Ebook Decision making in emergency critical care: Part 1

(BQ) Part 1 book “Decision making in emergency critical care” has contents: Emergency critical care, tissue oxygenation and cardiac output, noninvasive hemodynamic monitoring, arterial blood pressure monitoring, the central venous and pulmonary artery catheter,… and other contents.

Decision Making in Emergency Critical Care

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To John and Marlene for a lifetime of support, to Rani for her editorial genius, and to Morgan for never letting me forget the bigger

picture

Assistant Clinical Professor

Alexis Halpern, BA, MD

Assistant Professor of Clinical Medicine

Assistant Director, Geriatric Emergency Medicine Fellowship Department of Medicine

Weill Cornell Medical College

Attending Physician

Division of Emergency Medicine

New York-Presbyterian Hospital/Weill Cornell Medical College New York, New York

Department of Emergency Medicine

NYU Langone Medical Center

Assistant Professor, Chief of Emergency Medicine Critical Care Division of Pulmonary and Critical Care

Staff Physician Anesthesia and Critical Care Department of Anesthesia Veteran Affairs Hospital

Attending Physician

Attending Physician

Department of Emergency Medicine

NYU Langone Medical Center and Bellevue Hospital Center New York, New York

Clinical Instructor

Department of Anesthesiology, Perioperative and Pain Medicine Divisions of Cardiac Anesthesia and Critical Care Medicine Stanford University School of Medicine

Department of Medicine, Division of Pulmonary and Critical Care Medicine Stanford University Medical Center

Neuroendovascular Surgery Fellow

Department of Neurosurgery

New York Presbyterian Hospital/Weill Cornell Medical Center New York, New York

Assistant Professor

Division of General Internal Medicine and Public Health Department of Internal Medicine

Emergency physicians are caring for a growing number of critically ill patients.This increase in ED-critical care volume, coupled with prolonged patient stays,has placed new demands on the emergency physician He or she must nowprovide not only acute resuscitative care, but also extended management ofcomplex cardiac, pulmonary, and neurologic emergencies

Leadership in the field of emergency medicine has embraced this broadeningED-ICU overlap in a timely and skillful manner Residency program directorsare placing new emphasis on critical care medicine in resident education andclinical training Nationally, emergency departments have become a focus forevidence-based trials in goal-directed therapy for the critically ill And finally, in

a much-anticipated collaboration, the American Board of Emergency Medicine(ABEM) and the American Board of Internal Medicine (ABIM) have agreed toallow graduates of emergency medicine residencies to sit for board certification

in critical care medicine following fellowship training

Decision Making in Emergency Critical Care: An Evidence-Based Handbook

is a portable guide to diagnosis and treatment in emergency critical care for theresident and attending emergency physician Its collaborating authors includefellows and attending physicians in the fields of emergency medicine, pulmonaryand critical care medicine, cardiology, gastroenterology, and neurocritical care It

is not intended as a guide to what emergency physicians already do best; namely,recognize and correct acute life-threatening conditions Rather, it details thefundamentals of critical care medicine for the emergency physician who mustmake sustained data-driven decisions for the critically ill patient in an oftenchaotic and resource-limited environment

Each chapter provides a streamlined review of a common problem in criticalcare medicine, evidence-based guidelines for management, and a summary ofrelevant literature The result, we hope, is a valuable guide to rational clinicaldecision making in the challenging—and changing—world of emergency criticalcare

John E Arbo, MD

SECTION 1 Introduction

1 Emergency Critical Care

Robert M Rodriguez THE GROWTH OF EMERGENCY DEPARTMENT CRITICAL CARE

Emergency physicians are assuming an ever-expanding role in the care ofcritically ill patients The emergency department (ED) is the hospital entry pointfor virtually all trauma admissions, over 70% of adult sepsis admissions, and thevast majority of patients with acute myocardial infarction, acute stroke, andmajor gastrointestinal bleeding.1

More than a quarter of all patients admitted to the hospital from the ED arecritically ill at their time of presentation.2,3 While some of these patients areadmitted to the ICU, many more are resuscitated and stabilized in the ED.Because of increases in ED boarding and delays in ICU transfer, however, EDsare being asked to provide extended ICU-level care.4 This new volume of ED-based critical care has not only demanded an increasingly solid foundation incritical care medicine from the emergency physician but also given rise to a newspecialist: the emergency intensivist As experts on the presenting phase ofcritical illness, these physicians are valued members of the critical care team andare uniquely suited to provide a seamless patient transition from the ED to theICU

Physicians with dual training in emergency and critical care medicine havesuccessfully combined careers in the ED and ICU for decades; but only in thepast several years has there been a formal EM/critical care certification pathway.Historically, emergency physicians who wanted critical care medicinecertification had to complete a second residency in addition to fellowshiptraining (usually through an EM/internal medicine/critical care medicinecombination) Years of intense lobbying have finally resulted in a more practicalcertification pathway for the EP After completing an EM residency and anapproved 2-year critical care medicine fellowship, emergency physicians cannow be certified in critical care medicine through the American Board ofInternal Medicine This cohort, which began as a handful of triple-trained EM

critical care physicians, now encompasses more than 200 EM physicianscertified in critical care medicine in the United States.6

This surge of EM intensivists has been paralleled by exciting innovations inED-based diagnosis and therapy Given that patient physiology changes mostrapidly during the first few hours of patient presentation, it is not surprising thatthese new approaches are profoundly affecting morbidity and mortality in thecritically ill.3 ED-based landmark trials have revolutionized approaches toresuscitation, sepsis, and trauma and have had an impact on many critical caredisciplines

ILLNESS

One of the most important ED-centered concepts, ushered in by Rivers'landmark study of early goal-directed therapy (EGDT), is that outcomes areimproved by early recognition of critical illness and by prompt, aggressiveresuscitation.7 An excellent example of this paradigm of timely, structured EDcritical care is the current ED sepsis “bundle” of care (i.e., early identification ofseptic patients, prompt antibiotic delivery, and aggressive hemodynamicresuscitation) endorsed by the Society of Critical Care Medicine and otherinternational organizations.8 ED protocols incorporating sepsis bundles havebeen shown not only to significantly improve survival outcomes but also todecrease the rate of ICU admission by approximately 11%.2,8

To continue the example, the first step in ED sepsis protocols is rapididentification and risk stratification, which is accomplished using algorithms thatincorporate triage vital signs and lactate point-of-care devices.9,10 Followingidentification of severe sepsis, computer-generated and other automatic flaggingsystems may speed up and ensure reliable activation of sepsis bundle protocols

To further accelerate this process, EM investigators have recently proposed lessinvasive alternatives for determining central venous oxygen saturationmeasurement (SCvO2) and central venous pressure, facilitating implementation

of EGDT In a recent study, clearance of >10% of venous blood lactate wasfound to be an equivalent resuscitative endpoint as achieving an SCvO2 > 70%,effectively reducing the need for placement of central venous catheters.11 New

minimally invasive techniques for assessing intravascular volume status andvolume responsiveness have also been introduced, including systolic pressureand pulse pressure variation arterial waveform analysis, physiologic response topassive leg raising, and respirophasic changes in inferior vena cava diameter asmeasured by bedside ultrasound.12–16 ED-based research networks and studies,such as the Protocolized Care for Early Septic Shock (ProCESS) trial, continue

to refine optimal emergency sepsis management.17

Structured early identification and risk-stratification protocols haveimproved ED care for many other critical disease processes as well Rapididentification of ST-segment elevation MI (STEMI) via point-of-first-contactelectrocardiogram analysis is now standard practice in order to reducereperfusion (door-to-balloon) times Many emergency medical systems have alsoimplemented prehospital wireless transmission of 12-lead ECGs to facilitateearly identification of STEMI patients and timely transport to dedicated cardiaccare centers.18

Similarly, in acute stroke management, ED protocols that incorporate earlystroke scale examinations are improving diagnosis and management Manyemergency physicians have trained their paramedics to screen patients withabbreviated stroke detection instruments in the field, in order to direct at-riskpatients to comprehensive stroke centers for potential reperfusion therapy.19Improved ED-staging algorithms also help identify patients with impendingrespiratory failure due to pneumonia, COPD, and other respiratory illnesses.10,20These tools promote early delivery of appropriate antibiotics, timely initiation ofventilatory support and judicious triage of ICU beds Analogous to earlyhemodynamic fluid resuscitation in patients with shock, timely, aggressiverespiratory support with non-invasive positive pressure ventilation (NIPPV) inthe ED has been shown to improve outcomes and, in many cases, to avertendotracheal intubation and ICU admission.21 Formerly limited to use in patientswith COPD, NIPPV has now been shown to decrease respiratory distress andimprove outcomes in a broad spectrum of pulmonary disorders.21,22

THE ED–ICU TEAM APPROACH

Protocols emphasizing a team-oriented approach have transformed the delivery

of ED critical care Based on the “golden hour” model of trauma resuscitation,emergency physicians and intensivists have developed ED-based critical carecollaborations for treating acute coronary syndrome, stroke, and sepsis.Enhanced communication and structured, automated activation of protocols are

the keys to the success of these endeavors The first step in these protocols isearly recognition of critical illness, which ideally begins in the prehospitalsetting After recognition of acute disease, prompt notification of key consultants(STEMI team, stroke team, or sepsis team) mobilizes resources and bringscritical care personnel to the ED for a timely, orchestrated resuscitation and asmooth transition to the cardiac catheterization laboratory, endovascular suite, orother critical care unit.

Just as ED-derived critical care concepts can benefit ICU practice, so too canICU-centered concepts improve outcomes in the ED, especially in the setting ofextended wait times for transfer to the ICU For example, with the reported 20%increase in risk of ventilator-associated pneumonia (VAP) per hour spent in the

ED, simple ICU VAP reduction measures (head of bed elevation, oralchlorhexidine application, and oral gastric tube decompression) should now bethe standard of care in the ED.26–28 Likewise, ED application of ICU-derivedventilator management standards, such as ARDSnet protocols, should be fullyimplemented The lung-protective ventilation strategies outlined in the ARDSnetprotocols have recently been demonstrated to benefit a broader population ofpatients without adult respiratory distress syndrome, making early consideration

of these protocols in a broader ED population a logical extension of ICU care.29

FUTURE DIRECTIONS

The expanded delivery of critical care in the ED opens fertile ground foremergency physician and intensivist research collaboration on a number ofunresolved management issues In sepsis, for example, the best choice (if there is

a best choice) of a first-line vasopressor for patients with septic shock has yet to

be clearly determined Similarly, the adrenal suppression effects of etomidatehave raised debate as to whether it should continue to be used as an intubationinduction agent in patients with sepsis.30,31

A number of unresolved issues also remain for cardiac arrest patientsreceiving postresuscitation care in the ED For example, the optimal timing andtemperature goals for therapeutic hypothermia (or avoidance of hyperthermia)are unclear, as is the question of whether the neuroprotective benefits extend topatient populations beyond those resuscitated from ventricular fibrillation.Likewise, the potential detrimental effects of postresuscitation hyperoxia andhyperglycemia are undetermined,32 as are optimal blood pressure targets andglucose control in patients with traumatic brain injury Collaboration betweenemergency physicians and intensivists will be needed to address these questions