Daniel Howes

Rapid induction of therapeutic hypothermia using convective-immersion surface cooling: Safety, efficacy and outcomes

Therapeutic hypothermia has become an accepted part of post-resuscitation care. Efforts to shorten the time from return of spontaneous circulation to target temperature have led to the exploration of different cooling techniques. Convective-immersion uses a continuous shower of 2 degrees C water to rapidly induce hypothermia. The primary purpose of this multi-center trial was to evaluate the feasibility and speed of convective-immersion cooling in the clinical environment. The secondary goal was to examine the impact of rapid hypothermia induction on patient outcome. 24 post-cardiac arrest patients from 3 centers were enrolled in the study; 22 agreed to participate until the 6-month evaluations were completed. The median rate of cooling was 3.0 degrees C/h. Cooling times were shorter than reported in previous studies. The median time to cool the patients to target temperature (<34 degrees C) was 37 min (range 14-81 min); and only 27 min in a subset of patients sedated with propofol. Survival was excellent, with 68% surviving to 6 months; 87% of survivors were living independently at 6 months. Conductive-immersion surface cooling using the ThermoSuit System is a rapid, effective method of inducing therapeutic hypothermia. Although the study was not designed to demonstrate impact on outcomes, survival and neurologic function were superior to those previously reported, suggesting comparative studies should be undertaken. Shortening the delay from return of spontaneous circulation to hypothermic target temperature may significantly improve survival and neurologic outcome and warrants further study.

The Use of Task-Evoked Pupillary Response as an Objective Measure of Cognitive Load in Novices and Trained Physicians: A New Tool for the Assessment of Expertise.

Purpose Task-evoked pupillary responses (TEPRs), or changes in pupil size, correlate with changes in cognitive processing demands. The magnitude of this change is a reliable marker of cognitive load. The authors used TEPRs to compare cognitive load between novices and trained physicians as they answered clinical knowledge questions. Method In 2013, 20 emergency medicine trainees were recruited and divided into novice (n = 10) and trained physician (n = 10) groups. The authors used mobile eye-tracking glasses to assess changes in pupil diameter as participants answered arithmetic questions, general knowledge questions, and clinical emergency medicine questions in a controlled setting. Questions were categorized by difficulty a priori. Results Difficult arithmetic questions caused greater changes in TEPRs than easy ones (P = .024). TEPRs were similar between groups when answering general knowledge questions (P = .383) but were significantly greater for novices than trained physicians when answering clinical questions (P < .001). TEPRs in trained physicians were significantly greater when answering difficult clinical questions than easy ones (P < .001), whereas TEPRs in novices were similar (P = .291). For those clinical questions answered correctly by both groups, TEPRs in novices were greater than those in trained physicians despite all participants answering correctly (P < .001). Conclusions Novices require more mental effort to answer clinical questions than trained physicians, even when both respond correctly. Measuring TEPRs has the potential to be a valuable assessment tool by providing objective measures of expertise and is worthy of further study.

Stock your emergency department with ice packs: a practical guide to therapeutic hypothermia for survivors of cardiac arrest

Prognosis after cardiac arrest is dismal, with an overall survival rate of less than 6%. Outcomes vary with cardiac arrest rhythm: less than 2% of patients with asystolic or pulseless electrical activity survive, compared with up to 33% of patients with ventricular fibrillation or pulseless

Brain Tissue Oxygenation in Patients with Septic Shock: a Feasibility Study.

BACKGROUND Delirium is common in critically ill patients and its presence is associated with increased mortality and increased likelihood of poor cognitive function among survivors. However, the cause of delirium is unknown. The purpose of this study was to demonstrate the feasibility of using near-infrared spectroscopy (NIRS) to assess brain tissue oxygenation in patients with septic shock, who are at high risk of developing delirium. METHODS This prospective observational study was conducted in a 33-bed general medical surgical intensive care unit (ICU). Patients with severe sepsis or septic shock were eligible for recruitment. The FORESIGHT NIRS monitor was used to assess brain tissue oxygenation in the frontal lobes for the first 72 hours of ICU admission. Physiological data was also recorded. We used the Confusion Assessment Method-ICU to screen for delirium. RESULTS From March 1st 2014-September 30th 2014, 10 patients with septic shock were recruited. The NIRS monitor captured 81% of the available data. No adverse events were recorded. Brain tissue oxygenation demonstrated significant intra- and inter-individual variability in the way it correlated with physiological parameters, such as mean arterial pressure, heart rate, and peripheral oxygen saturation. Mean brain tissue oxygen levels were significantly lower in patients who were delirious for the majority of their ICU stay. CONCLUSION It is feasible to record brain tissue oxygenation with NIRS in patients with septic shock. This study provides the infrastructure necessary for a larger prospective observational study to further examine the relationship between brain tissue oxygenation, physiological parameters, and acute neurological dysfunction.

How we developed a comprehensive resuscitation-based simulation curriculum in emergency medicine

Abstract Over the past decade, simulation-based education has emerged as a new and exciting adjunct to traditional bedside teaching and learning. Simulation-based education seems particularly relevant to emergency medicine training where residents have to master a very broad skill set, and may not have sufficient real clinical opportunities to achieve competence in each and every skill. In 2006, the Emergency Medicine program at Queen’s University set out to enhance our core curriculum by developing and implementing a series of simulation-based teaching sessions with a focus on resuscitative care. The sessions were developed in such as way as to satisfy the four conditions associated with optimum learning and improvement of performance; appropriate difficulty of skill, repetitive practice, motivation, and immediate feedback. The content of the sessions was determined with consideration of the national training requirements set out by the Royal College of Physicians & Surgeons of Canada. Sessions were introduced in a stepwise fashion, starting with a cardiac resuscitation series based on the AHA ACLS guidelines, and leading up to a more advanced resuscitation series as staff became more adept at teaching with simulation, and as residents became more comfortable with this style of learning. The result is a longitudinal resuscitation curriculum that begins with fundamental skills of resuscitation and crisis resource management (CRM) in the first 2 years of residency and progresses through increasingly complex resuscitation cases where senior residents are expected to play a leadership role. This paper documents how we developed, implemented, and evaluated this resuscitation-based simulation curriculum for Emergency Medicine postgraduate trainees, with discussion of some of the challenges encountered.

Canadian Association of Emergency Physicians sepsis treatment checklist: optimizing sepsis care in Canadian emergency departments.

OBJECTIVE The Canadian Association of Emergency Physicians (CAEP) sepsis guidelines created by the CAEP Critical Care Practice Committee (C4) and published in the Canadian Journal of Emergency Medicine (CJEM) form the most definitive publication on Canadian emergency department (ED) sepsis care to date. Our intention was to identify which of the care items in this document are specifically necessary in the ED and then to provide these items in a tiered checklist that can be used by any Canadian ED practitioner. METHODS Practice points from the CJEM sepsis publication were identified to create a practice point list. Members of C4 then used a Delphi technique consensus process over May to October 2009 via e-mail to create a tiered checklist of sepsis care items that can or could be completed in a Canadian ED when caring for the septic shock patient. This checklist was then assessed for use by a survey of ED practitioners from varying backgrounds (rural ED, community ED, tertiary ED) from July to October 2010. RESULTS Twenty sepsis care items were identified in the CAEP sepsis guidelines. Fifteen items were felt to be necessary for ED care. Two levels of checklists were then created that can be used in a Canadian ED. Most ED physicians in community and tertiary care centres could complete all parts of the level I sepsis checklist. Rural centres often struggle with the ability to obtain lactate values and central venous access. Many items of the level II sepsis checklist could not be completed outside the tertiary care centre ED. CONCLUSION Sepsis care continues to be an integral and major part of the ED domain. Practice points for sepsis care that require specialized monitoring and invasive techniques are often limited to larger tertiary care EDs and, although heavily emphasized by many medical bodies, cannot be reasonably expected in all centres. When the resources of a centre limit patient care, transfer may be required.

Airbag pneumonitis: a report and discussion of a new clinical entity

This report describes the occurrence of pneumonitis in a young male immediately after inhalation of aerosolized chemicals subsequent to motor vehicle airbag deployment. The clinical presentation was one of mild shortness of breath associated with bilateral alveolar infiltrates on chest radiology. Not previously described, this diagnosis should be considered in the differential of pulmonary infiltrates in motor vehicle crash patients.

Combining First-Person Video and Gaze-Tracking in Medical Simulation: A Technical Feasibility Study

Crisis decision-making is an important responsibility of the resuscitation team leader but a difficult process to study. The purpose of this pilot study was to explore the potential of gaze-tracking technology to study decision-making and leadership behaviours in simulated medical emergencies. We studied five physicians with a broad range of experience in a simulated medical emergency using gaze-tracking glasses. Subjects were interviewed immediately after the scenario while viewing a first-person recording of their performance with a superimposed gaze indicator. The recordings were then studied independently by two reviewers, and rated for quality and their observations collated. Portable gaze-tracking devices were found to be useful and effective tools for studying information gathering and decision-making behaviours in simulated medical emergencies. The data obtained in this study provided information about the discrepancy between what each participant looked at compared to what each participant consciously noted. Analysis of the data also identified a number of recurrent gaze patterns performed by team leaders that could be used as end-points in future research. Gaze-tracking in resuscitation medicine is a new and promising field of study. The potential to study crisis decision-making behaviours, and cognitive load, as well as differences between novice and expert team leaders is substantial.

A severe case of iatrogenic lactation ketoacidosis

Lactation ketosis is a recognised disorder in postpartum lactating cows where a negative energy balance develops because the energy demands of milk production exceed the energy capacity of the animal. Rarely, nursing women can develop problems with lactation ketosis when their glycogen stores are depleted, causing the body to turn to gluconeogenesis as an energy substrate for galactopoiesis. The authors describe the case of a breastfeeding woman admitted to hospital and made nil per os (NPO) to treat a bowel obstruction. She did not receive intravenous glucose and 3 days postadmission developed a dangerous starvation ketosis (venous pH of 6.64). She was treated with intravenous dextrose, bicarbonate as well as cessation of breastfeeding and recovered quickly. Only four previous reports describe human lactation ketosis and this is the first iatrogenic case reported to our knowledge. It highlights the importance of addressing the unique caloric requirements of nursing women, especially when they are kept NPO.

Hiccups: A new explanation for the mysterious reflex

The hiccup may have evolved to remove swallowed air from the stomach, which may help suckling mammals to consume more milk.