When Minutes Matter: Rapid Infusion in Emergency Care

Purpose of Review This review provides historical context and an update on recent advancements in volume resuscitation for circulatory shock. Emergency department providers who manage critically ill patients with undifferentiated shock will benefit from the insights of early pioneers and an overview of newer techniques which can be used to optimize resuscitation in the first minutes of care. Recent Findings Rapid infusion of fluids and blood products can be a life-saving intervention in the management of circulatory and hemorrhagic shock. Recent controversy over the role of fluid resuscitation in sepsis and trauma management has obscured the importance of early and rapid infusion of sufficient volume to restore circulation and improve organ perfusion. Evidence from high-quality studies demonstrates that rapid and early resuscitation improves patient outcomes. Summary Current practice standards, guidelines, and available literature support the rapid reversal of shock as a key priority in the treatment of hypotension from traumatic and non-traumatic conditions. An improved understanding of the physiologic rationale of rapid infusion and the timing, volume, and methods of fluid delivery will help clinicians improve care for critically ill patients presenting with shock. Clinical Case A 23-year-old male presents to the emergency department (ED) after striking a tree while riding an all-terrain vehicle. On arrival at the scene, first responders found an unconscious patient with an open skull fracture and a Glasgow coma scale score of 3. Bag-valve-mask (BVM) ventilation was initiated, and a semi-rigid cervical collar was placed prior to transport to your ED for stabilization while awaiting air transport to the nearest trauma center. You are the attending emergency medicine physician at a community ED staffed by two attending physicians, two physicians assistants, and six nurses covering 22 beds. On ED arrival, the patient has no spontaneous respiratory effort, and vital signs are as follows: pulse of 140 bpm, blood pressure of 65/30 mmHg, and oxygen saturation 85% while receiving BVM ventilation with 100% oxygen. He is bleeding profusely through a gauze dressing applied to the exposed dura. The prehospital team was unable to establish intravenous access. What are the management priorities for this patient in shock, and how should his hypotension best be addressed?

Development of Core Contents of Point-of-Care Ultrasound Curriculum for Pediatric Emergency Medicine Physician Training: A Modified Delphi Survey

Background: As the frequency of ultrasound use in pediatric emergency departments increases, it is necessary to train pediatric emergency medicine (PEM) physicians on pediatric point-of-care ultrasonography (POCUS). We discussed the core content of POCUS applications and proposed a POCUS training curriculum for PEM physicians in South Korea. Methods: Twenty-three experts were included if had performed over 1500 POCUS scans, had at least three years of experience teaching POCUS to physicians, were POCUS instructors or had completed a certified pediatric POCUS program. Experts rated 61 possible POCUS applications in terms of the importance of their inclusion in a PEM POCUS curriculum using the modified Delphi technique. Results: In round one, twelve (52.2%) out of 23 experts responded to the email. Eleven experts satisfied the inclusion criteria. Eleven experts participated in round one of a survey and agreed on 27 (44.3%) out of a total of 61 items. In round two, all 11 experts participated in the survey; they agreed on two (5.9%) of the remaining 34 items, and no items were excluded. Conclusion: Using the Delphi method, 61 applications were discussed, and a consensus was reached on 29 core applications.

A Case for the Non-Neurologist Telestroke Provider

Introduction: Telestroke networks have effectively increased the number of ischemic stroke patients who have access to acute stroke therapy. However, the availability of a dedicated group of stroke subspecialists is not always feasible. We hypothesize that rates of tPA recommendation, sensitivity of final diagnosis, and post-tPA hemorrhagic complications do not differ significantly between neurologists and an emergency-medicine physician during telestroke consultations.Methods: Retrospective review of all telestroke consults performed at a comprehensive stroke center over 1 year. Statistical analysis: Chi squared test.Results: Three hundred and three consults were performed among 6 spoke sites. 16% (48/303) were completed by the emergency medicine physician; 25% (76/303) were performed by non-stroke-trained neurologists, and 59% (179/303) were completed by a board-certified Vascular Neurologist. Overall rate of tPA recommendation was 40% (104/255), 38% (18/48), 41% (73/179), and 41% (31/76) among the all neurology-trained, emergency medicine-trained, stroke neurology-trained and other neurology- trained provider groups, respectively (p = 0.427). Sensitivity of final stroke diagnosis was 77% (14/18) and 72% (75/104) in the emergency-medicine trained and neurology-trained provider groups (p = 0.777) No symptomatic hemorrhagic complications following the administration of tPA via telestroke consultation occurred in any group over this time period. One asymptomatic intracerebral hemorrhage was observed (0.96% or 1/104) in the neurology-trained provider group.Discussion/Conclusion: Our results did not illustrate any statistically significant difference between care provided by an emergency medicine-trained physician and neurologists during telestroke consultation. While our study is limited by its relatively low numbers, it suggests that identifying a non-neurologist provider who has requisite clinical experience with acute stroke patients can safely and appropriately provide telestroke consultation. The lack of formerly trained neurologists, therefore, may not need to serve as an impediment to building an effective telestroke network. Future efforts should be focused on illuminating all strategies that facilitate sustainable telestroke implementation.

Subarachnoid hemorrhage in the emergency department

Background Subarachnoid hemorrhage accounts for more than 30,000 cases of stroke annually in North America and encompasses a 4.4% mortality rate. Since a vast number of subarachnoid hemorrhage cases present in a younger population and can range from benign to severe, an accurate diagnosis is imperative to avoid premature morbidity and mortality. Here, we present a straightforward approach to evaluating, risk stratifying, and managing subarachnoid hemorrhages in the emergency department for the emergency medicine physician. Discussion The diversities of symptom presentation should be considered before proceeding with diagnostic modalities for subarachnoid hemorrhage. Once a subarachnoid hemorrhage is suspected, a computed tomography of the head with the assistance of the Ottawa subarachnoid hemorrhage rule should be utilized as an initial diagnostic measure. If further investigation is needed, a CT angiography of the head or a lumbar puncture can be considered keeping risks and limitations in mind. Initiating timely treatment is essential following diagnosis to help mitigate future complications. Risk tools can be used to assess the complications for which the patient is at greatest. Conclusion Subarachnoid hemorrhages are frequently misdiagnosed; therefore, we believe it is imperative to address the diagnosis and initiation of early management in the emergency medicine department to minimize poor outcomes in the future.

A Pilot Study to Assess Urban, Fire-Based Paramedic Accuracy in Identification of Anatomical Landmarks Necessary for Cricothyrotomy and Needle Chest Decompression Using Live Patient Models

Background: Cricothyrotomy and chest needle decompression (NDC) have a high failure and complication rate. This article sought to determine whether paramedics can correctly identify the anatomical landmarks for cricothyrotomy and chest NDC. Methods: A prospective study using human models was performed. Paramedics were partnered and requested to identify the location for cricothyrotomy and chest NDC (both mid-clavicular and anterior axillary sites) on each other. A board-certified or board-eligible emergency medicine physician timed the process and confirmed location accuracy. All data were collected de-identified. Descriptive analysis was performed on continuous data; chi-square was used for categorical data. Results: A total of 69 participants were recruited, with one excluded for incomplete data. The paramedics had a range of six to 38 (median 14) years of experience. There were 28 medical training officers (MTOs) and 41 field paramedics. Cricothyroidotomy location was correctly identified in 56 of 68 participants with a time to identification range of 2.0 to 38.2 (median 8.6) seconds. Chest NDC (mid-clavicular) location was correctly identified in 54 of 68 participants with a time to identification range of 3.4 to 25.0 (median 9.5) seconds. Chest NDC (anterior axillary) location was correctly identified in 43 of 68 participants with a time to identification range of 1.9 to 37.9 (median 9.6) seconds. Chi-square (2-tail) showed no difference between MTO and field paramedic in cricothyroidotomy site (P = .62), mid-clavicular chest NDC site (P = .21), or anterior axillary chest NDC site (P = .11). There was no difference in time to identification for any procedure between MTO and field paramedic. Conclusion: Both MTOs and field paramedics were quick in identifying correct placement of cricothyroidotomy and chest NDC location sites. While time to identification was clinically acceptable, there was also a significant proportion that did not identify the correct landmarks.

Harnessing the Chaplain’s Capacity to Identify Unmet Palliative Needs of Vulnerable Older Adults in the Emergency Department

Objective: To explore chaplains’ ability to identify unmet palliative care (PC) needs in older emergency department (ED) patients. Methods: A palliative chaplain-fellow conducted a retrospective chart review evaluating 580 ED patients, age ≥80 using the Palliative Care and Rapid Emergency Screening (P-CaRES) tool. An emergency medicine physician and chaplain-fellow screened 10% of these charts to provide a clinical assessment. One year post-study, charts were re-examined to identify which patients received PC consultation (PCC) or died, providing an objective metric for comparing predicted needs with services received. Results: Within one year of ED presentation, 31% of the patient sub-sample received PCC; 17% died. Forty percent of deceased patients did not receive PCC. Of this 40%, chaplain screening for P-CaRES eligibility correctly identified 75% of the deceased as needing PCC. Conclusion: Establishing chaplain-led PC screenings as standard practice in the ED setting may improve end-of-life care for older patients.

Conducting Pre-deployment Training in Honduras: The 240th Forward Resuscitative Surgical Team Experience

ABSTRACT Introduction Since January 2002, pre-deployment training of forward resuscitative and surgical units has taken place at the U.S. Army Trauma Training Center (ATTC) in Miami, FL. In June 2019, the 240th Forward Resuscitative Surgical Team (FRST) conducted the first pre-deployment Surgical Readiness Training Exercise (SURGRETE) in San Pedro Sula, Honduras, to allow the team to rehearse in a resource-constrained environment more similar to that expected on deployment. The purpose of this study is to describe and compare the pre-deployment training experiences of the 240th FRST during their SURGRETE in Honduras and ATTC rotation in Miami, FL. Materials and Methods A descriptive analysis of prospectively collected data was performed for surgical cases, trauma resuscitations, and nonsurgical procedures by the 240th FRST over a 2-week SURGRETE in Honduras and 2-week ATTC rotation in Miami, FL. Items accomplished within the Individual Critical Task Lists (ICTLs) of key clinical providers on the team (general surgeon, orthopedic surgeon, emergency medicine physician, and Certified Registered Nurse Anesthetist) were identified and compared to those accomplished at the ATTC. Results During the SURGRETE in Honduras, 64 surgical cases, 1 trauma resuscitation, 2 Advanced Cardiac Life Support codes, and 213 nonsurgical procedures were performed collectively by the team. During ATTC rotation, the team performed a combined total of 10 surgical cases, 6 trauma resuscitations, and 56 nonsurgical procedures. For each key clinical provider, more of their assigned ICTLs were conducted during the Honduras SURGRETE than during ATTC rotation. The ATTC, however, offered more cases of acute life-threatening trauma. Conclusion Appropriately planned SURGRETEs can provide a concentrated case volume in a resource-constrained setting and challenge the team to consider definitive management algorithms. The cases performed may not necessarily reflect the type and acuity of operations performed in a deployed environment; however, they facilitate repetition of basic skills, team cohesion, and cross-training. The SURGRETE experience could be improved by locating a facility with a trauma-dominant patient population that allows increased autonomy of U.S. physicians.