Some of the biggest challenges facing emergency physicians can be managing the sickest of the sick. Peter M.C. DeBlieux, MD, FACEP, director of emergency medicine services at the Medical Center of Louisiana at New Orleans, Louisiana State University Health Science Center Interim Hospital, shared some of the latest trends in critical care management. The suggestions came fast and furiously.

Dr. DeBlieux noted that identifying systemic inflammatory response syndrome (SIRS) and sepsis can present a challenge in the ED. The problem is that these patients often are sicker than they appear, he noted. One strategy he finds helpful is the Shock Index. “I’m using it more and more,” he said. Another indicator that a patient is really sick is if the heart rate is higher than the systolic blood pressure.

He used a memory technique that helps the process, focusing on the patient’s tank (volume status), hose (systemic vascular resistance), and pump (cardiac assessment). To correctly identify volume status, Dr. DeBlieux recommends using inferior vena cava ultrasound. He also suggested treating with balanced solutions to increase volume rather than only considering normal saline.

To avoid prolonged hypotension, Dr. DeBlieux said he treats simultaneously with peripheral vasopressors, although there are no current safety studies to support this.

Cardiac assessment doesn’t need to be difficult. “You don’t need to be a cardiologist. You only need to discern between wimpy and vigorous hearts,” he said, demonstrating for the audience with examples. Dr. DeBlieux recommends utilizing point-of-care echocardiology to determine the treatment based on four possible variations.

Emergency physicians often face a dilemma when considering intubating the critically ill—you know you need to intubate the patient, but you also know he or she will crash when you do. Dr. DeBlieux suggested asking yourself, “Will the patient will be better off physiologically with my resuscitative efforts in the next 15 minutes?” If yes, resuscitate before rapid sequence intubation (RSI). If no, proceed with RSI.

Other suggestions included using a checklist and ensuring that your team is on the same page before treating the patient. “Almost all patients need volume,” he said. Perfusion is the priority and timing is everything.

Dr. DeBlieux also made what sounded like an outrageous recommendation. If positive end-expiratory pressure (PEEP) goals are not met, he suggested prone positioning. “It freaks people out,” he admitted. Although it makes nursing care more difficult and requires sedation and initial paralysis, there is a 10 percent survival advantage with the procedure. There is one caveat. “Someone must own the tube,” he warned.

The best way to identify moderate to severe acute respiratory distress syndrome (ARDS), said Dr. DeBlieux, is the common X-ray. “We shouldn’t work at carnivals guessing weight,” he said. “If there is more white than black [on the X-ray], suspect ARDS,” he said. “The evidence is 10 years out and we are slow to make changes in the ED.”

Teresa McCallion is a freelance medical writer based in Washington State.