Randomized Controlled Trial of Ultrasound-guided Fluid Resuscitation of Sepsis-Induced Hypoperfusion and Septic Shock.

INTRODUCTION: The ultrasound measurement of inferior vena cava (IVC) diameter change during respiratory phase to guide fluid resuscitation in shock patients is widely performed, but the benefit on reducing the mortality of sepsis patients is questionable. The study objective was to evaluate the 30-day mortality rate of patients with sepsis-induced tissue hypoperfusion (SITH) and septic shock (SS) treated with ultrasound-guided fluid management (UGFM) using ultrasonographic change of the IVC diameter during respiration compared with those treated with the usual-care strategy. METHODS: This was a randomized controlled trial conducted in an urban, university-affiliated tertiary-care hospital. Adult patients with SITH/SS were randomized to receive treatment with UGFM using respiratory change of the IVC (UGFM strategy) or with the usual-care strategy during the first six hours after emergency department (ED) arrival. We compared the 30-day mortality rate and other clinical outcomes between the two groups. RESULTS: A total of 202 patients were enrolled, 101 in each group (UGFM vs usual-care strategy) for intention-to-treat analysis. There was no significant difference in 30-day overall mortality between the two groups (18.8% and 19.8% in the usual-care and UGFM strategy, respectively; p > 0.05 by log rank test). Neither was there a difference in six-hour lactate clearance, a change in the sequential organ failure assessment score, or length of hospital stay. However, the cumulative fluid amount given in 24 hours was significantly lower in the UGFM arm. CONCLUSION: In our ED setting, the use of respiratory change of IVC diameter determined by point-of-care ultrasound to guide initial fluid resuscitation in SITH/SS ED patients did not improve the 30-day survival probability or other clinical parameters compared to the usual-care strategy. However, the IVC ultrasound-guided resuscitation was associated with less amount of fluid used.

Effect of predischarge blood pressure on follow-up outcomes in patients with severe hypertension in the ED.

BACKGROUND: Although emergency department (ED) patients with asymptomatic severe hypertension (ASH) generally have no serious short-term hypertension-related adverse events, it is unclear whether persistently high discharge blood pressure (BP) affects the outcome due to the dynamic nature of BP. OBJECTIVES: This study aims to investigate the effect of predischarge BP on short-term follow-up results for ED patients with ASH. METHODS: The prospective observational study was performed in the ED of a tertiary care hospital during a 3-month period. Adult patients who had systolic BP ≥180 mm Hg and diastolic BP ≥100 mm Hg without acute end-organ damage were enrolled and treated at the emergency physicians' discretion. Discharge BP was precategorized into severely high and moderately high groups. We compared the groups using direct telephone contact and medical record reviews of follow-up BP within 1 week and identified their related adverse events. RESULTS: One hundred and forty-six eligible cases were identified in this study; 1 patient (0.7%) had a serious hypertension-related adverse event. One hundred and thirteen patients had follow-up BP information available. There was no difference in mean systolic BP and diastolic BP at follow-up between patients who were discharged from the ED with severely high vs moderately high BP. CONCLUSION: Predischarge BP value is not associated with immediate serious adverse events and does not affect short-term BP control in ED patients with ASH. Further study on the need to lower BP during the ED stay and on antihypertensive prescriptions for these patients is required.

Venous lactate in predicting the need for intensive care unit and mortality among nonelderly sepsis patients with stable hemodynamic.

OBJECTIVES: Our study aims to investigate the role of initial venous lactate in predicting the probability of clinical deterioration and 30-day mortality in nonelderly sepsis patients with acute infections, without hemodynamic shock. METHODS: We enrolled emergency department patients aged 18 to 65 years with acute major infections, but without organ hypoperfusion, and obtained a single venous lactate measurement at initial presentation. As the primary end point, the eligible patients were tracked for the need for vasopressor or mechanical ventilation (MV) in the next 72 hours. The patients' venous lactate and related risk factors were analyzed. We also followed the cohort and the predictors to investigate their prognostic role for 30-day mortality. RESULTS: Of 392 patients, 74 required vasopressor/MV, and 388 patients were available for mortality analysis. An initial lactate greater than or equal to 2 mmol/L was the strongest independent predictor for the requirement of vasopressor/MV (adjusted odds ratio, 6.2; 95% confidence interval, 3.4-11.3). The other independent risk factors were immunosuppressive drug users and positive blood culture. However, the initial lactate was not associated with 30-day mortality. The factors that were associated with mortality were the use of vasopressor/MV, active malignancy, Rapid Emergency Medicine Score greater than or equal to 6, and hospitalization within 90 days. CONCLUSIONS: In nonelderly sepsis patients with stable hemodynamic, elevated venous lactate (≥2 mmol/L) was associated with an increased probability of the need for vasopressor/MV. However, unfavorable medical histories and the severity of physiologic changes may be associated with short-term mortality to a greater extent than the single value of initial lactate.

The prehospital management of traumatic brain injury.

Traumatic brain injury (TBI) is an important cause of death and disability, particularly in younger populations. The prehospital evaluation and management of TBI is a vital link between insult and definitive care and can have dramatic implications for subsequent morbidity. Following a TBI the brain is at high risk for further ischemic injury, with prehospital interventions targeted at reducing this secondary injury while optimizing cerebral physiology. In the following chapter we discuss the prehospital assessment and management of the brain-injured patient. The initial evaluation and physical examination are discussed with a focus on interpretation of specific physical examination findings and interpretation of vital signs. We evaluate patient management strategies including indications for advanced airway management, oxygenation, ventilation, and fluid resuscitation, as well as prehospital strategies for the management of suspected or impending cerebral herniation including hyperventilation and brain-directed hyperosmolar therapy. Transport decisions including the role of triage models and trauma centers are discussed. Finally, future directions in the prehospital management of traumatic brain injury are explored.

Yield of routine provocative cardiac testing among patients in an emergency department-based chest pain unit.

IMPORTANCE: The American Heart Association recommends routine provocative cardiac testing in accelerated diagnostic protocols for coronary ischemia. The diagnostic and therapeutic yield of this approach are unknown. OBJECTIVE: To assess the yield of routine provocative cardiac testing in an emergency department-based chest pain unit. DESIGN AND SETTING: We examined a prospectively collected database of patients evaluated for possible acute coronary syndrome between March 4, 2004, and May 15, 2010, in the emergency department-based chest pain unit of an urban academic tertiary care center. PARTICIPANTS: Patients with signs or symptoms of possible acute coronary syndrome and without an ischemic electrocardiography result or a positive biomarker were enrolled in the database. EXPOSURES: All patients were evaluated by exercise stress testing or myocardial perfusion imaging. MAIN OUTCOMES AND MEASURES: Demographic and clinical features, results of routine provocative cardiac testing and angiography, and therapeutic interventions were recorded. Diagnostic yield (true-positive rate) was calculated, and the potential therapeutic yield of invasive therapy was assessed through blinded, structured medical record review using American Heart Association designations (class I, IIa, IIb, or lower) for the potential benefit from percutaneous intervention. RESULTS: In total, 4181 patients were enrolled in the study. Chest pain was initially reported in 93.5%, most (73.2%) were at intermediate risk for coronary artery disease, and 37.6% were male. Routine provocative cardiac testing was positive for coronary ischemia in 470 (11.2%), of whom 123 underwent coronary angiography. Obstructive disease was confirmed in 63 of 123 (51.2% true positive), and 28 (0.7% overall) had findings consistent with the potential benefit from revascularization (American Heart Association class I or IIa). CONCLUSIONS AND RELEVANCE: In an emergency department-based chest pain unit, routine provocative cardiac testing generated a small therapeutic yield, new diagnoses of coronary artery disease were uncommon, and false-positive results were common.