Michael E. Winters, MD, FACEP, associate professor of emergency medicine and medicine, and co-director of the combined emergency medicine/internal medical/critical care program at the University of Maryland School of Medicine in Baltimore, shared his top picks for recent articles involving the critical care of the emergency patient.
He noted that, over the past decade, critical care delivered in the emergency department has increase by more than 200 percent. “We are the first intensivists to see these patients,” he said. “If we can intervene in those first few hours, we can make the difference between life and death.”
He presented the results from a recent study, “Guidelines for Management of Spontaneous Intracerebral Hemorrhage (ICH); A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association,” by Hemphill et al, published in 2015. The study compared the efficacy of standard blood pressure treatment versus intensive therapy.
“The take home message is that there is no difference,” Dr. Winters said. Rapid reduction in systolic blood pressure doesn’t decreases death or disability in this patient population.
Standard treatment for these patients is a platelet transfusion. A 2016 randomized, open-label, parallel-group trial published in Lancet, called “Platelet Transfusion Versus Standard Care After Acute Stroke Due to Spontaneous Cerebral Hemorrhage Association With Antiplatelet Therapy (PATCH),” assessed whether platelet transfusion reduces death or dependence.
Despite receiving a transfusion within six hours of symptom onset, the results found a lower three-month survival, more patients with disability, and more adverse events among the platelet group. “We really need to rethink reflexively ordering platelet transfusion in patients with an ICH taking antiplatelet therapy,” Dr. Winters said.
The next study involved cardiac arrest patients “These are the most critical patients we encounter and ones we can routinely hope to save,” he said. The study focused on three areas including minimizing hands-off time during compressions, when to intubate, and which intubation tool to use. “The Video Laryngoscopy vs. Direct Laryngoscopy: Which Should Be Chosen for Endotracheal Intubation During Cardiopulmonary Resuscitation? A Prospective Randomized, Controlled Study of Experienced Intubators,” was published this year in Resuscitation.
Dr. Winters noted that experienced intubators included those who had more than 50 emergency tracheal intubations.
The study found that there was no difference in the success rate or esophageal intubations between direct laryngoscopy (DL) versus video laryngoscopy (VL), but there were significant interruptions in compressions for DL. “If you have both available…consider when to intervene and what equipment you use to avoid detracting from chest compressions.” Dr. Winters said.
“A Study Comparing Amiodarone, Lidocaine, or Placebo in Out-of Hospital Cardiac Arrest (OCHA),” by Kudenchuk et al, examined nontramatic OCHA in adult patients with shock-refractory ventricular fibrillation or pulseless ventricular tachycardia. They found that there was no definitive evidence that any antiarrhythmics improve either survival to discharge or neurological outcomes.
A further study examined the ability of physicians to use a neurologic exam as a reliable prognosticator of post cardiac arrest patient survival. An original contribution published in 2016 in the American Journal of Emergency Medicine, entitled, “Early Neurologic Examination Is Not Reliable for Prognostication in Post-cardiac Arrest Patients Who Undergo Therapeutic Hypothermia.”
The result was no positive exam findings. “Families want to know…but we really need to refrain from counseling families on positive outcomes,” Dr. Winters said.
He also addressed the findings a task force examining sepsis. “The Third International Consensus Definitions for Sepsis and Septic Shock,” was published in the Journal of the American Medical Association (JAMA) in 2016. He noted that no emergency physicians served on the task force.
They developed the Sequential Organ Failure Assessment (SOFA) Score, which, according to Dr. Winters, is useful in the ICU, “but not so much in the ED.” An ensuing controversy wondered if specifics have been traded for sensitivity.
A study out of Chicago that has not yet been published reviewed a quick SOFA (qSOFA), systemic inflammatory response syndrome (SIRS) and Early Warning Score (EWS) to determine which was most effective. It found that existing early warning scores are more accurate than qSOFA for predicting in-hospital mortality. “The question at the end of the day is, ‘Do patients really benefit?’ and we don’t know,” Dr. Winters said.
He saved the best for last—a study, “Predicting Fluid Responsiveness by Passive Leg Raising: A Systematic Review and Meta Analysis of 23 Clinical Trials,” just published in JAMA examined when enough fluids are enough. It specifically focused on passive leg raise as method to predict fluid responsiveness. “This is one of the article I’d say you should absolutely review,” he said. The technique works across a wide range of patients and was proven to be an extremely accurate predictor of fluid responsiveness. The researchers also determined that physicians treating these patients must have a method to measure carbon monoxide. “Do not use change in arterial pressure,” Dr. Winters said.
He concluded by saying that he has the advantage of generous resources at his hospital. He recognized that not everyone is as lucky, yet they continue to save lives. “You are the true heroes,” he said.
Teresa McCallion is a freelance medical writer based in Washington State.