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1 Robert M. Rodriguez, MD FAAEM Clinical Professor of Medicine and Emergency Medicine, UCSF No conflicts of interest Major Points Most ICU patients start in ED Chain of critical care starting in field and ED Cases: Illustrate translation of critical care to ED Collaborate, develop protocols (define roles), communicate early and often LIKE TRAUMA Critical care starts in ED Most ICU patients come from ED (58% of MICU) Trauma--ALL Acute MI nearly all Stroke nearly all Sepsis (70% start in ED) Respiratory failure CHF GI bleed 1

2 Roles of ED for Critically Ill Diagnose quickly Resuscitate and stabilize Critical early interventions Triage to appropriate service/unit Communicate with intensivists and others Begin family communication Case 1 72 yo female with cough, SOB, fever Has history of CHF Hypotensive 76/48; Temp 40 C; HR 120 Multi-lobar pneumonia Still hypoxic on 100% Etomidate for sepsis intubation 2 independent meta-analyses Both show with single dose etomidate Increased adrenal insufficiency and Increased mortality Bottom line: We have alternatives (ketamine) so use them. Non-ARDS: Still use low tidal volume Meta-analyis of 20 studies non ARDS Lower mortality Lower incidence of lung injury If hypoxic--avoid excessive PEEP USE GRAVITY---GOOD LUNG DOWN! 2

3 Should you paralyze? Concerns of prolonged weakness/paralysis stuck on vent NEJM (Sep 2010) RCT double blind Within 48 hours onset Better 90 day survival Increase time of survival No increase weakness Early fluids when hypoxic: ED Early fluid resuscitation (save the kidneys) Shock mortality correlates with renal failure EGDT (early fluids rather than later) Don t worry about volume overload WHEN IN SHOCK Later fluids in ICU (save the lung) Established ARDS conservative fluid better Less time on vent Fewer ICU days No change in organ failure Only when no longer shock What type of fluids? Crytstalloid Colloid does not work with possibly 1 exception Bicarb not helpful even in extreme acidosis 3

4 Which crystalloid? Sequential trial of ICU patients NS vs low chloride (Lactated Hartmann s, plasmalyte) NS had more AKI, more renal replacement therapy Bottom line not definitive, but would switch to LR after 2 liters of NS Ultrasound in critically ill ED patients CVP limited utility IVC diameter instead of pulse pressure variation Contractility of heart Improves confidence Changes treatment plans Early Appropriate Antibiotics 1 hour in septic shock Broad is better in ED Prepared regimens Cover MRSA! Vasopressors When do you start pressor? ANYTIME don t have to wait for full tank Quick burst: ephedrine or phenylephrine 4

5 Bottom line: Pressors in Sepsis Prob should use NE Dopa greater mortality and more dysrhythmias Look at HR If low HR, might use dopamine If high HR or any dysrhythmias use NE Add vasopressin if refractory shock (fixed dose) No clear mortality benefit Lower NE dose Early Goal Directed Therapy without Catheters 3 rd goal in EGDT = ScvO2 > 70 Traditional--catheter to measure serial ScvO2 Catheters are expensive and not widely available Lactate for EGDT Lactate is best perfusion marker in sepsis Serial lactates equivalent to ScVO2 Clearance of 10% lactate Send every 2 hours Peripheral venous is fine Case 2 60 yo F COPD C/O cough, SOB T 37, P 120, RR 30 labored, BP 100/70, Sat 80 Chest wheeze, little air movement Awake, 2 word sentences ABG /70/70 5

6 BiPAP Early rather than late Better for COPD than asthma Not so good for pneumonia How to make BiPAP work If no improvement post 20 min won t work Sit there with them Adjust straps Don t give too much oxygen Adjust I and E appropriately Sedatives can help Fentanyl KETAMINE When to intubate COPD Gases not very helpful Mental status Respiratory effort Post-intubation care Watch for hypotension push fluids/phenylephrine No nasal tubes HOB at 30 Oral gastric tube GI prophylaxis Give sedative, esp if used rocuronium 6

7 Case 3 68 yo male VF arrest in the field Paramedics on scene Cardiac Arrest--Compressions Focus on compressions not intubation Prehospital intubation attempt assoc w poorer outcomes Avoid peri-shock pauses of compression Cardiac Arrest When Check Rhythm Early vs later rhythm analysis After seconds CPR vs after 180 seconds No outcome difference Cardiac Arrest- Access INTRA-OSSEOUS Rapidly becoming emergent access of choice Pre-tibial is best Highest first attempt success Fastest time to success 7

8 Achieved ROSC Intubated Considering hypothermia vent settings Hyperoxia after Cardiac Arrest Is too much supplemental oxygen bad postarrest? Post-arrest: oxidant stress leads to increased cell death Experimental models of hyperoxia Worse oxidative stress Worse neuro outcomes Hyperoxia Adults post-medical arrest Hyperoxia highest mortality (63%) Hypoxia (57%) Normoxia (45%) Survivors significantly lower independent function with hyperoxia (29% vs 38%) Odds ratio poor outcome 1.8 for hyperoxia Bottom Line FiO2 No reason to give too much Titrate down using pulse oxymetry to sat 95% 8

9 ICU/ER: Team Approach Treat sepsis and other medical ICU like trauma Protocols Team approach Improve ED interface with ICU collaborate Continuity of care--smoother transition Develop multidisciplinary teams Develop protocols for early recognition and therapy Sepsis team Stroke team Cardiac arrest team Remember that ED is operating under different conditions limited information and often no prep time. EM Critical Care Certification Many years no pathway except through other specialties (EM/IM) Recent agreement to allow certification through IM Must complete IM approved critical care fellowship (2 years) 9