POTD- EFAST

What:

Extended Focused assessment with sonography in trauma

Trauma evaluation for blunt or penetrating chest/abdomen/back/pelvic trauma as well as in the evaluation of the unexplained hypotensive patient as part of the RUSH protocol and the patient with a possible ruptured ectopic pregnancy.

Why:

FAST has 82% sensitivity and 99% specificity for blunt intraabdominal injury in adult patients

When:

·      Usually performed as a part of the primary survey but that is not an absolute.

·      Use your clinical judgement to decide whether the FAST should performed during the primary survey or secondary survey.

·      For example, if patient had a penetrating trauma to the extremity, secondary survey might be more important and urgent than performing an EFAST.

Who:

Adults and Pediatric patients with blunt or penetrating trauma

How:

Your patient should be kept supine to increase your accuracy
Sequence of EFAST

1.     Subxiphoid

2.     RUQ/ R thorax

3.     LUQ/ L thorax

4.     Pelvic

5.     Anterior Lung view bilaterally

Subxiphoid first

·      Traumatic cardiac tamponade/pericardial effusion is the first thing you want to rule out. Acute accumulation for a very small amount of fluid can put the patient in severe obstructive shock and cause cardiopulmonary collapse so make sure to rule that out first

·      Increase the depth and go to the RUQ

·      Next, RUQ- Why? It is the most sensitive location for identification of free fluid in the abdomen because the posterior peritoneum attaches in such a way that free fluid from any injury anywhere will travel to the right upper quadrant in a supine patient

·      Place probe on the Horizontal Subxiphoid line with the marker towards patient head in the Mid Axially line

·      The RUQ  can be divided into 3 zones.

o   Above/Below the diaphragm

o   Morrison’s pouch (hepato-renal recess)

o   Paracolic gutter: Around the inferior hepatic edge/inferior pole of kidney

·      Evaluate above the diaphragm to evaluate for intrathoracic free fluid

·      Evaluate below the diaphragm to evaluate for intraperitoneal fluid

·      Evaluate between the liver and the entire superior pole of the kidney – Morrisons Pouch view. Make sure you visualize the liver tip- It is the most sensitive area for free fluid on the FAST Exam;

·      Evaluate between the left edge of the liver and the entire inferior pole of the kidney.

·      Move on to the LUQ next; The LUQ can also be divided into 3 zones:

o   Above/Below the diaphragm,

o   Spleno-Renal recess

o   3. Paracolic gutter: Around the inferior pole of kidney

·      The only difference between the RUQ and LUQ here is that you should place your probe at the posterior axillary line on the left, instead of midaxillary line of the right. Have your “knuckles on the gurney”.

·      Beware of the stomach Sabotage ??

·      Evaluate above the diaphragm to evaluate for intrathoracic free fluid like the RUQ

·      Evaluate below the diaphragto evaluate for intraperitoneal fluid. This is where free intraperitoneal fluid will usually develop first in the left upper quadrant (LUQ) (different from the RUQ where the first area of free fluid is usually around the inferior pole of the kidney and right paracolic gutter).

Pelvic View

·      Make sure you obtain the pelvic view before the RN places the foley because you will loose the acoustic window that the bladder provides

·      Always obtain a longitudinal and Transverse view

·       Rectovesical pouch (male patients)

·       Rectouterine / pouch of Douglas in female patients

·       Do not be fooled by the seminal vesicles in males  

Remember

·      New blood is anechoic (black).

·      Ascites is anechoic (impossible to differentiate.

·      Clotted blood is echogenic (shades of gray)

Limitations

·      Not a diagnostic test but a screening tool

·      Injuries that do not cause free fluid

·      Injuries causing retroperitoneal free fluid

·      Injuries that cause <300 cc intraperitoneal free fluid (the lower the fluid amount the more likely to miss)

·      Injuries causing free fluid where the FAST scan is done too early in free fluid accumulation, and, therefore, will not detect it

·      Lower sensitivity in kids about 60-85%. Specificity 90-99%

References:

Dr Eitan Dickman

EmCrit

SonoSpot

Rozycki, Grace S., et al. "Early detection of hemoperitoneum by ultrasound examination of the right upper quadrant: a multicenter study." Journal of Trauma and Acute Care Surgery 45.5 (1998): 878-883.

Shokoohi, Hamid, Keith S. Boniface, and Audra Siegel. "Horizontal subxiphoid landmark optimizes probe placement during the Focused Assessment with Sonography for Trauma ultrasound exam." European Journal of Emergency Medicine 19.5 (2012): 333-337.

Targeted Temperature Management

Great job on resuscitating that V fib cardiac arrest and achieving sustained ROSC. 

Now what? Cool them!

Whether you cool them or not could determine whether your patient goes into multisystem organ failure in the ICU or walks out of the hospital few weeks later.

What:

Targeted temperature management (TTM) to improve survival and neurological outcomes among comatose survivors of patients with cardiac arrest

Who:

Adults with out-of-hospital cardiac arrest with an initial shockable rhythm and nonshockable rhythm

Inclusion criteria (must meet all criteria)

• Postcardiac arrest status (any rhythm as a cause of arrest is eligible)

• ROSC < 30 minutes from EMS/code team arrival

• Time at induction < 6 hours from ROSC

• Comatose status (patient does not follow commands)

• MAP ≥ 65 mm Hg (may include use of vasopressor drugs)

Exclusions may include

• DNR advanced directive, MOLST, poor baseline status, or terminal disease

• Traumatic etiology for the arrest

• Active bleeding or known intracranial bleeding (relative)

• Cryoglobulinemia (relative)

• Pregnancy (relative; consider obstetrician/gynecologist consultation)

• Recent major surgical procedure (relative)

• Severe sepsis/septic shock as cause of arrest (relative)

Why:

• Decreased fever-related tissue injury

• Reduction in ischemic-reperfusion injury

• Cerebral metabolic rate decreases by a 6-7% for every 1ºC drop in body temperature which reducing oxygen demand, preserving phosphate compounds and preventing lactate production and acidosis

• Bernard, et al (2002) found an Absolute Risk Reduction (ARR) for death or severe disability of 23%, NNT was 4.5

• The Hypothermia After Cardiac Arrest (HACA) Group (2002) found an ARR for unfavourable neurological outcome of 24%, and NNT of 4

How:

• IV cold saline 2-3 mL/kg

• Cooling vest and cooling machine- Arctic Sun

• If shivering does not occur, do not use neuromuscular blockade

• If paralysis employed, titrate to degree of shivering- do not need train-of-four monitoring

• Sedation of choice is institution dependent (MMC CICU uses Fentanyl and Midazolam)

When:

Initiation of TTM within122 minutesof hospital admission was associated with improved survival.
Most guidelines recommend initiation within6 hours

What temperature should be targeted:

This remains controversial, with guidelines accepting a range of temperature targets from 33-36C. Available evidence shows no benefit to hypothermia (33C) compared to normothermia (36C). In the absence of evidence, targeting 36C is prudent

• TTM36 is more hemodynamically stable than TTM33, which is relevant because these are often very unstable patients.

• TTM36 avoids electrolytic shifts associated with raising and lowering the temperature.

• Hypothermia at 33C suppresses immune function and associates with increased rates of pneumonia.

• TM33 will induce bradycardia, which is dangerous in patients with underlying torsades de pointes.

References

Bernard SA et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557-63. PMID 11856794

Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346:549-56. PMID 11856793

Nielsen N et al. Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest. N Engl J Med 2013; 369: 2197-206. PMID 24237006

Stanger, Dylan, et al. "Door‐to‐targeted temperature management initiation time and outcomes in out‐of‐hospital cardiac arrest: insights from the Continuous Chest Compressions Trial." Journal of the American Heart Association 8.9 (2019): e012001.

Donnino, Michael W., et al. "Temperature management after cardiac arrest: an advisory statement by the advanced life support task force of the international liaison committee on resuscitation and the American Heart Association emergency cardiovascular care committee and the council on cardiopulmonary, critical care, Perioperative and Resuscitation." Circulation 132.25 (2015): 2448-2456.

REBEL EM
LITFL
EB Medicine
Mayo Clinic Florida TTM Guideline

Status Epilepticus

Status Epilepticus

Background

• Definition

  • >5 min of seizure activity without response to treatment // recurrent seizure without return to baseline mental status

• mortality is 22%

• can be convulsive or non-convulsive (tricky)

  • non-convulsive can be change in behavior/complete loss of consciousness with signs such as twitching/blinking/eye deviation

  • eeg shows continuous epileptiform discharges

• get a fingerstick/BGM

• ABCs

  • try to place in left lateral decubitus position (can aspirate)

  • place a NC/NRB/LMA early

    1. intubate if benzos are not breaking the seizure

       • this is obviously at the discretion of the team, best to consider all circumstances…intubate if you need to

       • standard RSI is fine but if at all possible, then try to use induction agent only

         • paralytic can mask seizures and put them in non-convulsive state

           • if must use, then succ is quicker on/off

  • IV line for meds (IO/IM/IN if desperate)

Treatment

• First line: Benzos

  • Not controversial, should be first line

  • Versed

    1. If no IV, then give versed IM or IN

  • Ativan

  • Valium

  • Try to use weight based dosing the way we do in peds

  • *if no response after 4 min, give another dose

• Second line: depends

  • Traditionally:

    • Phenytoin 20 mg/kg IV

    • Fosphenytoin 20-30 mg/kg IV (/IM)

    • Keppra 40 mg/kg IV (max 4.5g)

  • BUT, consider anesthetic instead

    • Propofol 1.5-2mg/kg IV

      • followed by 20-200mcg/kg/min drip

      • can add Ketamine 1mg/kg IV to propofol

    • Phenobarb 15-20 mg/kg over 10 min

      • followed by 5-10mg/kg after 10 min

      • followed by .5-4mg/kg/hr drip

      • May not be as readily available as propofol/ketamine is in your ED

    • **still hang the phenytoin/keppra even though you’re giving them an anesthetic, will need long term anticonvulsant on board anyway

• Eclampsia

  • give 4g magnesium IV

**management slightly different in peds 

Find the cause

• infectious

• eclampsia

• INH

  • Give pyridoxine (1g for every 1g of INH taken….or can just give the max of 5g empirically)

• Hyponatremia

  • 3% NaCl 2ml/kg q 10 min

    1. if in a pinch, then give amp of bicarb (consists of 6% NaCl) which will always be available somewhere in a code cart

• Alcohol withdrawal

  • High dose benzos, but also consider propofol/phenobarb if need to

• Drugs

• Metabolic

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