Michael T. McCurdy

Angiotensin II for the Treatment of Vasodilatory Shock

Background Vasodilatory shock that does not respond to high‐dose vasopressors is associated with high mortality. We investigated the effectiveness of angiotensin II for the treatment of patients with this condition. Methods We randomly assigned patients with vasodilatory shock who were receiving more than 0.2 μg of norepinephrine per kilogram of body weight per minute or the equivalent dose of another vasopressor to receive infusions of either angiotensin II or placebo. The primary end point was a response with respect to mean arterial pressure at hour 3 after the start of infusion, with response defined as an increase from baseline of at least 10 mm Hg or an increase to at least 75 mm Hg, without an increase in the dose of background vasopressors. Results A total of 344 patients were assigned to one of the two regimens; 321 received a study intervention (163 received angiotensin II, and 158 received placebo) and were included in the analysis. The primary end point was reached by more patients in the angiotensin II group (114 of 163 patients, 69.9%) than in the placebo group (37 of 158 patients, 23.4%) (odds ratio, 7.95; 95% confidence interval [CI], 4.76 to 13.3; P<0.001). At 48 hours, the mean improvement in the cardiovascular Sequential Organ Failure Assessment (SOFA) score (scores range from 0 to 4, with higher scores indicating more severe dysfunction) was greater in the angiotensin II group than in the placebo group (‐1.75 vs. ‐1.28, P=0.01). Serious adverse events were reported in 60.7% of the patients in the angiotensin II group and in 67.1% in the placebo group. Death by day 28 occurred in 75 of 163 patients (46%) in the angiotensin II group and in 85 of 158 patients (54%) in the placebo group (hazard ratio, 0.78; 95% CI, 0.57 to 1.07; P=0.12). Conclusions Angiotensin II effectively increased blood pressure in patients with vasodilatory shock that did not respond to high doses of conventional vasopressors. (Funded by La Jolla Pharmaceutical Company; ATHOS‐3 ClinicalTrials.gov number, NCT02338843.)

Learned helplessness among families and surrogate decision-makers of patients admitted to medical, surgical, and trauma ICUs

BACKGROUND We sought to determine the prevalence of and clinical variables associated with learned helplessness, a psychologic state characterized by reduced motivation, difficulty in determining causality, and depression, in family members of patients admitted to ICUs. METHODS We conducted an observational survey study of a prospectively defined cohort of family members, spouses, and partners of patients admitted to surgical, medical, and trauma ICUs at a large academic medical center. Two validated instruments, the Learned Helplessness Scale and the Perceived Stress Scale, were used, and self-report of patient clinical characteristics and subject demographics were collected. RESULTS Four hundred ninety-nine family members were assessed. Of these, 238 of 460 (51.7%) had responses consistent with a significant degree of learned helplessness. Among surrogate decision-makers, this proportion was 50% (92 of 184). Characteristics associated with significant learned helplessness included grade or high school education (OR, 3.27; 95% CI, 1.29-8.27; P = .01) and Perceived Stress Scale score > 18 (OR, 4.15; 95% CI, 2.65-6.50; P < .001). The presence of a patient advance directive or do not resuscitate (DNR) order was associated with reduced odds of significant learned helplessness (OR, 0.56; 95% CI, 0.32-0.98; P = .05). CONCLUSIONS The majority of family members of patients in the ICU experience significant learned helplessness. Risk factors for learned helplessness include lower educational levels, absence of an advance directive or DNR order, and higher stress levels among family members. Significant learned helplessness in family members may have negative implications in the collaborative decision-making process.

The Use of Therapeutic Hypothermia After Cardiac Arrest in a Pregnant Patient

Therapeutic hypothermia is an effective intervention for the postresuscitative care of patients who have sustained a cardiac arrest. There has been only 1 documented case of successful resuscitation of a pregnant patient and fetus with therapeutic hypothermia, with an abbreviated developmental follow-up of the child. A 33-year-old woman in her 20th week of pregnancy presented to our emergency department after experiencing a cardiac arrest. After successful resuscitation and a discussion with a multidisciplinary team about expected outcomes, the mother and fetus were successfully treated with therapeutic hypothermia, and a healthy baby was delivered 19 weeks later. The mothers cardiac and neurologic function was normal 36 months after the arrest, and the child has reached all growth and neurodevelopmental milestones. We present a case demonstrating excellent immediate and long-term maternal-fetal neurologic, cardiac, and developmental outcomes after the use of therapeutic hypothermia after cardiac arrest in a pregnant patient.

Monitoring the Critically Ill Emergency Department Patient

Many critically ill patients are remaining in the emergency department for extended periods of time, and delays in diagnosis and/or therapy may increase patient morbidity and mortality. All emergency physicians use monitoring modalities in critically ill patients to detect early cardiovascular compromise and impaired oxygen delivery before disastrous collapse occurs. The authors hope the discussion in this article regarding the monitoring of oxygenation, ventilation, arterial perfusion pressure, intravascular volume, markers of tissue hypoxia, and cardiac output will help the EP provide optimal care for this complicated patient population.

Calcium, Magnesium, and Phosphate Abnormalities in the Emergency Department

Derangements of calcium, magnesium, and phosphate are associated with increased morbidity and mortality. These minerals have vital roles in the cellular physiology of the neuromuscular and cardiovascular systems. This article describes the pathophysiology of these mineral disorders. It aims to provide the emergency practitioner with an overview of the diagnosis and management of these disorders.

Alcoholic Metabolic Emergencies

Ethanol intoxication and ethanol use are associated with a variety of metabolic derangements encountered in the Emergency Department. In this article, the authors discuss alcohol intoxication and its treatment, dispel the myth that alcohol intoxication is associated with hypoglycemia, comment on electrolyte derangements and their management, review alcoholic ketoacidosis, and end with a section on alcoholic encephalopathy.

Sepsis in Haiti: Prevalence, treatment, and outcomes in a Port-au-Prince referral hospital

Purpose: Developing countries carry the greatest burden of sepsis, yet few descriptive data exist from the Western Hemisphere. We conducted a retrospective cohort study to elucidate the presentation, treatment, and outcomes of sepsis at an urban referral hospital in Port‐au‐Prince, Haiti. Materials and methods: We studied all adult emergency department patient encounters from January through March 2012. We characterized presentation, management, and outcomes using univariable and multivariable analyses. Results: Of 1078 adult patients, 224 (20.8%) had sepsis and 99 (9.2%) had severe sepsis. In‐hospital mortality for severe sepsis was 24.2%. Encephalopathy was a predictor of intravenous fluid administration (adjusted odds ratio [OR], 5.63; 95% confidence interval [CI], 1.46‐21.76; P = .01), and lower blood pressures predicted shorter time to fluid administration. Increasing temperature and lower blood pressures predicted antibiotic administration. Encephalopathy at presentation (adjusted OR, 6.92; 95% CI, 1.94‐24.64; P = .003), oxygen administration (adjusted OR, 15.96; 95% CI, 3.05‐83.59; P = .001), and stool microscopy (adjusted OR, 45.84; 95% CI, 1.43‐1469.34; P = .03) predicted death in severe sepsis patients. Conclusions: This is the first descriptive study of sepsis in Haiti. Our findings contribute to the knowledge base of global sepsis and reveal similarities in independent predictors of mortality between high‐ and low‐income countries.

Ultrasound images transmitted via FaceTime are non-inferior to images on the ultrasound machine

PURPOSE Remote telementored ultrasound (RTMUS) systems can deliver ultrasound (US) expertise to regions lacking highly trained bedside ultrasonographers and US interpreters. To date, no studies have evaluated the quality and clinical utility of US images transmitted using commercially available RTMUS systems. METHODS This prospective pilot evaluated the quality of US images (right internal jugular vein, lung apices and bases, cardiac subxiphoid view, bladder) obtained using a commercially available iPad operating FaceTime software. A bedside non-physician obtained images and a tele-intensivist interpreted them. All US screen images were simultaneously saved on the US machine and captured via a FaceTime screen shot. The tele-intensivist and an independent US expert rated image quality and utility in guiding clinical decisions. RESULTS The tele-intensivist rated FaceTime images as high quality (90% [69/77]) and could comfortably make clinical decisions using these images (96% [74/77]). Image quality did not differ between FaceTime and US images (97% (75/77). Strong inter-rater reliability existed between tele-intensivist and US expert evaluations (Spearmans rho 0.43; P<.001). CONCLUSION An RTMUS system using commercially available two-way audiovisual technology can transmit US images without quality degradation. For most anatomic sites assessed, US images acquired using FaceTime are not inferior to those obtained directly with the US machine.

Rapid Response Systems: Identification and Management of the “Prearrest State”

Rapid response systems (RRS) are both intuitive and supported by data, but the institution of an RRS is not a panacea for in-hospital cardiac arrest or unexpected deaths. RRS implementation should be one component of an institution-wide effort to improve patient safety that includes adequate nursing education and staffing, availability and involvement of a patients primary caregivers, and hospital provision of sufficient resources and efficiency.

Mortality and ratio of blood products used in patients with severe trauma.

Mortality and Ratio of Blood Products Used in Patients With Severe Trauma To the Editor Dr Holcomb and the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) study collaborative1 completed a multicenter randomized trial with the hypothesis that a 1:1:1 ratio for units of plasma and platelets to red blood cells (RBCs) would be superior to a 1:1:2 ratio. These investigators did not find a survival advantage in their primary outcomes of 24-hour and 30-day mortality, achieving greater than 95% power to detect a 10% mortality reduction. Survival was an objective end point, whereas the secondary end points of hemostatic control and death attributed to exsanguination were subjective and vulnerable to observer bias by the unblinded treating surgeon. For example, in Table 3 in the article, the 1:1:1 group had 31 exsanguination deaths during the first 24 hours and 5 deaths after 24 hours. However, in the 1:1:2 group, all 50 exsanguination deaths occurred within the first 24 hours and none after 24 hours. These values are difficult to reconcile because the 1:1:1 cohort reportedly had superior hemostasis and delayed deaths from bleeding, whereas the 1:1:2 group did not. Resuscitation with fixed ratios of blood products has been associated with worse outcomes compared with goaldirected resuscitation.2 The likely mechanistic explanation is that patients with trauma manifest a spectrum of coagulation abnormalities following injury3 to which a ratio approach does not adapt. Goal-directed hemostatic resuscitation allows tailoring of transfusions to the dynamic changes in hemostasis occurring between different patients and within the same patient during the course of resuscitation, guided by results obtained within minutes.4 Thrombelastography has been previously reported to be the optimal tool to predict transfusion requirements in patients with trauma.5 Only the R value for thrombelastography was reported in this article despite the other variables (angle, MA, LY30) being recognized as reliable predictors of transfusion requirements and death. It would be instructive to see these additional thrombelastography variables at enrollment and examine the effect of the resuscitation strategies on these measures of hemostatic capacity over time. In contrast to the authors’ conclusion, we suggest that a 1:1:2 ratio, which uses less blood product, may be the preferred strategy from a health care resource use perspective. With mounting evidence that patients with trauma have different phenotypes of coagulation abnormalities, personalizing resuscitation strategies over a formulaic fixed ratio approach warrants prospective evaluation.