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Separating The Wheat From The Chaff Making 2012 Sense Of Acute Resuscitation In The ED

Separating The Wheat From The Chaff Making 2012 Sense Of Acute Resuscitation In The ED. Inadequate Perfusion, Access, Fluids, Ventilatory Support Restore Perfusion, Identify Insult And Remove Or Relieve, Reassess. Dave Milzman, MD , FACEP. MILZMAND@GEORGETOWN.EDU (202) 210-8018

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Separating The Wheat From The Chaff Making 2012 Sense Of Acute Resuscitation In The ED

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  1. Separating The Wheat From The ChaffMaking 2012 Sense Of Acute Resuscitation In The ED Inadequate Perfusion, Access, Fluids, Ventilatory Support Restore Perfusion, Identify Insult And Remove Or Relieve, Reassess

  2. Dave Milzman, MD , FACEP • MILZMAND@GEORGETOWN.EDU (202) 210-8018 • Professor of Emergency Medicine Adjunct Professor of Pharmacology/ Physiology Assistant Dean for Student Research Medical Director for Community Outreach Georgetown University School of Medicine Senior Advisor PreHealth Sciences, Georgetown University • Medical Director, DC Sports Concussion Center Research  Director Georgetown U./Washington Hospital  Center Emergency Medicine Residency

  3. What Do I Really Want? • Tuition Benefits

  4. Objective: Primum non nocere, and Save Lives • "To Separate The Wheat From The Chaff”Matthew3.0 • To Separate Things of Value From things of NO VALUE!!

  5. What Works in the ED? • Talking To and Making Actual Contact with Patient and Family • Pain Control • Controlling Hemorrhage • Suturing Wound, Removing FB, Reducing Dislocation, I and D, Asthma RX, Appendectomy,.. • Works Sometimes: Airway Control, CPR, PCI, Central Access, Treating PID and • RESUSCITATION

  6. EGDT is on the Table • Everyone NEED Understand the Concept: Inadequate Perfusion (Shock) is Best Treated Early (Cryptic Shock) and Aggressively (EGDT)!

  7. EGDT Original Recipe Warning!! toys not Included, cost extra

  8. EGDT in 2012 What we Know? • Treat in the ED, Maybe EMS • Early Aggressive Fluid Resuscitation: • Large catheter, or IO Crystalloid then Blood • Improve Oxygenation: Mechanical Ventilation, Contractility • Remove Insult: Antibiotics, Operation, • Re-Assess

  9. EGDT in 2012 What we Don’t Know? • Best Marker to Follow • Endpoints of Resuscitation

  10. QUANTITATIVE RESUSCITATION (HEMODYNAMIC OPTIMIZATION OR GDT) • Lactate Clearance Monitoring (10% reduction) Is A Superior Therapeutic Target To Oxygen-derived Variables Such As Scvo2 (>70%) • Multicenter Studies Have Failed To Show The Use Of Svo2 As A Resuscitation • Ability To Clear Lactate Has Consistently Predicted Better Survival • Its Easier Chest Jones 2011

  11. Dr Rivers Responds • It Is Common Knowledge That Many Septic Patients Develop Multiple Organ Failure And Die Despite Normal Blood Lactate Levels Levraut Et Al CCM2003 • Be Careful Of Non-inferiority Studies: Smaller Numbers Bias Toward Non-inferiority. …. Still Waiting On Process • 10% Drop In Lactate Has Different Implications If The Initial Value Is 12 Mmol/L Than 4 Mmol/L • “Today's Prudent Clinician Will Use Both Normalization Of Scvo2 And Lactate Levels To Guide Resuscitation Rather Than Rely On One Parameter Alone.” • Rivers et al Chest 2011

  12. Last Word and Take-Away Point • In Rivers. Patients had much higher lactate, much lower ScvO2, and much higher mortality …patients in Detroit between 1997 - 2000 were markedly different in the world's literature and/or …selection bias was a significant problem in …study. Jones Chest part 2, 2011 • LACTATES study reported no significant concordance in achieving lactate clearance and ScvO2 goals Jones, shapiro Trzeciak JAMA 2010 • FEW ED Resuscitation Actually Using GDT • Jones et al 2006 CCM, 2007 AEM

  13. ED Resucitations • What We Think We Do • And • What usually Happens • SIRS Criteria • Gets a Lactate • 2 L IVF • And ICU Consult

  14. What IS Most Important during Acute ED Resuscitation • What to Follow: • Vitals NO Shock Index Trend • Lactate Yes • CVP Yes • Scv02 Not Proven

  15. What we can do tomorrow in the ED • Jones Kline, Trzeciak, Et Al. Acad EM 2006 • Only 2/36 Academic Programs surveyed routinely used EGT • Most Don’t Have Team Or Effective Protocol: If Its Not You What Do Most EP Do?? • Get A Lactate Give 2 L Start Pressors, Give Blood, • Mech Vent If Needed • Monitoring Invasive Vs Follow Biomarkers

  16. SGO 1904 Use of ‘Suit’ in Surgery, Inflated when BP dropped Deflated after Operation, Marked inproved survival 25-40% What Else did Dr. Crile Do:….. Administration Of Oxygen Under Pressure For Gas Casualties, Epinephrine For Patients In Shock, Diluted Sea Water Infusions To Support Victims Of Massive Trauma.

  17. Shock: Catching up to the last Century: Dr. Crile • Prevention Of Shock Was Of Far Greater Importance Than Its Treatment • Successfully Used Saline Solutions And Epinephrine To Treat Patients Seemingly In Extremis. • 1903 Crile Had Realized That Saline Solutions Were Of Limited Benefit To Prevention And Treatment Of Shock, And He Was One Of The First To Use Blood Transfusions Regularly In Surgery • 1903 Crile Had Realized That Saline Solutions Were Of Limited Benefit In The Prevention And Treatment Of Shock, And He Was One Of The First To Use Blood Transfusions Regularly In Surgery • Moratorium Wards" Where Soldiers Were Taken To Die Be Redesignated "Resuscitation Wards," Where Soldiers Would Be Given Whole Blood To Resuscitate Them Instead Of Morphine To Ease Their Deaths.

  18. Early Invasive Monitoringpart Deux Geriatric Blunt Multiple Trauma: Improved Survival With Early Invasive Monitoring. Scalea et al J Trauma 1990 optimize patients to a cardiac index : 4 L / min / M[2] or an oxygen consumption index of 170 cc / min / M[2] statistically significant differences between optimized cardiac output and systemic vascular resistance in survivors compared with non-survivors. early use of invasive hemodynamic monitoring will identify this deficit and afford the opportunity to help improve survival.

  19. Scalea Way Ahead in 1986 • Central venous oxygen saturation: An early accurate measurement of volume during hemorrhage. J Trauma1988;28:725-732. 29. Scalea TM, Simon HM, Duncan AO. ...

  20. Gastric Tonometry • Gastric Mucosal pHi Is Measured According To An Equation That Assumes That Arterial Bicarbonate Is Equal To Intramucosal Bicarbonate Lancet 1992 Guitierrez et al. • pHi-Guided Resuscitation May Help Improve Outcome In Such Patients By Preventing Splanchnic Organ Hypoxia And The Development Of A Systemic Oxygen Deficit. • Could identify patients with increased mortality but not successful as marker to treat

  21. Easy to Place But Hard to Use

  22. pHi Vs Parameters in Survival • Gastric Tonometry*The Hemodynamic Monitor of Choice Chest 2003 • J Heard

  23. Nagdev AD, et al. Emergency department bedside ultrasonographic measurement of the caval index for noninvasive determination of low central venous pressure. Ann Emerg Med 2010 • Fig 1- IVC diameter at end inspire Fig 2- IVC diameter at end expire. The Caval Index calculation is (expire IVC diameter – inspire IVC diameter) / expire IVC diameter and the Caval Index Percentage = caval index x 100

  24. Lessons Learned from EMS • Immed VS Delayed Resus had lower Survival 62% VS 70% P <0.04 • No Difference In Blood • But Increased ICU and Total LOS • OverResus with Fluid leads to ALI

  25. Lessons Learned from EMS • Not Exactly NO Fluid Prehospital • And Some Fluid Given In ED • No Difference In OR Requirements • No Difference In Blood Products Intra OP • Only Rate Of Administration In OR Was Different

  26. The Prognostic Value Of Blood Lactate Levels Relative To That Of Vital Signs In The Pre-hospital Setting: Jansen Et Al. 2008 Crit Care

  27. PreHospital Predictors of Outcome:Lactate Better then SBP

  28. Non-Inferiority in our Monitors

  29. Sublingual Capnography Marik chest 2001

  30. Blood Products in ED 2012 • When to Transfuse: • 1. There is No Absolute Level • 2. J Trauma 1992 Editorial Stop Transfusion a Hct30 , ongoing ischemia is indication and hemorrhage • 3. Acute Resus New Formula 1:1:1 pRBC: FFP: Plt • JB Holcomb Hematology 2010

  31. multiple large military and civilian retrospective single and multicenter studies that associate a high ratio of plasma and platelets to RBCs with improved survival in MT trauma patients. Because the majority of these reports are retrospective and subject to bias, particularly survivorship bias, they must be interpreted with caution • Between July 2009 and October 2010, PROMMTT screened 12,561 trauma admissions and enrolled 1245 patients who received one or more blood transfusions within 6 h of Emergency Department (ED) admission. A total of 297 massive transfusions were observed over the course of the study at a combined rate of 5.0 massive transfusion patients/week.

  32. Capnography in the ED • monitor C02 production, pulmonary perfusion and alveolar ventilation as well as respiratory patterns • End tidal CO2 • normal values of  ETCO2 is around 5% or 35-37 mm Hg. The gradient between the blood CO2 (PaCO2) and exhaled CO2 (end tidal CO2 or PetCO2) is usually 5-6 mm Hg.  PetCO2 can be used to estimate PaCO2 in patients with essentially normal lungs.

  33. Shock index • A comparison of the shock index and conventional vital signs to identify acute, critical illness in the emergency department. Ann Emerg Med October 1994;24:685-690. Rady Rivers et al. • patients who were triaged to a priority requiring immediate treatment (23 versus 45; P<.01) and required admission to the hospital (35 versus 105; P<.01) and continued therapy in an ICU (10 versus 13; P<.01

  34. Shock index • Shock index (SI) (heart rate/systolic blood pressure; normal range, 0.5 to 0.7) ABORMAL > 0.9 • Shock index: a re-evaluation in acute circulatory failure Resuscitation Rady 1992 • a non-invasive means to monitor deterioration or recovery of LVSW during acute hypovolemic and normovolemic circulatory failure and its therapy

  35. Shock index: Wheat or Chaff • Yealy and delbridge Ann EM 1994 editorial • All that glitters… Despite Negative Editorial and Loss for a decade • It is definitely useful Birrkram et al Am J EM 2007 • Proved change in blood donation study

  36. Boys and their toys part 2 • Biomarkers Get Rapid Results • Which Markers Really Work

  37. Lactate all the time Annals of Surgery 1971

  38. What lactate what about cytokines • I wanna go fast • Insert pix, play clip • Size of molecule 90 daltonsvs 7000 vs bigger • mrna • Time to disuse out • Time to clear post acute insult

  39. Do we always need to get invasive • Does Non invasive really work • Monitor Wizards

  40. Vital Signs alone • Shock index final yea or nea • Controlling for HR • Do we learn • Who do you believe : me or your lying eyes

  41. Rapid US learning from FAST • Yes Ultrasound is Important • Not Just to find Vessels , Babys and FAST • Rapid assessment of Fluid status • Cardiac contractility in CPR and even StEMI NSTEMI • Volume Status in Hypovolemia • Accuracy in Pneumothorax • If you don’t have these skills, you better get them or will not be able to care for your patients as well.

  42. Final Answer? Cystalloid or Colloids Favors Crystalloids Favors Colloids

  43. Endpoints and outcomes • Have we really improved survival • Do fewer patients die of sepsis • Do fewer patients die from shock • Do they die of other causes

  44. Costs VS Outcomes • Is it worth it?WHAT GETS REIMBURSEDWHAT CAN I TELL MY CHAIR?CLINI DIRECTOR

  45. Multicenter Study of Noninvasive Monitoring Systems as Alternatives to Invasive Monitoring of Acutely III Emergency Patients • Shoemaker et al Chest 1998

  46. Monitor Wizards

  47. Monitoring Wizards or Wizards Monitoring The main endpoints evaluated for accuracy were: Accuracy-absolute bias compared to the reference method Precision Sensitivity and specificity to detect directional changes in CO Time Responsiveness

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