation/get-with-the-guidelines-resuscitation-clinical-tools

2.    Gilmartin, S., Martin, L., Kenny, S., Callanan, I., & Salter, N. (2020). Promoting hot debriefing in an emergency department. BMJ Open Quality, 9(3), e000913. https://doi.org/10.1136/bmjoq-2020-000913

3.    Tannenbaum, S. I., & Cerasoli, C. P. (2012). Do Team and Individual Debriefs Enhance Performance? A Meta-Analysis. Human Factors: The Journal of the Human Factors and Ergonomics Society, 55(1), 231–245. https://doi.org/10.1177/0018720812448394

4.    Vanyo, L., Sorge, R., Chen, A., & Lakoff, D. (2017). Posttraumatic Stress Disorder in Emergency Medicine Residents. Annals of Emergency Medicine, 70(6), 898–903. https://doi.org/10.1016/j.annemergmed.2017.07.010

5.    Walker, C. A., McGregor, L., Taylor, C., & Robinson, S. (2020). STOP5: a hot debrief model for resuscitation cases in the emergency department. Clinical and Experimental Emergency Medicine, 7(4), 259–266. https://doi.org/10.15441/ceem.19.086

John Bailitz, MD

Vice Chair for Academics, Department of Emergency Medicine

Professor of Emergency Medicine, Feinberg School of Medicine

Northwestern Memorial Hospital

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Halloran, D. Long, A. Wleklinski, N. (2022, Sept 12). Debriefing in the ED. [NUEM Blog. Expert Commentary by Bailitz, J]. Retrieved from http://www.nuemblog.com/blog/debriefing-ED

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Proper Preparation for Mass Casualty Incidents

Written by: August Grace, MD (NUEM ‘24) Edited by: Andrew Rogers, MD, MBA (NUEM ‘22)
Expert Commentary by: Andra Farcas, MD (NUEM ‘21)

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Introduction

In the setting of trauma, most hospitals are adept at treating and managing patients with a variety of injuries. However, the ability of a hospital to handle a mass casualty incident (MCI) requires a completely different approach and, most importantly, adequate triage and pre-planning. An MCI is defined as “an event that overwhelms the local healthcare system, where the number of casualties vastly exceeds the local resources and capabilities in a short period of time [7].” MCI events can include anything from hurricanes, earthquakes, and other natural disasters to terrorism or other man-made situations that include the use of explosive or biological weapons, mass shootings, or dysfunction in modes of transportation (car, plane, train crash) [3]. Although this is just a short list of the possibilities, each hospital must prioritize its response preparedness to match the likelihood of events that it could receive. For example, as a major urban center, Chicago is more likely to encounter events such as mass shootings, biological terrorism, or explosive injuries. Mobile, Alabama, on the other hand, must have adequate preparation for hurricanes and floods [4]. This post will discuss a brief overview of hospital planning and operational setup with key elements of a disaster response from events that cause high numbers of blunt trauma, penetrating trauma, burns or crush injuries that may be seen following explosive events, mass shootings, or large scale motor vehicle collisions, to name a few. 

Casualty Planning & Staffing Considerations

Arguably the most important step in an MCI is the planning that occurs before a single patient is even seen. In most events, hospitals have communication with EMS personnel that are on scene allowing them to have some sort of estimation of the scale of the event and type of disaster encountered. If the mechanism and scale are appropriate, a properly planned disaster response should be initiated and set in motion a sequence of coordinated events. 

In creating a disaster response plan, the first step is the designation of the Disaster Medical Officer (DMO). This person should be the most senior ED attending physician and he/she oversees available hospital medical personnel and resources [1]. This person will have no role in patient care and instead will be in charge of all ED operations, delegating tasks, and problem solving issues that arise in the future. 

The first task of the DMO is to get help and get it now. Approximately half of all casualties will arrive at the hospital within a one hour window, with 50-80% arriving within 90 minutes. Time begins after the first patient arrives at the hospital [8]. Therefore, getting the appropriate staff to the hospital as quickly as possible is vital to saving lives. How much staff is needed? This can be gauged by the type of disaster encountered and with assistance from EMS personnel at the scene. A five-car motor vehicle collision (MVC) will not require as much additional staff as a collapsed high rise building. The DMO will delegate the task of calling available staff to maximize the number of staff present in the ED and hospital. Contacting surgeons, scrub techs, anesthesiologists, and nurses to get as many ORs operational is invaluable to saving lives. 

Continuous staffing adjustments can be monitored and made by using the casualty predictor tool (Figure 2). When in doubt, it is better to have more staff available than needed. To reiterate, the most important part of any disaster situation is to GET HELP.

Triage/ED Setup

Once the process is underway for increasing the level of resources available, the next step is hospital setup and triage. The most important part of this step is creating enough space to allow for the massive influx of patients and maintaining proper flow throughout the ED. It is well known that most hospitals in large population centers already operate at or near full capacity [4]. This makes it even more challenging when presented with an acute influx of patients in a short period of time. There is not much that can be done in the acute setting about patients that are already admitted; however, the ED can be restructured to account for the increased surge. Patients currently in the ED with a condition deemed to be stable (will likely not require an acute intervention in the next 24 hours) can be moved to a different area (green triage area, discussed below). The patients who have a more acute condition can be triaged and recategorized using the same criteria as the incoming casualties. 

One current method of triaging patients is the tagging method. In this system, patients are tagged with a red, yellow, or green identification that categorizes patients based on acuity. Other things listed on tags can be a patient’s name, bar code, MRN or other tracking criteria. These patients are then able to be treated based on the level of care needed. In theory, this is a good way for patients to be tracked and accounted for. However, some experts believe that when there is a large volume of patients, this can slow the triage process and extend the amount of time it takes the patient to receive care that may be lifesaving. Another limitation is that it does not allow for a dynamic system, it provides a false sense of security, and can cause confusion. For example, a patient may have a green tag when initially triaged but could decompensate to a yellow or red tag [6]. Thus, there should be an appropriate system for re-evaluation if resources allow. 

One system that could be used instead is a tag zone. In this system, the ED could be set up into different zones that would correlate with the tag color and acuity of the condition. Who should triage? The second most senior ED attending physician. The zone system could be set up as follows: 

Red zone: Patients that need immediate medical or surgical attention. This includes patients presenting with an acute airway, circulatory or neurologic problem, multi-system involvement, or penetrating injuries to the head, neck, or chest. These patients are likely to need the vast majority of resources and staff. 

Orange zone: Not originally categorized in the tag system. These patients are expected to decompensate within the hour but did not need immediate resuscitation [2]. 

Yellow zone: Patients that are relatively stable that will likely not decompensate within the hour. Extremity injuries or conditions that have time to be worked up. 

Green zone: Patients with minor injuries that are unlikely to decompensate. “Walking wounded.” Will not require vast amounts of resources or staffing to be cared for. 

The different zones allow for a dynamic system. Patients in each zone will be cared for by a team of physicians and nurses with the majority of staffing located in Red and Orange zones. Patients can be moved “up” a zone (from yellow to orange) if their condition deteriorates or could be moved “down” a zone (from yellow to green) if they are able to be stabilized [1, 2, 3]. The “black tag” patients were not categorized into a zone as they were patients who were either already dead, or not likely to survive given the current staffing and resources available. Figure 3 shows a brief triaging algorithm (without the orange designation). This is one possible system to triage patients and get them to an appropriate level of care rapidly. The hospital system is now ready for the rapid influx of critical patients.

Implementation

All patients should enter through a single triage area. Multiple points of entry can cause confusion and overwhelm each area by not knowing the number of patients entering from each point [4]. As the number of patients in each zone starts to fill up, adequate communication about the space and number of resources available should be communicated to the DMO and charge nurse. Once patients are able to be stabilized in each zone, the goal is to get them to the OR for immediate surgery if needed, or to move them down a zone (yellow to green) in order to make space for additional critically injured patients.  

Who are the first patients to arrive? The “dual wave phenomenon” explains how patients usually present to the hospital following MCIs. The first wave of casualties are described as the “walking wounded” or those who are able to self-ambulate and usually only require minor care. These patients begin to arrive within 15-30 minutes of the incident depending on the distance from the scene to the hospital. It is important that these patients do not take up too many hospital resources or staff as they are likely well enough to survive with minimal therapeutic interventions. These patients can easily overwhelm the system and prevent proper care to more critical patients. The second wave includes the patients that arrive via EMS or other assistance from bystanders as they are not well enough to transport themselves. These are the patients who will require a vast majority of hospital staffing, resources, and time in order to prevent deaths [3, 4]. 

Summary

• The first step to preparing for an MCI is having a plan in place.

• GET HELP. If you only have time to do one thing it should be this. It does not matter how many resources you have or how much space is available if you do not have enough staff to use them.

• Have a triage plan. Create zones of various acuity with the majority of staff occupying the higher acuity areas. Patients can always be moved to a higher zone if they need more care or a lower zone if they have been stabilized. 

• Get patients to the proper provider. If the patient needs surgery, get them to the OR. This also creates space for new patients to be seen.

• Have one single area of entry. This allows the system to maintain consistency and flow. 

References

1. Emergency Safety Officer Management Plan For Mass Casualty. Kings County Hospital Center, www.downstate.edu/emergency_medicine/pdf/KCHCSection03.pdf. 

2. Menes, Kevin. “How One Las Vegas ED Saved Hundreds of Lives After the Worst Mass Shooting in U.S. History: Emergency Physicians Monthly.” EPM, 5 Apr. 2020, epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooting-u-s-history/. 

3. Hospital Medical Surge Planning for Mass Casualty Incidents. Florida Department of Health, www.urmc.rochester.edu/MediaLibraries/URMCMedia/flrtc/documents/WNY-Hospital-Medical-Surge-Planning-For-Mass-Casualty-Incidents.pdf. 

4. Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. https://doi.org/10.17226/11621

5. “SALT Mass Casualty Triage Algorithm - CHEMM.” U.S. National Library of Medicine, National Institutes of Health, chemm.nlm.nih.gov/salttriage.htm. 

6. “Report: Mass Casualty Trauma Triage Paradigms and Pitfalls .” Journal of Emergency Medical Services , Office of the United States Assistant Secretary for Preparedness and Disaster Response. 

7. DeNolf, Renee L. “EMS Mass Casualty Management.” StatPearls [Internet]., U.S. National Library of Medicine, 15 Oct. 2020, www.ncbi.nlm.nih.gov/books/NBK482373/. 

8. “Mass Casualty Predictor .” Homeland Security Digital Library , Centers for Disease Control and Prevention . 

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Expert Commentary

This is a great review of MCI management in the Emergency Department by Drs. Grace and Rogers. Although the past few years of the COVID-19 pandemic have felt like we’ve been working in a perpetual MCI, these are important principles to review on a regular basis, as they are not something we necessarily practice every day in the emergency department.

The authors do a good job of emphasizing the importance of preparing for an MCI ahead of time. Another important aspect of preparation is decontamination. An ED disaster response plan should incorporate how to effectively put patients (both walk-ins and EMS arrivals) through decontamination if the disaster at hand requires it. The authors emphasize the importance of having patients enter through a single triage area, and the decontamination station should be similarly set up nearby allowing for one-directional flow of patients through the decontamination process. This is not only vital to patient treatment but also to ensuring staff safety. Additionally, it is necessary to ensure that the ED has sufficient and adequate level Personal Protective Equipment and that the appropriate staff are trained on donning/doffing procedures. 

In addition to gathering the staffing resources, there should also be an emphasis on gathering disaster-specific supplies: alerting the blood bank if it is a traumatic MCI, amassing antidotes if it is toxicological in nature, compiling medical equipment (such as ventilators) as applicable, etc. Additionally, alerting other EDs in the system as to the impending influx of patients as well as reaching out to disaster-specific specialty centers (ie, hyperbarics facility for a structure fire for carbon monoxide treatment) can also help take pressure off and allocate more resources. 

Finally, the importance of a hotwash or after-action review cannot be emphasized enough. This is a process by which participants can have an open and honest professional discussion about what went well and what can be improved in the future. It centers around four main questions (What was supposed to happen? What did happen? What caused the difference? What can we learn from this?) and is vital for building an ED’s capacity for conducting an adequate emergency response to an MCI. 

References

1. Blackwell, T.H., DeAtley, C., Yee, A. (2021). Medical support for hazardous materials response. Cone, D.C. (ed). Emergency Medical Services Clinical Practice and Systems Oversight; Volume 2: Medical Oversight of EMS. (3rd edition, p339-351). UK: John Wiley and Sons, Ltd. 

2. Greenberg, T., Adini, B., Eden, F., Chen, T., Ankri, T., Aharonson-Daniel, L. An after-action review tool for EDs: learning from mass casualty incidents. Am J Emerg Med. May 2013;31(5):798-802. Doi 10.1016/j.ajem.2013.01.025. Epub 2013 Mar 6. PMID: 23481154.

3. Metz, T. How to Facilitate an After-Action Review (AAR or Hot Wash): Agenda and Tips. MG Rush Facilitation Training & Meeting Design. https://mgrush.com/blog/after-action-review/. 

4. Salem-Schatz, S., Ordin, D., Mittman, B. Guide to the after action review. Center for Evidence-Based Management. Oct 2010.  https://www.cebma.org/wp-content/uploads/Guide-to-the-after_action_review.pdf.

Andra Farcas, MD

Emergency Medicine & EMS Physician

CU Department of Emergency Medicine

University of Colorado School of Medicine

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Grace, A. Rogers, A. (2021, Apr 26). Proper Preparation for Mass Casualty Incidents. [NUEM Blog. Expert Commentary by Farcas, A]. Retrieved from http://www.nuemblog.com/blog/mass-casualty-incident-preparation

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Nephrolithiasis: Ultrasonography versus Computed Tomography

Written by: Kishan Ughreja , MD (NUEM ‘23) Edited by: Ade Akhentuamhen, MD (NUEM ‘21)
Expert Commentary by: Tim Loftus, MD, MBA

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Journal Club: Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis

A 70-year-old man with BPH s/p TURP, hypertension, hyperlipidemia and stroke presents to the ED with acute onset of intermittent sharp left flank pain radiating into the groin that awoke him from sleep. He endorses nausea without vomiting and denies fever. He also endorses slightly decreased urination with “dribbling.” His urinalysis shows >100 RBC and no signs of infection. Nephrolithiasis is likely high on your differential diagnosis. How do you proceed?

What is your initial imaging test of choice, ultrasound (US) or non-contrast CT, and why?

Would you be satisfied with only US and no follow-up CT?

Would you be confident in a point-of-care-ultrasound evaluation or a formal ultrasound?

Do outcomes for patients with suspected nephrolithiasis differ based on the initial imaging?

Should your medical decision-making change if the patient has a history of nephrolithiasis?

What would you do if the same patient presented again with persistent pain from a previously diagnosed stone?

Pain from suspected nephrolithiasis is a very common complaint in the ED and the incidence of the disease continues to increase. The estimated incidence over the past two decades is up to 340 visits per 100,000 individuals.1 Low-dose non-contrast abdominal CT has become the gold standard for diagnosis as it has become readily available in emergency departments nationwide, with some studies touting sensitivity and specificity of 97% and 95%, respectively.2  However, low dose CT still exposes the patient to radiation and may increase their risk of cancer, as many nephrolithiasis patients often undergo repeat imaging because of recurring pain or urological intervention. Additionally, CT scans prolong average ED lengths of stay.  However, with ultrasonography becoming more prevalent in EDs, it may be possible that initial imaging may avoid this radiation risk and still have similar outcomes for patients. Let’s analyze this NEJM article comparing US to CT for the assessment of nephrolithiasis.

Study design: a multicenter, pragmatic, randomized comparative effectiveness trial

Population

• N = 2759

• ages 18- 76 yo

• reported flank or abdominal pain that the treating physician wished to order imaging to establish or rule out a primary diagnosis of nephrolithiasis

• not considered at high risk for serious alternative diagnoses e.g. cholecystitis, appendicitis, aortic aneurysm, or bowel disorders

• no pregnant patients

• no men >129 kg, no women >113 kg

• no history of single kidney, renal transplantation, undergoing dialysis

Patient selection

Intervention protocol

• patients randomized to 3 groups each using a different initial imaging modality (POCUS vs. Radiology US vs. CT)

• patients contacted at 3, 7, 30, 90, and 180 days after randomization to assess study outcomes

Outcome measures

Primary Outcomes

• high-risk diagnoses with complications that could be related to missed or delayed diagnoses — within 30 days of ED visit, including:

• AAA w/rupture, PNA w/sepsis, appendicitis w/rupture, diverticulitis w/abscess or sepsis, bowel ischemia or perforation, renal infarction, renal stone w/abscess, pyelonephritis w/urosepsis or bacteremia, ovarian torsion w/necrosis, aortic dissection w/ischemia

• cumulative radiation exposure from all imaging within 6 months after randomization

• total cost (not reported in this study, ongoing analysis)

Secondary Outcomes

• serious adverse events (FDA definition) 

• serious adverse events related to study participation

• delayed diagnosis, like acute cholecystitis, appendicitis, bowel obstruction

• return ED visits

• hospitalizations after being discharged from ED

• self-reported pain scores

• diagnostic accuracy for nephrolithiasis

• by comparing ED diagnosis at discharge to reference standard of confirmed stone by patient’s observation of passage or report of surgical removal

Results

• no significant differences among groups in terms of pain scores, medical history, physical exam findings, and ED physician’s assessment of the likelihood of other diagnoses (Table 2)

• POCUS and US groups had significantly lower cumulative radiation exposure over 6 months than the CT group (difference attributed to initial ED visit’s imaging choice)

• 11 patients (0.4%) had high risk diagnoses with complications during first 30 days after randomization, with no significant difference among the 3 groups

• no difference when stratified by patients with a history of nephrolithiasis

• no significant difference among groups in the number of patients with serious adverse events; total of 466 SAE in 316 patients (91.4% were hospitalizations during f/u period; 26.4% involved surgical treatment of complications of nephrolithiasis)

• 5 reported deaths (occurred between 38 and 174 days after randomization) — none thought to be related to study participation

• the proportion of patients with a confirmed stone diagnosis within 6 months was similar in all 3 groups (POCUS 34.5% vs. US 31.2% vs. 32.7% CT)

• diagnostic accuracy based on result of initial imaging modality

  • POCUS          sensitivity 54% [48 - 60]; specificity 71% [67 - 75]

  • US                   sensitivity 57% [51 - 64]; specificity 73% [69 - 77]

  • CT                   sensitivity 88% [84 - 92]; specificity 58% [55 - 62]

Interpretation

• The US group was exposed to less radiation than the CT group and had no significant differences in the incidence of high-risk diagnoses with complications, total serious adverse events, or related serious adverse events.

• There also were no significant differences in pain scores, hospitalizations, ED readmissions among the groups.

• Many patients in the ultrasound groups did get additional imaging, but this was not the majority.

• Patients with a history of nephrolithiasis were less likely to undergo additional imaging with CT if they already had an ultrasound first (31% vs 36%). They did not have poorer outcomes than patients without a history of nephrolithiasis.

• Patients only undergoing POCUS and no other testing had a significantly shorter ED stay (1.3 hours)

• It is safe to pursue ultrasound as the initial imaging of choice for suspected nephrolithiasis (with additional imaging ordered as necessary at clinical discretion), though it should not necessarily be the only testing performed.

Strengths

• large size, diversity in ED settings, randomized design, assessment of clinically important outcomes, a high follow-up rate

Weaknesses

• no blinding of investigators, physicians, or patients as this was a pragmatic trial design

• independent review was used to characterize serious adverse events related to study participation

• strict reference standard for stone diagnosis which was unbiased, but prone to error based on the patient’s memory of self-reporting of stone passage

Internal/external validity

• Given the aforementioned strengths of this study and its pragmatic design, these findings appear both internally and externally valid and may be applied to daily clinical practice

Take-Home Points

What is your initial imaging test of choice, ultrasound (US) or non-contrast CT, and why?

• Ultrasound is a good choice for initial imaging as most patients do not end up requiring additional imaging during their visit. This leads to reduced cumulative radiation exposure.

Would you be satisfied with only US and no follow-up CT?

• In this study, 40.7% of those in the POCUS group and 27% in the formal ultrasound group underwent subsequent CT. Follow up CT should depend on the patient and ultrasound operator. Keep in mind that this study excluded patients with kidney disease, pregnant patients, and obese patients. They also excluded patients who were high risk for other pelvic and abdominal diseases. Lastly the POCUS operators were ED physicians with training “recommended by ACEP.”

Would you be confident in a point-of-care-ultrasound evaluation compared to a formal ultrasound?

• Yes. Sensitivity and specificity between these groups were similar.

Do outcomes for patients with suspected nephrolithiasis differ based on the initial imaging?

• No. There was no significant difference in subsequent adverse events, pain, return visits or hospitalizations, or delayed diagnoses of other serious conditions.

Should your medical decision-making change if the patient has a history of nephrolithiasis?

• In this study, patients with a history of nephrolithiasis were less likely to undergo additional imaging with CT if they already had an ultrasound first. They did not have poorer outcomes than patients without a history of nephrolithiasis. This suggests that it is safe to avoid ordering a CT in patients with recurrent stones.

What would you do if the same patient presented again with persistent pain from a previously diagnosed stone?

• The majority of patients with adverse outcomes were due to infectious causes. Consider alternative diagnoses such as pyelonephritis. Additionally, although rare, renal infarct can present with acute flank pain and is diagnosed with a contrast CT.

References

1. Fwu, C. W., Eggers, P. W., Kimmel, P. L., Kusek, J. W., & Kirkali, Z. (2013). Emergency department visits, use of imaging, and drugs for urolithiasis have increased in the United States. Kidney international, 83(3), 479-486.

2. Coursey, C. A., Casalino, D. D., Remer, E. M., Arellano, R. S., Bishoff, J. T., Dighe, M., ... & Leyendecker, J. R. (2012). ACR Appropriateness Criteria® acute onset flank pain–suspicion of stone disease. Ultrasound quarterly, 28(3), 227-233.

3. Smith-Bindman, R., Aubin, C., Bailitz, J., Bengiamin, R. N., Camargo Jr, C. A., Corbo, J., ... & Kang, T. L. (2014). Ultrasonography versus computed tomography for suspected nephrolithiasis. New England Journal of Medicine, 371(12), 1100-1110.

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Expert Commentary

Thank you very much to Dr.’s Ughreja and Akhetuamhen for an excellent blog post on a very relevant clinical topic.  This is a great summary of the landmark randomized trial published in NEJM in 2014 assessing CT vs two types of US for patients with suspected renal colic in the ED setting.  It is worth mentioning that this study was a multicenter study based in the US with representation from ED, Radiology, and Urology.  The above study was well summarized and bears repeating that, in this multicenter randomized study assessing CT vs POCUS vs radiology performed US in patients with suspected renal colic in the ED setting, initial US reduced radiation exposure without adversely affecting patient-centered outcomes.  It is worth mentioning several additional considerations and placing emphasis on others elucidated from this journal club review.

First, a subsequent systematic review (1) incorporating multispecialty (ED, Radiology, Urology) expert panel consensus recommendations has reiterated that in younger patients without a high suspicion for alternative diagnoses or complicating features of nephroureterolithiasis (such as fever, pyelonephritis, solitary kidney, dialysis, etc), US should be the initial diagnostic imaging modality of choice, if any.  It's a great paper, worth reading (and appreciating who the authors are), and worth recalling for bedside teaching to junior learners in the ED. 

Additionally, this paper brings to mind my second point, and something that is worth shouting from the hilltops -- a kidney stone is a clinical diagnosis!  Now, of course, this is exclusive of those patients with high-risk or complicating features (e.g. pediatrics, pregnancy, solitary kidney, fever, unstable/critically ill, unrelenting pain, atypical features, etc).  You don’t need any imaging to tell you the diagnosis in the vast majority of patients.  US or CT are helpful in confirming the diagnosis when there is uncertainty or non-trivial pretest probability of alternative diagnoses, excluding alternative diagnoses, and identifying exact stone location and size, which can be used to help counsel patients at the bedside regarding the anticipated clinical course and next steps in management. 

 Third, for those with proper training, and with some exceptions (see the systematic review paper for case vignettes that highlight these), POCUS is non-inferior to radiology-performed US.  And, it's not a “formal” US.  I can’t remember the last time I attended a black-tie ultrasonography session, but that's just me. 

 Fourth, it's worth mentioning that although CT use can lead to the identification of incidental findings more commonly than US, identification of these incidental findings still happens rather often with POCUS (a common example is a renal cyst).  Please ensure that you document and discuss with the patient accordingly.

 Finally, a burden on us as EM clinicians is training in and awareness of clinical practice guidelines and recommendations from specialties outside of EM.  As it relates to the diagnostic evaluation of suspected renal colic in the ED setting, the Choosing Wisely recommendations endorsed by the AUA are worth perusing as are the European/EUA guidelines, both of which suggest US as the initial diagnostic imaging modality of choice, for pediatric (CW) and non-high-risk patients without complicating features (EUA).

The bottom line is that CT is helpful for older patients or those in whom you are less sure about the diagnosis of renal colic.  For younger or low-risk patients, suspected renal colic is a clinical diagnosis and often needs no imaging, but ultrasound would be an evidence-based first step.  Thanks again toDr.’s Ughreja and Akhetuamhen.

References

1) Moore et al. Imaging in suspected renal colic: a systematic review of the literature and multispecialty consensus. J Urol 2019. 202(3):475-483.

Tim Loftus, MD, MBA

Assistant Professor of Emergency Medicine

Fellowship Director of the Clinical Operations and Administration Fellowship Program, Northwestern Department of Emergency Medicine

Medical Director of Emergency Services Northwestern Lake Forest Hospital and Grayslake Emergency Center

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Ughreja, K. Akhentuamhen, A. (2022, May 16). Journal Club: Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis. [NUEM Blog. Expert Commentary by Loftus, T]. Retrieved from http://www.nuemblog.com/blog/nephrolithiasis-ultrasonography-versus-computed-tomography.

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Neuroleptic Malignant Syndrome

Written by: Maren Leibowitz, MD (NUEM ‘23) Edited by: Nick Wleklinski, MD (NUEM ‘22)
Expert Commentary by: Zachary Schmitz, MD (NUEM '21)

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Expert Commentary

This is an awesome, focused review of neuroleptic malignant syndrome (NMS). NMS is hard to diagnose because it's rare. There is no gold standard with respect to its definition, and it requires a medication history (which we typically don't do very well in the emergency department). A tricky cause of NMS is the removal of a dopamine agonist. For this reason, carbidopa/levodopa should never be discontinued during hospital admission - or ED boarding. [1]

Supportive care is more important than antidotal therapy during NMS management. The most acute cause of death from NMS is hyperthermia, which is induced both by D2 receptor antagonism leading to rigidity and impaired thermoregulation from the striatum and hypothalamus. Any life-threatening hyperthermia should be treated immediately with an ice bath.[2] Rigidity will lead to rhabdomyolysis with subsequent hyperkalemia and myoglobin-induced renal failure. Therefore, fluid resuscitation and maintenance are important. Profound immobility can precipitate DVT, so anticoagulation may be necessary.

In terms of pharmacotherapy, benzodiazepines are universally used. Dantrolene inhibits calcium-mediated muscle contraction to reduce muscle rigidity. However, it doesn't address the underlying central D2 antagonism, and its efficacy has only been shown in case reports. Bromocriptine acts more centrally as a dopamine agonist but should be used cautiously in patients with psychiatric diseases as it may exacerbate psychosis. Overall, benzodiazepine use and supportive care should get you through most cases of NMS, though additional therapies may be necessary in severe cases.

References

1. Institute for Safe Medication Practices. Delayed Administration and Contraindicated Drugs Place Hospitalized Parkinson’s Disease Patients at Risk. 12 March 2015. Accessed February 11, 2022.

2. Juurlink JN. Antipsychotics. In: Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. eds. Goldfrank's Toxicologic Emergencies, 11e. Page 1037-1039. McGraw Hill; 2019. Accessed February 11, 2022.

Zachary Schmitz, MD

Toxicology Fellow

Ronald O. Perelman Department of Emergency Medicine

NYU Langone Health

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Leibowitz, M. Wleklinski, N. (2022, May 9). Neuroleptic Malignant Syndrome. [NUEM Blog. Expert Commentary by Schmitz, Z]. Retrieved from http://www.nuemblog.com/blog/neuroleptic-malignant-syndrome.

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Beyond the Burns: Toxic House Fire Gases

Written by: Adam Payne, MD (NUEM ‘24) Edited by: Emily Wessling, MD (NUEM ‘22)
Expert Commentary by: Justin Seltzer, MD (NUEM ‘21)

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Expert Commentary

Congratulations to Drs. Payne and Wessling on an excellent post. 

Management of toxic gas exposure from a house fire is essential knowledge for all emergency physicians. The two major toxic gases of interest are carbon monoxide and hydrogen cyanide; it is important to note that fires in other environments, such as factories or industrial sites, may result in alternative exposures based on the nature of the fire and materials present. The post goes into detail on the pathophysiology, signs, symptoms, and diagnosis of both carbon monoxide and cyanide poisonings, so this commentary will focus on the clinical approach. 

I recommend the following simplified process to streamline diagnosis and treatment decision making:

1. Start high flow oxygen (15L NRB) immediately (or, if intubated, give 100% FiO2)

High flow oxygen reduces the half life of carbon monoxide from ~5 hours to ~90 minutes. Oxygen can be discontinued once carboxyhemoglobin normalizes (<2%)

2. Obtain a carboxyhemoglobin level, lactic acid level, and a venous blood gas (arterial is unnecessary unless oxygenation is also a concern) as soon as possible

Unfortunately, there is some disagreement as to what constitutes a “toxic” carboxyhemoglobin level. Weaver, et al. established 25% as an inflection point for the development of severe sequelae, which is now a commonly used (though not universally agreed upon) threshold value. Also, when evaluating a carboxyhemoglobin level, it is essential to consider the time period prior to the level being drawn to avoid false reassurance. For example, a level drawn after 90 minutes of high flow oxygen will be reduced by roughly 50% and interpreted accordingly. Further, do not rely on external co-oximeters alone to rule out carbon monoxide poisoning given limited sensitivity at the moment (though the technology will likely improve over time).

3. Treat with hydroxocobalamin empirically if symptomatic and/or if lactic acid elevated 

Hydroxocobalamin is a low risk intervention with significant potential therapeutic benefit, so it should be given early if there is any clinical concern. The other major cyanide antidote, sodium thiosulfate, should only be used if hydroxocobalamin is not available as it has no efficacy advantage and an undesirable side effect profile. It is essential to avoid using nitrites, as inducing methemoglobinemia in the setting of coincidental carbon monoxide poisoning can dramatically worsen tissue hypoxia.

An elevated lactic acid is a surrogate for cyanide poisoning, specifically a level of 8-10 mmol/L or greater is sensitive and should prompt intervention. More modest lactic acid elevations are less likely to be related to cyanide poisoning and should not prompt intervention, especially in an asymptomatic patient, unless the level is persistently elevated despite adequate resuscitation. Cyanide levels, while diagnostic, are of no acute clinical utility since they are rarely available in a timely manner. 

4. Consider hyperbaric oxygen therapy (HBOT) if readily available

HBOT for the treatment of carbon monoxide poisoning is controversial. While HBOT reduces the half life of carbon monoxide to roughly 20-30 minutes, HBOT is not used for this purpose alone. In fact, HBOT is primarily used to reduce associated cognitive, behavioral, and neurologic changes (collectively known as delayed neuropsychiatric sequelae). There is lower quality evidence for reduced myocardial infarction and mortality risk as well. 

However, several factors limit HBOT use. Primarily, it is not universally available at most institutions, incurring the risk and cost of transport to a distant site. The benefit is thought to be highest when the treatment is performed early (ideally within six hours of exposure), which adds to the logistical burden. Additionally, many chambers are not operated on nights and weekends, and of those available at off hours, many are unable to accommodate intubated patients. Recognizing the controversial nature of HBOT, the 2016 ACEP position statement noted that HBOT or high flow, normobaric oxygen can be used to treat carbon monoxide poisoning; though it likely carries clinical benefit in certain situations, at this time HBOT is not the standard of care for severe carbon monoxide poisoning. Rather, it should be offered if it can be readily and reasonably arranged.

Keeping this in mind, the following are generally accepted indications for HBOT in the setting of carbon monoxide poisoning

• Loss of consciousness associated with exposure

• Altered mental status

• Focal neurologic changes

• Evidence of end organ ischemia (pH ≤ 7.1, EKG changes, elevated troponin, angina)

• Pregnancy (with some resources citing a level ≥20%)

• Carboxyhemoglobin level ≥25%

Importantly, these are not hard and fast rules and there is no firm guideline mandating when HBOT should or should not be used. As a result, it is prudent to involve a medical toxicologist early in the process. 

In summary, a few key take home points:

• Carbon monoxide and cyanide are strongly associated with house fires – assume exposure to both until proven otherwise

• It is reasonable to treat any undifferentiated, symptomatic patient with high flow oxygen and hydroxocobalamin empirically; asymptomatic patients can wait safely for blood work on high flow oxygen alone

• The decision making regarding use of HBOT, in particular, is complex – early consultation with a medical toxicologist is strongly encouraged

Justin Seltzer, MD

Toxicology Fellow

Department of Emergency Medicine

University of California, San Diego

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Payne, A. Wessling, E. (2022, May 2). Toxic House Fire Gases. [NUEM Blog. Expert Commentary by Seltzer, J]. Retrieved from http://www.nuemblog.com/blog/toxic-house-fire-gases

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Traumatic Arthrotomy

Written by: Parisa Kermani, MD (NUEM ‘23) Edited by: Alex Herndon, MD (NUEM ‘21)
Expert Commentary by: Matt Levine, MD

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Case: A 25-year-old male comes into the ER after a saw accident at work.  The patient was using a circular saw to cut wood when it slipped and the saw touched up against his knee.  The patient has a 10cm linear vertical laceration over the anterior surface of his left knee (Figure 1). Bleeding is controlled. Patient ambulatory.  Reporting 10/10 pain over the laceration.  

What are the next best steps for evaluation and treatment of his injury?

Figure 1: Knee laceration

Background

Traumatic arthrotomy is defined as a soft tissue injury over a joint that penetrates the joint space.  Violation of the joint capsule exposes the sterile intra-articular space to the environment which can result in a deep infection and sepsis.   The morbidity associated with septic arthritis is high, so it is important that providers have a high index of suspicion when evaluating wounds over joint surfaces.  

The knee joint is the most common joint to be affected, followed by the ankle.  Penetrating injuries have a higher rate of capsule violation so a history of knives or bullets should raise suspicion, though MVCs, falls, motorcycle accidents can also result in a deep injury.  The capsule has little protection lateral to the patella (Figure 2 & 3), so even if the laceration does not appear deep there is potential that it penetrates the joint space.  

Figure 2: Knee capsule anatomy

Figure 3: Knee CT scan

Evaluation

Exploration: The first step of evaluation is local wound exploration.  It is useful to anesthetize the wound at this point, as this will make the patient more comfortable and allow for a better exam.  Irrigate the wound with sterile saline.  It is extremely important to visualize the base of the wound.  Using a hemostat or q-tip to probe the tissue at the base can be helpful as to not miss any tunneling segments.  Keep a close eye out for bubbles, synovial fluid (appears straw colored and oily) or visible bone/tendon as all of these indicate joint involvement.   It is important to note that the absence of these findings does not rule out a traumatic arthrotomy.   

X-ray: Many times, next step will be to get an X-ray to look for associated fractures.  Though this is not the most sensitive test for evaluating for joint space violation, if you see intra-articular air, this signifies joint involvement and no further imaging is required before calling the orthopedic surgeons.  Many times, the X-ray will be normal and further testing will need to be completed.  Of note, an x-ray is not required if there is no concern about injury to the bone as it is unlikely going to give a definitive answer on traumatic arthrotomy in less obvious cases.   
CT Scan: As far as imaging goes, CT scan is the imaging modality of choice for traumatic arthrotomy. Though not currently the gold standard for ruling out joint violation, CT scan has become more accepted as an alternative to saline load testing the joint. Although limited, a 2013 study by Konda et al, where direct arthroscopic visualization or septic arthritis at follow-up were used as the gold standard for diagnosis, found imaging by CT scan to be 100% sensitive and specific for diagnosing traumatic knee arthrotomy. When viewing a CT scan to evaluate for traumatic arthrotomy, the presence of gas in the joint, known as pneumarthrosis, indicates intra-articular extension (Figure 4).

Figure 4: Traumatic arthrotomy on CT scan

Source: Konda et al, 2013

Saline Load Test (SLT): Though not strongly backed by the literature, SLT is a standard tool used to assess for traumatic arthrotomy. SLT is done by performing an arthrocentesis of the affected joint away from laceration, once confirmed in the correct space, sterile saline is injected into the joint and the laceration site is observed for extravasation. The provider should also passively range the joint while injecting to ensure greater sensitivity. Table 1 below summarizes how much sterile saline should be injected to obtain 95% sensitivity for traumatic arthrotomy. Adding methylene blue to the saline has not been proven to increase sensitivity and generally no longer recommended. The sensitivity will be highly variable based on provider experience with the procedure and patient tolerance. It is important to remember that this procedure can be exquisitely painful and special attention should be paid towards the patient’s comfort.

Table 1: Amount of saline for 95% sensitivity SLT

Because strong, conclusive literature is lacking, the choice between CT versus SLT to rule out traumatic arthrotomy will depend on many different factors including provider procedural comfort, local practice patterns, available resources and patient input.   

Treatment

Once a diagnosis of traumatic arthrotomy is confirmed through an above modality, orthopedics should be emergently consulted.  Tetanus prophylaxis should be updated and the patient should be started on an IV antibiotic that covers both strep and staph.  A 1st generation cephalosporin is usually sufficient.   Other antibiotics should be considered if injury is from a human/animal bite, happened underwater, or if there is concern for fecal/other contamination. Definitive treatment is joint wash out in the Operating Room. 

If the above modalities do not show evidence of arthrotomy the patient’s laceration may be repaired in usual fashion.  The patient should be given strict return precautions and have close follow-up for wound/joint reevaluation and suture removal. 

Sources

Browning BB, Ventimiglia AV, Dixit A, Illical E, Urban WP, Jauregui JJ. Does the saline load test still have a role in the orthopaedic world? a systematic review of the literature. Acta orthopaedica et traumatologica turcica. 2016;50(6):597-600. doi:10.1016/j.aott.2016.01.004

Gittings D, Dattilo J, Fryhofer G, Martin A, Hast M, Mehta S. The saline load test is effective at diagnosing traumatic arthrotomies of the shoulder. Journal of surgical orthopaedic advances. 2019;28(4):268-271.

Gittings DJ, Fryhofer GW, Hast MW, Steinberg DR, Levin LS, Gray BL. The saline load test is effective at diagnosing traumatic arthrotomies of the wrist. Techniques in hand & upper extremity surgery. 2019;23(2):59-61. doi:10.1097

Jonathan Michael Strong. Saline Load or CT: What’s the Best Test for Traumatic Arthrotomy. Acepnow magazine. 2020; https://www.acepnow.com/article/saline-load-or-ct-whats-the-best-test-for-traumatic-arthrotomy

Konda SR, Howard D, Davidovitch RI, Egol KA. The saline load test of the knee redefined: a test to detect traumatic arthrotomies and rule out periarticular wounds not requiring surgical intervention. Journal of orthopaedic trauma. 2013;27(9):491-497. doi:10.1097/BOT.0b013e31828211f3

Konda SR, Davidovitch RI, Egol KA. Computed tomography scan to detect traumatic arthrotomies and identify periarticular wounds not requiring surgical intervention: an improvement over the saline load test. Journal of orthopaedic trauma. 2013;27(9):498-504. doi:10.1097/BOT.0b013e31828219bc

Metzger P, Carney J, Kuhn K, Booher K, Mazurek M. Sensitivity of the saline load test with and without methylene blue dye in the diagnosis of artificial traumatic knee arthrotomies. Journal of orthopaedic trauma. 2012;26(6):347-349. doi:10.1097/BOT.0b013e3182255167

Nord RM, Quach T, Walsh M, Pereira D, Tejwani NC. Detection of traumatic arthrotomy of the knee using the saline solution load test. The journal of bone and joint surgery american volume. 2009;91(1):66-70. doi:10.2106/JBJS.G.01682

Timothy D. Roberts. Traumatic arthrotomy with pneumarthrosis on plain radiograph of the knee. Western journal of emergency medicine. 2016;17(2):184-185. doi:10.5811/westjem.2015.12.29317

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Expert Commentary

What a great review of traumatic arthrotomy!  You now have a concise reference that teaches you everything you would probably ever need to know about this tricky diagnosis!  These injuries are so uncommon that the first hurdle to overcome is actually considering the diagnosis. If you don’t consider it, then you hopefully just get lucky by a diagnostic x-ray that was ordered for other reasons!

Physical exam and exploration is indeed important but has limitations and does not rule out the diagnosis if the suspicion is high enough.  The tract may be small, jagged, or there may be soft tissue destruction that limits your visualization.  Be sure to inspect the wound while passively ranging the joint in question since it is often unclear the precise position of the joint (fully flexed, fully extended, or somewhere in between) when the wound occurred.  This may bring the wound tract into your field of view.  Ideally your exploration should be in a bloodless, painless field and documented as such.

While x-rays lack sensitivity, they are a worthwhile starting point since they are less expensive, noninvasive, readily available, and you can stop if they are positive.  X-rays may also better define the extent and trajectory of the wound tract which my either heighten your suspicion or provide reassurance that the trajectory was away from the joint.

If the diagnosis is still in question, I prefer CT in most scenarios.  It provides additional information about any associated fractures.  CT is painless.  Intra-articular air is very easy to see on CT.  The downside is increased cost.  Saline load testing seems to have more room for error.  The joint must be properly entered.  Enough fluid must be injected to fill the joint enough to cause visible extravasation.  And the diagnosis can still be missed if it is forgotten to range the joint during the SLT.  It is also quite painful.  Consider all the patients you see who present with a painful joint effusion that has gradually accumulated.  In the SLT you are giving the patient a sudden acute joint effusion. Ouch! So just be thoughtful about the route you choose to go.

Matthew Levine, MD

Associate Professor

Department of Emergency Medicine

Northwestern Memorial Hospital

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Kermani, P. Herndon, A. (2022, Apr 25). Traumatic Arthrotomy. [NUEM Blog. Expert Commentary by Levine, M]. Retrieved from http://www.nuemblog.com/blog/traumatic-arthrotomy

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Toxic Alcohols

Written by: Rafael Lima, MD (NUEM ‘23) Edited by: Laurie Aluce, MD (NUEM ‘21)
Expert Commentary by: Zachary Schmitz (NUEM ‘21)

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Methanol Toxicity

Methanol itself is not toxic to the body. Methanol’s metabolite, formic acid, causes toxicity at serum levels greater than 20mg/dl [1].

Clinical Findings of Methanol Poisoning

• CNS sedation

• Seizures

• Rapid, Deep Breathing

• Hypotension

• Ocular findings: 

  • Blindness 

  • Afferent pupillary defect

  • Optic disk hyperemia

  • Mydriasis
    

Ethylene Glycol Toxicity

Similarly, the toxic metabolites of ethylene glycol cause end-organ damage at levels greater than 20mg/dl. The most notable toxic metabolites are glycolic acid and oxalic acid.” [1] .

Clinical Findings of Ethylene Glycol Poisoning

• CNS sedation

• Seizures

• Cranial nerve palsies

• Rapid, deep breathing

• Hypotension

• Hypocalcemia (can result in tetany) 

• Renal findings: 

  • Oliguria

  • Acute renal failure

  • Flank pain

  • Hematuria

  • Oxalate crystals in the urine under fluorescence

Isopropyl Alcohol Toxicity

Found in hand sanitizers and disinfectants, isopropyl alcohol is a less common source of alcohol poisoning.  The parent molecule does exhibit toxic effects here, unlike methanol and ethylene glycol. If untreated, the lethal dose is between 4-8 g/kg [2].

Alcohol dehydrogenase metabolizes isopropyl alcohol into acetone. Because acetone is a ketone, and ketones are not oxidized into carboxylic acids, isopropyl alcohol poisoning does not result in anion gap metabolic acidosis. 

Clinical Findings of Isopropyl Alcohol Poisoning

• CNS sedation

• Disconjugate gaze

• Fruity breath odor

• Hypotension

• Hematemesis

• Pulmonary edema

Plasma Osmolal Gap

One of the most reliable laboratory markers of toxic alcohol poisoning is a large osmolal gap. The osmolal gap is defined as the difference between the measured serum osmolality and the calculated, or expected, plasma osmalality:

OSMOLAR GAP = Measured plasma osmolality – calculated/expected plasma osmolality 

The common equation for calculating the expected plasma osmolality is listed below [3]. Of note, there are other formulas with slight variations. Using an online calculator can be helpful. 

Expected Serum Osmolality=2[Na]+BUN/2.8+Glucose/18

A gap < 10 is considered normal. Any elevation above 10 should raise the clinician’s suspicion of toxic alcohol ingestion.

Note: this tool is not helpful in late presentations as the metabolized forms of the different alcohols do not contribute to the osmolal gap. The calculated gap will be falsely low in late-stage poisoning.

Treatment of Toxic Alcohol Ingestions

Consult your medical toxicologist or poison control center if toxic alcohol ingestion is suspected.

The national poison control center hotline telephone number is 1(800)-222-1222.

Fomepizole

Fomepizole should be used only for methanol and ethylene glycol ingestions. It is not indicated for isopropyl alcohol intoxications [4]. It is an inhibitor of alcohol dehydrogenase (ADH). Evidence shows that it is a superior antidote to ethanol [5]. 

• Loading dose 15 mg/kg IV

• Then 10 mg/kg every 12 hours

Continue until blood pH is normal and serum alcohol concentration is less than 20 mg/dL in the presence of retinal or renal injury.

Ethanol

Ethanol works as a competitive inhibitor of ADH, having a higher affinity for the enzyme compared to the other alcohols. Ethanol was used historically before the effects of fomepizole were studied. Fomepizole is now the preferred treatment because the administration of ethanol is more difficult, ethanol causes sedation, and titration of the therapy is challenging in co-ingestions [6]. If ethanol must be used, the preferred route is IV and the studied therapeutic target level is 100 mg/dL [7]. 

Supplemental Therapy

Methanol poisoning patients should also receive folic acid (50mg IV every 6 hours) [7].

Ethylene glycol poisoning patients should also receive thiamine  (100mg IV) and pyridoxine (50mg IV) [8].

Hemodialysis

Consult your nephrologist early if you are considering hemodialysis. Renal replacement therapy should be considered in the following situations [9]:

• Anion gap metabolic acidosis with known toxic alcohol ingestion

• End-organ damage

  • Renal failure

  • Vision changes

• Unexplained anion gap metabolic acidosis with elevated osmolal gap in suspected toxic alcohol ingestion

References

1. Liesivuori, J. and H. Savolainen, Methanol and formic acid toxicity: biochemical mechanisms. Pharmacol Toxicol, 1991. 69(3): p. 157-63.

2. Slaughter, R.J., et al., Isopropanol poisoning. Clin Toxicol (Phila), 2014. 52(5): p. 470-8.

3. Bhagat, C.I., et al., Calculated vs measured plasma osmolalities revisited. Clin Chem, 1984. 30(10): p. 1703-5.

4. Su, M., R.S. Hoffman, and L.S. Nelson, Error in an emergency medicine textbook: isopropyl alcohol toxicity. Acad Emerg Med, 2002. 9(2): p. 175.

5. McMartin, K., D. Jacobsen, and K.E. Hovda, Antidotes for poisoning by alcohols that form toxic metabolites. Br J Clin Pharmacol, 2016. 81(3): p. 505-15.

6. Zakharov, S., et al., Fomepizole versus ethanol in the treatment of acute methanol poisoning: Comparison of clinical effectiveness in a mass poisoning outbreak. Clin Toxicol (Phila), 2015. 53(8): p. 797-806.

7. Barceloux, D.G., et al., American Academy of Clinical Toxicology practice guidelines on the treatment of methanol poisoning. J Toxicol Clin Toxicol, 2002. 40(4): p. 415-46.

8. Ghosh, A. and R. Boyd, Leucovorin (calcium folinate) in "antifreeze" poisoning. Emerg Med J, 2003. 20(5): p. 466.

9. Moreau, C.L., et al., Glycolate kinetics and hemodialysis clearance in ethylene glycol poisoning. META Study Group. J Toxicol Clin Toxicol, 1998. 36(7): p. 659-66.

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Expert Commentary

Thank you for this great review of a difficult subject! The combination of a lack of quick, confirmatory testing with delayed onset of symptoms makes toxic alcohol poisoning an incredibly difficult diagnosis to make. Additionally, even small ingestion can lead to major complications. For example, if a typical four-year-old (19kg) child drank windshield washer fluid that contained 50% methanol (a fairly standard formulation), it would take only 5.7 mL to potentially produce a methanol serum concentration of 25 mg/dL. Given the average 4-year-old’s mouthful is 8.9 mL, you can run into trouble quickly.[1]

We frequently see misuse or misunderstanding of osmol and anion gaps in diagnosing toxic alcohol ingestion when history is unclear. First, although a normal osmol gap is generally less than 10, baseline osmol gaps range from -10 to +14.[2] Therefore, a gap of 16 may represent a true gap of +2 in one person and +26 in another. Second, ethanol must be included in the osmol gap equation. An ethanol concentration of 200 mg/dL would increase your osmol gap by 43.5. Third, given metabolism over time, all values included in an anion gap calculation need to be drawn off of the same blood sample.

These considerations make finding the diagnosis even more complicated, but there are a few things that can help you out. First, an osmol gap > 50 is highly concerning for toxic alcohol. Second, an ethanol concentration > 100 mg/dL is sufficient to block ADH, meaning that few toxic metabolites from methanol or ethylene glycol could be made.[3] This means that an anion gap present with an ethanol > 100 mg/dL is not from toxic alcohol (unless the patient drank the ethanol after the toxic alcohol, which is very rare). Third, sequential values over time can be helpful. Metabolism of toxic alcohols should lead to a decreased osmol gap and increased anion gap over time. Proper use of the osmol and anion gap can help identify patients at high risk for morbidity and mortality while decreasing unnecessary administration of fomepizole, which typically costs thousands of dollars.

References

1. Ratnapalan S, Potylitsina Y, Tan LH, Roifman M, Koren G. Measuring a toddler's mouthful: toxicologic considerations. Journal of Pediatrics. 2003 Jun;142(6):729-30. doi: 10.1067/mpd.2003.216

2. Hoffman RS, Smilkstein MJ, Howland MA, Goldfrank LR. Osmol gaps revisited: normal values and limitations. J Toxicol Clin Toxicol. 1993;31(1):81-93.  doi: 10.3109/15563659309000375.

3. Jacobsen D, McMartin KE. Methanol and ethylene glycol poisonings: mechanism of toxicity, clinical course, diagnosis and treatment. Med Toxicol. 1986;1:309-334.

Zachary Schmitz, MD

Toxicology Fellow

Ronald O. Perelman Department of Emergency Medicine

NYU Langone Health

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Lima, R. Aluce, L. (2022, Jan 24). Toxic Alcohols. [NUEM Blog. Expert Commentary by Schmitz, Z]. Retrieved from http://www.nuemblog.com/blog/toxic-alcohols

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Marine Envenomations

Written by: Michael Tandlich, MD (NUEM ‘24) Edited by: Chloe Renshaw, MD (NUEM ‘22)
Expert Commentary by: Justin Seltzer, MD (NUEM ‘21)

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Expert Commentary

An excellent post by Drs. Tandlich and Renshaw. Marine envenomations are common problems around the world. Like with land-based envenomations, the venomous organisms of note vary with geography; jellyfish encountered in Australia are different from those encountered in Florida, for example. As a result, we will focus on major envenomations in the United States. 

The invertebrates account for a large but ultimately unknown number of envenomations. Cnidaria includes jellyfish, hydrozoa, anemones, and fire coral. A majority of stings from this group result in painful dermatitis; tentacles create a “whip-like” pattern on the skin, whereas fire coral creates localized skin wheals. The sea nettle and Portuguese man-of-war are of greatest interest, given their potential to cause severe systemic symptoms. Box jellyfish are rare in US coastal waters but produce a life-threatening toxicity. 

Initial treatment is somewhat controversial. Many resources advocate for the use of seawater for the initial decontamination, given concern for vinegar triggering nematocyst release in some species common to US waters. However, further research is needed to determine which is best. At this time, seawater is recommended for empiric decontamination in the US unless a box jellyfish is strongly suspected, in which case vinegar is appropriate (a very rare circumstance). Systemically ill box jellyfish envenomations should be treated with pain and blood pressure control. The antivenom is not readily available in the US and is unlikely to be beneficial in the time course it would take to obtain it.

Echinodermata, which includes sea urchins, have mild venom on their spines that can cause local tissue irritation and pain. There are reports of severe envenomations with systemic symptoms, but this is ultimately quite rare. These injuries respond well to hot water immersion. Imaging and local wound exploration for retained spines are recommended. Soaking the wound in vinegar may help dissolve superficial spines.  

Of the vertebrates, stingrays and spiny fish are of primary concern. 

Stingrays stings are common and can cause serious penetrating trauma but envenomation mainly produces localized pain and swelling. The venom is heat-labile, so significant pain relief can be achieved with hot water immersion. Stingrays stings have the potential for both retained stinger and wound infections; evaluation for retained stinger with radiographs and local wound exploration is recommended along with prophylactic antibiotics. 

Spinyfish, in particular stonefish, lionfish, and scorpionfish, have venom located in their spines. Stonefish have the most potent venom of any known fish. Lionfish are not native to the US but have become an invasive species. Human contact with these fish occurs both in the wild and in aquariums. These fish also have heat-labile venom susceptible to hot water immersion. However, systemically ill stonefish envenomations should receive the antivenom as this envenomation can be life-threatening; the antivenom will likely work against other spiny fish too, however, these other envenomations are usually much less severe and rarely require more than hot water immersion and supportive care. 

So key learning points:

• Most marine envenomations involve heat-labile venom. Hot water immersion is likely to help reduce local symptoms.

• Systemic illness is rare but some marine envenomations can produce life-threatening toxicity. Be very wary of a systemically ill envenomation and try to figure out the source due to the limited availability of antivenoms.

• Prophylactic antibiotics are recommended for stingray stings as they tend to get infected but otherwise are generally not necessary in most populations. Good wound care, evaluation for retained foreign bodies, and tetanus prophylaxis are the mainstays. 

• For further information, see this review article 

Justin Seltzer, MD

UCSD Health Toxicology Fellow

Emergency Physician, UCSD Health

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Tandlich, M. Renshaw, C. (2022, Mar 7). Marine Envenomations. [NUEM Blog. Expert Commentary by Seltzer, J]. Retrieved from http://www.nuemblog.com/blog/marine-envenomations

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Crashing Patient on a Ventilator

Written by: Patrick King, MD (NUEM ‘23) Edited by: Adesuwa Akehtuamhen, MD (NUEM ‘21)
Expert Commentary by: Matt McCauley, MD (NUEM ‘21)

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Expert Commentary

Thank you for this succinct summary of an incredibly important topic. We as emergency physicians spend a lot of time thinking about peri-intubation physiology but the challenges do not end once the plastic is through the cords. The frequency with which our ventilated patients stay with us in the ED has been increasing for years and will likely continue to do so1. This means that managing both acute decompensation and refractory hypoxemia needs to be in our wheelhouse. 

The crashing patient on the ventilator can be truly frightening and your post effectively outlines a classic cognitive forcing strategy for managing these emergencies. A truism in resuscitation is to always rule out the easily correctable causes immediately. In this case, it means removing the complexity of the ventilator and making things as idiot-proof as possible. Once you’ve ruled out the life threats like pneumothorax, tube displacement, and vent malfunction, you can try to bring their sats up by bagging. Just make sure that you have an appropriately adjusted PEEP valve attached to your BVM for your ARDS patients; the patient who was just requiring a PEEP of 15 isn’t going to improve with you bagging away with a PEEP of 5. 

Once you’ve gotten the sats up and the patient back on the vent, your ventilator display can provide you with further data as to why your patient decompensated. Does the flow waveform fail to reach zero suggesting breath stacking and a need for a prolonged expiratory time? Is the measured respiratory rate much higher than your set rate with multiple breaths in a row indicating double-triggering? The measured tidal volume might fall short of your set tidal volume. This points towards a circuit leak, cuff leak, or broncho-pleural fistula. Maybe you’re seeing the pressure wave dip below zero mid-inspiration and the patient is telling you that they are in need of faster flow, a bigger breath, or deeper sedation. In these situations, your respiratory therapist is going to be your best friend in managing this patient-ventilator interactions2. 

As your post alludes to, sometimes patients remain hypoxemic despite our usual efforts and refractory hypoxemia can be an intimidating beast when you’ve got a busy ED burning down around you. If your cursory efforts to maintain vent synchrony by playing with the ventilator dials have failed, there’s no shame in deepening sedation which will work to decrease oxygen consumption and prevent derecruitment. Once sedated, work with your RT to find appropriate PEEP and tidal volumes to meet your goals. 

Most patients can be managed with usual lung-protective ventilation but some patients will require more support and you’ve correctly identified several salvage therapies. My general approach is to pursue prone positioning in any patient with a P:F ratio approaching 150 despite optimal vent settings as it has the only strong mortality benefit of the therapies outlined above. Proning in the ED is resource intensive and is probably better pursued as a department-wide protocol rather than you and your charge nurse trying to figure it out in the middle of the night3. 

As you’ve pointed out, the neuromuscular blockade has more limited evidence and is not required for prone ventilation. Upstairs, we accomplish this with continuous infusions but in the ED you may be more comfortable using intermittent boluses of intubation dose rocuronium. Just make sure your patient is unarousable. I reach for this if I’m unable to achieve ventilator synchrony with sedation alone as it allows for very low tidal volumes and inverse ratio ventilation. I see inhaled pulmonary vasodilators in a similar light: there’s no data on patient-oriented outcomes but they can make your numbers look prettier while you wait for more definitive interventions such as transfer. 

This finally brings me to VV ECMO for refractory hypoxemia. It’s worth considering that while there is some evidence for a mortality benefit for ECMO in ARDS, the evidence base is mixed. The CESAR trial did show a mortality benefit in patients transferred to an ECMO center but only 76% of patients actually received ECMO upon transfer4. The larger and more recent EOLIA trial failed to demonstrate this improvement in mortality5. The conclusion I take from this is that treatment at a high volume center matters and that a boarding patient with refractory hypoxemia warrants an early consideration for transfer to a tertiary center if high-quality ARDS care can’t be accomplished upstairs at your shop. 

References

1. Mohr NM, Wessman BT, Bassin B, et al. Boarding of Critically Ill Patients in the Emergency Department. Crit Care Med. 2020;48(8):1180-1187. doi:10.1097/CCM.0000000000004385

2. Sottile PD, Albers D, Smith BJ, Moss MM. Ventilator dyssynchrony – Detection, pathophysiology, and clinical relevance: A Narrative review. Ann Thorac Med. 2020;15(4):190. doi:10.4103/atm.ATM_63_20

3. McGurk K, Riveros T, Johnson N, Dyer S. A primer on proning in the emergency department. J Am Coll Emerg Physicians Open. 2020;1(6):1703-1708. doi:10.1002/emp2.12175

4. Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet Lond Engl. 2009;374(9698):1351-1363. doi:10.1016/S0140-6736(09)61069-2

5. Combes A, Hajage D, Capellier G, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med. Published online May 23, 2018. doi:10.1056/NEJMoa1800385

Matt McCauley, MD

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How To Cite This Post:

[Peer-Reviewed, Web Publication] King, P. Akehtuamhen, A. (2022, Feb 28). Crashing Ventilator Patient. [NUEM Blog. Expert Commentary by McCauley, M]. Retrieved from http://www.nuemblog.com/blog/crashing -vent-patient.

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End of Life Care in the ED

Written by: Savannah Vogel, MD (NUEM ‘24) Edited by: Logan Wedel, MD (NUEM ‘22)
Expert Commentary by: Matt Pirotte, MD

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References

“Discussing Goals of Care.” UpToDate, www.uptodate.com/contents/discussing-goals-of-care

Ganta, Niharika, et al. “SUPER: A New Framework for Goals of Care Conversation.” SGIM Forum, vol. 40, no. 3, 2017.

“Transitions/Goals of Care.” VitalTalk, 9 May 2019, www.vitaltalk.org/guides/transitionsgoals-of-care

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Expert Commentary

This is a nice review of the steps of what can be a very difficult conversation from Drs. Vogel and Wedel; I encourage emergency providers (especially residents) to run towards these situations aggressively and not expect other doctors to begin these challenging discussions.

While their piece is chock full of great tips, let me throw out a few of my own that might help you on your next shift.

1. “I am worried” is a great phrase to open the conversation. These are confusing topics for families and loved ones, our medical jargon is usually not fully suppressed and generally makes things even worse. While a family member can misunderstand a diagnosis or a prognosis, no one can misunderstand another person’s worry. “I am worried that your husband might not survive this illness” is very clear.

2. Be the first step. Remember that you might be the first step in what might be a series of conversations. When you are admitted to a patient who you think is in big trouble, have a frank honest conversation with the family but do not force them to make decisions. Then your conversation becomes part of your handoff to the inpatient team. The care of the patient will benefit from open communication upfront that minimizes false hope. Emergency doctors know intuitively what trajectory patients are on, a chronically ill elderly patient presenting with shock requiring pressors have an extremely high mortality risk and we should be clear with families about that.

3. Reassure and validate at every opportunity. Jim Adams gave me a great pearl when I was training at Northwestern which was that when you see worried first-time parents at 3am in the ED with a benign newborn issue you compliment, reassure, and validate. “This kid looks great, you guys are doing a great job.” Same thing with families. Simple statements like “it’s obvious that you care about them” and “I know you are trying to make the right decision and you’re asking great questions” will go a long way towards helping families process this information.

4. Humanize the body filled with tubes and lines. A few minutes to ask about the patient at the beginning of a tough conversation go a long way. What did they do for a living? What were their hobbies? Families usually end up smiling a little bit here, reminiscing, and telling you some really cool stuff. Sometimes you find yourself laughing with a family that came in the door sobbing. I find these few minutes spent getting to know your patient also helps to steer discussions towards what the patient would have wanted.

5. Anticipatory guidance is not just for well-child checks! After tough goals of care conversations especially those that end in decisions to move towards palliative care goals I always do 2 things. First I tell the decision-maker that they are making a good and loving decision, that it is the decision I would make for a member of my family, and to not let anyone tell them otherwise. Second, I insist that the family especially the decision-maker drink a bottle of water and eat a sandwich. We’ve all seen an end-of-life situation generate a second patient with dehydration mediated syncopal episode at the bedside, let’s try to prevent that.

I am forever grateful to my PD at NUEM Mike Gisondi for sparking my interest in this topic, it has been an unbelievable gift to me in my clinical practice. As I frequently say in the ED, you cannot avoid difficult goals of care conversations and then complain about the lack of beds in the hospital.

Matt Pirotte, MD

Program Director & Associate Professor of Emergency Medicine

Vanderbilt University Medical Center

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Vogel, S. Wedel, L. (2022, Feb 21). End of Life Care in the ED. [NUEM Blog. Expert Commentary by Pirotte, M]. Retrieved from http://www.nuemblog.com/blog/end-of-life-care

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Review of the ATHOS 3 trial

Written by: Saabir Kaskar, MD (NUEM ‘23) Edited by: Amanda Randolph, MD (NUEM ‘20)
Expert Commentary by: Matt McCauley, MD (NUEM’ 21)

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Review of the ATHOS 3 Trial: Angiotensin II for the Treatment of Vasodilatory Shock

Angiotensin, first isolated in the late 1930s, in recent years has become the new innovative vasopressor used in intensive care units, a change driven largely by the results of the ATHOS-3 trial. The ATHOS-3 trial in 2017 explored the efficacy of angiotensin II as a vasopressor for severe vasodilatory shock.  Severe shock is defined as persistent hypotension requiring vasopressors to maintain a mean arterial pressure of 65mmHg and serum lactate <2 despite adequate volume resuscitation.  Two classes of vasopressors have been used in the past for hypotension. They are catecholamines and vasopressin-like peptides. The human body, however, employs a third class which is angiotensin.  Angiotensin II is an octapeptide hormone and a potent vasopressor that is an integral component of the renin-angiotensin-aldosterone system. It works by activating the ANGII type 1 receptor which subsequently activates a G coupled protein pathway and phospholipase C, thereby inducing vasoconstriction. 

The ATHOS-3 trial compared the efficacy and safety of angiotensin II versus placebo in catecholamine-resistant hypotension, which is defined as an inadequate response to standard doses of vasopressors. The study was designed as a phase III multicenter randomized placebo control trial taking place across 75 intensive care units in the United States from 2015 to 2017. The three main inclusion criteria were catecholamine-resistant hypotension (defined as >0.2ug/kg/min of norepinephrine or equivalent for 6-48 hours to maintain a MAP 55-70 mmHg), adequate volume resuscitation (25mL/kg of crystalloid), and features of vasodilatory shock (mixed venous O2 >70% and CVP >8mmHg or cardiac index >2.3 L/min/m2).

Patients in vasodilatory shock that met the criteria of catecholamine-resistant hypotension were randomized to treatment with angiotensin II or placebo. Angiotensin II was initiated at an infusion rate of 20ng/kg/min and adjusted during the first three hours to increase MAP to at least 75mmHg. The primary outcome of the study was the response in MAP three hours after the start of angiotensin II infusion. A response was deemed as a MAP increase of 10mmHg from baseline or a MAP over 75mmHg without an increase in baseline vasopressor infusions. During the first three hours, the angiotensin II group had a significantly greater increase in MAP than placebo (12.5mmHg vs 2.9 mmHg). Angiotensin II also allowed for rapid increases in MAP which permitted decreases in doses of baseline catecholamine vasopressor. Additionally, improvement in the cardiovascular SOFA score was significantly greater in the angiotensin II group than in the placebo group. However, the overall SOFA score did not differ between groups. Rates of adverse events such as tachyarrhythmias, distal ischemia, ventricular tachycardia, and atrial fibrillation were similar in the angiotensin II and placebo groups. Overall serious adverse events that included infectious, cardiac, respiratory, gastrointestinal, or neurologic events were reported in 60.7% of patients who received angiotensin II and 67.1% of patients who received placebo. 

The strengths and limitations of the ATHOS 3 trial are critical to how its author’s conclusions should be interpreted. The strengths of the study include that it was a randomized double-blind control trial examining a new class of vasopressor for refractory vasodilatory shock. Refractory shock is a common condition with high mortality, and so the investigation of an additional treatment modality can be of great clinical impact. However, one limitation of the study was that it was underpowered to demonstrate a mortality difference. It showed improvement in blood pressure which is a clinically important parameter but not a patient-oriented outcome. Interestingly, when vasopressin was studied in 2008, it similarly did not show a mortality benefit when added to norepinephrine infusion in septic shock2. It did, however, show a decrease in norepinephrine dosing which parallels the findings of the ATHOS 3 trial.

An additional point of contention with the ATHOS 3 trial is that the manuscript does not report an increase in thrombotic risk. It has been shown that angiotensin II increases thrombin formation and impairs thrombolysis3. The FDA even reports angiotensin II has a risk for thrombosis as there was a higher incidence (13% vs 5%) of arterial and venous thrombotic events in the angiotensin II vs placebo group in the ATHOS 3 trial itself. For this reason, the FDA recommends concurrent VTE prophylaxis with the use of angiotensin II. Further data regarding the thrombotic risk of angiotensin II would be helpful to determine which patient populations the vasopressor should be avoided in. 

Overall, the author’s conclusion in the ATHOS 3 trial is that angiotensin II increased blood pressure in patients with a vasodilatory shock that did not respond to high doses of conventional vasopressors. It has been shown to raise mean arterial pressure over 75 mm Hg or by an increase of 10 mm Hg within three hours. The ATHOS 3 trial, however, did not demonstrate a mortality benefit when using angiotensin II. Further studies are needed to elucidate whether Angiotensin II truly improves patient outcomes in vasodilatory shock. 

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Expert Commentary

Thank you for this great summary of the ATHOS 3 trial. While this trial paved the way for the clinical use of angiotensin II as a vasopressor, you’ve raised some salient points as to why we should approach this emerging intervention with skepticism. The biggest shortcoming in my mind is the primary outcome of the study; it’s not particularly impressive that a vasopressor resulted in higher blood pressures compared to a placebo. Mortality benefit is an extremely elusive goal in critical care research1 but that doesn’t discount the fact that ATHOS 3 wasn’t designed to demonstrate an improvement in any patient-oriented outcome. ICU length of stay, hospital length of stay, ventilator-dependent days, or rate of renal replacement therapy: these are all things that matter to our patients and to our health systems and they are more fruitful targets when we investigate interventions. 

There’s been some study of angiotensin II in the years since it has landed in our hospital formularies and there has not been robust data supporting its use. Some of the most recent data come from a multi-center retrospective study that includes patients from Northwestern. This review of 270 patients receiving angiotensin II demonstrated that 67% of patients were able to maintain a MAP of 65 with stable or reduced vasopressor doses. Univariate analysis showed that these patients that responded did have a statistically significant mortality benefit over the patients deemed nonresponders (41% vs 25%)2. If we are going to find a benefit of this drug, further study predicting which patients will be responders is necessary but this study did note that patients already receiving vasopressin and those with lower lactates (6.5 vs 9.5) were more likely to respond. Outside of septic shock, there is interest in the use of angiotensin II in refractory vasoplegia associated with post-cardiac surgery3 and anti-hypertensive overdose4. These are, of course, only hypothesis-generating. 

But what does that mean to us clinically in the ED and ICU? This data shows us that angiotensin II can make the blood pressure better but I would never let it distract you from the things we know matter in sepsis resuscitation. Source control timely antibiotics, rational fluid resuscitation, and ruling out other causes of vasopressor refractory shock to include anaphylaxis, hemorrhage, adrenal insufficiency, LVOT obstruction, and any other cause of cardiogenic shock need to be ruled out and addressed. In my personal practice, I make sure to optimize these and start vasopressin shortly after the initiation of norepinephrine. In a patient already on vaso that has stopped responding to escalating doses of norepinephrine, I reach for my ultrasound probe and reassure myself that there isn’t significant sepsis-related myocardial dysfunction because those patients may benefit from a trial of an inotrope like epinephrine. In those with a good cardiac squeeze, I think it’s appropriate to discuss with your intensivist and clinical pharmacist the utility of adding angiotensin II as part of a kitchen-sink approach. Until we have more data about the benefits of this extremely expensive intervention, I wouldn’t lose sleep if you’re unable to secure it for your patient.

References

1. Chawla LS et al. Intravenous Angiotensin II for the Treatment of High-Output Shock (ATHOS Trial): A Pilot Study. Crit Care 2014; 18(5): 534. PMID: 25286986

2. Russell JA et al. Vasopressin Versus Norepinephrine Infusion in Patients with Septic Shock. NEJM 2008; 358(9): 877 – 87. PMID: 18305265

3. Celi A et al. Angiotensin II, Tissue Factor and the Thrombotic Paradox of Hypertension. Expert Review of Cardiovascular Therapy 2010; 8(12): 1723-9 PMID: 21108554

4. Santacruz CA, Pereira AJ, Celis E, Vincent JL. Which Multicenter Randomized Controlled Trials in Critical Care Medicine Have Shown Reduced Mortality? A Systematic Review. Crit Care Med. 2019;47(12):1680-1691. doi:10.1097/CCM.0000000000004000

5. Wieruszewski PM, Wittwer ED, Kashani KB, et al. Angiotensin II Infusion for Shock: A Multicenter Study of Postmarketing Use. Chest. 2021;159(2):596-605. doi:10.1016/j.chest.2020.08.2074

6. Papazisi O, Palmen M, Danser AHJ. The Use of Angiotensin II for the Treatment of Post-cardiopulmonary Bypass Vasoplegia. Cardiovasc Drugs Ther. Published online October 21, 2020. doi:10.1007/s10557-020-07098-3

7. Carpenter JE, Murray BP, Saghafi R, et al. Successful Treatment of Antihypertensive Overdose Using Intravenous Angiotensin II. J Emerg Med. 2019;57(3):339-344. doi:10.1016/j.jemermed.2019.05.027

Matt McCauley, MD

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Kaskar, S. Randolph, A. (2022, Feb 14). Review of ATHOS 3 trial. [NUEM Blog. Expert Commentary by McCauley, M]. Retrieved from http://www.nuemblog.com/blog/review-athos3-trial.

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Nursemaid's Elbow

Written by: Richmond Castillo, MD (NUEM ‘23) Edited by: Shawn Luo, MD (NUEM ‘22)
Expert Commentary by: Jacob Stelter, MD (NUEM ‘19)

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Expert Commentary

This is an excellent summary of the diagnosis and management of radial head subluxation (nursemaid’s elbow) in children.  Clinically, as pointed out, these patients are usually toddlers and will come in after an injury to the arm.  Usually, the clinical history will involve the child’s arm having been pulled on while the elbow was extended leading to sudden onset of pain and reduced mobility of the arm.  The patient will most often be holding the elbow in flexion and be resistant to having it manipulated.  In general, I have a low threshold to obtain radiographs on these patients.  If the story and exam is classic for a radial head subluxation, imaging is technically not indicated, and reduction can be attempted.  However, more often than not, the history can be vague, and the mechanism of injury may be unclear.    In this situation, it is better to rule out a fracture first than to attempt a reduction without imaging.  Attempted reduction could worsen or lead to displacement of a supracondylar humerus fracture if that is present.  Keep in mind that it is not uncommon for the subluxation to reduce spontaneously during the process of obtaining x-rays.  

There are two preferred techniques for reduction of a radial head subluxation.  The method I start with is to support the patient's elbow and forearm and gently supinate the forearm while flexing the elbow and applying gentle pressure over the radial head.  A “pop” sensation will often be felt as the radial head reduces.  The other technique that can be used is to hyper-pronate the forearm while maintaining the elbow in a flexed position.  Both of these techniques have a high success rate.  Typically, the child will start using the arm again, but it may not be immediate.  I will typically reassess the patient about 10-15 minutes post-reduction to ensure they are using their arm normally again.  If the child is using their arm and able to extend and flex at the elbow without pain, they can be discharged, and no splinting is necessary.  If no radiographs were obtained prior to reduction and the patient is not back to baseline post-reduction, x-rays should be obtained to rule out a fracture. Keep a broad differential, especially if the patient is not responding as you would expect or has other vital sign or exam abnormalities.

Jacob Stelter, MD, CAQ-SM

Division of Emergency Medicine | NorthShore University HealthSystem

NorthShore Orthopaedic Institute | Primary Care Sports Medicine

Clinical Assistant Professor | University of Chicago Pritzker School of Medicine

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Castillo, R. Luo, F. (2022, Feb 7). Nursemaid’s Elbow. [NUEM Blog. Expert Commentary by Stelter, J]. Retrieved from http://www.nuemblog.com/blog/nursemaids-elbow.

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