Come to Dr. Moll’s new home to welcome our new interns Saturday, July 9 from 4 PM – 8 PM. Families are welcome. Come ready to eat and swim!
The trial was just published today in the NEJM and authored by the Resuscitation Outcomes Consortium Investigators (including our own chair Dr. Ornato).
In short there was no difference in survival or neurologically intact outcome between amiodarone, lidocaine, and placebo for refractory ventricular fibrillation or pulseless ventricular tachycardia.
However, this may not argue against antiarrhythmics in cardiac arrest as there was no increase in adverse events in the experimental groups either and there was an increase in ROSC in the antiarrhythmic groups.
There’s been quite an explosion of discussion on the new sepsis guidelines in the FOAM world.
I had just assumed that ACEP was one of the 31 societies that endorsed the new guidelines, but notably absent are any US emergency medicine societies (the European Society of Emergency medicine did endorse them). I think it’s easy to see why ACEP passed on this as the new guidelines do not add much to change our recognition, definition, or treatment of sepsis in the emergency department.
One of the main assertions of the new guidelines is: “The current use of 2 or more SIRS criteria to identify sepsis was unanimously considered by the task force to be unhelpful.”
We all recognize that the specificity of SIRS was lacking. While our patients with pharyngitis, pyelonephritis, and influenza often meet sepsis criteria using SIRS they rarely fit into our usual concept of sepsis. Worse yet is every anxious psych or trauma patient being flagged as having SIRS criteria.
However the authors provide no replacement for SIRS other than the very questionably useful qSOFA score (Altered mental status, hypotension, and tachypnea). If we haven’t considered sepsis in an obtunded patient in shock then a qSOFA score probably won’t help.
The new sepsis definitions essentially eliminate the old category of plain ‘sepsis.’ Instead, the new definitions don’t really start until we reach what we formerly called severe sepsis: sepsis + end organ dysfunction.
|Old Definition||New Definition|
|Sepsis||SIRS + Infection|
|Severe Sepsis||Sepsis + end organ dysfunction||Sepsis||Infection + SOFA ≥ 2|
|Septic Shock||Sepsis + hypotension||Septic Shock||Sepsis + vasopressors AND lactate ≥ 2|
Anecdotally, I don’t think the challenge with sepsis in the ED is identifying the very sick, it’s trying to identify which patients might become sick that we could otherwise miss. These new definitions just push sepsis farther down the pathological spiral of infection rather than contributing anything to pre-hospital or ED diagnosis and management.
Maybe the SOFA score could help us pick up on some end-organ dysfunction we weren’t paying close attention to before, but by the time an ED patient has all the parameters necessary to calculate a SOFA score including CBC, BMP, LFTs, and an ABG they are well on their way into their sepsis workup and have already bought themselves an admission.
I won’t be throwing SIRS out the window in my practice and I don’t see qSOFA or SOFA having much impact on the majority of patients I see in the ED.
We’ll hear more on sepsis and the new guidelines from Dr. Mayglothling during the ID block in April. Until then here are several posts on the guidelines to keep you entertained:
PulmCrit/EMCrit – Top 10 problems with new sepsis definition
First10EM – Sepsis 3.0
First10EM – Is SIRS really that bad?
REBEL EM – Sepsis 3
St. Emlyn’s – Sepsis 3
Latin American Sepsis Institute – Why we did not endorse the new definition of sepsis
JAMA just published new guidelines defining sepsis and septic shock from a task force from the Society of Critical Care Medicine and the European Society of Intensive Care Medicine.
In short, our old SIRS criteria are replaced by the new definitions:
- Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.
- Organ dysfunction can be identified as an acute change in total SOFA score ≥2 points consequent to the infection.
- A “quickSOFA” score can be used in pre-hospital, ED, or inpatient setting to identify these patients if they have at least 2 of the following: respiratory rate equal or greater than 22/min, altered mental status, or SBP < 100 mmHg.
- Septic shock is defined as sepsis plus hypotension requiring vasopressors to maintain MAP ≥65 mm Hg and lactate level >2 mmol/L despite adequate volume resuscitation.
The full SOFA score is more complex and requires multiple lab values.
By now we’re all pretty used to employing apneic oxygenation for RSI in the ED. However, most of the data comes from the OR and elective setting or is retrospective.
A recent randomized trial of apneic oxygenation in ICU patients actually failed to show benefit, though this population may have already been maximally preoxygenated and too sick to benefit from apneic oxygenation.
Sackles et al just published the results of their prospective data collection on apneic oxygenation in ED intubations by EM residents in Academic Emergency Medicine.
They found a 13.1% increase (CI 6.2% to 19.9%, OR 2.2 CI 1.5 to 3.3) in first pass success without hypoxemia when apneic oxygenation was used.
Other factors associated with first pass success without hypoxemia were a normal baseline SpO2 (OR 4.8, CI 2.2 to 10.3), used of video laryngoscopy (OR 2.7, CI 1.6 to 4.6), and intubation performed by a senior resident (OR 2.1, CI 1.1 to 3.7).
There are certainly many limitations to this study as it was prospective, non-randomized, and self-reported by the residents. Apneic oxygenation was not required but was its use was encouraged in every intubation. It may be that those who chose to use it were more likely to be successful in the first place.
In any case, apneic oxygenation was independently associated with an increased chance of first pass success without hypoxemia. This study bolsters the evidence for this fast, cheap, easy, low-risk, high-reward intervention for emergency department airway management.
Buis et al recently published an article in Resuscitation reviewing studies that evaluated intubation success in trainees.
To achieve a 90% success rate with no more than two attempts, most learners needed to have performed at least 50 prior intubations. While this seems like an easily achievable number to get in residency, these studies were all done in the OR in an elective setting. Certainly more practice would be required for the many difficult airways we encounter in the ED.
This is more evidence that we should take every opportunity to continue to hone our airway skills and get as many repetitions as possible.
You may recognize an author on this study just published in Academic Emergency Medicine on New Year’s Eve.
They recorded serial EKGs on 22 ED patients who received 4 mg of ondansetron. There was a small measurable prolongation of the QTc interval (20 ms, 95% CI = 14 to 26 ms) with a maximum QTc of 415 ms. The authors concluded that while the sample size was small, the clinical impact would likely be minimal.
I posted two review papers on septic arthritis on the conference page for today.
A brief summary of some historical, physical, and laboratory findings:
|Pain with motion||100%||–||–||–|
|Axial load pain||36%||–||–||–|
|Synovial WBC > 25K||64-81||73-81||2.3-4.4||0.23-0.50|
|Synovial WBC > 50K||49-63||88-92||2.5-8.5||0.38-0.72|
|Synovial WBC > 100K||14-20||96-100||3.6-5.1||0.80-0.89|
|Synovial PMN > 90%||51-68||75-80||2.1-3.5||0.39-0.65|
|Synovial Lactate > 10||55-100||95-100||19-∞||0-0.45|
As you can see, there is no single finding which guarantees septic arthritis. Don’t rely on absence of fever to exclude a septic joint. Realize that synovial fluid findings are all over the place and are very susceptible to misinterpretation. However, if you aren’t ordering a synovial lactate it’s probably a worthwhile test to add on to everything else.
A quick list of some changes I noticed:
- Changed recommendation system to GRADE
- CPR compression rate should be at least 100 and not greater that 120/min.
- Mechanical CPR devices may be considered, but manual CPR is still standard of care.
- ECMO is being studied, but no RCTs to demonstrate effect on survival. May be considered in refractory arrest with a suspected reversible cause.
- Vasopressin removed from cardiac arrest algorithm to streamline approach
- The steroids, vasopressin, and epinephrine bundle may be considered but cannot be recommended at this time.
- Lipid emulsion therapy may be considered for cardiac arrest due to drug toxicity.
- Recommend use of two troponins and risk stratification tool to identify patients at low risk of MACE at 30 days.
Many of you are familiar with the the the “AIR” series from Academic Life in Emergency Medicine.
They’ve introduced a new resource geared toward senior residents called the AIR Pro series.
They’ve just released their first module on several cardiovascular topics such as Sgarbossa criteria, ICDs, and LVADs.
This new series is already approved for asynchronous credit.