Resuscitation: News, Updates, Pearls and Practice Changers
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Transcript of Resuscitation: News, Updates, Pearls and Practice Changers
Objectives
Hit you with theme based short snappers that (hopefully) shed light on some recent changes or controversies in CRIT/ER practice
Too Hot
Be ready for the increasing number of severe methamphetamine, cocaine, ecstasy and PMMA exposures in our region
Medication induced hyperthermia Neuroleptic malignant syndrome Malignant Hyperthermia Serotonin syndrome
They kind of look the same But they are actually very different Because they are different, the ideal
treatments are different▪ Or are they?
MH Congenital calcium repolarization problem at SR▪ Increased intracellular calcium▪ Tx: abolish contraction-excitation coupling in muscle
(Dantrolene) NMS
Dopamine blockade (low dopamine state)▪ Tx: DA agonist (bromocryptine)
SS Xs serotonin ▪ Tx: 5HT antagonist (cryproheptadine)
Would dantrolene work in SS (ecstacy, meth, cocaine)?
Traditional thinking says no Muscle release (calcium lowering) would
not help serotonin problem 5HT antagonist for a 5HT problem
Too Hot?
MDMA and dantrolene Controversial Published data: case reports mostly
SR 53 articles 71 cases Dantrolene use in 26 cases
Temp >42C Temp 40-42C
Dantrolene use 8/13
survivednon Dantrolene use 0/4 survived
Dantrolene use10/10
survivedNon Dantrolene
15/27 survived
Too Cold?
Resuscitated VF/VT patients should undergo therapeutic hypothermia for potential treatment of anoxic brain injury ILCOR Level I recommendation ACC/AHA
Likely any patient who has suffered anoxic brain injury from resuscitated cardiac arrest should be considered for TH
Targeted Temperature Management at 33C vs 36C after Cardiac Arrest (TTM) NEJM, Nielsen et al
Big study Well done No difference in outcome
What now?
What does it mean? Maybe patients don’t have to be THAT
cool for benefit Maybe its easier to start TTH vs TH,
therefore, more accessible Hyperthermia and normothermia are
NOT acceptable
So what should we do? TTM should be considered for
resuscitated cardiac arrest Challenges
Tougher to get patient to 33C, but easier to keep them there
Easier to get patient to <36C, but harder to keep them there
Pump or Squeeze?
ER docs treat shock There are no evidence based
guidelines to assist in which pressor/trope to use in shock
VICE has created a document to address that CAEP standards committee CJEM
Shavaun MacDonald Rob GreenAndrea Wensel Osama LoubaniJames Lee Patrick ArchambaultJaneva Kircher Simon BordeleauKatherine Smith Adam SzulewskiJon Davidow Sara GrayDennis Djogovic Jean Marc Benoit
David
Messenger Dan Howes
What are inotropes?
Any agent that augments heart PUMP ▪ Ie emptying
Inotropy Chronotropy Decrease afterload
Inotropes VasopressorsIntra aortic Balloon Pump
PhenylephrineDobutamine Ephedrine Isoproteronol
Norepinephrine Epinephrine Dopamine Milrinone Nitroprusside Digoxin
For ED patients in shock, what are the side effects of vasopressors and inotropes?
Dopamine increases the risk of tachyarrhythmia compared to norepinephrine. ▪ (Grade A).
Epinephrine increases metabolic abnormalities compared to norepinephrine.▪ (Grade A).
Which vasopressors and inotropes should be used in the treatment of ED patients with cardiogenic shock?
Recommendation: Cardiogenic shock patients in the ED should receive norepinephrine as the first-line vasopressor▪ (Strong)
Which vasopressors and inotropes should be used in ED patients with distributive shock?
Recommendations: Norepinephrine is the first line vasopressor for use in septic shock▪ (Strong)
Recommendation: Dobutamine should be used for septic shock with low cardiac output despite adequate volume resuscitation▪ (Strong)
Which vasopressors and inotropes should be used in ED patients with distributive shock?
Recommendation: Epinephrine infusion is the preferred agent for anaphylactic shock that does not respond to intramuscular or intravenous bolus epinephrine. ▪ (Strong)
Which vasopressors and inotropes should be used in ED patients with undifferentiated shock?
Recommendation: In undifferentiated shock not responding to fluid resuscitation, norepinephrine should be the first-line vasopressor. ▪ (Strong)
Stay Together or Break Up?
Small PE IV heparin or LMWH
Massive unstable PE Thrombolyze (tPA)
Massive “stable” PE ????????????????
Massive “stable” PE May have
Dilated right ventricle▪ On TTE or CT
Septum: flat or bowed Elevated troponin▪ Suggesting right heart ischemia/strain
Elevated BNP hypoxia
30% of normotensive patients have RV dysfunction
10% progress to shock 5% mortality
▪ Of those who have survived this far
Dilemma
If you lyse Risk of bleed▪ 20% major bleed▪ 3-5% intracranial bleed
If you don’t lyse Pulmonary HTN, exercise tolerance Higher chance recurrent thromboembolic
disease
MOPETT, J Cardiol 2013 ½ dose tPA for moderate (submassive)
PE
No difference in survival▪ No difference in death
Less pulmonary hypertension if tPA▪ 16 vs 57%▪ ???
PEITHO, NEJM 2014 1000 patients, moderate PE, tenecteplase
No mortality difference 30 days Less hemodynamic decompensation and death in
7 days Bleeding
More extracranial bleeding▪ 6.3 vs 1.2%
More hemorrhagic stroke▪ 2.0 vs 0.2%
If >75 ya, more extracranial bleeding (11 vs 4%, but not significant)
Chatterjee, JAMA 2014 Meta analysis, thrombolysis in PE ▪ But includes ALL thrombo given for ALL PEs
16 trials 1/4 trials accounted for ¾ of patients
Mortality 2.2 vs 3.9%
Major bleeding 9.2 vs 3.4%▪ Major bleeding if >65ya: 12.9 vs 4.1%▪ Major bleeding if <65 ya: 2.8 vs 2.3%
ICH 1.5 vs 0.2%
So, what to do?
If you have a submassive but scary PE, you should talk to someone Not really time emergent but time
urgent therapy▪ 12-24hrs?
What do I do?
IF CT shows extensive clot TTE shows right heart failure Positive troponin Elevated BNP “soft” BP <65 years age NO bleeding risks identified in history No access to interventional radiology
4 or 10? Which and When?
Burn resuscitation Dilemma
Too little fluid▪ End organ dysfunction (renal failure, gut
hypoperfusion, acidosis) Too much fluid
▪ Compartment syndromes▪ Chest: cant ventilate▪ Worsen limb compartments▪ Abdomen: decompressive laparotomy
Huge increase in mortality
Parkland formula Current standard 40 years old Many burn centres quickly move away
from Parkland numbers Many centres also start using colloid at
8-12 hr mark Parkland likely overresuscitates most
large burns
Parkland formula 4cc/kg/%TBSA burned
4cc x BW in kg x “number” of percent Split into half Give the first half in 8 hours, last half in
16 hours
High potential for confusion, miscalulations
Rule of Tens USAISR
10 x percent TBSA / hr
If >80 kg BW, add 100cc/hr for every additional 10kg of BW
Titrate to urine output (30-50cc/hr)
Example with Parkland
50 yr old male in house fire, 60% TBSA burn Body weight 90 kg
4 x 90 x 60 = 21600cc Half of this = 10800cc
Half in first 8 hrs = 10800/8 =1350cc/hr
Second half in next 16 hours=10800/16 =675cc/hr
Example with Rule of Tens
50 yr old male in house fire, 60% TBSA burn Body weight 90 kg
10 x 60=600cc/hr + 100 cc/hr
▪ (for his extra 10kg in BW above 80 kg)
700 cc/hr IV Ringers lactate