Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) and ultrasound-guided left stellate ganglion block to rescue out of hospital cardiac arrest due to refractory ventricular fibrillation: A case report

Out of hospital cardiac arrest from shockable rhythms that is refractory to standard treatment is a unique challenge. Such patients can achieve neurological recovery even with long low-flow times if perfusion can somehow be restored to the heart and brain. Extracorporeal cardiopulmonary resuscitation is an effective treatment for refractory cardiac arrest if applied early and accurately, but often cannot be directly implemented by frontline providers and has strict inclusion/exclusion criteria. We present the case of a novel treatment strategy for out of hospital cardiac arrest due to refractory ventricular fibrillation utilizing Resuscitative Endovascular Balloon Occlusion of the Aorta-assisted cardiopulmonary resuscitation and intra-arrest left stellate ganglion blockade to achieve return of spontaneous circulation and eventual good neurological outcome after 101 minutes of downtime.

Comparison of the NIO and EZIO for Resuscitative Vascular Access in the Emergency Department: A Quasi-Experimental, Before-and-After Study

INTRODUCTION

Intraosseous (IO) needle insertion is a key adjunctive procedure in the care of critically ill and injured patients in a variety of settings, including the battlefield. The NIO is a new, fully disposable, single-piece, IO device with potential practical advantages under austere conditions. We sought to compare the efficacy and safety of the NIO to an established, well-studied device, the EZIO, when used for resuscitative vascular access in the emergency department (ED).

METHODS

Retrospective, single-center, quasi-experimental, before-and-after, observational cohort study performed at an urban, tertiary-care hospital ED among adult patients receiving IO access during resuscitation. The before/NIO period lasted from July 1, 2019, to May 31, 2020, and the EZIO/after period from June 1, 2020, to April 30, 2021. Patient demographics, prehospital treatment, ED presentation, characteristics and results of IO insertion(s), potential procedure-associated adverse events, and ED and hospital outcomes were abstracted from the medical record. The primary outcome, rate of first-pass success (FPS), was compared between the NIO and EZIO periods using multivariable regression after adjustment for potential confounding factors.

RESULTS

We enrolled 63 total patients/66 limbs (mean age 61 ± 18, 51% female), 34 patients/35 limbs during the NIO period and 29 patients/31 limbs during the EZIO period. The most common reason for IO insertion was cardiac arrest (40/63, 63%), followed by respiratory failure, trauma, and sepsis. The majority of IO insertions were performed at the proximal tibia (58/66, 88%) by senior emergency medicine residents or faculty. The overall rate of FPS was 53/66 (80%), 24/35 (69%) with the NIO compared to 29/31 (94%) with the EZIO. After multivariable modeling, the odds of FPS with the NIO vs. the EZIO was 0.19 (95% CI, 0.01-1.5, P = .16). Procedure-related adverse events were infrequent in both groups. In-hospital mortality was 45/63 (71%).

CONCLUSIONS

We found that the NIO device was associated with a lower-than-expected rate of FPS compared to the EZIO device, although not significantly different after adjusting for between-group imbalances and considering limitations in the study design. Further, prospective research into the efficacy and safety of the NIO is needed before clinical use can be encouraged.

Duration of cardiopulmonary resuscitation and phenotype of post-cardiac arrest brain injury

BACKGROUND

Patients resuscitated from cardiac arrest have variable severity of primary hypoxic ischemic brain injury (HIBI). Signatures of primary HIBI on brain imaging and electroencephalography (EEG) include diffuse cerebral edema and burst suppression with identical bursts (BSIB). We hypothesize distinct phenotypes of primary HIBI are associated with increasing cardiopulmonary resuscitation (CPR) duration.

METHODS

We identified from our prospective registry of both in-and out-of-hospital CA patients treated between January 2010 to January 2020 for this cohort study. We abstracted CPR duration, neurological examination, initial brain computed tomography gray to white ratio (GWR), and initial EEG pattern. We considered four phenotypes on presentation: awake; comatose with neither BSIB nor cerebral edema (non-malignant coma); BSIB; and cerebral edema (GWR ≤ 1.20). BSIB and cerebral edema were considered as non-mutually exclusive outcomes. We generated predicted probabilities of brain injury phenotype using localized regression.

RESULTS

We included 2,440 patients, of whom 545 (23%) were awake, 1,065 (44%) had non-malignant coma, 548 (23%) had BSIB and 438 (18%) had cerebral edema. Only 92 (4%) had both BSIB and edema. Median CPR duration was 16 [IQR 8-28] minutes. Median CPR duration increased in a stepwise manner across groups: awake 6 [3-13] minutes; non-malignant coma 15 [8-25] minutes; BSIB 21 [13-31] minutes; cerebral edema 32 [22-46] minutes. Predicted probability of phenotype changes over time.

CONCLUSIONS

Brain injury phenotype is related to CPR duration, which is a surrogate for severity of HIBI. The sequence of most likely primary HIBI phenotype with progressively longer CPR duration is awake, coma without BSIB or edema, BSIB, and finally cerebral edema.

Goal-directed cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest in the emergency Department: A feasibility study

Aim

To describe the feasibility of prospective measurement of intra-arrest diastolic blood pressure (DBP) and goal-directed treatment of refractory out-of-hospital cardiac arrest (OHCA) in the emergency department (ED).

Methods

Retrospective case series performed at an urban, tertiary-care hospital from 12/1/2018 - 12/31/2019. We studied consecutive adults presenting with refractory, non-traumatic OHCA treated with haemodynamic-targeted resuscitation that entailed placement of a femoral arterial catheter, transduction of continuous BP during CPR, and administration of vasopressors (1 mg noradrenaline) and, if applicable, Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), to achieve DBP ≥ 40 mmHg. Feasibility was measured by the success rate and time to achieve arterial catheterization and BP transduction. Additional outcomes included the change in DBP with vasopressor administration and occurrence of sustained ROSC.

Results

Goal-directed treatment was successfully performed in 8/9 (89%) patients. Arterial access required 1.5 (interquartile range (IQR) 1-2) attempts and BP transduction occurred within 10.5 ± 2.4 minutes of patient arrival. Noradrenaline slightly increased DBP (pre 21.6 ± 8.3 mmHg, post 26.1 ± 12.1 mmHg, p < 0.025), but only 4/23 (17%) doses resulted in DBP ≥ 40 mmHg. REBOA was attempted in 2/8 (25%) patients and placed successfully in both cases. Three (37.5%) patients achieved ROSC, but none survived to hospital discharge.

Conclusions

In ED patients with refractory OHCA, measurement of DBP during CPR and titration of resuscitation to a DBP goal is feasible. Future research incorporating this approach should seek to develop haemodynamic-targeted treatment strategies for OHCA patients that do not achieve ROSC with initial resuscitation.

Design and implementation of a temporary emergency department-intensive care unit patient care model during the COVID-19 pandemic surge

The ongoing pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in rapid surges of critically ill patients infected with coronavirus disease 2019 (COVID-19) pneumonia presenting to the emergency department (ED) and requiring ICU admission nationwide. Despite adaptations in critical care personnel staffing, bed availability and supply provision, many inpatient ICUs have become acutely crowded, leading to boarding of critically ill patients with COVID-19 and other diseases in the ED. To address this scenario at our urban, safety net, tertiary care institution in the spring of 2020, we designed and implemented a temporary "emergency department-intensive care unit" (ED-ICU) patient care service. Critical care-trained emergency physicians took call and came into the hospital overnight/on weekends to provide bedside treatment to admitted ICU patients boarding for prolonged periods in our ED. In this manuscript, we describe the creation and execution of the ED-ICU service and the characteristics and management of the patients who received care under this model.

Hemodynamic Instability and Abnormal Vasopressor Responsiveness in the Setting of Severe Metabolic Acidosis Treated With Adapted Alkalinization and Continuous Renal Replacement Therapy in the Emergency Department

BACKGROUND

Whereas laboratory data and clinical experience suggest that metabolic acidosis deleteriously affects certain cardiovascular functions and may contribute to hemodynamic compromise, treatment of acidemia itself with alkalinization therapy, predominantly in the form of bolus dosing of intravenous sodium bicarbonate, has not been shown to improve hemodynamics or patient-oriented outcomes in clinical trials. Detailed examination of the biochemical effects of standard sodium bicarbonate administration reveals a possible explanation: ionized serum hypocalcemia, serum hypercarbia, and a paradoxical decrease in intracellular pH occur when bicarbonate is given alone and rapidly, without adjustment in minute ventilation or calcium supplementation. "Adapted alkalinization" treatment countering these side effects through hyperventilation, calcium supplementation, and slower sodium bicarbonate infusion has been studied in animals, but not yet described in humans.

CASE REPORT

We report a case of successful treatment of severe hemodynamic instability and vasopressor hyporesponsiveness in the setting of profound metabolic acidosis with such an adapted alkalinization approach, plus short-term continuous renal replacement therapy, in a critically ill patient, all performed in the emergency department. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians encounter patients with severe metabolic acidosis, shock, and hemodynamic instability despite vasopressor agents. Adapted alkalinization therapy with sodium bicarbonate, hyperventilation, and calcium administration may promote hemodynamic stability in such patients and allow for successful treatment of the underlying disease process.

Sex Differences in In-hospital Complications Among Older Adults After Traumatic Brain Injury

BACKGROUND

Older adults have the highest rates of hospitalization and mortality after traumatic brain injury (TBI) and suffer poorer outcomes compared with younger adults with similar injuries. Non-neurological complications can significantly impact outcomes. Evidence suggests that women may have better outcomes after TBI. However, sex differences in in-hospital complications among older adults after TBI have not been studied. The objective of this study was to assess sex differences in in-hospital complications after TBI among adults aged 65 y and older.

METHODS

We conducted a retrospective cohort study of adults aged ≥65 y treated for isolated moderate to severe TBI at the R Adams Cowley Shock Trauma Center between 1996 and 2012. Using the Shock Trauma Center registry, we identified TBI using the International Classification of Disease, Ninth Revision, Clinical Modification codes and required an abbreviated injury scale head score ≥3, abbreviated injury scale scores for other body regions ≤2, and a blunt injury mechanism. We searched the Shock Trauma Center registry for the International Classification of Disease, Ninth Revision, Clinical Modification codes representing in-hospital complications.

RESULTS

Of 2511 patients meeting inclusion criteria, 1283 (51.1%) were men and 635 (25.1%) developed an in-hospital complication. Men were more likely than women to develop an in-hospital complication (28.1% versus 22.0, P < 0.001). In an adjusted analysis, men were at increased risk of any in-hospital complication (hazards ratio 1.23; 95% confidence interval 1.05, 1.44) compared with women.

CONCLUSIONS

Older men were more likely to have any in-hospital complications than women.

Comparison of a novel, endoscopic chest tube insertion technique versus the standard, open technique performed by novice users in a human cadaver model: a randomized, crossover, assessor-blinded study

Background

The technique of tube thoracostomy has been standardized for years without significant updates. Alternative procedural methods may be beneficial in certain prehospital and inpatient environments with limited resources. We sought to compare the efficacy of chest tube insertion using a novel, endoscopic device (The Reactor™) to standard, open tube thoracostomy.

Methods

Novice users were randomly assigned to pre-specified sequences of six chest tube insertions performed on a human cadaver model in a crossover design, alternating between the Reactor™ and standard technique. All subjects received standardized training in both procedures prior to randomization. Insertion site, which was randomly assigned within each cadaver’s hemithorax, was marked by the investigators; study techniques began with skin incision and ended with tube insertion. Adequacy of tube placement (intrapleural, unkinked, not in fissure) and incision length were recorded by investigators blinded to procedural technique. Insertion time and user-rated difficulty were documented in an unblinded fashion. After completing the study, participants rated various aspects of use of the Reactor™ compared to the standard technique in a survey evaluation.

Results

Sixteen subjects were enrolled (7 medical students, 9 paramedics) and performed 92 chest tube insertions (n = 46 Reactor™, n = 46 standard). The Reactor™ was associated with less frequent appropriate tube positioning (41.3% vs. 73.9%, P = 0.0029), a faster median insertion time (47.3 s, interquartile range 38–63.1 vs. 76.9 s, interquartile range 55.3–106.9, P < 0.0001) and shorter median incision length (28 mm, interquartile range 23–30 vs. 32 mm, interquartile range 26–40, P = 0.0034) compared to the standard technique. Using a 10-point Likert scale (1-easiest, 10-hardest) participants rated the ease of use of the Reactor™ no different from the standard method (3.8 ± 1.9 vs. 4.7 ± 1.9, P = 0.024). The Reactor™ received generally favorable scores for all parameters on the post-participation survey.

Conclusions

In this randomized, assessor-blinded, crossover human cadaver study, chest tube insertion using the Reactor™ device resulted in faster insertion time and shorter incision length, but less frequent appropriate tube placement compared with the standard technique. Additional studies are needed to evaluate the efficacy, safety and potential advantages of this novel device.

Use of an intravascular temperature control catheter for rewarming of hypothermic trauma patients with ongoing hemorrhagic shock after combined damage control thoracotomy and laparotomy: A case series

BACKGROUND

Correction of hypothermia is a key component of the resuscitation of critically injured patients with hemorrhagic shock who require damage control surgery. External rewarming methods may not be sufficient in this population, while extracorporeal techniques lack widespread feasibility. Intravascular catheter-based temperature modulation is increasingly being employed in different critically ill patient populations but has not been described as part of a damage control resuscitation strategy in trauma patients.

METHODS

We retrospectively reviewed the medical records of all patients admitted to our multi-trauma intensive care unit from July 1, 2015 - December 31, 2017 in whom an intravascular temperature control catheter (IVTCC) was employed for rewarming from hypothermia during the immediate postoperative resuscitation of continued hemorrhage after undergoing combined damage control thoracotomy and laparotomy for trauma. All patients received baseline treatment with active external rewarming modalities and inline fluid/blood warmers. Core temperature values over the first 24 h of hospital admission were analyzed. Efficacy (rewarming rate) and safety (associated adverse events) of the IVTCC system were determined.

RESULTS

Three patients (age 22 ± 4.6, 100% male, 100% torso gunshot wounds with prehospital cardiac arrest) meeting the inclusion criteria were treated with the IVTCC system during the study period. Temperature at the start of rewarming using the IVTCC ranged from 30.1 to 35.5 °C. Despite ongoing severe hemorrhagic shock (24-hour ICU blood product requirement: 104 ± 44 units), a mean rewarming rate of 1.04 ± 0.63°C/hour was achieved. One patient suffered an uncomplicated catheter-associated deep vein thrombosis. Two of the 3 patients survived to hospital discharge with intact cognitive function.

CONCLUSIONS

Use of an IVTCC may be a minimally-invasive, practical, and effective method for rewarming critically ill trauma patients with ongoing hemorrhagic shock after multi-cavitary damage control surgery. Further studies are needed to compare this technology with currently available rewarming methods.

Risk factors for mortality despite early protocolized resuscitation for severe sepsis and septic shock in the emergency department

PURPOSE

The purpose was to identify risk factors associated with in-hospital mortality among emergency department (ED) patients with severe sepsis and septic shock managed with early protocolized resuscitation.

METHODS

This was a retrospective, observational cohort study in an academic, tertiary care ED. We enrolled 411 adult patients with severe sepsis and lactate ≥4.0 mmol/L (n = 203) or septic shock (n = 208) who received protocolized resuscitation from 2005 to 2009. Emergency department variables, microbial cultures, and in-hospital outcomes were obtained from the medical record. Multivariable regression was used to identify factors independently associated with in-hospital mortality.

RESULTS

Mean age was 59.5 ± 16.3 years; 57% were male. Mean lactate was 4.8 mmol/L (3.5-6.7), 54% had positive cultures, and 27% received vasopressors in the ED. One hundred and five (26%) patients died in-hospital. Age, active cancer, do-not-resuscitate status on ED arrival, lack of fever, hypoglycemia, and intubation were independently associated with increased in-hospital mortality. Lactate clearance and diabetes were associated with a decreased risk of in-hospital death.

CONCLUSIONS

We identified a number of factors that were associated with in-hospital mortality among ED patients with severe sepsis or septic shock despite treatment with early protocolized resuscitation. These findings provide insights into aspects of early sepsis care that can be targets for future intervention.

Accuracy of Handheld Point-of-Care Fingertip Lactate Measurement in the Emergency Department

Introduction: Early recognition of elevated lactate levels in sepsis may hasten the detection of those patients eligible for aggressive resuscitation. Point-of-care (POC) testing is now increasingly available for use in the emergency department (ED). We examined the accuracy and time-saving effect of a handheld POC device for the measurement of fingertip and whole blood lactate as compared with reference laboratory testing in critically ill ED patients.

Methods: A convenience sample of adult ED patients receiving serum lactate testing was prospectively enrolled at an urban, tertiary care US hospital. Consenting patients underwent fingertip POC lactate measurement with a portable device and simultaneous whole blood sampling for analysis by both the POC device and standard laboratory analyzer (“reference method”). Lactate measurements were compared by intraclass correlation (ICC) and Bland and Altman plots. Differences in time to test result were compared by paired t test.

Results: Twenty-four patients, 19 (79%) with sepsis and 21 (88%) with lactate levels below 4 mmol/L, were included from April 2005 to May 2005. Fingertip POC and whole blood POC lactate measurements each correlated tightly with the reference method (ICC = 0.90 and ICC = 0.92, respectively). Mean time between obtaining fingertip lactate samples and whole blood reference lactate samples was 8 ± 13 minutes. Mean time between obtaining POC and reference laboratory lactate results was 65 minutes (95% confidence interval, 30–103).

Conclusion: Fingertip POC lactate measurement is an accurate method to determine lactate levels in infected ED patients with normal or modestly elevated lactate values and significantly decreases time to test results. These findings should be verified in a larger, more critically ill, ED population.

Point-of-care urine albumin:creatinine ratio is associated with outcome in emergency department patients with sepsis: a pilot study

OBJECTIVES

Sepsis is characterized by an initial systemic proinflammatory response leading to endothelial damage and increased capillary permeability. The authors conducted a pilot study to determine if microalbuminuria, measured by the urine albumin:creatinine ratio (ACR), was associated with outcome in emergency department (ED) sepsis patients.

METHODS

This was an observational cohort study of a convenience sample of adult patients presenting to two EDs over 10 months with sepsis (two or more systemic inflammatory response syndrome [SIRS] criteria and suspected infection). Those who received a urinalysis were prospectively enrolled. Patients with anuria, grossly contaminated specimens, or concurrent noninfectious diagnoses were excluded. Urine ACR was measured on a point-of-care (POC) device. The primary study outcome was ED disposition (three groups): treated and discharged, admitted to the floor, or admitted to the intensive care unit (ICU). Kruskal-Wallis testing was used to compare ACR based on disposition. Variables associated with ACR were identified by Spearman rank correlation or Mann-Whitney rank-sum testing. A post hoc subgroup analysis of patients with and without a genitourinary (GU) source of infection was also performed.

RESULTS

A total of 121 patients were screened, and 29 (24%) were excluded; 92 patients met criteria (mean ± SD age, 51.2 ± 17.0 years; 51 [55%] had severe sepsis, three [3%] had septic shock). There were three in-hospital deaths. Median ACR for patients treated and discharged (n = 22), admitted to floor (n = 50), and admitted to ICU (n = 20) was 2.54 (interquartile range [IQR] = 0.89 to 6.16) versus 2.8 (IQR = 1.69 to 8.8) versus 12.15 (IQR = 4.76 to 20.95), respectively (p = 0.0049). Age, serum creatinine, and GU source of infection were associated with ACR. ACR was significantly associated with disposition among patients without a GU source of infection (p = 0.003), but not among patients with a GU source (p = 0.3744).

CONCLUSIONS

In this pilot study, microalbuminuria measured by POC ACR was associated with disposition in ED patients with sepsis or severe sepsis. Larger studies using more robust outcomes comparing ACR with validated sepsis biomarkers are needed to elaborate on these results.

Economic impact of additional radiographic studies after registered diagnostic medical sonographer (RDMS)-certified emergency physician-performed identification of cholecystitis by ultrasound

BACKGROUND

The standard evaluation of patients with right upper quadrant (RUQ) abdominal pain consists of a history and physical examination, laboratory analysis, and radiological investigation. Given the increasing availability of bedside ultrasound in the Emergency Department (ED), a growing proportion of Emergency Physicians are now performing their own ultrasound examinations in patients with RUQ abdominal pain to circumvent diagnostic delays and improve patient care.

OBJECTIVE

To determine the economic "opportunity" costs of additional radiographic testing after identification of acute cholecystitis by focused ED ultrasound performed by registered diagnostic medical sonographer (RDMS)-certified personnel.

METHODS

A retrospective analysis of a consecutive sample of patients with "positive" focused ED ultrasounds of the RUQ that were significant for cholecystitis, who presented from June 1, 2005 through February 30, 2006. Cost analysis was performed using standard Medicare compensation indices for radiological examinations of the abdomen/hepatobiliary system.

RESULTS

There were 37 patients enrolled; 32 patients exhibited RUQ pain with a focused ED ultrasound significant for cholecystitis. Eight (25%) patients received no further radiographic tests and exhibited positive pathology. Twenty-four (75%) patients had additional diagnostic examinations; 22 (92%) showed positive pathology. Based upon Medicare compensation indices, an opportunity cost of $6885.34 was incurred at our institution over 9 months due to additional examinations. Using nationally comparable indices, this was extrapolated to an opportunity cost of $63 million (95% confidence interval $48.3-$78.9 million) per year across the nation, assuming that 50% of patients with cholecystitis present to the ED and receive an ultrasound examination by an RDMS-certified Emergency Physician.

CONCLUSIONS

In this small sample, additional radiological testing after ED ultrasounds significant for acute cholecystitis led to sizable economic costs on a local and national level. Formal cost-benefit analyses are needed to evaluate the full economic and patient care implications of ED ultrasound use in this setting.

Point-of-care testing at triage decreases time to lactate level in septic patients

Early recognition of elevated lactate levels may hasten the detection of time-sensitive illness. We studied a method to measure lactate levels in septic patients using a point-of-care (POC) device at Emergency Department triage. A convenience sample of adult patients with sepsis was enrolled. Consenting patients received a fingertip lactate measurement using a POC device. Treating clinicians were blinded to study and POC test results. Whole blood lactate levels were drawn at the discretion of the treating physician. A total of 238 patients were eligible; 154 (65%) consented, 5 left without treatment after consenting. Of the remaining 149, 44 (30%) patients received both POC and whole blood lactates. Median time from triage to POC lactate result was 21 min (interquartile range [IQR] 14-25). Median time from triage to whole blood lactate result was 172 min (IQR 119-256). The time difference between POC test result and whole blood lactate result was 151 min (IQR 101-247). Triage POC fingertip lactate is a feasible method for reducing time to identification of lactate levels in patients with sepsis. Larger studies are needed to determine the ability of POC lactate measurement to aid in the risk stratification of septic patients.

Evaluation of extraction techniques for the forensic analysis of human scalp hair using gas chromatography/mass spectrometry (GC/MS)

Preliminary research using on-line supercritical fluid extraction/gas chromatography-mass spectrometry (SFE/GC-MS) has shown that the natural and artificial surface components of human scalp hair are reproducible and differentiable. Therefore, these components may be useful for individualization or determining demographic characteristics or both. However, it is not known how the efficiency and selectivity of on-line SFE/GC-MS compares to other extraction methods. In this study, ultrasound, Soxhlet, and pressurized-fluid extraction were used to extract 1 mg to 1.3 g portions of a composite hair sample taken from an Asian male between the ages of 10 and 18. Percent extractables ranged from 0.9% to 5.6%, depending on the solvent used, and tended to increase with solvent polarity. Chemical analysis using GC/MS showed that the extracts contained large proportions of free fatty acids, squalene, cholesterol, and various wax esters. Finally, comparisons to SFE/GC-MS showed that this method possesses adequate efficiency, no observable differences in selectivity, and greater potential for miniaturization.