Keith Corl

Bedside sonographic measurement of the inferior vena cava caval index is a poor predictor of fluid responsiveness in emergency department patients

Sonographic measurement of the inferior vena cava (IVC) caval index predicts central venous pressure in ED patients. Fluid responsiveness (FR) is a measure of preload dependence defined as an increase in cardiac output secondary to volume expansion. We sought to determine if the caval index is an accurate measurement of FR in ED patients.

The use of impedance cardiography in predicting mortality in emergency department patients with severe sepsis and septic shock.

OBJECTIVES Pulmonary artery catheterization poses significant risks and requires specialized training. Technological advances allow for more readily available, noninvasive clinical measurements of hemodynamics. Few studies exist that assess the efficacy of noninvasive hemodynamic monitoring in sepsis patients. The authors hypothesized that cardiac index, as measured noninvasively by impedance cardiography (ICG) in emergency department (ED) patients undergoing early goal-directed therapy (EGDT) for sepsis, would be associated with in-hospital mortality. METHODS This was a prospective observational cohort study of patients age over 18 years meeting criteria for EGDT (lactate > 4 or systolic blood pressure < 90 after 2 L of normal saline). Initial measurements of cardiac index were obtained by ICG. Patients were followed throughout their hospital course until discharge or in-hospital death. Cardiac index measures in survivors and nonsurvivors are presented as means and 95% confidence intervals (CI). Diagnostic performance of ICG in predicting mortality was tested by receiver operating characteristic (ROC) curve and areas under the ROC curves (AUC) were compared using Wilcoxon test. RESULTS Fifty-six patients were enrolled; one was excluded due to an inability to complete data acquisition. The mean cardiac index in nonsurvivors (2.3 L/min.m(2), 95% CI = 1.6 to 3.0) was less than that for survivors (3.2, 95% CI = 2.9 to 3.5) with mean difference of 0.9 (95% CI = 0.12 to 1.71). The AUC for ICG in predicting mortality was 0.71 (95% CI = 0.58 to 0.88; p = 0.004). A cardiac index of < 2 L/min.m(2) had a sensitivity of 43% (95% CI = 18% to 71%), specificity of 93% (95% CI = 80% to 95%), positive likelihood ratio of 5.9, and negative likelihood ratio of 0.6 for predicting in-hospital mortality. CONCLUSIONS Early, noninvasive measurement of the cardiac index in critically ill severe sepsis and septic shock patients can be performed in the ED for those who meet criteria for EGDT. There appears to be an association between an initial lower cardiac index as measured noninvasively and in-hospital mortality.

Tissue oxygenation does not predict central venous oxygenation in emergency department patients with severe sepsis and septic shock.

OBJECTIVES This study sought to determine whether tissue oxygenation (StO(2)) could be used as a surrogate for central venous oxygenation (ScVO(2)) in early goal-directed therapy (EGDT). METHODS The study enrolled a prospective convenience sample of patients aged > or =18 years with sepsis and systolic blood pressure <90 mm Hg after 2 L of normal saline or lactate >4 mmol, who received a continuous central venous oximetry catheter. StO(2) and ScVO(2) were measured at 15-minute intervals. Data were analyzed using a random coefficients model, correlations, and Bland-Altman plots. RESULTS There were 284 measurements in 40 patients. While a statistically significant relationship existed between StO(2) and ScVO(2) (F(1,37) = 10.23, p = 0.002), StO(2) appears to systematically overestimate at lower ScVO(2) and underestimate at higher ScVO(2). This was reflected in the fixed effect slope of 0.49 (95% confidence interval [CI] = 0.266 to 0.720) and intercept of 34 (95% CI = 14.681 to 50.830), which were significantly different from 1 and 0, respectively. The initial point correlation (r = 0.5) was fair, but there was poor overall agreement (bias = 4.3, limits of agreement = -20.8 to 29.4). CONCLUSIONS Correlation between StO(2) and ScVO(2) was fair. The two measures trend in the same direction, but clinical use of StO(2) in lieu of ScVO(2) is unsubstantiated due to large and systematic biases. However, these biases may reflect real physiologic states. Further research may investigate if these measures could be used in concert as prognostic indicators.

Inferior vena cava collapsibility detects fluid responsiveness among spontaneously breathing critically-ill patients

Purpose: Measurement of inferior vena cava collapsibility (cIVC) by point‐of‐care ultrasound (POCUS) has been proposed as a viable, non‐invasive means of assessing fluid responsiveness. We aimed to determine the ability of cIVC to identify patients who will respond to additional intravenous fluid (IVF) administration among spontaneously breathing critically‐ill patients. Methods: Prospective observational trial of spontaneously breathing critically‐ill patients. cIVC was obtained 3 cm caudal from the right atrium and IVC junction using POCUS. Fluid responsiveness was defined as a ≥ 10% increase in cardiac index following a 500 ml IVF bolus; measured using bioreactance (NICOM™, Cheetah Medical). cIVC was compared with fluid responsiveness and a cIVC optimal value was identified. Results: Of the 124 participants, 49% were fluid responders. cIVC was able to detect fluid responsiveness: AUC = 0.84 [0.76, 0.91]. The optimum cutoff point for cIVC was identified as 25% (LR + 4.56 [2.72, 7.66], LR‐ 0.16 [0.08, 0.31]). A cIVC of 25% produced a lower misclassification rate (16.1%) for determining fluid responsiveness than the previous suggested cutoff values of 40% (34.7%). Conclusion: IVC collapsibility, as measured by POCUS, performs well in distinguishing fluid responders from non‐responders, and may be used to guide IVF resuscitation among spontaneously breathing critically‐ill patients. HIGHLIGHTSIVC collapsibility, as measured by POCUS, is able to detect fluid responsiveness.Use of a passive leg raise did not improve detection of fluid responsiveness.The optimum cutoff point for IVC collapsibility is cIVC = 25%.cIVC, measured by POCUS may be used to direct fluid resuscitation.

Non-Traumatic Orbital Hemorrhage

*Department of Emergency Medicine, Brown University, Rhode Island Hospital, Providence, Rhode Island and †Department of Ophthalmology, Brown University, Rhode Island Hospital and Rhode Island Eye Institute, Providence, Rhode Island Reprint Address: Keith Corl, MD, Department of Emergency Medicine, Rhode Island Hospital, Brown Medical School, 593 Eddy Street, Claverick Building, 2 Floor, Room 274, Providence, RI 02903

Prognostic value of noninvasive measures of contractility in emergency department patients with severe sepsis and septic shock undergoing early goal-directed therapy

PURPOSE Reversible ventricular dysfunction is common in sepsis. Impedance cardiography allows for noninvasive measurement of contractility through time interval or amplitude-based measures. This study evaluates the prognostic capacity of these measures in patients with severe sepsis or septic shock in the emergency department. METHODS This is a prospective observational cohort study of 56 patients older than 18 years meeting criteria for early goal-directed therapy (lactate level >4 mmol/L or systolic blood pressure <90 mm Hg after 2-L isotonic sodium chloride solution). Continuous collections of contractility measures were performed, and patients were followed until discharge or in-hospital death. RESULTS A significant 57% reduction in the accelerated contractility index (ACI) in nonsurvivors (71 1/s(2) [41-102]) compared with survivors (123 1/s(2) [98-147]) existed. Only ACI predicted in-hospital mortality (area under the receiver operating characteristic curve = 0.70, P < .01). Accelerated contractility index did not correlate with amount of prior fluid administration, central venous pressure, number of cardiac risk factors, or troponin I value. An ACI of less than 40 1/s(2) is 95% (84-99) specific with a positive likelihood ratio of 8.8 for predicting in-hospital mortality. CONCLUSIONS A reduced ACI is associated with mortality in critically ill emergency department patients presenting with severe sepsis and septic shock meeting criteria for early goal-directed therapy. This association appears to be independent of clinical or laboratory predictors of cardiac dysfunction or preload.

A modified Montpellier protocol for intubating intensive care unit patients is associated with an increase in first-pass intubation success and fewer complications

Background: The Montpellier protocol for intubating patients in the intensive care unit (ICU) is associated with a decrease in intubation‐related complications. We sought to determine if implementation of a simplified version of the Montpellier protocol that removed selected components and allowed for a variety of pre‐oxygenation modalities increased first‐pass intubation success and reduced intubation‐related complications. Methods: A prospective pre/post‐comparison of a modified Montpellier protocol in two medical and one medical/surgical/cardiac ICU within a hospital system. The modified eight‐point protocol included: fluid administration, ordering sedation, two intubation trained providers, pre‐oxygenation with non‐invasive positive pressure ventilation, nasal high flow cannula or non‐rebreather mask, rapid sequence intubation, capnography, sedation administration, and vasopressors for shock. Results: Patient characteristics and indications for intubation were similar for the 275 intubations in the control (137) and intervention (138) periods. In the intervention vs. control periods, the modified Montpellier protocol was associated with a significant 16.2% [95% CI: 5.1–30.0%] increase in first‐pass intubation success and a 12.6% [95% CI: 1.2–23.6%] reduction in all intubation‐related complications. Conclusion: A simplified version of the Montpellier intubation protocol for intubating ICU patients was associated with an improvement in first‐pass intubation success rates and a reduction in the rate of intubation‐related complications. HighlightsOur modified Montpellier Protocol is readily adapted and easily adhered to in the ICU setting.Our modified Montpellier protocol was associated with a 16.2% [95% CI: 5.1‐30.0%] increase in first‐pass intubation success.Additionally, it was associated with a 12.6% [95% CI: 1.2‐23.6%] reduction in all intubation‐related complications.

Interrater reliability and parallel forms reliability of two noninvasive hemodynamic monitoring devices in clinically stable emergency department patients.

Objective To evaluate the interrater reliability and parallel forms reliability of transcutaneous Doppler ultrasonography (TCDU) and impedance cardiography (ICG) in clinically and hemodynamically stable emergency department patients. Methods We enrolled 30 emergency department patients over a 2-day period. Patients had three consecutive simultaneously blinded measurements of stroke volume (SV) and heart rate (HR) recorded by TCDU (USCOM) and ICG (Cardiodynamics). Two physicians, with basic familiarity but no clinical experience with either device recorded three measurements of SV and HR on each device. Intraclass correlation coefficients (ICC), mixed linear models for repeated measures, and Bland–Altman plots were used to assess interrater reliability and nature of relationships between measures from the devices (parallel forms reliability). Results The ICC for TCDU was 0.96 for HR and 0.95 for SV, whereas the ICC for ICG was 0.93 for HR and 0.98 for SV. The device HR estimates were significantly related (P<0.0001 for all slopes) for all phases, but SV failed to reach significance following the first 50 trials [t(94.2)=2.72, P=0.0077]. Although HR estimates were within reasonable clinical tolerances (bias 0.5%, limits of agreement −15.4 to 16.4%) SV disagreement was concerning (bias 3.8%, limits of agreement −58 to 66%). Conclusion Both TCDU and ICG have fair interrater reliability of SV independent of operator experience. A statistically significant relationship exists between the two devices but this does not produce predictable values in SV. Over time comparative results become less biased but remain limited by a great degree of variability.

308: IVC COLLAPSIBILITY SHOWS PROMISE IN DETECTING FLUID RESPONSIVENESS AMONG CRITICALLY ILL PATIENTS

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) 95% CI, 1.023–1.105; p=0.002), and continuous NMB requirement (HR, 0.636; 95% CI, 0.422–0.957; p=0.030) compared to no NMB were associated with six-month mortality. However, the serum lactate level (p=0.658) and lactate clearance (p=0.440) were not different among NMB groups. Conclusions: Continuous NMB requirement rather than no NMB was associated with six-month survival in cardiac arrest survivors treated with TH. The method of NMB use was not associated with serum lactate level and lactate clearance.

Resuscitative thoracotomy for nontraumatic pericardial tamponade: case reports and review of the literature.

Nontraumatic cardiac tamponade is a life-threatening process, and pericardiocentesis is the established treatment designed to relieve tamponade physiology during a cardiac arrest. We report 2 cases, where after traditional resuscitation including serial pericardiocentesis failed, a resuscitative thoracotomy was performed. Cardiac tamponade is a life-threatening condition that results from an accumulation of fluid, blood, pus, clots, or gas in the pericardial space leading to compression of the heart and limitations in cardiac output [1]. In nontraumatic cases, pericardiocentesis is the established modality of treatment and has been shown to be effective in a majority of patients [2]; however, there are circumstances where the procedure fails to correct tamponade physiology. We present 2 cases of pulseless electrical activity arrest secondary to cardiac tamponade; the first being secondary to an inflammatory effusion and the second to a malignant effusion. The patients were managed with resuscitative thoracotomy after traditional resuscitation using advanced cardiac life support algorithms, and serial pericardiocenteses proved unsuccessful. Case #1: A 58-year-old woman presented to a tertiary, academic emergency department with a chief complaint of dyspnea and generalized weakness. The patient had presented 2 days earlier to the same emergency department with left-sided chest pain and dyspnea but then left against medical advice after a chest x-ray (Fig. 1). On the second presentation, the patient had an initial blood pressure of 127/84 mm Hg, heart rate of 107 beats per minute, respiratory rate of 18 breaths per minute, an oxygen saturation of 99% on room air, and a temperature of 97.4°F. Medical history included paroxysmal atrial fibrillation, hypertension, and a right middle cerebral artery aneurysm repair 8 years prior. On physical examination, the patient appeared to be in no acute distress. Lung fields were clear to auscultation, heart sounds were regular and audible, her abdomen was soft and nontender, and the extremities had no significant edema. Approximately 90 minutes into her emergency department stay, the patient was directly observed by staff to abruptly collapse secondary to a PEA arrest. Chest compressions were initiated; an endotracheal tube was secured; and epinephrine, atropine, calcium, bicarbonate, and normal saline were administered without return of spontaneous circulation (ROSC). The prior chest x-ray obtained before arrest was notable for cardiomegaly (Fig. 1), and an intraarrest bedside echocardiography showed pericardial tamponade. Ultrasound☆ Funding: None. ☆☆ Previously presented: No. ★ Conflicts of interest: All authors have no conflicts of interest. 0735-6757/© 2014 Elsevier Inc. All rights reserved. guided pericardiocentesis was performed using an 18-gauge spinal needle that yielded 20 cm of dark clotted blood. The patient was then noted to be in ventricular fibrillation and was defibrillated; however, the patient did not have return of spontaneous circulation. The code continued, and 4 subsequent pericardiocenteses were performed yielding 5 to 20 cm of blood. In total, approximately 60 cm of fluid was aspirated; however, repeated attempts were limited by clotting, and the patient remained in a PEA arrest with visible cardiac contractility on bedside ultrasound. During the code, a surgical consultation was obtained. An emergent left-sided anterolateral thoracotomywas performed. Upon incision of the pericardium, a large amount of tense bloody fluid was released, and the patient regained cardiac activity and peripheral pulses. Twenty-eight minutes elapsed from initial PEA arrest to completion of the thoracotomy and ROSC. Of significance, the patient was noted to have inflammatory adhesions in the pericardial sack. Upon further exploration in the operating room, the patient was found to have multiple sources of slowly oozing blood without any lesion that required ligation. The patient had a 6-week hospital stay complicated by pneumonia and a prolonged ventilator wean. During the course of her care, her antinuclear antibody returned strongly positive, and the etiology of the tamponade was attributed to systemic lupus erythematous. The patient was discharged to a long-term care facility. Approximately 5 months after initial presentation, the patient had recovered to her baseline state of health and was neurologically intact. Case #2: A 65-year-old woman was admitted to a community, level 2 trauma center with a diagnosis of chest pain. The patient had a medical history that included lymphoma, congestive heart failure, hypothyroidism, and thrombocytopenia. Several hours after admission, the patient had agonal breathing that progressed to a PEA arrest. Cardiopulmonary resuscitation (CPR) was initiated, and the patients airway was secured. During the cardiac arrest, the patient received epinephrine, atropine, calcium, bicarbonate, and a normal saline bolus without return of spontaneous circulation. A simultaneous review of the record noted that a prior computed tomographyof the chest (Fig. 2) showed a large pericardial effusion. Laboratory data revealed awhite blood cell count of 82000 and platelets of 32000. An echocardiogram was immediately obtained which showed a massive pericardial effusion. An ultrasoundguided percardiocentesis with an 18-gauge spinal needle was performed, yielding 50 to 60 cm of serous fluid. Cardiac motion was observed to improve marginally with the fluid removal; however, the patient did not regain pulses. A repeat pericardiocentesis was performed yielding 60 cm of additional fluid. The echo showed no significant reduction in the size of the effusion, and ROSC was not achieved. Fig. 1. A chest x-ray taken 2 years prior and on the day of presentation showing significant cardiomegaly. 600.e6 K.A. Corl et al. / American Journal of Emergency Medicine 33 (2015) 600.e5–600.e7 Given the lack of response to aspiration, an emergent left-sided anterolateral thoracotomy was performed. Upon dissecting through the intracostal muscles, the distended pericardium was incised, as parts of it were adherent to the chest wall. An estimated 500 cm of serosanguineousfluidwas released, and after a brief period of cardiac massage, the patient regained spontaneous circulation. The time elapsed between the initial PEA arrest and completion of thoracotomy was 29 minutes. The cardiothoracic surgeon was consulted, and the patient was further resuscitated with blood transfusions, vasopressors, and normal saline, while the operating team was assembled. Operative exploration showed fibrinousmatter inside the pericardium without active bleeding consistent with a malignant effusion. The patient survived the initial arrest and operation; however, at 48 hours postoperatively, she remained on multiple vasopressors in the cardiothoracic intensive care unit. At this time, resuscitative effortswerewithdrawn per family request, and the patient died. Fig. 2. A computed tomography of the chest showing amassive pericardial effusion on the day of admission. Resuscitative thoracotomy is widely accepted and recommend as a treatment modality for patients with penetrating and, under some circumstances, blunt traumatic arrest [3]. A large meta-analysis reviewing 25 years of trauma datawith 4620 patients showed a combined survival rate of 7.4%. Among the subset, where the location of major injury was cardiac, the rate increases to 19.4% [4]. Open chest cardiac massage was a common and accepted practice for nontraumatic arrest during the first half of the 20th century [5]. In 1953, Stephenson et al [6] presented a case series of 1200 arrests managed with open chest cardiac massage; 28% of the patients survived to discharge with a favorable neurologic outcome. The practice became less popular in 1960 when Jude et al [7] showed that closed chest compressions were an effective alternative. Since this time, the research has been limited to a handful of clinical trials, case reports, and animal models. Research in canine models provides the most substantial supportive evidence for the use of open chest CPR (OCCPR). Bircher et al [8] showed that when the dogs received 30 minutes of OCCPR before defibrillation, nearly all survived with a favorable neurologic outcome, compared with standard CPR, where nearly all died or had a poor neurologic outcome. Because OCCPR is a deviation from what is currently accepted to be standard care, most human studies are limited to patients who have failed standard CPR or have had prolonged resuscitations. A clear criticism of this data is that the opportunity to intervene when the physiologic conditions may be amenable to OCCPR is missed. This was substantiated in a canine study that showed if OCCPR was initiated within the first 20 minutes of untreated ventricular fibrillation, all animals were resuscitated, compared with poor long-term survival in a 20 to 40-minute window and 100% mortality after 40 minutes [9]. Contemporary data from human clinical trials are limited. A 1995 study that enrolled 10 patients who failed standard CPR (average arrest time, 54 minutes) showed that the mean coronary perfusion pressures were 4.5 times higher in patients receiving OCCPR [10]. Notably, this study had 3 OCCPR survivors who were initially considered to be unsalvageable. A subsequent study underscored the limitations of using OCCPR as a rescue therapy, where there was 100% mortality associated with prolonged delays in initiation of the resuscitative efforts [11]. More recently, there are case reports documenting successful resuscitative thoracotomies for medical arrests, all secondary to cardiac tamponade physiology. One report documents a patient who 24 days after admission to a trauma service developed constrictive pericarditis leading to a PEA arrest who regained ROSC with 600.e7 K.A. Corl et al. / American Journal of Emergency Medicine 33 (2015) 600.e5–600.e7 thoracotomy after pericardiocentes