Disparities Exist in the Application of Low Tidal-volume Ventilation in the Emergency Department.

INTRODUCTION: Low tidal-volume ventilation (LTVV), defined as a maximum tidal volume of 8 milliliters per kilogram (mL/kg) of ideal body weight, is a key component of lung protective ventilation. Although emergency department (ED) initiation of LTVV has been associated with improved outcomes, disparities in LTVV application exist. In this study our aim was to evaluate whether rates of LTVV are associated with demographic and physical characteristics in the ED. METHODS: We conducted a retrospective observational cohort study using a dataset of patients who underwent mechanical ventilation at three EDs in two health systems from January 2016-June 2019. Demographic, mechanical ventilation, and outcome data including mortality and hospital-free days were abstracted by automatic query. A LTVV approach was defined as a tidal volume ≤8 mL/kg ideal body weight. We performed descriptive statistics and univariate analysis as indicated, and created a multivariate logistic regression model. RESULTS: Of 1,029 patients included in the study, 79.5% received LTVV. Tidal volumes of 400-500 mL were used in 81.9% of patients. Approximately 18% of patients had tidal volumes changed in the ED. Female gender (adjusted odds ratio [aOR] 4.17, P< 0.001), obesity (aOR 2.27, P< 0.001), and first-quartile height (aOR 12.2, P < 0.001) were associated with receiving non-LTVV in multivariate regression analysis. Hispanic ethnicity and female gender were associated with first quartile height (68.5%, 43.7%, P < 0.001 for all). Hispanic ethnicity was associated with receiving non-LTVV in univariate analysis (40.8% vs 23.0%, P < 0.001). This relationship did not persist in sensitivity analysis controlling for height, weight, gender, and body mass index. Patients who received LTVV in the ED had 2.1 more hospital-free days compared to those who did not (P = 0.040). No difference in mortality was observed. CONCLUSION: Emergency physicians use a narrow range of initial tidal volumes that may not meet lung-protective ventilation goals, with few corrections. Female gender, obesity, and first-quartile height are independently associated with receiving non-LTVV in the ED. Using LTVV in the ED was associated with 2.1 fewer hospital-free days. If confirmed in future studies, these findings have important implications for achieving quality improvement and health equality.

A NOVEL EQUATION SUCCESSFULLY CALCULATES TIDAL VOLUMES FOR LUNG PROTECTIVE VENTILATION.

BACKGROUND: Early application of low-tidal-volume ventilation (LTVV) has been associated with improved outcomes in the emergency department (ED) and intensive care unit (ICU), but is not consistently applied. The perceived complexity of calculating an ideal body weight (IBW)-based tidal volume (Vt) may contribute to this disparity. We hypothesized that a simplified equation could successfully predict LTVV. OBJECTIVE: To create a memorable, single-step, sex-independent equation to estimate LTVV based on height. METHODS: We conducted a retrospective observational cohort study of patients who received mechanical ventilation (MV) at 2 EDs from January 2016 to June 2019. Data were abstracted by automatic query. Patients < 18 years old, < 60 inches in height, and with implausible or incomplete data were excluded. LTVV was defined as ≤ 8 mL/kg IBW. We created a formula predicting a 6-8-mL/kg IBW Vt. We applied this formula to a population of ICU patients in the same health care system who received MV from January 2017 to December 2019 using the same exclusion criteria. The outcome was whether the equation predicted a 6-8-mL/kg IBW Vt. RESULTS: A total of 982 ED patients were included; 753 (76.7%) had an initial Vt < 8 mL/kg IBW. The equation Vt = 20*(Ht-60) + 300 was derived. A total of 3720 ICU patients were included. The Vt equation successfully predicted a Vt of 6-8 mL/kg IBW in 3720 (100%) of ICU patients. CONCLUSIONS: A novel equation successfully predicted a 6-8-mL/kg IBW Vt in a cohort of patients with height ≥ 60 inches.

Ketamine is not associated with more post-intubation hypotension than etomidate in patients undergoing endotracheal intubation.

INTRODUCTION: Emergency department (ED) patients undergoing emergent tracheal intubation often have multiple physiologic derangements putting them at risk for post-intubation hypotension. Prior work has shown that post-intubation hypotension is independently associated with increased morbidity and mortality. The choice of induction agent may be associated with post-intubation hypotension. Etomidate and ketamine are two of the most commonly used agents in the ED, however, there is controversy regarding whether either agent is superior in the setting of hemodynamic instability. The goal of this study is to determine whether there is a difference in the rate of post-intubation hypotension who received either ketamine or etomidate for induction. Additionally, we provide a subgroup analysis of patients at pre-existing risk of cardiovascular collapse (identified by pre-intubation shock index (SI) > 0.9) to determine if differences in rates of post-intubation hypotension exist as a function of sedative choice administered during tracheal intubation in these high-risk patients. We hypothesize that there is no difference in the incidence of post-intubation hypotension in patients who receive ketamine versus etomidate. METHODS: A retrospective cohort study was conducted on a database of 469 patients having undergone emergent intubation with either etomidate or ketamine induction at a large academic health system. Patients were identified by automatic query of the electronic health records from 1/1/2016-6/30/2019. Exclusion criteria were patients <18-years-old, tracheal intubation performed outside of the ED, incomplete peri-intubation vital signs, or cardiac arrest prior to intubation. Patients at high risk for hemodynamic collapse in the post-intubation period were identified by a pre-intubation SI > 0.9. The primary outcome was the incidence of post-intubation hypotension (systolic blood pressure < 90 mmHg or mean arterial pressure < 65 mmHg). Secondary outcomes included post-intubation vasopressor use and mortality. These analyses were performed on the full cohort and an exploratory analysis in patients with SI > 0.9. We also report adjusted odds ratios (aOR) from a multivariable logistic regression model of the entire cohort controlling for plausible confounding variables to determine independent factors associated with post-intubation hypotension. RESULTS: A total of 358 patients were included (etomidate: 272; ketamine: 86). The mean pre-intubation SI was higher in the group that received ketamine than etomidate, (0.97 vs. 0.83, difference: -0.14 (95%, CI -0.2 to -0.1). The incidence of post-intubation hypotension was greater in the ketamine group prior to SI stratification (difference: -10%, 95% CI -20.9% to -0.1%). Emergency physicians were more likely to use ketamine in patients with SI > 0.9. In our multivariate logistic regression analysis, choice of induction agent was not associated with post-intubation hypotension (aOR 1.45, 95% CI 0.79 to 2.65). We found that pre-intubation shock index was the strongest predictor of post-intubation hypotension. CONCLUSION: In our cohort of patients undergoing emergent tracheal intubation, ketamine was used more often for patients with an elevated shock index. We did not identify an association between the incidence of post-intubation hypotension and induction agent between ketamine and etomidate. Patients with an elevated shock index were at higher risk of cardiovascular collapse regardless of the choice of ketamine or etomidate.

Dispelling myths and misconceptions about the treatment of acute hyperkalemia.

Hyperkalemia represents a widespread and potentially lethal condition that affects millions of people across their lives. Despite the prevalence and severity of the condition, there are no consensus guidelines on the treatment of hyperkalemia or even a standard definition. Herein, we provide a succinct review of what we believe to be the most significant misconceptions encountered in the emergency care of hyperkalemia, examine current available literature, and discuss practical points on several modalities of hyperkalemia treatment. Additionally, we review the pathophysiology of the electrocardiographic effects of hyperkalemia and how intravenous calcium preparations can antagonize these effects. We conclude each section with recommendations to aid emergency physicians in making safe and efficacious choices for the treatment of acute hyperkalemia.

A BERIBERI UNHEALTHY LATTE: ENCEPHALOPATHY AND SHOCK FROM SEVERE NUTRITIONAL DEFICIENCY.

BACKGROUND: Thiamine deficiency is an uncommon cause of severe illness in the United States that can lead to significant morbidity because of high-output cardiac failure, peripheral neuropathy, and permanent neurologic impairment. We report the case of a middle-aged woman with extreme malnutrition caused by complications of Roux-en-Y gastric bypass (RYGB) surgery who presented with signs and symptoms of severe thiamine deficiency and septic shock. CASE REPORT: A 43-year-old woman who had undergone RYGB surgery and who had multiple complications presented to the emergency department with agitation, confusion, and lethargy. The physical examination revealed an obtunded woman appearing much older than her reported age with significant peripheral edema. She was hypoxemic, hypotensive, and febrile. The initial laboratory analysis revealed a serum lactate level above the measurable limit, a normal thyroid-stimulating hormone, and elevated levels of troponin and brain natriuretic peptide. A transthoracic echocardiogram showed high-output heart failure. The patient's family later revealed that for the past year her diet had consisted almost exclusively of frozen blended lattes. High doses of thiamine and folate were started. Her shock, hyperlactatemia, and respiratory failure resolved by hospital day 3 and her encephalopathy resolved soon thereafter. Why Should an Emergency Physician be Aware of This?: Thiamine deficiency is a rare but reversible cause of shock, heart failure, and encephalopathy. Identifying patients who are at risk for severe nutritional deficiencies may aid in more rapid treatment with relatively benign medications with little downside, in this case high-dose vitamin B1, and ultimately improve patient-oriented outcomes such as mortality, morbidity, and hospital length of stay.

Demystifying Lactate in the Emergency Department.

The role of lactic acid and its conjugate base, lactate, has evolved during the past decade in the care of patients in the emergency department (ED). A recent national sepsis quality measure has led to increased use of serum lactate in the ED, but many causes for hyperlactatemia exist outside of sepsis. We provide a review of the biology of lactate production and metabolism, the many causes of hyperlactatemia, and evidence on its use as a marker in prognosis and resuscitation. Additionally, we review the evolving role of lactate in sepsis care. We provide recommendations to aid lactate interpretation in the ED and highlight areas for future research.

Wandering spleen presenting as recurrent pancreatitis.

INTRODUCTION: A wandering spleen occurs when there is a laxity of the ligaments that fix the spleen in its normal anatomical position. CASE REPORT: We present the case of a wandering spleen in a 20-year-old female who presented with recurrent pancreatitis and underwent a laparoscopic splenectomy. DISCUSSION: The presentation of a wandering spleen varies from an asymptomatic mass to splenic infarct with an acute abdomen. Its correct diagnosis relies mostly on imaging studies. Treatment consists of performing either splenectomy or splenopexy. CONCLUSION: The diagnosis of wandering spleen can often be difficult due to the intermittent nature of the torsion. Computed tomography studies for diagnosis and laparoscopic surgery have changed the management of this interesting disease.

Medical admission of elderly trauma patients with isolated injuries.

We sought to evaluate the outcomes of trauma patients admitted to medical services rather than to the general trauma team, particularly those elderly patients with isolated injuries of a specialty nature. Over the 2-year retrospective study period, 3017 trauma patients were admitted. The trauma service directed care in 2740 (90.8%) of this group versus the 277 (9.2%) admitted to medical services (MS). The patients in each group were then classified according to age younger than 55 years or older than 55 years (elderly). Of the 277 patients admitted to the MS, 177 (63.8%) were elderly compared with only 13 per cent of the trauma service group. Smaller proportions (16.9%) of the elderly medical patients were admitted to the intensive care unit as compared with the trauma group (22.1%). There was a higher morbidity rate, 41.9 per cent, in the trauma service group as compared with the MS group, 20 per cent. No patients on the MS underwent a laparotomy for intraabdominal injuries nor were there any missed injuries of a general surgical nature. Allowing elderly trauma patients with isolated specialty injuries to be managed by the MS is not associated with increased morbidity or mortality.

Review of tracheo-esophageal fistula associated with endotracheal intubation.

Tracheo-esophageal fistula (TEF) formation is a rare complication of either endotracheal intubation or tracheostomy. This complication is generally thought to be iatrogenic and occurs in less than 1% of patients. High-volume, low-pressure cuffs have made TEFs an infrequent occurrence; however, it still poses as a potential life-threatening condition. Evaluation and close monitoring of endotracheal tube (ETT) cuff pressures is an area of significance commonly overlooked and/or underemphasized by surgical residents. To illustrate and review this clinical problem, a case of an iatrogenic TEF as a consequence of excessive endotracheal cuff pressures is reported.

Abdominal wall abscess formation two years after laparoscopic cholecystectomy.

BACKGROUND: Spillage of gallstones within the subcutaneous tissue during laparoscopic cholecystecomy may lead to considerable morbidity. METHODS: We describe an abdominal wall abscess formation in a 50-year-old female that developed 24 months after a laparoscopic cholecystectomy. RESULTS: Spilled gallstones at the umbilical port site went undetected. Subsequently, an umbilical port-site abscess formed and was treated 2 years later. CONCLUSION: Any patient with a foreign body in the subcutaneous tissues after a laparoscopic cholecystectomy should be considered to have a retained stone. Use careful dissection, copious irrigation, and a retrieval device to avoid stone spillage. If spillage does occurs, percutaneous drainage and antibiotics followed by open retrieval of the stones should achieve adequate results during those delayed presentations of abdominal wall abscesses.

Managing breast cancer in the renal transplant patient: a unique dilemma.

Improvements in immunosuppression have increased patient and graft survival in transplant recipients. As a result, there is greater risk of neoplastic processes such as breast cancer. Treatment in this population is complicated by the necessary immunosuppression, vascular accesses, and transplant grafts. General surgeons may expect to encounter more of these complex patients in the community setting. We sought to evaluate the surgical treatment of breast cancer in patients with renal transplants. Hospital and private physician records were queried to identify patients who developed breast cancer after a renal or pancreatic/renal transplantation. These charts were reviewed for demographics, type of breast cancer and treatment, location of dialysis access, and complications. From June 1, 1994, to May 31, 2004, 14 patients were identified. Eight patients had functioning transplants. All patients underwent operative interventions. Ten patients underwent adjuvant treatment. Three had functioning transplants and chose not to risk the graft with cessation of immunotherapy. However, no patient with functioning transplants who underwent chemotherapy developed organ failure. Breast cancer after transplantation poses a unique dilemma. The threat of transplanted organ failure is a major concern to these patients and often supersedes adjuvant therapies.

The benefit of routine thoracic, abdominal, and pelvic computed tomography to evaluate trauma patients with closed head injuries.

BACKGROUND: The evaluation of multitrauma patients for blunt truncal injuries remains open for debate. We sought to evaluate the role of routine computed tomography (CT) of the chest, abdomen, and pelvis as a screening tool for patients already undergoing cranial CT studies. METHODS: Charts of blunt trauma patients admitted from June 2000 to June 2001 were reviewed for demographics, Glascow Coma Scale (GCS), physical and radiological findings, and length of stay. RESULTS: Our study found that 38% of patients undergoing cranial CT scanning had a unexpected finding on body scans. Changes were made in 26% of the study group because results found on the adjuvant CTs. CONCLUSIONS: Additional body CTs add minimal cost to the care of trauma patients but can significantly change the management. We believe it is beneficial to perform routine body CT examinations when performing cranial imaging for blunt head injury.