Critical Care in the Emergency Department

Transcription

1 Critical Care in the Emergency Department Jenny Wilson MD, MS May 29, 2014 Disclosures No conflicts to disclose Overview ED critical care by the numbers Scope of practice Collaborations Current controversies New directions ED Critical Care By The Numbers 1

2 What percentage of ICU patients are admitted from the ED? A % B % C % Median ED LOS for Critically Ill? A. <1 hr B. 1-2 hrs C. 2-3 hrs D. 3+ hrs Lilly CM, Zuckerman IH, Badawi O, et al. Benchmark data from more than 240,000 adults that reflect the current practice of critical care in the United States. Chest. 2011; 140: Herring AA, Ginde AA, Fahimi J et al. Increasing Critical Care Admissions from US Emergency Departments, Crit Care Med 2013;41: What the ED can do for you... Scope of Practice Resuscitate the undifferentiated critically ill patient --lines, tubes, electricity, fluid, blood Diagnose life-threatening conditions --e.g. stroke, MI, CHF, dissection, bleeding, acute abdomen, sepsis Initiate critical treatment early --e.g. TPA, ASA, heparin, afterload reduction, antibiotics Triage to appropriate service/unit Begin communication with family 2

3 What the ED (Often) Can t Do Focus 100% of resources on one patient for extended periods Individualize initial work-up and treatment for all critically ill patients Establish longitudinal therapeutic relationships Which Patient Do You See First? A. 2 week old infant with fever and lethargy B. 82 yo woman in Afib with BP of 85/60 C. 42 yo man with sore throat, hot potato voice, and pooling secretions 3

4 Collaborative Care Collaborations Trauma --Regionalization, ATLS ACS --STEMI centers, protocols to minimize DTB time Stroke --Stroke centers, EM/rad/neuro collaboration Sepsis --Protocols/bundles Post-Arrest Care --Cardiac Arrest Centers, targeted temperature management, invasive monitoring, etc. Controversies Controversies Prehospital airway management Ambulance diversion Limits of focused cardiac ultrasound Epinephrine/early defib in cardiac arrest Bypassing ED for cath lab activation Target temperature in post-arrest patients Sepsis care since ProCESS Antifibrinolytic agents and transfusion ratios in trauma 4

5 Hasegawa K, Hiraide A, Chang Y, Brown DF. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-ofhospital cardiac arrest. JAMA Jan 16;309(3): Shen YC and Hsia RY. Association between ambulance diversion and survival among patients with acute myocardial infarction. JAMA Jun 15;305(23):

6 New Directions New Directions ED ECMO Novel decision rules, clinical scoring systems, and biomarkers The ED ICU Sakamoto T et al. Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: A prospective observational study Resuscitation 85 (2014)

7 Goto Y, Maeda T, Goto YN. Termination-of-resuscitation rule for emergency department physicians treating out-of-hospital cardiac arrest patients: an observational cohort study. Crit Care Oct 13;17(5):R235. ED-Critical Care Pathways References 1. Bellezo JM, Shinar Z, Davis DP et al. Emergency Physician-Initiated Extracorporeal Cardiopulmonary Resuscitation. Resuscitation 2012;83: Callaway CW. Epinephrine for cardiac arrest. Curr Opin Cardiol Jan;28(1): Cha WC, Lee SC, Shin SD, et al. Regionalisation of out-of-hospital cardiac arrest care for patients without prehospital return of spontaneous circulation. Resuscitation Nov;83(11): doi: /j.resuscitation Epub 2012 Mar Goto Y, Maeda T, Goto YN. Termination-of-resuscitation rule for emergency department physicians treating out-of-hospital cardiac arrest patients: an observational cohort study. Crit Care Oct 13;17(5):R Hasegawa K, Hiraide A, Chang Y, Brown DF. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest. JAMA Jan 16;309(3): Herring AA, Ginde AA, Fahimi J et al. Increasing Critical Care Admissions from US Emergency Departments, Crit Care Med 2013;41: Shen YC and Hsia RY. Association between ambulance diversion and survival among patients with acute myocardial infarction. JAMA Jun 15;305(23): Lilly CM, Zuckerman IH, Badawi O, et al. Benchmark data from more than 240,000 adults that reflect the current practice of critical care in the United States. Chest. 2011; 140: Sakamoto T et al. Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: A prospective observational study Resuscitation 85 (2014) Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma Dec;71(6): Weingart SD, Sherwin RL, Emlet LL et al. ED Intensivists and ED intensive care units. American Journal of Emergency Medicine 31 (2013)