DebunkingDogmaintheED-BridgingtheKnowledgeTranslationgaptoBringCuttingEdgeCaretotheBedside

SupplementalSelectedEvidenceandReferences

Backboards:

Thelateraltraumaposition:whatdoweknowaboutitandhowdoweuseit?Across-sectionalsurveyofallNorwegianemergencymedicalservices.BACKGROUND:Traumapatientsarecustomarilytransportedinthesupinepositiontoprotectthespine.TheAirway,Breathing,Circulation,Disability,andExposure(ABCDE)principlesclearlygiveprioritytoairways.InNorway,thelateraltraumaposition(LTP)wasintroducedin2005.WeinvestigatedtheimplementationandcurrentuseofLTPinNorwegianEmergencyMedicalServices(EMS).CONCLUSIONS:LTPisimplementedandusedinthemajorityofNorwegianEMS,despitelittleevidenceastoitspossiblebenefitsandharms.HowthepatientispositionedintheLTPdiffers.MoreresearchonLTPisneededtoconfirmthatitsuseisbasedonevidencethatitissafeandeffective.Limitations-datacollectedthroughsurveysdistributedtofirstrespondersaskingiftheyaretrainedinandusetheposition.Patientoutcomedatawasnotcollected.EMSSpinalPrecautionsandtheUseoftheLongBackboard–ResourceDocumenttothePositionStatementoftheNationalAssociationofEMSPhysiciansandtheAmericanCollegeofSurgeonsCommitteeonTraumaAbstract:Fieldspinalimmobilizationusingabackboardandcervicalcollarhasbeenstandardpracticeforpatientswithsuspectedspineinjurysincethe1960s.Thebackboardhasbeenacomponentoffieldspinalimmobilizationdespitelackofefficacyevidence.Whilethebackboardisausefulspinalprotectiontoolduringextrication,useofbackboardsisnotwithoutrisk,astheyhavebeenshowntocauserespiratorycompromise,pain,andpressuresores.Backboardsalsoalterapatient'sphysicalexam,resultinginunnecessaryradiographs.Becausebackboardspresentknownrisks,andtheirvalueinprotectingthespinalcordofaninjuredpatientremainsunsubstantiated,theyshouldonlybeusedjudiciously.Conclusion:AlltraumapatientsshouldreceivespinalassessmentfromEMSprovidersinthefield.Ataminimum,patientswithpotentialforspineinjuryshouldbetransportedtothehospitalusingspinalprecautionsthatincludecervicalcollarandlogrollprocedures.Patientswhoareambulatoryorabletoself-extricatewithoutcausing

unduepainshouldbeencouragedtomovethemselvestoasupinepositionontheEMScot,afterapplicationofacervicalcollar.Backboardsremainavaluableadjuncttospinalimmobilizationduringpatientextrication.Carefulpatienthandlingandtransportofthepatientwithsuspectedspinalinjuryusingspinalprecautionsremainsprudent.Effectsofspinalimmobilizationdevicesonpulmonaryfunctioninhealthyvolunteerindividuals.BACKGROUND:Weaimedtoinvestigatetheeffectsofspinalimmobilizationdevicesonpulmonaryfunctions.CONCLUSION:WedeterminedthatbothKEDandlongspinalbackboardcauseadecreaseinpulmonaryfunctions.Pressureulcersfromspinalimmobilizationintraumapatients:asystematicreview.BACKGROUND:Toprotectthe(possibly)injuredspine,traumapatientsareimmobilizedonbackboardorvacuummattress,withacervicalcollar,lateralheadblocks,andstraps.Severalstudiesidentifiedpressureulcer(PU)developmentfromthesedevices.TheaimofthisliteraturestudywastogaininsightintotheoccurrenceanddevelopmentofPUs,theriskfactors,andthepossibleinterventionstopreventPUsrelatedtospinalimmobilizationwithdevicesinadulttraumapatients.CONCLUSION:TheresultsfromthissystematicreviewshowthatimmobilizationwithdevicesincreasestheriskforPUdevelopment.Thisriskisdemonstratedinnineexperimentalstudieswithhealthyvolunteersandinfourclinicalstudies.Changesinphysicalexaminationcausedbyuseofspinalimmobilization.OBJECTIVE:Todeterminewhetherspinalimmobilizationcauseschangesinphysicalexamfindingsovertime.CONCLUSION:Thisstudyshowsthatovertime,standardimmobilizationcausesafalse-positiveexamformidlinevertebraltenderness.Inordertoreducethishighfalse-positiverateformidlinevertebraltenderness,theauthorsrecommendthat,initiallyonarrivaltotheemergencydepartment,immediateevaluationoccurofallimmobilizedpatients.Furthermore,backboardsshouldbemodifiedtoreducepatientdiscomforttopreventtheiatrogenicallyinducedmidlinevertebraltenderness,therebyreducingsubsequentfalse-positiveexaminations.

Longbackboardversusvacuummattresssplinttoimmobilizewholespineintraumavictimsinthefield:arandomizedclinicaltrial.

INTRODUCTION:Patientswithpossiblespinalinjurymustbeimmobilizedproperlyduringtransporttomedicalfacilities.Theaimofthisresearchwascomparingspinalimmobilizationusingalongbackboard(LBB)withusingavacuummattresssplint(VMS)intraumavictimstransportedbyanEmergencyMedicalServices(EMS)system.CONCLUSION:TheresultsofthisstudyshowedthatimmobilizationusingLBBwaseasier,faster,andmorecomfortableforthepatient,andprovidedadditionaldecreaseinspinalmovementwhencomparedwithaVMS.

C-Collars

PrehospitalUseofCervicalCollarsinTraumaPatients:ACriticalReviewAbstract:Thecervicalcollarhasbeenroutinelyusedfortraumapatientsformorethan30yearsandisahallmarkofstate-of-the-artprehospitaltraumacare.However,theexistingevidenceforthispracticeislimited:Randomized,controlledtrialsarelargelymissing,andthereareuncertaineffectsonmortality,neurologicalinjury,andspinalstability.Evenmoreconcerning,thereisagrowingbodyofevidenceandopinionagainsttheuseofcollars.Ithasbeenarguedthatcollarscausemoreharmthangood,andthatweshouldsimplystopusingthem.Inthiscriticalreview,wediscusstheprosandconsofcollaruseintraumapatientsandreflectonhowwecanmoveourclinicalpracticeforward.Conclusively,weproposeasafe,effectivestrategyforprehospitalspinalimmobilizationthatdoesnotincluderoutineuseofcollars.Conclusion:Theexistingevidenceforusingcollarsisweak,andourpracticeismainlyaresultofthehistoricalinfluenceofpoorevidence.Moresignificantandconcerning,thereisawellofless-appreciateddocumentationofharmfuleffectsfromcollars.Apracticechangeseemswarrantedbasedonacriticalevaluationoftheprosandconsofprehospitalcollaruseintraumapatients.Withthisperspective,weproposeasafe,effectiveimmobilizationstrategythatwillnotrequireanynewequipmentandshouldbeeasytoimplement;themaindifferencefromcurrentprotocolsistheomissionofroutinecollarapplication.Fewpatientsareinneedofspinalimmobilization,andclearanceprotocolsshouldbeoptimizedtoidentifythesehigh-riskpatients.Thesepatientsshouldnotbefittedwithacollar,butimmobilizedonspineboardswithheadblocksandstraps.Temporaryuseofarigidcollarisanoptionduringextricationproceduresfrom,forexample,cars.Unconscious,nonintubatedtraumapatientsshouldbetransportedinamodifiedlateralrecoverypositionthatmaintainsnearneutralspinealignmentandairwaypatency.Finally,prehospitalmanagementshould,bynomeans,delaytransportationofcriticallyinjuredpatientstodefinitivecare.Futureeffortsshouldalsoaimtodiscontinuetheuseofrigidspineboardsinfavorofvacuummattressesorothersofterboardsthataremorecomfortableandadaptabletotheindividualvariationsinbodycomposition.

WhyEMSShouldLimittheUseofRigidCervicalCollarsMakingthecaseforsoftcollars&alternativemethodsofspinalstabilization.(Editorial)Conclusion:It'stakenover20yearstodevelopthenecessarybodyofscientificevidencetochangeourpracticesofspinalimmobilization.Fearsofworseningaspinalinjury,fearsofmissingaspinalinjuryandfearsoflitigationhavelongdriventhisprocessinsteadofscientificevidence.Inthecourseofthiswe'vemadeourpatientsuncomfortable,sometimeshurtthem,andmadetheirhealthcaremorecomplicatedandmoreexpensive.ThisisoneofthebestcustomersatisfactionpracticesthatEMScanadopt.It'simportanttopointoutthatweshouldn'tabandonourvarioustoolsformovingpatients.There'salimitedroleforbackboardsinextrication.Scoop-typestretchersandbasketstretchersareexcellentdevicesformovingpatients,especiallyoverunevenorroughterrain.Thevacuummattressisalsoanexcellentdeviceformovingpatientsandactuallyprovidesprobablythebeststabilizationofthespineofanydeviceoutthere.Wedon'twanttothrowthebabyoutwiththebathwater;wejustwanttoprovidethebestpossibleevidence-basedcareforourpatients.Overall,ourpatientcarewillimproveandourpatientswillremainmorecomfortable.InternationalLiasonCommitteeonResuscitation(ILCOR)CervicalCollarGuidelines(draft)Question:Amongadultsandchildrenwithsuspectedtraumaticcervicalspinalinjury(P),doesspinalmotionrestriction(I),comparedwithnospinalmotionrestriction(C),changeneurologicalinjury,complications,overallmortality,pain,patientcomfort,movementofthespine,hospitallengthofstay(O)?TreatmentRecommendation:Wesuggestagainsttheuseofcervicalcollarsbyfirstaidproviders(weakrecommendation,very-low-qualityevidence).Values,Preferences,andTaskForceInsightsConsistentwiththefirstaidprincipleofpreventingfurtherharm,thepotentialbenefitsofapplyingacervicalcollardonotoutweighharmssuchasincreasedintracranialpressureandtheconsequencesofunnecessaryneckmovement.Werecognizethatfirstaidprovidersmightnotbeabletodiscriminatebetweenhigh-orlow-riskindividuals.Wealsorecognizethepotentialvalueofmanualstabilizationincertaincircumstances,butthiswasnotevaluatedinthisreview.Taskforcediscussionaboutthisreviewincludedtherecognitionthat,althoughevidencefromthefewstudiesthatareavailablecomes

primarilyfromhealthyvolunteersandcadavers,thereisagrowingbodyofevidencedemonstratingharmfuleffects,suchasthedevelopmentofraisedintracranialpressure.Inaddition,therewasconcernexpressedthattheprocessforapplicationofacervicalcollarbyafirstaidprovidertoanindividualwithcervicalspinaltraumacouldresultinfurtherinjury.Applicationofacervicalcollarrequirestrainingandregularpracticetobeperformedproperly,andsuchtrainingmaynotbeacomponentofeveryfirstaidcoursecurriculum.Anotherimportantdiscussiontopicwaswhetherafirstaidproviderisabletodistinguishbetweenhigh-andlow-riskinjurycriteria.Asaresultoftheseconcernsandtheconsensusonsciencefindings,thetaskforcesuggestsagainsttheroutineapplicationofcervicalcollarsbyfirstaidproviders.Limitations:Evidenceis‘lowquality’foravarietyofreasonsandonlybunttraumawasstudied.Howeverthereislittle,ifanyevidencetorefutefindings.Extricationcollarscanresultinabnormalseparationbetweenvertebraeinthepresenceofadissociativeinjury.BACKGROUND:Cervicalcollarsareappliedtomillionsoftraumavictimswiththeintentofprotectingagainstsecondaryspineinjuries.Adverseclinicaloutcomesduringthemanagementoftraumapatientsledtothehypothesisthatextricationcollarsmaybeharmfulinsomecases.Theliteratureprovidesindirectsupportforthisobservation.Thepurposeofthisstudywastodirectlyevaluatecervicalbiomechanicsafterapplicationofacervicalcollarinthepresenceofsevereneckinjury.CONCLUSIONS:Thisstudywasconsistentwithpreviousevidencethatextricationcollarscanresultinabnormaldistractionwithintheuppercervicalspineinthepresenceofasevereinjury.Theseobservationssupporttheneedtoprioritizeadditionalresearchtobetterunderstandtherisksandbenefitsofcervicalstabilizationmethodsandtodeterminewhetherimprovedstabilizationmethodscanhelptoavoidpotentiallyharmfuldisplacementsbetweenvertebrae.Effectofcervicalhardcollaronintracranialpressureafterheadinjury.BACKGROUND:Patientssufferingheadtraumaareathighriskofhavingaconcomitantcervicalspineinjury.Arigidcervicalcollarisusuallyappliedtoeachpatientuntilspinalstabilityisconfirmed.Hardcollarspotentiallycausevenousoutflowobstructionandareanociceptivestimulus,whichmightelevateintracranialpressure(ICP).ThisstudytestedthehypothesisthatapplicationofahardcollarisassociatedwithanincreaseinICP.METHODS:Aprospectiveseriesof10head-injuredpatientswithapostresuscitationGlasgowcomascalescoreofnineorlesshadICPmeasurementsbeforeandaftercervicalhardcollarapplication.

RESULTS:Nineoutof10patientshadariseinICPfollowingapplicationofthecollar.Thedifferenceinpre-andpostapplicationICPwasstatisticallysignificant(P<0.05).CONCLUSIONS:Earlyassessmentofthecervicalspineinhead-injuredpatientsisrecommendedtominimizetheriskofintracranialhypertensionrelatedtoprolongedcervicalspineimmobilizationwithahardcollar.Limitations:Smallsamplesize,buteasyexperimenttoreplicate.

Headinjury=C-spineinjury?Epidemiologyandpredictorsofcervicalspineinjuryinadultmajortraumapatients:amulticentercohortstudy.BACKGROUND:Patientswithcervicalspineinjuriesareahigh-riskgroup,withthehighestreportedearlymortalityrateinspinaltrauma.METHODS:Thiscohortstudyinvestigatedpredictorsforcervicalspineinjuryinadult(≥16years)majortraumapatientsusingprospectivelycollecteddataoftheTraumaAuditandResearchNetworkfrom1988to2009.Univariateandmultivariatelogisticregressionanalyseswereusedtodeterminepredictorsforcervicalfractures/dislocationsorcordinjury.CONCLUSIONS:3.5%ofpatientssufferedcervicalspineinjury.PatientswithaloweredGCSorsystolicbloodpressure,severefacialfractures,dangerousinjurymechanism,malegender,and/orage≥35yearsareatincreasedrisk.Contrarytocommonbelief,headinjurywasnotpredictiveforcervicalspineinvolvement.

LogrollingTransferringpatientswiththoracolumbarspinalinstability:aretherealternativestothelogrollmaneuver?STUDYDESIGN:Usingacadavericmodel,theamountofspinalmotiongeneratedduringtheexecutionofvariousprehospitaltransfertechniqueswasevaluatedusingacrossoverstudydesign.OBJECTIVE:Toassessthequantityofsegmentalmotiongeneratedacrossagloballyunstablethoracolumbarspineduringtheexecutionofthelogroll(LR),lift-and-slide,and6-plus-person(6+)lift.CONCLUSION:TheexecutionoftheLRmaneuvertendstogeneratemoremotionthaneitheroftheliftingmethodsexaminedinthisinvestigation.Moreresearchis

neededtoidentifythesafestpossiblemethodfortransferringormovingpatientswiththoracolumbarinstability.ControlledLaboratoryComparisonStudyofMotionWithFootballEquipmentinaDestabilizedCervicalSpine:ThreeSpine-BoardTransferTechniques.BACKGROUND:Numerousstudieshaveshownthattherearebetteralternativestologrollingpatientswithunstablespinalinjuries,althoughthismethodisstillcommonlyusedforplacingpatientsontoaspineboard.Nopreviousstudieshaveexaminedtransfermaneuversinvolvinganinjuredfootballplayerwithequipmentinplaceontoaspineboard.CONCLUSION:Thelogrollresultedinthemostmotionatanunstablecervicalinjuryascomparedwiththeother2spine-boardingtechniquesexamined.The8-personliftandlift-and-slidetechniquesmaybothbemoreeffectivethanthelogrollatreducingunwantedcervicalspinemotionwhenspineboardinganinjuredfootballplayer.Reductionofsuchmotioniscriticalinthepreventionofiatrogenicinjury.

LevophedComparisonofDopamineandNorepinephrineintheTreatmentofShockBACKGROUND:Bothdopamineandnorepinephrinearerecommendedasfirst-linevasopressoragentsinthetreatmentofshock.Thereisacontinuingcontroversyaboutwhetheroneagentissuperiortotheother.Conclusions:Althoughtherewasnosignificantdifferenceintherateofdeathbetweenpatientswithshockwhoweretreatedwithdopamineasthefirst-linevasopressoragentandthosewhoweretreatedwithnorepinephrine,theuseofdopaminewasassociatedwithagreaternumberofadverseevents.Safetyofperipheralintravenousadministrationofvasoactivemedication.BACKGROUND:Centralvenousaccessiscommonlyperformedtoadministervasoactivemedication.Theadministrationofvasoactivemedicationviaperipheralintravenousaccessisapotentialmethodofreducingtheneedforcentralvenousaccess.Theaimofthisstudywastoevaluatethesafetyofvasoactivemedicationadministeredthroughperipheralintravenousaccess.CONCLUSIONS:Administrationofnorepinephrine,dopamine,orphenylephrinebyperipheralintravenousaccesswasfeasibleandsafeinthissingle-centermedicalintensivecareunit.Extravasationfromtheperipheralintravenouslinewasuncommon,andphentolaminewithnitroglycerinpastewereeffectiveinpreventinglocalischemicinjury.Cliniciansshouldnotregardtheuseofvasoactivemedicationisanautomaticindicationforcentralvenousaccess(Timeofperipheralvasopressoradministrationwas1-3days).

Ketamine-Towardsevidencebasedemergencymedicine:bestBETsfromtheManchesterRoyalInfirmary.BET3:isketamineaviableinductionagentforthetraumapatientwithpotentialbraininjury.Abstract:Ashortcutreviewwascarriedouttoestablishwhetherketamineisaviableinductionagentintraumapatientswithpotentialbraininjuries.276paperswerefoundusingthereportedsearches,ofwhich5presentedthebestevidencetoanswertheclinicalquestion.Theauthor,dateandcountryofpublication,patientgroupstudied,studytype,relevantoutcomes,resultsandstudyweaknessesofthesebestpapersaretabulated.ItisconcludedthatthereisnoevidencetosuggestharmwithKetamineuseasinductionagentforthepatientwithpotentialtraumaticbraininjury.Thedrughasmajoradvantagesinthosepatientswithassociatedhaemodynamiccompromiseandshouldpotentiallyberegardedastheagentofchoice.TheketamineeffectonICPintraumaticbraininjury.AbstractOurgoalwastoperformasystematicreviewoftheliteratureontheuseofketamineintraumaticbraininjury(TBI)anditseffectsonintracranialpressure(ICP).AllarticlesfromMEDLINE,BIOSIS,EMBASE,GlobalHealth,HealthStar,Scopus,CochraneLibrary,theInternationalClinicalTrialsRegistryPlatform(inceptiontoNovember2013),referencelistsofrelevantarticles,andgrayliteratureweresearched.TworeviewersindependentlyidentifiedallmanuscriptspertainingtotheadministrationofketamineinhumanTBIpatientsthatrecordedeffectsonICP.Secondaryoutcomesofeffectoncerebralperfusionpressure,meanarterialpressure,patientoutcome,andadverseeffectswererecorded.Tworeviewersindependentlyextracteddataincludingpopulationcharacteristicsandtreatmentcharacteristics.ThestrengthofevidencewasadjudicatedusingboththeOxfordandGRADEmethodology.Oursearchstrategyproducedatotal371citations.Sevenarticles,sixmanuscriptsandonemeetingproceeding,wereconsideredforthereviewwithallutilizingketamine,whiledocumentingICPinsevereTBIpatients.Allstudieswereprospectivestudies.Fiveandtwostudiespertainedtoadultsandpediatrics,respectively.Acrossallstudies,ofthe101adultand55pediatricpatientsdescribed,ICPdidnotincreaseinanyofthestudiesduringketamineadministration.ThreestudiesreportedasignificantdecreaseinICPwithketaminebolus.Cerebralperfusionpressureandmeanbloodpressureincreasedintwostudies,leadingtoadecreaseinvasopressorsinone.Nosignificantadverseeventsrelatedtoketaminewererecordedinanyofthestudies.Outcomedatawerepoorlydocumented.TherecurrentlyexistsOxfordlevel2b,GRADECevidencetosupportthatketaminedoes

notincreaseICPinsevereTBIpatientsthataresedatedandventilated,andinfactmayloweritinselectedcases.Whatisthenatureoftheemergencephenomenonwhenusingintravenousorintramuscularketamineforpaediatricproceduralsedation?OBJECTIVE:KetaminehasbecomethedrugmostfavouredbyemergencyphysiciansforsedationofchildrenintheED.Someemergencyphysiciansdonotuseketamineforpaediatricproceduralsedation(PPS)becauseofconcernaboutemergencedeliriumonrecovery.Thepresentstudysetouttodeterminethetrueincidenceandnatureofthisphenomenon.CONCLUSION:Thebeliefthatketamine,inthedosesusedforEDPPS,causesfrequentemergencedeliriumisflawed.Apleasantemergencephenomenoniscommon,butisnotdistressingforthechild,andhasnolong-term(upto30days)negativesequelae.Rarely,thereisanxietyordistressonawakeningfromketaminesedation,whichsettlesspontaneously.ThisshouldnotdeteremergencyphysiciansfromusingketamineforPPS.ClinicalPracticeGuidelineforEmergencyDepartmentKetamineDissociativeSedation:2011UpdateRecoveryreactions:Theabilityofketaminetoinducehallucinatoryreactions—bothpleasantandunpleasant—duringrecoveryislegendary.Althoughtheseso-calledemergencereactionsarerarelydisturbinginchildren(1.4%incidenceofreactionsjudgedclinicallyimportantinthelargemeta-analysis),theirincidenceinadultsvarieswidely(0%to30%).TheEDexperiencethusfaristhatsuchrecoveryreactionsareuncommonandgenerallymildinadults;however,cliniciansshouldbeawareoftherarepotentialforpronouncedreactions,includingnightmares,delirium,excitation,andphysicalcombativeness.Titratedbenzodiazepinesappeartorapidlyandconsistentlydiminishsuchreactions.Transientdiplopiaasaresultofrotarynystagmusiscommonduringrecovery,andtransientblindnesshasbeenreported.Inthelargemeta-analysisinchildren,recoveryagitationwasnotrelatedtoage,dose,orotherfactorstoanyclinicallyimportantdegree,exceptahigherincidenceinpatientsreceivingsubdissociative(<3mg/kgIM)dosing.Incontrasttotraditionalthinking,adolescentswerenotatsubstantiallyhigherrisk.Recoveryagitationwithoutanapparenthallucinatorycomponentafterdissociativesedationisnotuncommon.Giventhatitoccursatafrequencysimilartothatofmidazolamalone,suchagitationappearstobeaseparateentityfromtheketamine-inducedhallucinatoryreactions.Ithasbeenassociatedwiththedegreeofpreproceduralagitationbutnotthedegreeofexternalstimulationduringrecovery.Inonestudy,emergencyphysiciansgradedtheseverityofketaminerecoveryagitationwitha100-mmvisualanalogscale,andthemedianratingwas5mm,ie,amagnitudeofminimalclinicalimportance.

CVPinFemoralCentralLinesCentralvenouspressureinfemoralcatheter:correlationwithsuperiorapproachafterheartsurgery.OBJECTIVE:Itiscommontoobtainfemoralvenousapproachinpatientsundergoingcombinedheartsurgeryorasanalternativetosuperiorapproach(internaljugularveinorsubclavianvein).Theaimofthisstudywastocomparethemeasuresofcentralvenouspressure(CVP)attwodifferentsites(superiorversusfemoral).CONCLUSION:TheCVPcanbemeasuredwithaccuracyinthefemoralvenousapproachintheimmediatepostoperativeperiodofheartsurgerywithbetterlinearcorrelationobtainedwiththemeasuresmadewiththeheadboardpositionedatzerodegree.Measurementofcentralvenouspressurefromaperipheralveinininfantsandchildren.BACKGROUND:Previousstudiesinadultshavedemonstratedaclinicallyusefulcorrelationbetweencentralvenouspressure(CVP)measuredfromaperipheralintravenouscatheterandthatmeasuredfromacentralvenouscatheter.ThecurrentstudyprospectivelycomparesCVPmeasurementsfromacentralcatheterandaperipheralcatheterininfantsandchildren.CONCLUSION:CVPcanbemeasuredfromaperipheralIVcatheterininfantsandchildrenprovidedthatthereiscontinuitywiththecentralvenouscompartmentdemonstratedbyshowinganincreaseintheCVPfromtheperipheralIVcatheterinresponsetoasustainedinspiratoryeffortandbyocclusionoftheextremityabovethesiteofthecatheter.

Lidocainewithepinephrineinextremities-Epinephrine-supplementedlocalanestheticsforearandnosesurgery:clinicalusewithoutcomplicationsinmorethan10,000surgicalprocedures.INTRODUCTION:Localanestheticssupplementedwithepinephrinearegenerallyregardedascontraindicatedforsurgicalproceduresinvolvingthefingers,toes,penis,outerearandthetipofthenose[1],butepinephrineisessentialifautomatedtumescencelocalanesthesia(Auto-TLA)isused.CONCLUSION:Epinephrinesupplementationoflocalanestheticsdoesnotblockbloodperfusionintheearanddidnotinduceorgan,tissueorflapnecrosis.Local

anesthesiawithepinephrinesupplementationisthereforesafeforacralareassuchastheearornose.Despitetherelativelysmallinfluenceonbloodperfusion,epinephrinesupplementationresultsinarelativelybloodlessoperatingfieldandlongereffectivenessoflocalanesthesia.Therelativeabsenceofbloodintheoperatingfieldoftheearandnosesignificantlyreducesthedurationofsurgeryandincreasesthehealingrate,aslesselectrocauteryisneeded.

LidocaineduringRSIInpatientswithheadinjuryundergoingrapidsequenceintubation,doespretreatmentwithintravenouslignocaine/lidocaineleadtoanimprovedneurologicaloutcome?Areviewoftheliterature.AbstractItiswellknownthatlaryngealinstrumentationandendotrachealintubationisassociatedwithamarked,transientriseinintracranialpressure(ICP).PatientswithheadinjuryrequiringendotrachealintubationareconsideredparticularlyatriskfromthistransientriseinICPasitreducescerebralperfusionandthusmayincreasesecondarybraininjury.Thefavouredmethodforsecuringadefinitiveairwayinthispatientgroupisbyrapidsequenceintubation(RSI).IntheUnitedStatestheEmergencyAirwayCourseteachesemergencyphysicianstoroutinelyadministerintravenouslidocaineasapretreatmentforRSIinthispatientgroupinanattempttoattenuatethisriseinICP.AliteraturesearchwascarriedouttoidentifystudiesinwhichintravenouslidocainewasusedasapretreatmentforRSIinmajorheadinjury.Anylinktoanimprovedneurologicaloutcomewasalsosought.Papersidentifiedwereappraisedinthemannerrecommendedbytheevidencebasedmedicinegrouptoensurevalidity.Therewerenostudiesidentifiedthatansweredourquestiondirectlyand,furthermore,itisourbeliefthatnosuchstudy,atpresent,existsintheliterature.Sixvalidpaperswerefound,whichindividuallycontainedelementsofthequestionposedandthesearepresentedinanarrativeandgraphicform.ThereiscurrentlynoevidencetosupporttheuseofintravenouslidocaineasapretreatmentforRSIinpatientswithheadinjuryanditsuseshouldonlyoccurinclinicaltrials.

AtropineduringRSI:

Bradycardiaduringcriticalcareintubation:mechanisms,significanceandatropine.Abstract:Bradycardiaoccursduringtheintubationofsomecriticallyillchildrenasaresultofvagalstimulationduetohypoxiaand/orlaryngealstimulation;such'stable'bradycardiaisaccompaniedbyselectivevasoconstriction.Someinductiondrugsalsoinducebradycardiawhichmaybeaccompaniedbyvasodilatationwhichisalsoafeatureofcertainpathologies,whichinfluencetheprogressionto'unstable'bradycardia,whichdoesnotrespondtore-oxygenationandapauseinlaryngoscopy.Preintubationatropinediminishestheoverallincidenceofstable

bradycardiaduringroutineanaesthesia.However,clinicalstudiesofcriticalcareintubationshowthatatropinedoesnotpreventallepisodesofbradycardiaandspecificallycannotaffectvasodilatation.Assuch,thereisinsufficientevidencetosupportarecommendationfortheindiscriminateuseofatropineforintubationduringcriticalcareillness,includingsimpleneonatalrespiratorydistress.Atropineisappropriateduringsepticorlatestagehypovolaemicshockwhereabnormalvasomotortoneandbradycardiamaypotentiallysetupanegativefeedbackloopofcardiachypo-oxygenationandhypoperfusionandduringpremedicationwhenusingsuxamethonium.Pediatricrapidsequenceintubation:incidenceofreflexbradycardiaandeffectsofpretreatmentwithatropine.OBJECTIVE:TodescribetheincidenceofreflexbradycardiaanditsrelationshiptotheadministrationofatropineduringL/TIinaPediatricEmergencyDepartment.CONCLUSION:AtropineisnotroutinelyadministeredpriortoL/TIinthispediatricED.Pretreatmentwithatropinedidnotpreventbradycardiainallcases.ThesedatasuggestthatuseofatropinepriortoL/TImaynotberequiredforallpediatricpatients.Somepatientswillexperiencebradycardiaregardlessofatropinepretreatment.

Cricoidpressure:Controlledrapidsequenceinductionandintubation-ananalysisof1001children.BACKGROUND:Classicrapidsequenceinductionputspediatricpatientsatriskofcardiorespiratorydeteriorationandtraumaticintubationduetotheirreducedapneatoleranceandrelatedshortenedintubationtime.A'controlled'rapidsequenceinductionandintubationtechnique(cRSII)withgentlefacemaskventilationpriortointubationmaybeasaferandmoreappropriateapproachinpediatricpatients.TheaimofthisstudywastoanalyzethebenefitsandcomplicationsofcRSIIinalargecohort.CONCLUSION:ControlledRSIIwithgentlefacemaskventilationpriortointubationsupportsstablecardiorespiratoryconditionsforsecuringtheairwayinchildrenwithanexpectedorsuspectedfullstomach.Pulmonaryaspirationdoesnotseemtobesignificantlyincreased.APilotRandomizedClinicalTrialAssessingtheEffectofCricoidPressureonRiskofAspiration.INTRODUCTION:Patientsatriskformicroaspirationduringelectiveintubationoftenreceivecricoidpressureinthehopesofmitigatingsuchrisk.However,thereisscarceevidencetoeithersupportorrejectthispractice.Theobjectiveofthis

investigationwastoassesstheeffectofcricoidpressureonmicroaspirationandtoinformthepotentialfeasibilityofconductingalarger,moredefinitiveclinicaltrial.CONCLUSIONS:UtilizingpepsinAasabiomarkerofaspiration,thispilotclinicaltrialdidnotfindevidenceforareducedrateofaspirationoradverseclinicaleventswiththeadministrationofcricoidpressureduringelectiveendotrachealintubationofpatientswithriskfactorsformicroaspiration.Thisarticleisprotectedbycopyright.Allrightsreserved.CricoidpressureimpedestrachealintubationwiththePentax-AWSAirwayscope®:aprospectiverandomizedtrial.BACKGROUND:ItisunclearhowcricoidpressureaffectstrachealintubationwiththePentax-AWSAirwayscope(®)(AWS).Weconductedaprospectiverandomizedclinicaltrialinanaesthetizedpatients.CONCLUSIONS:CricoidpressureimpedestrachealintubationusingtheAWS,andisassociatedwithlongerintubationtime,whichcanbeattributedtoincreaseddifficultyinthepassageofatubethroughtheglottis.Videographicanalysisofglotticviewwithincreasingcricoidpressureforce.STUDYOBJECTIVE:Cricoidpressuremaynegativelyaffectlaryngealviewandcompromiseairwaypatency,accordingtopreviousstudiesofdirectlaryngoscopy,endoscopy,andradiologicimaging.Inthisstudy,weassesstheeffectofcricoidpressureonlaryngealviewwithavideolaryngoscope,thePentax-AWS.CONCLUSION:Cricoidpressureapplicationwithincreasingforceresultedinaworseglotticview,asexaminedwiththePentax-AWSVideolaryngoscope.Thereismuchindividualdifferenceinthedegreeofchange,evenwiththesameforce.CliniciansshouldbeawarethatcricoidpressureaffectslaryngealviewwiththePentax-AWSandlikelyothervideolaryngoscopes.

NeedleThoracostomy:Radiologicevaluationofalternativesitesforneedledecompressionoftensionpneumothorax.OBJECTIVE:Tocomparethedistancetobetraversedduringneedlethoracostomydecompressionperformedatthesecondintercostalspace(ICS)inthemidclavicularline(MCL)withthefifthICSintheanterioraxillaryline(AAL).CONCLUSIONS:Inthiscomputedtomography-basedanalysisofchestwallthickness,needlethoracostomydecompressionwouldbeexpectedtofailin42.5%ofcasesatthesecondICSintheMCLcomparedwith16.7%atthefifthICSinthe

AAL.ThechestwallthicknessatthefifthICSAALwas1.3cmthinneronaverageandmaybeapreferredlocationforneedlethoracostomydecompression.Cadavericcomparisonoftheoptimalsiteforneedledecompressionoftensionpneumothoraxbyprehospitalcareproviders.BACKGROUND:Computedtomographicandcadavericstudieshavedemonstratedneedledecompressionoftensionpneumothoraxatthefifthintercostalspace(ICS),anterioraxillaryline(AAL)hasadvantagesoverthesecondICSmidclavicularline(MCL).Thepurposeofthisstudywastocomparetheabilityofprehospitalcareproviderstoaccuratelydecompressthechestatthesetwolocations.CONCLUSION:Forprehospitalcareproviders,thefifthICSAALcanbelocalizedanddecompressedwithahigherdegreeofaccuracythanthetraditionalsecondICSMCL.Itisratedaseasiertoperformandcanbedonejustasquickly.Basedonthesedata,thefifthICSAALshouldbeconsideredasanequivalentfirst-linepositionforneedledecompressioninpatientswithclinicalevidenceofatensionpneumothorax.

BronchodialatorsinRSV:Pulmonarymechanicsfollowingalbuteroltherapyinmechanicallyventilatedinfantswithbronchiolitis.BACKGROUNDANDAIMS:Bronchiolitisisacommoncauseofcriticalillnessininfants.Inhaledβ(2)-agonistbronchodilatorsarefrequentlyusedaspartoftreatment,despiteunproveneffectiveness.Thepurposeofthisstudywastodescribethephysiologicresponsetothesemedicationsininfantsintubatedandmechanicallyventilatedforbronchiolitis.CONCLUSIONS:Inthispopulationofmechanicallyventilatedinfantswithbronchiolitis,relativelyfewhadareductioninpulmonaryresistanceinresponsetoinhaledalbuteroltherapy.Thisresponsewasnotassociatedwithimprovementsinoutcomes.

GCS8=Intubate?WhatistherelationshipbetweentheGlasgowcomascaleandairwayprotectivereflexesintheChinesepopulation?AIM:TodescribetherelationshipofgagandcoughreflexestoGlasgowcomascore(GCS)inChineseadultsrequiringcriticalcare.CONCLUSIONS:OurstudyhasshownthatinaChinesepopulationwithawiderangeofcriticalillness(butlittletraumaorintoxication),reducedGCSissignificantlyrelatedtogagandcoughreflexes.However,aconsiderableproportionofpatients

withaGCS≤8haveintactairwayreflexesandmaybecapableofmaintainingtheirownairway,whilstmanypatientswithaGCS>8haveimpairedairwayreflexesandmaybeatriskofaspiration.Thishasimportantimplicationsforairwaymanagementdecisions.DecreasedGlasgowComaScalescoredoesnotmandateendotrachealintubationintheemergencydepartment.BACKGROUND:Decreasedconsciousnessisacommonreasonforpresentationtotheemergencydepartment(ED)andadmissiontoacutehospitalbeds.Intrauma,aGlasgowComaScalescore(GCS)of8orlessindicatesaneedforendotrachealintubation.Someadvocateasimilarapproachforothercausesofdecreasedconsciousness,however,thelossofairwayreflexesandriskofaspirationcannotbereliablypredictedusingtheGCSalone.RESULTS:Thestudyincluded73patientswithdecreasedconsciousnessasaresultofdrugoralcoholintoxication.TheGCSrangedfrom3to14,and12patientshadaGCSof8orless.NopatientwithaGCSof8orlessaspiratedorrequiredintubation.Therewasonepatientwhorequiredintubation;thispatienthadaGCSof12onadmissiontotheward.CONCLUSIONS:Thisstudysuggeststhatitcanbesafetoobservepoisonedpatientswithdecreasedconsciousness,eveniftheyhaveaGCSof8orless,intheED.

OxygeninCOPDOxygen-inducedhypercapniainCOPD:mythsandfactsAbstract:Despitesubsequentstudiesandreviews[3]describingtheeffectofoxygenontheventilatordriveinpatientswithCOPD,disprovingthe'hypoxicdrive'theorem,manycliniciansarestillbeingtaughtduringtheirmedicaltrainingthatadministrationofoxygeninpatientswithCOPDcanbedangerousgiventhatitinduceshypercapniathroughthe'hypoxicdrive'mechanism;thatis,increasingarterialO2tensionwillreducetherespiratorydrive,leadingtoa(dangerous)hypercapnia.ThismisconceptionhasresultedinthereluctanceofcliniciansandnursestoadministeroxygentohypoxemicpatientswithCOPD.Inmostcases,thisisanunwisedecision,puttingatriskthesafetyofpatientswithacuteexacerbationofCOPD.Inthisconcisepaper,wewilldiscusstheimpactandpathophysiologyofoxygen-inducedhypercapniainpatientswithacuteexacerbationofCOPD.Conclusions:InpatientswithCOPD,hypoxicpulmonaryvasoconstrictionisthemostefficientwaytoaltertheVa/Qratiostoimprovegasexchange.Thisphysiologicalmechanismiscounteractedbyoxygentherapyandaccountsforthelargestincreaseofoxygen-inducedhypercapnia.Atitratedoxygentherapytoachievesaturationsof88%to92%isrecommendedinpatientswithanacute

exacerbationofCOPDtoavoidhypoxemiaandreducetheriskofoxygen-inducedhypercapnia.

Rectalexamintrauma:Reasonstoomitdigitalrectalexamintraumapatients:nofingers,norectum,nousefuladditionalinformation.BACKGROUND:Performanceofdigitalrectalexamination(DRE)onalltraumapatientsduringthesecondarysurveyhasbeenadvocatedbytheAdvancedTraumaLifeSupportcourse.However,thereisnoclearevidenceofitsefficacyasadiagnostictestfortraumaticinjury.ThepurposeofthisstudyistoanalyzethevalueofapolicymandatingDREonalltraumapatientsaspartoftheinitialevaluationprocessandtodiscernwhetheritcanroutinelybeomitted.CONCLUSION:DREisequivalenttoOCIforconfirmingorexcludingthepresenceofindexinjuries.Whenindexinjuriesaredemonstrated,OCIismorelikelytobeassociatedwiththeirpresence.DRErarelyprovidesadditionalaccurateorusefulinformationthatchangesmanagement.OmissionofDREinvirtuallyalltraumapatientsappearspermissible,safe,andadvantageous.EliminationofroutineDREfromthesecondarysurveywillpresumablyconservetimeandresources,minimizeunpleasantencounters,andprotectpatientsandstafffromthepotentialforfurtherharmwithoutanysignificantnegativeimpactoncareandoutcome.Lackofevidencetosupportroutinedigitalrectalexaminationinpediatrictraumapatients.BACKGROUND:Currentadvancedtraumalifesupportguidelinesrecommendthatadigitalrectalexamination(DRE)shouldbeperformedaspartoftheinitialevaluationofalltraumapatients.OurprimarygoalwastoestimatethetestcharacteristicsoftheDREinpediatricpatientsforthefollowinginjuries:(1)spinalcordinjuries,(2)bowelinjuries,(3)rectalinjuries,(4)pelvicfractures,and(5)urethraldisruptions.CONCLUSIONS:TheDREhaspoorsensitivityforthediagnosisofspinalcord,bowel,rectal,bonypelvis,andurethralinjuries.OurfindingssuggestthattheDREshouldnotberoutinelyusedinpediatrictraumapatients.

MONA-doweneedthe‘O’?

EffectofsupplementaloxygenexposureonmyocardialinjuryinST-elevationmyocardialinfarction.OBJECTIVE:SupplementaloxygentherapymayincreasemyocardialinjuryfollowingSTelevationmyocardialinfarction(STEMI).Inthisstudy,weaimedto

evaluatetheeffectofthedoseanddurationofoxygenexposureonmyocardialinjuryafterSTEMI.CONCLUSIONS:Supplementaloxygenexposureinthefirst12hafterSTEMIwasassociatedwithaclinicallysignificantincreaseincTnI(troponin)andCKrelease.AirVersusOxygeninST-Segment-ElevationMyocardialInfarction.BACKGROUND:OxygeniscommonlyadministeredtopatientswithST-elevation-myocardialinfarctiondespitepreviousstudiessuggestingapossibleincreaseinmyocardialinjuryasaresultofcoronaryvasoconstrictionandheightenedoxidativestress.CONCLUSION:SupplementaloxygentherapyinpatientswithST-elevation-myocardialinfarctionbutwithouthypoxiamayincreaseearlymyocardialinjuryandwasassociatedwithlargermyocardialinfarctsizeassessedat6months.

EpinephrineincardiacarrestPatient-centricbloodpressure-targetedcardiopulmonaryresuscitationimprovessurvivalfromcardiacarrest.RATIONALE:Althoughcurrentresuscitationguidelinesarerescuerfocused,theopportunityexiststodeveloppatient-centeredresuscitationstrategiesthatoptimizethehemodynamicresponseoftheindividualinthehopestoimprovesurvival.OBJECTIVES:Todetermineiftitratingcardiopulmonaryresuscitation(CPR)tobloodpressurewouldimprove24-hoursurvivalcomparedwithtraditionalCPRinaporcinemodelofasphyxia-associatedventricularfibrillation(VF).CONCLUSIONS:Bloodpressure-targetedCPRimproves24-hoursurvivalcomparedwithoptimalAmericanHeartAssociationcareinaporcinemodelofasphyxia-associatedVFcardiacarrest.Hemodynamic-directedcardiopulmonaryresuscitationduringin-hospitalcardiacarrest.Abstract:Cardiopulmonaryresuscitation(CPR)guidelinesassumethatcardiacarrestvictimscanbetreatedwithauniformchestcompression(CC)depthandastandardizedintervaladministrationofvasopressordrugs.Thisnon-personalizedapproachdoesnotincorporateapatient'sindividualizedresponseintoongoingresuscitativeefforts.Inpreviouslyreportedporcinemodelsofhypoxicandnormoxicventricularfibrillation(VF),ahemodynamic-directedresuscitationimprovedshort-termsurvivalcomparedtocurrentpracticeguidelines.Skilledin-hospitalrescuersshouldbetrainedtotailorresuscitationeffortstotheindividual

patient'sphysiology.Suchastrategywouldbeamajorparadigmshiftinthetreatmentofin-hospitalcardiacarrestvictims.HemodynamicdirectedCPRimprovescerebralperfusionpressureandbraintissueoxygenation.AIM:Advancesincardiopulmonaryresuscitation(CPR)havefocusedonthegenerationandmaintenanceofadequatemyocardialbloodflowtooptimizethereturnofspontaneouscirculationandsurvival.Muchofthemorbidityassociatedwithcardiacarrestsurvivorscanbeattributedtoglobalbrainhypoxicischemicinjury.Theobjectiveofthisstudywastocomparecerebralphysiologicalvariablesusingahemodynamicdirectedresuscitationstrategyversusanabsolutedepth-guidedapproachinaporcinemodelofventricularfibrillation(VF)cardiacarrest.CONCLUSIONS:Hemodynamicdirectedresuscitationstrategytargetingcoronaryperfusionpressure>20mmHgfollowingVFarrestwasassociatedwithhighercerebralperfusionpressuresandbraintissueoxygentensionsduringCPR.

STEMIvs.NSTEMISHORTANDLONG-TERMMORTALITYAFTERSTEMIVERSUSNON-STEMI:ASYSTEMATICREVIEWANDMETA-ANALYSISBackground:AcutecoronarysyndromesmaymanifestasST-ElevationMyocardialInfarction(STEMI)orNon-STElevationMyocardialInfarction(NSTEMI).AlthoughpatientswhopresentwithSTEMIorNSTEMIsharethesamecardiacrisksfactors,isitnotclearintheliteratureifSTEMIpatientshaveabetterorworseprognosisthanNSTEMIpatients,bothonashortandlongtermperspective.Conclusions:Inthismeta-analysis,thefirsttocompareshortandlongtermmortalityinSTEMIandNSTEMIpatients,bothtypesofACSshareasimilarlong-termprognosis,despiteaworseshort-termprognosisafterSTEMI.YoungerageinSTEMIisafactorrelatedtobetterlong-termprognosis.Differencesintheprofile,treatment,andprognosisofpatientswithcardiogenicshockbymyocardialinfarctionclassification:AreportfromNCDR.BACKGROUND:Cardiogenicshockisadeadlycomplicationofanacutemyocardialinfarction(MI).Wesoughttocharacterizedifferencesinpatientfeatures,treatments,andoutcomesofcardiogenicshockbyMIclassification:ST-segment-elevationMI(STEMI)versusnon-ST-segmentelevationMI(NSTEMI).CONCLUSIONS:CardiogenicshockisassociatedwithhighmortalityinpatientswithSTEMIandNSTEMI.However,urgentrevascularizationismorecommonlypursuedinpatientswithSTEMIpresentingwithshockthaninpatientswithNSTEMI.More

researchisneededtoimprovetheoutcomesforpatientswithMIpresentingwithshock,particularlythosepresentingwithNSTEMI.

Blownpupils:Prognosisofpatientswithbilateralfixeddilatedpupilssecondarytotraumaticextraduralorsubduralhaematomawhoundergosurgery:asystematicreviewandmeta-analysisPrimaryobjective:Toreviewtheprognosisofpatientswithbilateralfixedanddilatedpupilssecondarytotraumaticextradural(epidural)orsubduralhaematomawhoundergosurgery.Conclusionsandimplicationsofkeyfindings:Despitethepooroverallprognosisofpatientswithclosedheadinjuryandbilateralfixedanddilatedpupils,ourfindingssuggestthatagoodrecoveryispossibleifanaggressivesurgicalapproachistakeninselectedcases,particularlythosewithextraduralhaematoma.

LactateLactateclearancefordeathpredictioninseveresepsisorsepticshockpatientsduringthefirst24hoursinIntensiveCareUnit:anobservationalstudyBackground:Thisstudywasdesigntoinvestigatetheprognosticvaluefordeathatday-28oflactatecourseandlactateclearanceduringthefirst24hoursinIntensiveCareUnit(ICU),afterinitialresuscitation.Conclusions:Duringthefirst24hrintheICU,lactateclearancewasthebestparameterassociatedwith28-daymortalityrateinsepticpatients.Protocoloflactateclearance-directedtherapyshouldbeconsideredinsepticpatients,evenafterthegoldenhours.THEROLEOFLACTATECLEARANCEASAPREDICTOROFORGANDYSFUNCTIONANDMORTALITYINPATIENTSWITHSEVERESEPSISBackground:Littleisknownaboutbiomarkerswhichareusedtoclassificationofpatientsinordertodiagnosisseverityofsepsisamongclientsofemergencyunits.ItseemsthatLactate’sclearancecanbeusedinthisregard.ThisstudyaimedtodeterminetherelationshipbetweenLactate’sclearance,mortalityandorgan’sdysfunctionwithseveresepsis.Conclusion:Itwasconcludedthatpatientswithseveresepsisisamarkerwhichisrelatedtotissuehypoxia,alsolactate’sclearanceincreasingisrelatedtodrasticreductioninbiomarkers,mortality,andincidenceoforgan’sdysfunction.Overall,

patientswithlowerlactate’sclearancearecountedahighriskgroupformortalityandorgans’dysfunction.Sepsis-associatedhyperlactatemiaAbstract:Thereisoverwhelmingevidencethatsepsisandsepticshockareassociatedwithhyperlactatemia(sepsis-associatedhyperlactatemia(SAHL)).SAHLisastrongindependentpredictorofmortalityanditspresenceandprogressionarewidelyappreciatedbyclinicianstodefineaveryhigh-riskpopulation.Untilrecently,thedominantparadigmhasbeenthatSAHLisamarkeroftissuehypoxia.Accordingly,SAHLhasbeeninterpretedtoindicatethepresenceofan`oxygendebt’or`hypoperfusion’,whichleadstoincreasedlactategenerationviaanaerobicglycolysis.InlightofsuchinterpretationofthemeaningofSAHL,maneuverstoincreaseoxygendeliveryhavebeenproposedasitstreatment.Moreover,lactatelevelshavebeenproposedasamethodtoevaluatetheadequacyofresuscitationandthenatureoftheresponsetotheinitialtreatmentforsepsis.However,alargebodyofevidencehasaccumulatedthatstronglychallengessuchnotions.MuchevidencenowsupportstheviewthatSAHLisnotdueonlytotissuehypoxiaoranaerobicglycolysis.ExperimentalandhumanstudiesallconsistentlysupporttheviewthatSAHLismorelogicallyexplainedbyincreasedaerobicglycolysissecondarytoactivationofthestressresponse(adrenergicstimulation).Moreimportantly,newevidencesuggeststhatSAHLmayactuallyservetofacilitatebioenergeticefficiencythroughanincreaseinlactateoxidation.Inthissense,thecharacteristicsoflactateproductionbestfitthenotionofanadaptivesurvivalresponsethatgrowsinintensityasdiseaseseverityincreases.CliniciansneedtobeawareofthesedevelopmentsinourunderstandingofSAHLinordertoapproachpatientmanagementaccordingtobiologicalprinciplesandtointerpretlactateconcentrationsduringsepsisresuscitationaccordingtocurrentbestknowledge.Conclusion:Hyperlactatemiaiscommoninpatientswithsepsis,amarkerofillnessseverityandastrongpredictorofmortality.However,inthisreview,wecritiquethetheorythatSAHLindicatesanoxygendebtorhypoperfusionortissuehypoxiaor`anaerobicglycolysis’.WeprovideevidencethatmetabolicchangescanaccountforSAHLandthatsuchevidenceisrecurrent,logicalandconsistentandnotyetcontradictedbyanyempiricalobservation.SAHLmaythusreflectseverityofillnessandthedegreeofactivationofthestressresponse(andreleaseofepinephrine).IfthemetabolictheoryofSAHLiscorrect,theninametaphoricalsenseSAHLmaybethecellularequivalentoffeverandmayrepresenttheimpactofmajorchangesinnumerousmetabolicprocesses.Understress,lactateisasourceofenergyinthesamecellwhereitisproducedandalsoinothercellswhereitcanbeusedasanimportantfuelforoxidationandglucosegeneration.Fluidresuscitation-orhemodynamic-basedprotocolsmaynotdirectlyaffectlactateifthemechanismsofitsproductionarenotdirectlytargetedbysuchactivities.Similarly,lactatemaynotnecessarilyindicatetheneedtodeliberatelyincreasecalculatedsystemicoxygendeliverybecauseitmaynotrepresentanoxygendeficiency.Incontrast,ifthetissuehypoxiatheoryofSAHLiscorrect,thenthetherapeuticimplicationsarevery

different.Itispossible,maybelikely,thatboth(tissuehypoxiaandmetabolicadaptation)explainSAHLindifferentpatientsatdifferenttimesoroccursimultaneouslytoadegreethatchangesfrompatienttopatientandaccordingtoillnessseverity,geneticsandinterventions,inawaythatwedonotyetunderstand.Theextraordinarycomplexityoflactatemakesitimpossible,atthisstage,toachievesuchdeeperunderstanding.Untilthen,cliniciansshouldbeawareofsuchcomplexityandmaketherapeuticchoicesonthebasisofsuchknowledge.

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