Downeast Emergency Medicine: Recent Episodes

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THE CASEA 13-year-old boy is seen in the Emergency Department (ED) for a cough. He reports a viral illness starting two weeks ago, and four days ago, he was seen in the ED because his symptoms were worsening. At that time, he got a chest X-ray showing a right lower lobe consolidation. He was diagnosed with pneumonia and started on high-dose amoxicillin and azithromycin. However, his symptoms failed to improve, and he now returns with a worsening cough and shortness of breath despite antibiotics. His vitals are notable for a fever of 102.4F, HR 131, BP 112/78, RR 24,and 93% oxygen saturation on room air. A repeat chest X-ray is ordered and read as persistent right lower lobe opacity (Image 1).

**Image 1:** Current chest X-ray on the left, chest X-ray from 4 days ago on the right. Credits: Andrew fried, md

A point-of-care lung ultrasound is performed, with the following findings on the left lung fields.

Point of Care Ultrasound of the Left Lung Fields.

Point of Care Ultrasound of the Left Lung Fields.

The patient is diagnosed with pneumonia that has failed outpatient treatment and is started on ceftriaxone and admitted to the pediatric hospitalist service.

REVIEWShortness of breath and cough are common complaints in the emergency room, both in children and adults. In evaluating these patients, chest X-rays are frequently ordered to evaluate for pneumonia. It is essential to understand the limitations of this imaging modality when interpreting results and making clinical decisions. Several studies have examined the sensitivity of plain films in diagnosing pneumonia, with results ranging from 50-79% sensitivity[1,2,3]. This means that you can miss up to half(!!) of pneumonia cases if you rely on a chest x-ray for your diagnosis. Point-of-care ultrasound offers an alternative imaging modality that is fast, available at the bedside, lacks radiation, and is more sensitive than a chest x-ray. One study from 2012 found lung ultrasound to be 93% sensitive for pneumonia [4]. A meta-analysis from 2019 found lung ultrasound to be 82% sensitive for pneumonia[5]. While these numbers are not perfect, and ultrasound should not be treated as a “rule-out” test for pneumonia, when done correctly, it is a more sensitive and specific test than a chest x-ray. The biggest caveat is that to perform a complete lung ultrasound, all lung fields must be examined, particularly the posterior lobes, as this is where most consolidations will be seen. Furthermore, remember that a lung consolidation on ultrasound does not necessarily mean pneumonia – it generates a differential, including mass, atelectasis, and pulmonary contusion. However, in the right clinical picture (as in the case above), it can be an excellent addition to the workup and can change management.

**Image 2:** Make sure to examine the lower posterior lung fields, as this is the most common location for consolidations to appear.

Summary: Chest x-ray is not sensitive for pneumonia. Lung ultrasound – when performed correctly – is more sensitive and specific than chest x-ray. Consider performing a lung ultrasound next time you have a patient in whom you are considering pneumonia.

Want to learn more about Lung Ultrasound? Check out Dr. Avila’s Lecture below Written by Weeden Bauman, MD

Ultrasound Fellow, Maine Medical Center Emergency Medicine Residency

Edited and Posted by Jeffrey A. Holmes, MD

References:

1. Hagaman JT, Rouan GW, Shipley RT, Panos RJ. Admission chest radiograph lacks sensitivity in the diagnosis of community-acquired pneumonia. Am J Med Sci. 2009;337(4):236-240. doi:10.1097/MAJ.0b013e31818ad805 [Pubmed]
2. Ye X, Xiao H, Chen B, Zhang S. Accuracy of Lung Ultrasonography versus Chest Radiography for the Diagnosis of Adult Community-Acquired Pneumonia: Review of the Literature and Meta-Analysis. PLoS One. 2015;10(6):e0130066. Published 2015 Jun 24. doi:10.1371/journal.pone.0130066 [Full Text]
3. Cortellaro F, Colombo S, Coen D, Duca PG. Lung ultrasound is an accurate diagnostic tool for the diagnosis of pneumonia in the emergency department. Emerg Med J. 2012;29(1):19-23. doi:10.1136/emj.2010.101584 [Pubmed]
4. Reissig A, Copetti R, Mathis G, et al. Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study. Chest. 2012;142(4):965-972. doi:10.1378/chest.12-0364 [Pubmed]
5. Staub LJ, Mazzali Biscaro RR, Kaszubowski E, Maurici R. Lung Ultrasound for the Emergency Diagnosis of Pneumonia, Acute Heart Failure, and Exacerbations of Chronic Obstructive Pulmonary Disease/Asthma in Adults: A Systematic Review and Meta-analysis. J Emerg Med. 2019;56(1):53-69. doi:10.1016/j.jemermed.2018.09.009 [Pubmed]

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**Ijeoma Oluo, author of "So You Want to Talk About Race"**

Background
In the United States, racism is a critical public health problem, permeating everyday systems including educational and health care systems; criminal justice and legal systems; financial, housing, and economic systems; environmental issues and beyond to create differential health outcomes that adversely affect Black, Indigenous, and other people of color. This pervasive system of power is based on the socio-politically constructed notion that non-Hispanic white people are inherently superior to people of color (Black, African American, Indigenous, Native American, Alaska Native, Native Hawaiian, Pacific Islander, Asian, Latine, Hispanic) and this ideology operates across multiple levels (individual, interpersonal, institutional) to unjustly advantage non-Hispanic white people, unjustly disadvantaging people of color. We recognize that racism is an important cause of health disparities and that, as health care providers, we have a responsibility to educate ourselves about racism so that we will be prepared to acknowledge the impact of racism on our patients’ health and work towards more equitable systems in support of health equity. One important component of that education is learning how to engage in productive conversations about race and racism.

In service of that goal, we chose Ijeoma Oluo’s book, So you want to talk about race, as our common read for this special Journal Club session.

Chapters discussed1. Introduction

2. Chapter 1: Is it really about race?

3. Chapter 2: What is racism?

4. Chapter 3: What if I talk about race wrong?

5. Chapter 5: What is intersectionality and why do I need it?

6. Chapter 12: What are microaggressions?

7. Chapter 17: Talking is great, but what else can I do?

Introduction and Chapters 1&2 - Is it really about race? What is racism?

““Racism is any prejudice against someone because of their race, when those views are reinforced by systems of power.””

— Ijeoma Oluo Ijeoma Oluo introduces So You Want to Talk About Race by offering that her experiences as a Black, queer woman living in US society have deeply affected her life. She describes growing up in poverty, the daughter of a Nigerian father and a white mother and begins by discussing the often-argued notion that the inequities we observe in US society are the result of class rather than race. She explains that our country was founded using racial oppression – the genocide of Indigenous people and enslavement of Black people – and was intentionally designed to benefit white men by stealing both land and labor from people of color. Systems were designed to maintain the wealth and privilege of those in power – white men – to the detriment of people of color. Our society and institutions continue to function in a manner that maintains this racist system, creating the many inequities we observe in health, education, and many other important outcomes. Oluo suggests that forms of oppression in US society are like cancer: classism is like one type of cancer and racism is another; treating one will not cure the other, so both need to be addressed. She argues that fighting racism is not about changing the minds of individual people, but rather changing the racist system that is designed to be self-perpetuating.

Olou defines racism as, ‘Any prejudice against someone because of their race, when those views are reinforced by systems of power.’ She believes that when we define racism as only ‘prejudice against someone because of their race,’ we reduce racism in America to be about individual racist people, rather than the larger system of oppression that it actually is.

Chapter 3 - What if I talk about racism wrong?Talking about race and racism can be challenging and uncomfortable; however, being able to participate in productive conversations on these topics is critical to our ability to combat racism and advance health equity. Oluo asks readers to lean into their discomfort understanding that such conversations will not always go smoothly and that we will inevitably make mistakes. She offers some suggestions and strategies that can help us to have more productive conversations. These include:

• Stating our intentions. Being clear about the purpose of a conversation. It can help those involved determine their willingness to participate, avoiding competing agendas and frustration.
• Remember the top priority and avoid letting emotions take over. Keep focused on the goal of the conversation and do not let emotions steer the discussion elsewhere.
• Do your research. Learn about the topic before engaging in conversation and, especially if you are a white person, understand that it is not the job of people of color to educate you.
• Do not oppress other groups. Do not attempt to combat racism by oppressing other groups with sexism, ableism, transphobia, etc. We must be willing to fight all forms of oppression.
• Do not “tone police.” Oluo describes “tone policing” as ‘when someone (usually the privileged person) in a conversation or situation about oppression shifts the focus of the conversation from the oppression being discussed to the way it is being discussed.’ This shifts the focus of the conversation to make it more comfortable for the privileged person. Conversations about race and racism require us to lean into and sit with our discomfort; we should not try to make things more comfortable for ourselves by tone policing those who experience oppression firsthand.
• If you are white, watch how many times you say ‘I’ and ‘me.’ Avoid making conversations about race and racism focused on you and your feelings.
• Ask yourself: Am I trying to be right, or am I trying to do better? Conversations about race and racism are not about ‘winning’ or being right. We should engage in these conversations to share and learn.
• Do not force people of color into discussions of race. People of color live with racism every day and should be free to choose how, when (or when not), and with whom to engage in conversations about race. Respect their decisions about engaging in conversation on these topics.

Chapter 5 - What is intersectionality and why do I need it?Intersectionality as described by Oluo, is the notion that each of us has a myriad of identities – our gender, class, race, sexuality and so much more – that inform our experiences in life and our interactions with the world. The different hierarchies, privileges, and oppressions assigned to these identities affect our lives in many ways, but they do not exist in a vacuum. They combine with each other, compound each other, mitigate each other, and contradict each other. Unfortunately, many of today’s social justice movements fail to recognize this, centering on their one issue or group of focus and leaving others behind. Intersectionality theory addresses this issue by actively considering the ways that different aspects of identity come together to marginalize and oppress people and by working to consciously center those people and their experiences.

Oluo argues that incorporating intersectionality into our social justice work as a practice helps us to make our systems more fair and effective, helps us to identify our own privileges, and avoids oppressing others. She offers some reflective questions to help readers increase intersectionality in discussions about race, including consideration of:

• How might race, gender, sexuality, ability, class, or sex impact this topic?
• Could the identity differences between me and the person I’m talking with be contributing to our differences of opinion or perspective?
• Am I listening to people whose identities and experiences are different than mine?
• Am I shifting some focus and power away from the most privileged in the conversation?

Incorporating intersectionality into our work and discussions can help us to recognize and confront the privileges in our lives while nurturing a more inclusive and just society.

Chapter 12 - What are microaggressions?Oluo describes microaggressions as the small daily insults and indignities perpetrated against marginalized or oppressed people because of their affiliation with that marginalized or oppressed group, in this case, microaggressions perpetrated against people of color. Microaggressions are constant reminders that the recipient is ‘less than,’ and regular exposure to microaggressions causes their recipients to feel isolated and invalidated. In addition, research has demonstrated that exposure to microaggressions is associated with experiencing mental and physical depressive symptoms.

Oluo explains that microaggressions can be difficult to address for a myriad of reasons including that they are, by definition, small acts that can be easily explained away; that they are cumulative – meaning that individually they may seem like no big deal, but collectively, they have a profound impact – and that they are perpetrated by many people, making it a challenge to address with each person without becoming exhausted and potentially written off as being hypersensitive.

When folks recognize that they are witnesses to a microaggression, they often wonder what they should say or how they should address the situation. Oluo shares some strategies that may be helpful such as:

• State what actually happened, for example, ‘You just assumed that I don’t speak English.’
• Ask some uncomfortable questions which can help the perpetrator to examine their motives, for example, ‘Why did you say that?’ or ‘I don’t get it. Please clarify what you meant.’
• Ask some more uncomfortable questions, if the person becomes flustered or responds that they did not mean anything by what they said. Examples include, ‘Is this something you would have said to a white person?’ and ‘How exactly was I supposed to take what you just said?’
• Reinforce that good intentions are not the point. ‘You may not have meant to offend me, but you did.’
• Remember that you have every right to address the issue. ‘I can see that this is making you uncomfortable, but this is a real problem that needs to be addressed.’

It is also important to recognize when we commit a microaggression and we should avoid the tendency to deflect responsibility or deny we ‘meant anything’ by it. We should offer an authentic apology and spend time in reflection examining why we may have said what we did, whether or not we would have said the same thing to a person of our same race, and whether we might have been feeling threatened or uncomfortable at the time. If we want racial oppression to stop, we must take responsibility for the ways we contribute to it.

Chapter 17 - Talking is great, but what else can I do?Oluo writes, ‘We cannot understand race and racial oppression if we cannot talk about it. But understanding, on its own, will never equal action.’ While having (many) conversations about race and racism is important, Oluo offers many suggestions for ways that we can all help to fight racial oppression. These include:

• Vote and note that local elections are just as important as national ones. Be active in your schools and find out what the district is doing to address the racial achievement gap.
• Bear witness when necessary. Especially if you are white, bear witness and offer to help if it is safe to do so if you see a person of color being harassed.
• Speak up in your unions. Work to make your workplace more diverse and inclusive.
• Support businesses owned by people of color.
• Boycott banks that prey on people of color.
• Give money to organizations working to fight racial oppression and support communities of color.
• Boycott businesses that exploit workers of color.
• Support music, film, television, art, and books created by people of color.
• Support minimum wage increases.
• Push your local leaders for policing reform.
• Demand diversity in colleges and universities.
• Vote for diverse government representatives.

Our journal club discussed additional actions that we can take specific to healthcare and the practice of Emergency Medicine. These included continuing to conduct research on health disparities and strategies to promote health equity, ensuring that our educational materials accurately reflect the spectrum of skin tones so that clinicians are prepared to identify alterations in health in patients of color, ensuring that medical devices and prediction rules are accurate in patients of color, engaging in a reflective pause when planning patient care to ensure that bias is not influencing our care decisions, supporting and mentoring students from historically marginalized or underrepresented groups, and continuing to engage in antiracist educational activities.

* **Racism is a public health crisis in the United States, contributing to the differential health outcomes we observe for people of color.**

• The ability to effectively converse about race and racism is critical to our ability to understand racism’s origins, causes, and systems that maintain it. We need this understanding to be able to fight racial oppression and dismantle systems of white supremacy.
• Talking about racism can be hard, but there are strategies we can use to have more effective, productive conversations.
• While talking about racism is important, antiracism is an action, not a sentiment. We must actively work to dismantle racist systems and nurture racial equity.

Interested in Learning More?Watch Iljeoma Oluo lead a discussion on her book with

Tufts University Tisch College of Civic Life and Dr. Joyce Sackey

Additional ResourcesIMPLICIT BIAS1. Implicit Bias: Peanut Butter, Jelly and Racism from PBS/NYT POV 2. A TED talk by Verna Meyers, who is an attorney working as an inclusion strategist. Her talk is about how we can overcome our biases.

SYSTEMIC RACISM

1. Animated video explaining systemic racism
2. Classic article by Dr. Carmara Phyllis Jones from the American Journal of Public Health offering a model for understanding the various forms of racism

WHITE FRAGILITY

1. Robin DiAngelo, PhD is a fantastic Associate Professor of Education and a Sociologist at the University of Washington who came to speak at Tufts on her book White Fragility: Why It’s So Hard for White People to Talk About Racism a few years ago. Here are a couple of videos of her sharing some concepts from her work.

   • Debunking The Most Common Myths White People Tell About Race
   • Deconstructing White Privilege

   • Here is a quick read from Dr. DiAngelo regarding “White Fragility”

   • A Sociologist Examines the “White Fragility” That Prevents White Americans from Confronting Racism | The New Yorker

INTERSECTIONALITY1. Kimberlé Crenshaw is a legal scholar, civil rights advocate, and professor at the UCLA School of Law and Columbia Law School. She is a leading scholar on critical race theory and is the person who introduced and developed intersectionality theory.

* Here is a brief video of Professor Crenshaw explaining intersectionality
* Here is a fantastic TED talk where she discusses intersectionality more in-depth

1. Many folks probably first learn about intersectionality theory in readings from Women’s Studies, Sociology, etc., but it is interesting that, as a legal scholar, Professor Crenshaw’s ideas stemmed from legal cases where a court’s narrow definition of discrimination did not account for the experiences of folks who identified as both female and Black, leading to the development of her theory. You can read more about its origins and those cases here:

   • Intersectionality, explained: meet Kimberlé Crenshaw, who coined the term - Vox
   • Here is Professor Crenshaw’s original paper (1989, University of Chicago Legal Forum) is also attached for those who are interested in her arguments and ideas

CALLING FOLKS INTO THE WORK VS CALLING THEM OUT1. Over the last few years, I think that many of us have heard about the importance of ‘calling out’ racist behavior, microaggressions, etc. when we witness these things. Acknowledging the importance of not letting these things slide, but finding a potentially more constructive way of addressing them is the idea of ‘calling in’ people to the discussion with compassion and understanding that we are all learning. I thought that idea was really cool and Professor Ross (Smith College) does a really nice job explaining it. * Video from Loretta Ross on the notion of calling in vs. calling out * Here is a New York Times article where she explores the importance of calling in vs. calling out

MICROAGGRESSIONS1. How microaggressions can reinforce and normalize racism video by the Black Experience Project 2. A tool for recognizing microaggressions and the messages they send 3. Here is an article by Dr. Molina on Addressing the Elephant in the Room: Microaggressions in Medicine; Annals of Emergency Medicine

CALL TO ACTION1. Here is a great editorial by Dr. Cortlyn Brown, Dear White People in Emergency Medicine 2. Antiracism in Emergency Medicine – EMRA video presented by Dr. Sadiqa Kendi 3. SAEM Diversity, Equity & Inclusion Curriculum – a compendium of resources by topic that is in development and available for use

Authored by Tania Strout

Edited and Posted by Jeffrey A. Holmes, MD

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Alcohol abuse is common in the United States with 14.1 million adults estimated to have some degree of alcohol use disorder. Emergency physicians will encounter this quite often, either as the primary presenting problem or as a complicating factor in a patient’s care. Unfortunately, alcohol consumption appears to be increasing, with the World Health Organization projecting ongoing increases through at least 2025. As a result, it is becoming increasingly important that we understand the serious and potentially life-threatening consequences of alcohol withdrawal syndrome (AWS) and the treatment options that exist in order to best manage these patients. The following three journal club articles sought to investigate potential clinical benefits for the use of phenobarbital in the emergency department (ED) for the treatment of AWS.

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Interviewing and beginning your career in medicine comes with challenges! Dr. Sarah Bunting, MD is a PGY-1 emergency medicine resident at Maine Medical Center. Listen in to hear her advice on transitioning from medical school to residency, virtual interviewing, and what to look for in a residency!

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Abdominal pain is the most common chief complaint for adult patients in the ED. It’s one of the presenting symptoms that can run the gamut between largely benign to imminently lethal, making it imperative for medical students to be able to triage and assess it appropriately.

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Welcome back to the first installment of the Ultrasound of the Month in the new year! After reviewing our cases from January we have selected a case of unilateral knee swelling to highlight the use of ultrasound in this extremely common ED chief complaint. The amazing images with obtained by Dr. Hadley Gunnell, anouther one of our stellar interns!

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How and when do medical students become interested in emergency medicine? In this post we review how Tufts University School of Medicine’s 2021 class of EM-bound students reflect on the circumstances behind how they first became interested in the field and what experiences were most important in their decision to pursue EM.

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We're back with some more exciting and beautiful echocardiogram images this month! This case and images are courtesy of Dr. Sarah Bunting, a rising ultrasound star within our program. Here she has obtained some uncommon images of an unfortunately more and more prevalent disease process. So grab your warm holiday drink of choice and enjoy our ultrasound of the month.

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Recent data from the National Center for Health Statistics reveal that in the 12-month period ending in April 2021, more than 100,000 Americans died of an overdose, a staggering increase of nearly 30% the prior year. While the ongoing COVID-19 pandemic has contributed to overdose deaths and taxed constrained ED resources, it has also clarified the important role that emergency physicians have in expanding access to life-saving medications to treat opioid use disorder. In this journal club, we review the evidence on ED-initiated buprenorphine, including barriers to implementing ED-buprenorphine here in rural Maine.

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This is the inagural installment of our monthly series recognizing some great point of care ultrasound images performed in our department. This case will highlight some beautiful echocardiogram images obtained by the one and only Dr. Nicholas Fling, one of our chief resident physicians. Echo is a basic ultrasound skill that all EM docs need to have, and making sure your probe marker is set up appropriately on the screen is a great first step. The apical four-chamber view of Dr. Fling's would make anyone double check that!

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Suicide is disturbingly prevalent among patients we care for in the Emergency Department. It is unfortunately also common among physicians. Most estimates suggest that approximately 400 physicians die by suicide annually. Physicians also have a higher rate of suicide than the general population. Male physicians have a 40% increased risk of suicide compared to their age-matched peers and female physicians have a 130% increased risk. We chose this topic for Journal Club with the goals to raise awareness around these shocking statistics, discuss etiologies behind these high rates of suicide and to normalize the discussion around physician mental health.

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There is a new kid on the block for the treatment of stroke - tenecteplase (TNK). In this post, Dr. Morris explains the evidence behind its preferred use over alteplase (tPA) as well as address some common concerns about its use for stroke.

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Renal colic is a commonly encountered diagnosis in the emergency department that is known to cause significant pain. In clinical practice, the initial goal is prompt pain management while simultaneously working to confirm the suspected diagnosis. Because of the severity and acuity of the pain associated with renal colic, opioid pain management has often been used. Given the overall goal of reducing the use of opioid pain medications, emergency physicians have been working to identify alternative pain management strategies with agents such ketorolac and lidocaine. In this journal club, we examine the evidence in support of these treatment strategies.

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The 21st Century CURES act has mandated that starting on April 5th, 2021 patient notes (with a few very narrow exceptions) must be easily available to patients via their patient portal. How did this come about, and what does it mean for us?

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In this Vodcast episode. Dr. Andrew Fried, ultrasound Jedi, give us a masterclass on placing ultrasound guided IVs.

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On January 23rd, 1849 Elizabeth Blackwell became the first female graduate of a US medical school, graduating from Geneva College in New York as the Valedictorian of her class. Despite the passage of 172 years from that remarkable moment, female physicians continue to face both implicit and explicit gender bias within the medical profession and culture. This journal club examined the impact of gender bias on female emergency medicine trainees.

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The use of TXA in the care of the trauma patient has become prevalent since the publication of the MATTERs and CRASH-2 studies which demonstrated significant mortality benefits in trauma patients who received early TXA after admission. Since these publications, there continues to be several additional questions regarding its TXA: 1) If earlier treatment with TXA for the trauma patient is better, would there be benefit in its administration in the prehospital setting? 2) Is there benefit to the use of TXA in patients with TBI to prevent the progression and subsequent morbidity and mortality? 3) Lastly, does TXA carry a significant risk for side effects, including venous thromboembolic events? This journal club reviewed four articles that aim to answer these questions.

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This year we are very fortunate to have Dr. Amal Mattu, EKG Jedi, as teaching faculty for our 39th Maine Medical Center/Maine ACEP Winter Symposium. In this lecture, he helps us differentiate septal STEMIs from other potentially life threatening mimics.

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Kids poop. Most of the time it is benign (aside from the blowouts, the wiping, cleaning and changing of clothes). Occassionaly, pediatric diarrhea has a more serious etiology. In this interview with pediatrician Dr. Jay Larmon we go over the spectrum of pediatric diarrhea, from the '“A-okay” to the “not-so-right” . . . and everything in between.

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In medicine we often draw a solid line between community and academic medicine, but this is likely a fallacy. In fact there is a huge amount of academia that can be found and thrive in a community hospital. In this interview we talk with Dr. Salim Rezaie of the REBEL EM blog and podcast, a man who has walked both sides of this imaginary line between community and academics. In our chat we discuss ways to get involved in academics in the community and the vast array of rewards that come with that, including improved patient care, increased fervor for your work, decreased burnout, and increased career longevity.

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COVID vaccines have dominated the media and our recent efforts to combat the SARS-CoV-2 virus. It will likely take some time, however, until we reach herd immunity. To help curb the severity of disease, the medical community continues to investigate other therapeutics. By examining the virus life cycle and our immune system’s response to it (both protective and destructive), we may be able to develop anti-viral and immune therapy that counteracts the cytokine storm and leads to acute respiratory distress syndrome, respiratory failure, shock, organ failure and potentially death. In this journal club, we reviewed the use of steroids and convalescent plasma for the treatment of patients with SARS-CoV-2.

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Ludwig’s Angina is an uncommon but dangerous floor of the mouth infection. It is important to recognize and manage it appropriately. For this reason we present images and video of a case of Ludwig’s Angina… and sprinkle in nuggets of wisdom regarding source, presentation, complications, and management.

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In this post and podcast we review mRNA vaccines and the Pfizer phase 3 study to help frontline providers answer some important questions- What is an mRNA vaccine? How does this differ from the traditional vaccines? Is it safe? Efficacious? We take a closer look at the recent NEJM article to help us come to a final answer on the most important question- Should I feel comfortable getting this vaccine?

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BackgroundVasopressors are used in Emergency Medicine to treat cardiac arrest, hypotension, and shock. Recent studies have sought to investigate questions around timing, medication choices, and administration of these medications in varying clinical scenarios. The emergency provider must be familiar with the properties of, and indications for, vasopressors in the ED setting. In this journal club summary, we review the evidence on the impact vasopressors have on clinical outcomes.

Articles reviewed1. Hansen M et al. Time to Epinephrine Administration and Survival from Non-Shockable Out-of-Hospital Cardiac Arrest Among Children and Adults. Circulation. 2018 May 8;137(19):2032-2040.[Full Text]

1. Mentzelopoulos S et al. Vasopressin, Steroids, and Epinephrine and Neurologically Favorable Survival After In-Hospital Cardiac Arrest A Randomized Clinical Trial. JAMA. 2013 Jul 17:310(3):270-9. [Pdf]

2. Acquisto N, Bodkin R and Johnstone C. Medication Errors with Push Dose Pressors in the Emergency Department and Intensive Care Units. Am J Emerg Med. 2017 Dec;35(12): 1964-1965.[Pubmed]

3. Schwartz M, Ferreira J and Aaronson P. The Impact of Push-Dose Phenylephrine Use on Subsequent Preload Expansion in the ED Setting. Am J Emerg Med. 2016 Dec;34(12);2419-2422.[Pubmed]

Additional reading5. Djogovic D et al. Vasopressor and Inotrope Use in Canadian Emergency Departments: Evidence Based Consensus Guidelines. Canadian Journal of Emergency Medicine. 2015 Feb; 17(1): 1-2.[Pdf]

1. Lundin A et al., Drug Therapy in Cardiac Arrest: A Review of the Literature. Eur Heart J Cardiovasc Pharmacother. 2016 Jan; 2(1), 54-75.[Pdf]

HANSEN M. ET ALThis study was a secondary analysis of 32,101 patients treated by EMS for out of hospital cardiac arrest (OOHCA) with an initial unshockable rhythm. Each minute from EMS arrival to administration of epinephrine was associated with a 4% decrease in odds of survivial for adults and a 9% decrease in survival for pediatric patients.

Bottom Line: The data on the effectiveness of epinephrine in cardiac arrest remains variable (most recently a RCT of epinephrine vs placebo in OOHCA showed a survival benefit but no change in favorable neurologic outcome). However, epinephrine is a cornerstone of current guideline-based treatment of cardiac arrest. This paper indicates that minimizing the time to epinephrine in OOHCA may improve survival.

MENTZELOPOULOS S. ET AL

This was a randomized, double-blind, placebo-controlled trial of 268 patients with in-hospital cardiac arrest requiring epinephrine according to guidelines. Patients received either vasopressin/epinephrine for their first five rounds of CPR plus 40 mg methylprednisolone followed by hydrocortisone infusion, or epinephrine only with placebo replacing the vasopressin, methylprednisolone, and hydrocortisone. Outcome measures were ROSC at 20 minutes and survival to hospital discharge. The results showed that the VSE combination group had improved survival to hospital discharge with favorable neurologic status (13.9%) vs the control group (5.1%).

VSE = Vasopressor-steroids-epinephrine combination

Bottom Line: This study must be evaluated in the context of negative evidence regarding vasopressin; the current ACC/AHA guideline specifically recommends against using vasopressin in combination with epinephrine. However, based on this study and one other, they recommend considering VSE in in-hospital cardiac arrest. At the current time use of a VSE protocol for OOHCA (the majority of ED cardiac arrest patients) is not guideline-supported.

SCHWARTZ M. ET AL AND ACQUISTO N. ET AL

This was a single-center retrospective chart review of ED patients who had received push-dose phenylephrine for hypotension. The primary outcome was percent of patients initiated on a continuous vasopressor infusion within 30 minutes after receiving push-dose phenylephrine and the secondary outcome was an assessment of the appropriateness of fluid challenge given to patients. The results showed that 46% of patients who received push-dose phenylephrine were then initiated on continuous vasopressor infusion. The patients who were started on continuous infusions were less likely to be adequately volume challenged. We additionally reviewed an editorial (Acquisito et al.) that emphasized the risk of dosing errors with push-dose pressors.

PHE= PHENYLEPHRINE; CVI = continuous vasopressor infusion

Bottom Line: Push-dose pressors should not replace adequate volume resuscitation in the hypotensive patient, and the ED clinician has to be very cautious with dosing given the possibility of dosing errors.

• Administer epinephrine as soon as possible in OOHCA with an initial unshockable rhythm if indicated by ACLS guidelines.

• Vasopressin/Steroids/Epinephrine combined therapy is not recommended by current guidelines for OOHCA.

• Push dose pressors probably have a role in the ED, but be sure not to neglect adequate volume resuscitation and early initiation of vasopressor infusions if indicated.

Written by Tania Strout, PhD, RN, MS

Edited and Posted by Jeffrey A. Holmes, MD

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Intubation in the emergency department (ED) can be a stressful endeavor. We are often presented with patients who have complex anatomy and tenuous physiology. Because of this, it can be hard to look past the critical step of securing the airway. Rapid sequence intubation (RSI) and positive pressure ventilation can dismantle patients’ physiology and contribute to an almost 4% rate of post intubation cardiac arrest (PICA). Is there anything we can do to predict or prevent this? In this podcast, Sam Wood gives us an overview of the literature to help us answer these questions.

Why do patients die when we intubate them?* Initiation of positive pressure ventilation increases intrathoracic pressure and decreases venous return * With RSI, patients can loss their compensatory endogenous catecholamine surge (“sympatholysis”) * Direct effects of induction agents * Hypoxia * Worsening of acidosis during apneic period of oxygenation * Worsening of “high risk” physiologic states like acidosis, bronchospasm

Which patients are at highest risk for PICA?[1-4]

• Hypoxia and absence of preoxygenation
• “High risk” physiology: i.e. severe acidosis, hyperkalemia, severe bronchospasm

• Unstable hemodynamics

  • A shock index (SI) >/= 0.9 significantly increases the risk of PICA. This has been remarkably consistent across multiple studies.
  • SBP<90 has also been shown to be predictive

  • Other risk factors:

  • BMI >25

  • Age >75
  • Nursing shift change
  • Crash versus emergent intubations

What interventions to prevent PICA have been studied?

• Intervention bundle

  • Decreased PICA in the ICU setting from 34% to 21% [5]

    • It is not clear which components made the difference
    • It is unclear how this may help us in the ED as some of these items we scrutinize (eg. Sellick maneuver) and some we already routinely do in the ED (eg. capnography and preoxygenation)
    • Preintubation IV fluids

  • “PREPARE” study [6]

    • Critically ill adults were randomized to receive 500cc IV fluid prior to intubation vs no IV fluid
    • There was no difference in cardiovascular collapse between the two groups
    • Push dose pressors

  • Overall, the data shows that push dose pressors increase blood pressure, improve hemodynamic stability, but do not clearly prevent PICA

  • It is worth noting that push dose pressors are associated with a medication error rate of 10% [7]
  • 30-70% of patients will still need a pressor infusion

  • Induction agent

  • Avoid propofol and benzodiazepines for their potential hypotensive effect

  • Ketamine seems attractive for hemodynamically tenuous patients

  • Interestingly, ketamine’s direct effect on the myocardium is negative inotropy [8], but this is typically offset by an increase in heart rate, arterial pressure, and cardiac output in a patient with an intact autonomic nervous system

    • But what about the patient that might be catecholamine depleted?

      • Study of 112 patients undergoing out of hospital rapid sequence induction with ketamine [9]

        • 26% of high SI patients got hypotensive vs 2% of non-high SI pts
        • This study suggests ketamine may not be as safe as originally thought for catecholamine depleted patients
          • Many sources recommend 0.5 mg/kg (“sub-sympatholytic dose”) of ketamine in the shock patient but there is no specific data to support this

What do we take away from this literature?* Calculate a shock index in all patients prior to intubation. * If there’s time, resuscitate first: fluids, push dose pressors, or pressor infusion (my preference). * There is no clear guidance on what the goal should be for a SI (SI <0.9 seems reasonable). * Use ketamine preferentially and at a lower dose (0.5 mg/kg IV) * Unfortunately, in a real emergency, the risk factors for cardiac arrest may not be modifiable before intubation (or at all)

Presented at the 2020 Maine Medical Center Winter Symposium

Samantha Wood, MD

Peer reviewed, edited and posted by Jeffrey A. Holmes, MD and Jason Hine, MD

References

1. Heffner AC et al. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation 2013; 84(11): 1500 – 4. [Pubmed]

2. De Jong A, Rolle A, Molinari N, et al. Cardiac arrest and mortality related to intubation procedure in critically ill adult patients: a multicenter cohort study. Crit Care Med. 2018 Apr 1;46(4):532-9.[Pubmed]

3. Wardi G, Villar J, Nguyen T, et al. Factors and outcomes associated with inpatient cardiac arrest following emergent endotracheal intubation. Resuscitation. 2017 Dec;121:76-80. [Full Text]

4. Kim WY et al. actors Associated with the Occurrence of Cardiac Arrest after Emergency Tracheal Intubation in the Emergency Department. Plos One 2014; 9(11): e112779. [Pdf]

5. Jaber S, Jung B, Corne P, et al. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple- center study. Intensive Care Med. 2010 Feb;36(2):248–55. [Pdf]

6. Janz DR et al. Effect of a fluid bolus on cardiovascular collapse among critically ill adults undergoing intubation (PREPARE): a randomized controlled trial. Lancet Resp Med 2019 Dec; 7(12): 1039-1047. [Pubmed]

7. http://www.emdocs.net/push-dose-vasopressors-an-update-for-2019/

8. Gellisen HP et al. Inotorpic effects of propofol, thiopental, midazolam, etomidate, and ketamine on isolated human atrial muscle. Anesthesiology 1996; 84:397-403. [Pubmed]

9. Miller M et al. Hemodynamic response after rapid sequence induction with ketamine in out-of-hospital patients at risk of shock as defined by the shock index. Ann Emerg Med 2016; 16: 181-188. [Pubmed]