The critical care literature 2023.

The number of critically ill patients that present to emergency departments across the world continues to rise. In fact, the proportion of critically ill patients in emergency departments is now higher than pre-COVID-19 pandemic levels. [1] The emergency physician (EP) is typically the first physician to evaluate and resuscitate the critically ill patient. Given the continued shortage of intensive care unit (ICU) beds, persistent staff shortages, and overall inefficient hospital throughput, EPs are often tasked with providing intensive care to these patients long beyond the initial resuscitation phase. Prolonged boarding of critically ill patients in the ED is associated with increased ICU and hospital length of stay, increased adverse events, ED staff burnout, decreased patient and family satisfaction, and, most importantly, increased mortality. [2-5]. As such, it is imperative for the EP to be knowledgeable about recent literature in resuscitation and critical care medicine, so that critically ill ED patients can continue to receive the best, most up-to-date evidence-based care. This review summarizes important articles published in 2023 that pertain to the resuscitation and management of select critically ill ED patients. Topics included in this article include cardiac arrest, post-cardiac arrest care, septic shock, rapid sequence intubation, severe pneumonia, transfusions, trauma, and critical procedures.

The critical care literature 2022.

The number of critically ill patients that present to emergency departments across the world has risen steadily for nearly two decades. Despite a decrease in initial emergency department (ED) volumes early in the COVID-19 pandemic, the proportion of critically ill patients is now higher than pre-pandemic levels [1]. The emergency physician (EP) is often the first physician to evaluate and resuscitate a critically ill patient. In addition, EPs are frequently tasked with providing critical care long beyond the initial resuscitation. Prolonged boarding of critically ill patients in the ED is associated with increased duration of mechanical ventilation, increased intensive care unit (ICU) length of stay, increased hospital length of stay, increased medication-related adverse events, and increased in-hospital, 30-day, and 90-day mortality [2-4]. Given the continued increase in critically ill patients along with the increases in boarding critically ill patients in the ED, it is imperative for the EP to be knowledgeable about recent literature in resuscitation and critical care medicine, so that critically ill patients continue to receive evidence-based care. This review summarizes important articles published in 2022 that pertain to the resuscitation and management of select critically ill ED patients. These articles have been selected based on the authors review of key critical care, resuscitation, emergency medicine, and medicine journals and their opinion of the importance of study findings as it pertains to the care of the critically ill ED patient. Topics covered in this article include cardiac arrest, post-cardiac arrest care, rapid sequence intubation, mechanical ventilation, fluid resuscitation, and sepsis.

The critical care literature 2021.

An emergency physician (EP) is often the first provider to evaluate, resuscitate, and manage a critically ill patient. Over the past two decades, the annual hours of critical care delivered in emergency departments across the United States has dramatically increased. During the period from 2006 to 2014, the extent of critical care provided in the emergency department (ED) to critically ill patients increased approximately 80%. During the same time period, the number of intubated patients cared for in the ED increased by approximately 16%. In addition to seeing more critically ill patients, EPs are often tasked with providing critical care long beyond the initial resuscitation period. Prolonged ED boarding times for critically ill patients is associated with increased duration of mechanical ventilation, increased intensive care unit (ICU) length of stay, increased hospital length of stay, increased medication-related adverse events, and increased in-hospital, 30-day, and 90-day mortality. As a result, it is imperative for the EP to be knowledgeable about recent developments in resuscitation and critical care medicine, so that the critically ill ED patient care receive current evidence-based care. These articles have been selected based on the authors review of key critical care, resuscitation, emergency medicine, and medicine journals and their opinion of the importance of study findings as it pertains to the care of the critically ill ED patient. Topics covered in this article include cardiac arrest, post-cardiac arrest care, rapid sequence intubation, mechanical ventilation, fluid resuscitation, cardiogenic shock, transfusions, and sepsis.

The critical care literature 2020.

Given the dramatic increase in critically ill patients who present to the emergency department for care, along with the persistence of boarding of critically ill patients, it is imperative for the emergency physician to be knowledgeable about recent developments in resuscitation and critical care medicine. This review summarizes important articles published in 2020 that pertain to the resuscitation and care of select critically ill patients. These articles have been selected based on the authors annual review of key critical care, emergency medicine and medicine journals and their opinion of the importance of study findings as it pertains to the care of critically ill ED patients. Several key findings from the studies discussed in this paper include the administration of dexamethasone to patients with COVID-19 infection who require mechanical ventilation or supplemental oxygen, the use of lower levels of positive end-expiratory pressure for patients without acute respiratory distress syndrome, and early initiation of extracorporeal membrane oxygenation for out-of-hospital cardiac arrest patients with refractory ventricular fibrillation if resources are available. Furthermore, the emergency physician should not administer tranexamic acid to patients with acute gastrointestinal bleeding or administer the combination of vitamin C, thiamine, and hydrocortisone for patients with septic shock. Finally, the emergency physician should titrate vasopressor medications to more closely match a patient's chronic perfusion pressure rather than target a mean arterial blood pressure of 65 mmHg for all critically ill patients.

The critical care literature 2019.

An emergency physician (EP) is often the first health care provider to evaluate, resuscitate, and manage a critically ill patient. In recent years, the annual hours of critical care delivered in emergency departments across the United States has steadily increased. From 2006 to 2014, emergency department (ED) visits for critically ill patients increased approximately 80%. In addition to seeing more critically ill patients, EPs are often tasked with providing critical care long beyond the initial resuscitation period. In fact, more than 50% of ED patients that require admission to the ICU remain in the ED for more than 6 h. Prolonged ED wait times for critically ill patients to be transferred to the ICU is associated with increased hospital, 30-day, and 90-day mortality. It is during these early hours of critical illness, while the patient is in the ED, where lives can be saved or lost. Therefore, it is important for the EP to be knowledgeable about recent developments in resuscitation and critical care medicine. This review summarizes important articles published in 2019 pertaining to the resuscitation and care of select critically ill patients. We chose these articles based on our opinion of the importance of the study findings and their application to emergency medicine. The following topics are covered: sepsis, rapid sequence intubation, mechanical ventilation, neurocritical care, post-cardiac arrest care, and ED-based ICUs.

Clinical Practice Statement: What is the Emergency Department Management of Patients with Angioedema Secondary to an ACE-Inhibitor?

BACKGROUND: Angioedema is a complication that has been reported in up to 1.0% of individuals taking angiotensin-converting enzyme inhibitors (ACE-Is). Importantly, the onset of angioedema can occur anywhere from hours to several years after initiation of therapy with ACE-Is. Although most cases of ACE-I-induced angioedema (ACE-I-AE) are self-limiting, a major clinical concern is development of airway compromise, which can potentially require emergent airway management. The underlying pathophysiology of ACE-I-AE is incompletely understood, but is considered to be due in large part to excess bradykinin. Numerous medications have been proposed for the treatment of ACE-I-AE. This article is an update to the 2011 Clinical Practice Committee (CPC) statement from the American Academy of Emergency Medicine. METHODS: A literature search in PubMed was performed with search terms angioedema and ACE inhibitors from August 1, 2012 to May 13, 2019. Following CPC guidelines, articles written in English were identified and then underwent a structured review for evaluation. RESULTS: The search parameters resulted in 323 articles. The abstracts of these articles were assessed independently by the reviewers, who determined there were 63 articles that were specific to ACE-I-AE, of which 46 were deemed appropriate for grading in the final focused review. CONCLUSIONS: The primary focus for the treatment of ACE-I-AE is airway management. In the absence of high-quality evidence, no specific medication therapy is recommended for its treatment. If, however, the treating physician feels the patient's presentation is more typical of an acute allergic reaction or anaphylaxis, it may be appropriate to treat for those conditions. Any patient with suspected ACE-I-AE should immediately discontinue that medication.

The critical care literature 2018.

An emergency physician (EP) is often the first health care provider to evaluate, resuscitate, and manage a critically ill patient. In recent years, the annual hours of critical care delivered in emergency departments (EDs) across the United States increased more than 200% (Herring et al., 2013). In addition to seeing more critically ill patients, EPs are often tasked with providing critical care long beyond the initial resuscitation period. In fact, more than 50% of ED patients that require admission to the intensive care unit (ICU) remain in the ED for more than 6 h (Rose et al., 2016). Longer ED boarding times for critically ill patients is associated with a negative impact on inpatient morbidity and mortality (Mathews et al., 2018). It is during these early hours of critical illness, while the patient is in the ED, where lives can be saved or lost. Therefore, it is important for the EP to be knowledgeable about recent developments in critical care medicine. This review summarizes important articles published in 2018 pertaining to the resuscitation and care of select critically ill patients. We chose these articles based on our opinion of the importance of the study findings and their application to clinical care in the ED. The following topics are covered: cardiac arrest, post-arrest care, septic shock, rapid sequence intubation, mechanical ventilation, fluid resuscitation, and metabolic acidosis.

National Early Warning Score Is Modestly Predictive of Care Escalation after Emergency Department-to-Floor Admission.

BACKGROUND: Decompensation on the medical floor is associated with increased in-hospital mortality. OBJECTIVE: Our aim was to determine the accuracy of the National Early Warning Score (NEWS) in predicting early, unplanned escalation of care in patients admitted to the hospital from the emergency department (ED) compared to the Shock Index (SI) and the quick Sepsis-Related Organ Failure Assessment (qSOFA) score. METHODS: We conducted a retrospective cohort study of patients admitted directly from the ED to monitored or unmonitored beds (November 9, 2015 to April 30, 2018) in 3 hospitals. Interhospital transfers were excluded. Patient data, vital status, and bed assignment were extracted from the electronic medical record. Scores were calculated using the last set of vital signs prior to leaving the ED. Primary endpoint was in-hospital death or placement in an intermediate or intensive care unit within 24 h of admission from the ED. Scores were compared using the area under the receiver operating curve (AUROC). RESULTS: Of 46,018 ED admissions during the study window, 39,491 (85.8%) had complete data, of which 3.7% underwent escalation in level of care within 24 h of admission. NEWS outperformed (AUROC 0.69; 95% confidence interval [CI] 0.68-0.69) qSOFA (AUROC 0.63; 95% CI 0.62-0.63; p < 0.001) and SI (AUROC 0.60; 95% CI 0.60-0.61; p < 0.001) at predicting unplanned escalations or death at 24 h. CONCLUSIONS: This multicenter study found NEWS was superior to the qSOFA score and SI in predicting early, unplanned escalation of care for ED patients admitted to a general medical-surgical floor.

Angiotensin II for the emergency physician.

Refractory hypotension is one of the most common and difficult clinical problems faced by acute care clinicians, and it poses a particularly large problem to the emergency physician when a patient in undifferentiated shock arrives in the department. Angiotensin II (Ang-2) has been previously used as a vasopressor to combat shock; the feasibility of its clinical use has been reinvigorated after approval of a human synthetic formulation of the medication by the US Food and Drug Administration in 2017 and the European Medicines Agency in 2019. A thorough literature search was completed, and in this review, we discuss the discovery and development of Ang-2, its complex mechanisms of vasoconstriction, its potential adverse effects and its potential role in clinical practice for emergency physicians.

The critical care literature 2017.

An emergency physician (EP) is often the first health care provider to evaluate, resuscitate, and manage a critically ill patient. Between 2001 and 2009, the annual hours of critical care delivered in emergency departments (EDs) across the United States increased >200% [1]! This trend has persisted since then. In addition to seeing more critically ill patients, EPs are often tasked with providing critical care long beyond the initial resuscitation period. In fact, >33% of critically ill patients who are brought to an ED remain there for >6 h [1]. Longer ED boarding times for critically ill patients have been associated with a negative impact on inpatient morbidity and mortality [2]. During these crucial early hours of illness, detrimental pathophysiologic processes begin to take hold. It is during these early hours of illness where lives can be saved, or lost. Therefore, it is important for the EP to be knowledgeable about recent developments in critical care medicine. This review summarizes important articles published in 2017 pertaining to the resuscitation and care of select critically ill patients in the ED. We chose these articles based on our opinion of the importance of the study findings and their application to clinical care. The following topics are covered: sepsis, vasolidatory shock, cardiac arrest, post-cardiac arrest care, post-intubation sedation, and pulmonary embolism.

Combined Residency Programs in Emergency Medicine.

There are currently 5 combined residencies in emergency medicine (EM), namely EM/pediatrics, EM/internal medicine, EM/internal medicine/critical care, EM/family medicine and EM/anesthesiology. These combined programs vary from 5-6 years in length. Like categorical programs, the decision to enter a 5- or 6-year program should be an informed and comprehensive decision. We describe the history and current status of the combined EM programs, discuss the process of applying to a combined EM program, describe the life of combined EM residents, and explore common career opportunities available to combined EM program graduates.

What is the Role of Reversal Agents in the Management of Emergency Department Patients with Dabigatran-Associated Hemorrhage?

BACKGROUND: In 2010, the U.S. Food and Drug Administration (FDA) approved dabigatran as the first non-warfarin oral anticoagulant for use in the United States. At the time of FDA approval, there was no antidote or effective treatment for dabigatran-induced hemorrhage. In 2015, the FDA approved idarucizumab for the treatment of dabigatran-induced hemorrhage. The purpose of this clinical practice statement is to evaluate the role of select reversal agents in the management of patients with dabigatran-associated bleeding. METHODS: A PubMed literature review was completed to identify studies that investigated the role of reversal agents in the management of emergency department patients with dabigatran-associated hemorrhage. Articles included were those published in the English language between January 2010 and January 2017, enrolled human subjects, and limited to the following types: randomized controlled trials, prospective trials, meta-analyses, and retrospective cohort studies. Review articles, case series, and case reports were not included in this review. All selected articles then underwent a structured review by the authors. RESULTS: Six hundred fifty-two articles were identified in the search. After use of predetermined inclusion and exclusion criteria, six articles were selected for structured review. CONCLUSION: The clinical efficacy of activated prothrombin complex concentrates, idarucizumab, and recombinant factor VIIa remains unclear until further research is performed. Activated prothrombin complex concentrates, idarucizumab, and recombinant factor VIIa may be considered in patients with serious bleeding from dabigatran, after careful consideration of possible benefits and risks.

The critical care literature 2016.

An emergency physician (EP) is often the first health care provider to evaluate, resuscitate, and manage a critically ill patient. Between 2001 and 2009, the annual hours of critical care delivered in emergency departments (EDs) across the United States increased >200%! (Herring et al., 2013). This trend has persisted since then. In addition to seeing more critically ill patients, EPs are often tasked with providing critical care long beyond the initial resuscitation period. In fact, >33% of critically ill patients who are brought to an ED remain there for >6h (Herring et al., 2013). During these crucial early hours of illness, detrimental pathophysiologic processes begin to take hold. During this time, lives can be saved or lost. Therefore, it is important for the EP to be knowledgeable about recent developments in critical care medicine. This review summarizes important articles published in 2016 pertaining to the care of select critically ill patients in the ED. The following topics are covered: intracerebral hemorrhage, traumatic brain injury, anti-arrhythmic therapy in cardiac arrest, therapeutic hypothermia, mechanical ventilation, sepsis, and septic shock.

Does Early Goal-Directed Therapy Decrease Mortality Compared with Standard Care in Patients with Septic Shock?

BACKGROUND: Current international guidelines for the treatment of patients with severe sepsis and septic shock recommend that patients receive targeted care to various physiologic endpoints, thereby optimizing tissue perfusion and oxygenation. These recommendations are primarily derived from a protocol published >15 years ago, which was viewed by many as complex and was therefore not widely adopted. Instead, many emergency physicians focused on the administration of early antibiotics, source control, aggressive fluid resuscitation, vasoactive medications as needed to maintain mean arterial blood pressure, and careful monitoring of these patients. The primary goal of this literature search was to determine if there is a mortality benefit to the early goal-directed protocol recommended by current international sepsis guidelines compared to current usual care. METHODS: A MEDLINE literature search was performed for studies published between January 1, 2010 and December 31, 2015. Studies were limited to the English language, human randomized controlled trials, meta-analyses, prospective trials, and retrospective cohort trials that met specific keyword search criteria. Case reports, case series, and review articles were excluded. All selected articles then underwent a structured review by the authors. RESULTS: Seven thousand four hundred twenty studies were initially screened; after the final application of inclusion and exclusion criteria, 10 studies were formally analyzed. Each study then underwent a rigorous review and evaluation from which a formal recommendation was made. CONCLUSION: There is no difference in mortality between current usual care and the goal-directed approach recommended by current international guidelines for patients with severe sepsis and septic shock.

The Use of Tissue Plasminogen Activator in the Treatment of Wallenberg Syndrome Caused by Vertebral Artery Dissection.

BACKGROUND: Acute cerebrovascular accident (CVA) is a devastating cause of patient morbidity and mortality. Up to 10% of acute CVAs in young patients are caused by dissection of the vertebral or carotid artery. Wallenberg syndrome results from a CVA in the vertebral or posterior inferior artery of the cerebellum and manifests as various degrees of cerebellar dysfunction. The administration of a thrombolytic medication has been recommended in the treatment of patients with stroke caused by cervical artery dissection. Surprisingly, there is scant literature on the use of this medication in the treatment of this condition. CASE REPORT: We describe a 42-year-old man with the sudden onset of headache, left-sided neck pain, vomiting, nystagmus, and ataxia 1 h after completing a weightlifting routine. Computed tomography angiography revealed a grade IV left vertebral artery injury with a dissection flap extending distally and resulting in complete occlusion. Subsequent magnetic resonance imaging and angiography demonstrated acute left cerebellar and lateral medullary infarcts, consistent with Wallenberg syndrome. The patient was treated with tissue plasminogen activator, which failed to resolve his symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians frequently manage patients with acute CVAs. For select patients, the administration of tissue plasminogen activator can improve outcomes. However, the risk of major hemorrhage with this medication is significant. Cervical artery dissection is an important cause of acute stroke in young patients and is often missed on initial presentation. It is imperative for the emergency physician to consider acute cervical artery dissection as a cause of stroke and to be knowledgeable regarding the efficacy of thrombolytic medications for this condition.

What is the Preferred Resuscitation Fluid for Patients with Severe Sepsis and Septic Shock?

BACKGROUND: Current guidelines for the management of patients with severe sepsis and septic shock recommend crystalloids as the initial fluid solution of choice in the resuscitation of these patients. In recent years, there have been numerous studies published on the type of fluid used in the resuscitation of patients with sepsis. The primary goal of this article is to determine the preferred intravenous fluid for the resuscitation of patients with severe sepsis and septic shock. METHODS: A MEDLINE literature review was completed to identify studies that investigated the type of resuscitation fluid in the management of patients with severe sepsis and septic shock. Articles included were those published in English between 2011 and 2016, enrolled human subjects, and limited to the following types: randomized controlled trial, prospective observational trial, retrospective cohort trial, and meta-analyses. All selected articles then underwent a structured review by the authors. RESULTS: Nine thousand sixty-two articles were identified in the search. After use of predetermined criteria, 17 articles were selected for review. Eleven of these were original investigations and six were meta-analyses and systemic reviews. CONCLUSION: Crystalloids are the preferred solution for the resuscitation of emergency department patients with severe sepsis and septic shock. Balanced crystalloids may improve patient-centered outcomes and should be considered as an alternative to normal saline, if available. There is strong evidence that suggests semi-synthetic colloids decrease survival and should be avoided. The role of albumin in the resuscitation of patients with severe sepsis and sepsis is uncertain.

Does Early and Appropriate Antibiotic Administration Improve Mortality in Emergency Department Patients with Severe Sepsis or Septic Shock?

BACKGROUND: Severe sepsis and septic shock remain significant public health concerns. Appropriate emergency department management includes early recognition, hemodynamic resuscitation, source control, and prompt antibiotic administration. Current international guidelines strongly recommend administration of early and appropriate antibiotics for patients with severe sepsis and septic shock. Interestingly, a recent Cochrane Review found insufficient evidence to provide a similar recommendation on antibiotic administration. The goal of this literature search was to systematically review the available literature on early and appropriate antimicrobial therapy and provide emergency physicians an evidence-based approach to antibiotic therapy for septic patients. METHODS: Four PubMed searches were completed to identify abstracts of relevant interest. We limited studies to those completed in adult humans that were composed in English between 2005 and 2015. Included studies were randomized controlled trials, meta-analyses, prospective trials, and retrospective cohort studies. These studies were identified by a rigorous search methodology. No review articles, case series, or case reports were included. Predefined criteria were used to evaluate the quality and appropriateness of selected articles as part of a structured review. RESULTS: A total of 1552 abstracts were evaluated for inclusion. After the review of these studies, 14 were included for formal review. The authors then systematically evaluated each study, which formed the basis for this clinical statement. CONCLUSIONS: Patients with severe sepsis and septic shock should receive early and appropriate antibiotics in the emergency department. Patients with septic shock who received appropriate antimicrobial therapy within 1 h of recognition had the greatest benefit in mortality.

Resistance Patterns of Escherichia coli in Women with Uncomplicated Urinary Tract Infection Do Not Correlate with Emergency Department Antibiogram.

BACKGROUND: Urine cultures are not always performed for female Emergency Department (ED) patients with uncomplicated urinary tract infection (UTI). Accordingly, hospital, and even ED-specific, antibiograms might be skewed toward elderly patients with many comorbidities and relatively high rates of antimicrobial resistance, and thus do not accurately reflect otherwise healthy women. Our ED antibiogram indicates Escherichia coli resistance rates for ciprofloxacin, levofloxacin, and trimethoprim-sulfamethoxazole (TMP-SMX) of 42%, 26%, and 33%, respectively. OBJECTIVES: This study aims to compare resistance rates of urinary E. coli from otherwise healthy women with uncomplicated UTI and pyelonephritis in the ED to rates in our ED antibiogram. METHODS: Females > 18 years old with acute onset of urinary frequency, urgency, or dysuria with pyuria identified on urinalysis (white blood cell count > 10/high-power field) were prospectively enrolled in the ED of an urban, academic medical center. Exclusion criteria indicating a complicated UTI were consistent with Infectious Diseases Society of America guidelines. Susceptibility patterns of E. coli to ciprofloxacin, levofloxacin, and TMP-SMX in the study group were compared to our ED antibiogram. RESULTS: Forty-five patients grew E. coli. Pyelonephritis was suspected in nine (20%) subjects. Compared with the ED antibiogram, significantly lower rates of resistance to ciprofloxacin (2% vs. 42%, p < 0.001), levofloxacin (2% vs. 26%, p < 0.001), and TMP-SMX (16% vs. 33%, p = 0.016) were observed. Six patients grew non-E. coli uropathogens. All were susceptible to both levofloxacin and TMP-SMX. CONCLUSIONS: ED antibiograms may overestimate resistance rates for uropathogens causing uncomplicated UTIs. In cases where nitrofurantoin cannot be used, fluoroquinolones and possibly TMP-SMX may remain viable options for treatment of uncomplicated UTI and pyelonephritis in women.

Anaphylaxis.

BACKGROUND: Anaphylaxis is the quintessential critical illness in emergency medicine. Symptoms are rapid in onset and death can occur within minutes. Approximately 1500 patients die annually in the United States from this deadly disorder. It is imperative, therefore, that emergency care providers be able to diagnose and appropriately treat patients with anaphylaxis. Any delays in recognition or initiation of therapy can result in unnecessary increases in patient morbidity and mortality. DISCUSSION: Recent literature, including updated international anaphylaxis guidelines, has improved our understanding and management of this critical illness. Anaphylaxis is a multisystem disorder that can manifest signs and symptoms related to the cutaneous, respiratory, cardiovascular, and gastrointestinal systems. Epinephrine remains the drug of choice and should initially be administered intramuscularly, into the anterolateral thigh, as soon as the diagnosis is suspected. For patients unresponsive to repeated intramuscular injections, a continuous infusion of epinephrine should be started. Antihistamines and corticosteroids are second-line medications and should never be given in lieu of, or prior to, epinephrine. Aggressive fluid resuscitation should also be used to treat the intravascular volume depletion characteristic of anaphylaxis. Patient observation and disposition should be individualized, as there is no well-defined period of observation after resolution of signs and symptoms. CONCLUSIONS: For patients with anaphylaxis, rapid and appropriate administration of epinephrine is critical for survival. Additional therapy, such as supplemental oxygen, intravenous fluids, antihistamines, and corticosteroids should not delay the administration of epinephrine.