Major Points. The ED-ICU Interface. Chain of Survival. It usually starts here

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1 Major Points The ED-ICU Interface Robert M. Rodriguez, MD FAAEM Most ICU patients start in ED Chain of critical care starting in field and ED Collaborate, develop protocols (define roles), communicate early and often LIKE TRAUMA Important early interventions in ED New developments in ED resuscitation Stabilize before transfer to ICU It usually starts here Chain of Survival 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

2 Roles of ED for Critically Ill Diagnose quickly ED WORKING WITH LESS TIME AND INFORMATION! Resuscitate and stabilize Begin treatments Triage to appropriate unit Communicate with intensivists and others Begin family communication Cardiac Arrest-- Compressions Cardiac Arrest When Check Rhythm Focus on compressions Prehospital intubation attempt assoc w poorer outcomes Avoid peri-shock pauses of compression Early vs Late Rhythm analysis After seconds CPR vs after 180 seconds No outcome difference

3 Cardiac Arrest- Access INTRA-OSSEOUS Rapidly becoming emergent access of choice Pre-tibial is best In cardiac arrest Highest first attempt success Fastest time to success Cardiac Arrest: Termination of Resuscitation Several rules to stop resuscitation and avoid transport Basic Life Support Rule performed best 1) No return of spontaneous circulation prior to transport 2) No shock given (not V-fib) 3) Arrest not witnessed 100% sensitivity (CI: %) and 100% NPV Avoid transport in 52% of patients Hypothermia postresuscitation Clearly beneficial with resusc post VF Unclear whether helps in PEA/other arrest Coordinate with ICU Neuro/Cardiology Protocol-driven?Ideal timing Acute Coronary Syndrome Door to balloon time correlates with infarct size and survival Now pushing envelope to make decisions in the field (EMS recognize ST elevation and transport to hospital with cath lab) Immediate ED interventions Aspirin Recognize ST elevation Stabilize hemodynamics Treat pain

4 CHF interventions Intensive nitrate therapy Sublinguals IV CPAP or BiPAP ACE inhibitors Surviving Sepsis Campaign: ED Bundle first 6 hours Recognition Early triage--risk stratify patients Lactate levels Start therapies Antibiotics prepared regimens Early goal directed therapy Aggressive fluids Source control Early Detection of Sepsis LACTATE Use triage protocols and instruments can t use APACHE MPM OK for ED but not commonly used MEDs Score for General Sepsis Sepsis triage-meds score + lactate levels Lactate levels: cutoff of 4 for EGDT MEDS: Prospective ED cohort of adults w/ blood cultures sent from ED--mortality prediction rule Major Factors Tachypnea, hypoxia, AMS, shock Thrombocytopenia, Bands > 5% Terminal CA, Nursing Home Pneumonia

5 Early Goal Directed Therapy Sepsis Pathways Did not work in ICU in general Rivers--ICU too late NNT = 6 Being re-examined on larger scale (multi-center) Coordinated Pathways of early empiric Abx, EGDT, +/- hydrocortisone, lung protective ventilation Start pathway in ED Involve team with ICU Improvements in mortality Updates lactate clearance Pneumonia-Triage Generally aimed at differentiating 2 groups: The Really Sick: High mortality Need for ICU care or mechanical ventilation. The Not Sick: Can be safely discharged home on oral therapy. CURB 65 just as good as more complicated Pneumonia Severity Index Severe Community Acquired Pneumonia (SCAP) CURB 65 Confusion Uremia (BUN > 19) Respiratory rate > 30 Blood Pressure < 90 Age > 65 PROBABLY CAN NOW GET RID OF THE U

6 Appropriate Antibiotics Broad is better in ED Prepared regimens Cover MRSA Respiratory Failure: ED Measures Asthma/COPD Intensive interventions start in ED to prevent intubation Continuous nebs BiPAP Mag and Heliox? Also starting BiPAP in the field (EMS) ED--Acute Stroke Centered around diagnosing strokes amenable to intervention Stroke teams/activation Rapid CT and NIH stroke scale exam EMS recognize stroke in field to transport to stroke center GI Bleeding: ED role Diagnose upper versus lower and severity Resuscitate Correct coagulopathy Involve ICU and gastroenterologists early Early intubation for severe, esp varices GI bleed cocktail: somatostatin, PPI, antibiotics

7 Develop multidisciplinary teams Improve ED interface with ICU--collaborate Treat other critical illness like trauma Develop protocols for early recognition and therapy Trauma Very well established ED-critical care team Golden hour Resuscitate Diagnose Initiate treatments Collaboration to make transition smooth Define team roles FAST exam ED Trauma Decision rules: NEXUS C spine Coordinated efforts: Intubation Massive transfusion protocols Fracture stabilization Relief of tension PTX, tamponade Stabilize before transfer ED is like an ICU Capable of most interventions Make sure stable before get on elevator Airway Rhythm Circulation/perfusion Stop bleeding Relieve tension PTX, tamponade

8 New 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)