Author Archives: James Buchanan

Reanimating the Dead

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It’s trauma season once again. As room 9 after room 9 roll in the door the rising 2nd and 3rd years will soon be dealing with traumatic arrest patients (if they haven’t already). While the ED resident works to control the airway, the trauma team is placing bilateral chest tubes and a cordis. All of this while the nurses and techs continuously perform compressions and give 1mg of epi every 3-5 minutes, while inadvertently interrupting everything else going on. At the end of the day are all those compressions and all the epi going to change outcomes? We know in medical cardiac arrest it will but is traumatic cardiac arrest different?

Reanimating Patients After Traumatic Cardiac Arrest A Practical Approach Informed by Best Evidence discusses 5 key principles to guide management. The emphasize this is only for isolated traumatic cardiac arrests and that if there is any indication that a medical cardiac arrest occurred prior to a trauma following guidelines such as ACLS should be given priority.

 

The 5 Key Principles:

  1. Start or Stop
  2. Deprioritrize Chest Compressions
  3. Fix Ventilation
  4. Stop the Bleeding
  5. Fix the Physiology

 

 

Start or Stop:

When do you start or stop a traumatic resuscitation? What Factors do you consider? Well there is some food for thought:

Favorable Prognostics Factors:

  1. Penetrating injury, particularly to the Thorax
  2. Vitals Signs at any time
  3. Signs of Life at any time
  4. Short Duration (<10min)
  5. Cardiac Contractility on POC USN

Without 1 of these signs, survival is <1%. Important to keep in mind when EMS is giving a report and you are try to determine how long to attempt a resuscitation.

Spectrum of Output States:

They note for their practice the category of “dead” does NOT receive any further resuscitation. The note this is in part to save the vital limited resource of blood prodcuts. I also found it interesting that they separate PEA from pseudo-PEA from severe hypovolemia. Thats why having the cardiac probe in hand on arrival can save be useful in determining how far you are going to push the resuscitation.

 

 

Deprioritize Chest Compressions

Chest compressions may work for medical arrest but the pathology behind traumatic arrest is so vastly different all they do is get in the way of more vital procedures: intubation, chest tubes, central access, cardiac USN. Until all this has been established it would probably be better just to hold compression. Be warned however this will likely be an uncomfortable experience for the nurses/techs.

 

Fix Ventilation:

Referring back to Table 3 we can clearly see that establishing an airway and decompressing both sides of the chest should be top priority in a traumatic arrest.

Remember that traumatic arrests are a low flow state and while most patients while not require a induction agent or paralytic if you do use a paralytic use TWICE the dose.

 

Stop the Bleeding:

Simple and straight forward if it’s bleeding make it stop. Direct Pressure, tourniquets, topical hemostatic agents (which as far as I’m aware we don’t have) and pelvic binders are all easily performed in room 9. Thoracotomy is also something to consider discussing with Trauma early on in these resuscitations. Both the Eastern Association for  the Surgery of Trauma and the Western Trauma Association recommend thoracotomy and though their conditions vary penetrating trauma to the torso and arrest for less than 15 minutes seems to be a good rule of thumb.

 

Fix the Physiology: 

Pretty straightforward recommendations that we do everyday:

  1. Keep the Patient warm to prevent exacerbating coagulopathies
  2. Establish AccessL Large bore (14-18 gauge) IV access above the diaphragm, IO access of the proximal humerus, 8 or 9-Fr CVC preferably subclavian while avoiding multiple lumen CVCs
  3. Minimize fluids and transfuse blood products 1:1:1 and allow for permissive hypotension

They go into some post-resuscitation recommendations as well when it comes to “fix the physiology” but those are less important to use.  I would recommend that everyone should briefly review this article as it has a lot more information and reasoning behind their recommendations.

 

 

Can you give Vasopressors through a PIV?

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I looked back and couldn’t find a post about this topic in the last year or so but forgive me if it has already been posted. I have been following R.E.B.E.L. EM for a few months now  and I would recommend it to everyone who has the time and wants quick summaries on the latest EM literature.  They have short written summaries of papers including pros/cons of the study and what they feel are the most important take away points. It was founded by Salim Rezaie with Rob Rogers, Matt Astin and Anand Swaminatham serving as editors.

Occasionally they will have a “mythbuster” post looking at common myths in the ED and the most uptodate literature available on the topic. (their latest mythbust is on “safe” glucose levels before ED discharge but I digress)

 

Back in May they reviewed the safety of vasopressors through a PIV. The topic paper was titled “A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters”

What the review found was very interesting: of 318 events, 204 results in local tissue damage, 114 were only extravasation events and 7 events involved the use of a CVC (so clearly not completely safe). Interesting, of the 204 local tissue events 85.3% involved PIV distal to the antecubital fossa and 96.8% involved administration of >4hrs.

REBEL EM’s take away points were:

In critically ill patients, with hemodynamic instability, vasopressor infusion through a proximal PIV (antecubital fossa or external jugular vein), for <4hours of duration is unlikely to result in tissue injury and will reduce the time it takes to achieve hemodynamic stability.

What I feel like this means for us is simple: If you have a crashing, hypotensive patient who needs a pressor without a CVC but good proximal PIVs, start the pressor immediately, stabilize the patient as best you can, then take the time to properly place a CVC.

Continue to monitor the PIV until it can be switch to the CVC and stop the pressor immediately if there is any suspicion for local extravasation. I am sure this will make some people nervous but I think this is better then placing a “crash line” that is less then sterile which will expose an already ill patient to infection or other complications secondary to a hastily placed CVC.

I highly recommend read their review and how they came to this conclusion along with their other posts. I have included the link to this study at the bottom.

http://rebelem.com/mythbuster-administration-of-vasopressors-through-peripheral-intravenous-access/

Delivery in the Emergency Department

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I will apologize for the wall of text in advance but I thought I to share an experience from last May that fits pretty well with the first 2 weeks of lectures this month. I think it definitely highlights the importance of  feeling comfortable with both delivery and newborn resuscitation in case they actually happen to you. I’ve also tried to point out all problems that came about but I am sure I didn’t hit them all and I am positive that I could have handled some of them better. 

It was nearly the end of a pretty typical shift at Jewish Downtown. For those of you who haven’t been there or don’t know there is zero OB coverage at Jewish. I was finishing my charts when I hear the secretary say “pregnant woman in labor” over the phone. That is a pretty unusual thing to hear at Jewish so I immediately asked the attending who was sitting closer if I heard that correctly. I also half-jokingly said I definitely wanted in on the patient if they were serious because I still needed a few more deliveries. The attending chuckles and replied that she thought the secretary was only joking because there shouldn’t be any reason for a laboring patient to come to Jewish, so I returned to my charts.

About 2 minutes later they call for a physician from the room behind the doctors area and we walk into what is in fact a laboring patient. The nurses state she seems to be contracting every 3-4 minutes but they don’t know much else at this point. While the attending checks her cervix, I grab the ultrasound and check the fetal position. She was about 8cm dilated and the best I could tell the baby was vertex but the head was so far down I gather this from the rest of the anatomy. Immediately calls start going out to the neonatologist at Kosair while we attempt to talk to the family and figure out how the patient ended up at Jewish. Here comes out first problem:

Problem 1: Neither the patient nor the family speak a word of english. Not only that but there is no translator phone in the room so the family has to be taken to another room to try to get some questions answered.

In the meantime I attempt to get a fetal heart rate to assess how the fetus is doing.

Problem 2: The only doppler is a pen style for checking pulses that doesn’t actually display a pulse number.

I go back to the ultrasound, find the heart and count the beats on the screen while a nurse counts for 15 seconds to get a FHR of about 144, which is always reassuring. In the mean time we are able to obtain some more information from the family.  

Apparently, the patient’s water broke during her office visit around 2pm (it’s now almost 11pm) and she was told to go to the hospital. For whatever reason they decided to wait and they got mixed up between Norton’s and Jewish hence our current situation. There are calls being made to Norton’s L&D informing them of the situation and transport is on the way. The neonatologist is also en route as a safety precaution in case she actually delivers here. The patient and fetus appear to be stable, and while still contracting around every 3-4 minutes she still isn’t fully dilated. I make the mistake of leaving the room assuming that the patient will soon be swept away to have her baby properly on an L&D floor. About 5 minutes later another call from the room and I walk in to see the beginning of this baby crowning.

The nurses wheel in their delivery kit as I gown and glove up. I apply a few packets of lubricant jelly, have the nurses move the patient closer to the end of the bed and attempt to create a semi-sterile field with the supplies available.

Problem 3: It’s nice and easy to set up to deliver in a room with a bed designed to deliver a baby. Unfortunately for me this situation involved a nurse/tech on each leg and the patient mostly laying flat in a bed with bag to collect fluid half hanging off the table but mostly just shoved under her bottom as best as I can with no real drainage.

Problems 4 & 5: Did I mention she didn’t speak english, also I have no idea what the word for “push” is in her language.  Also when you are on the L&D floor you have all kinds of cool toys such a tocometer to help you know when to tell the patient to push. I do not have that luxury.

I attempt to put a hand on her abdomen to feel her uterus contract so I know when to tell her to push and hope that she figures out what we want from her. Maybe it was a good thought but I have no idea, good thing she does and she is pushing every few minutes and the head is progressing it’s way out.. After a few good pushes the progress seems to slow a little bit and I start to worry a little bit that this 2 week post-dates baby may be stuck. What was that mnemonic for shoulder dystocia again? All I can remember is McRobert’s maneuver, but for anyone curious, Rosen’s has a nice one:

Help: Obstetrics, neonatology, anesthesia

Episiotomy: Generous, possibly even episioproctotomy

Legs flexed: McRoberts’ maneuver

Pressure Suprapubic pressure: shoulder pressure

Enter the vagina: Rubin’s maneuver or Wood’s maneuver

Remove posterior arm Splint, sweep, grasp, and pull to extension

Luckily, I have the nurses holding onto each leg (because this bed doesn’t have stirrups) so they flex her legs towards her as much as they can and everything continues to progress smoothly. Eventually the head is out and the rest of this baby boy delivers quickly. He is suctioned, wrapped in a warm blanket and the nurses begin assessing him. I think we put his APGAR at a 7 at 1 minute.

So I am done right? Baby is out, nothing more to see or do, lets ship them out. Right?……

Turning back to the patient I realize she seems still be bleeding a little more than I expected. It’s hard to figure out where she is bleeding from so I deliver the placenta which appears to be intact. I even sweep and massage the uterus just to be sure which seems to be contracting well.

Problem 6(?): Not really a problem because it seems her bleeding was not coming from the uterus but I have no access to the medications typically used to help control uterine bleeding after a deliver such a pitocin. Not that it matters because I didn’t know what the dose would be anyway. Just another interesting thought that I had during this whole process.

Since the placenta is whole, and seems to be firm I look for other sources of bleeding. This is when I realize the patient has a nice 2nd or 3rd degree tear (Dr Sterrett would be very disappointed I didn’t control the head well enough). I check to make sure it isn’t a 4th (thankfully it’s not), and start contemplating my next course of action. The attending asks what kind of suture I want to use to repair her tear. My only reaction was to smile and say “nothing”, followed by explaining that since the bleeding is slowing it’d probably be better to let the OB-GYNs fix her. I plan to pack her to make sure she doesn’t bleed too much in transport. 

Problem 7: No one had even seen a vaginal packing kit in the ED before, so we improvised and used some kerlex with a tail for easy removal.
By the time this had finished the neonatologist had arrived and began assessing the newborn. I think we ended up giving him apgars of 7 and 9. I started the patient on some fluids (because we didn’t have an IV when all of this started, another mistake I didn’t realize until it was all over) and within another 2 minutes transport had arrived to take the patient to Norton’s and she was actually swept away. Hopefully the OBs she finally got to didn’t think I botch the whole thing too much. Overall it was a pretty intimidating and adrenaline pumping situation. Not sure if I will ever have an experience quite like this again but if it does happen at least it will not be the first. 

Any comments, critiques, criticism or otherwise are welcome.