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REBEL Cast

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Health & Fitness
Medicine
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Rational Evidence-Based Evaluation of Literature

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Rational Evidence-Based Evaluation of Literature

iTunes Ratings

79 Ratings
Average Ratings
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1
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HFNC - Frank nailed it!

By Jlabarbe - Feb 18 2020
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Franks recent podcast on HFNC was extremely informative. Really appreciate the pneumonic and I took away some new information from it.

Leading the Way!

By flightRNaz - Feb 21 2019
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So excited you have joined IAMED to share your knowledge to even more people!

iTunes Ratings

79 Ratings
Average Ratings
73
5
0
1
0

HFNC - Frank nailed it!

By Jlabarbe - Feb 18 2020
Read more
Franks recent podcast on HFNC was extremely informative. Really appreciate the pneumonic and I took away some new information from it.

Leading the Way!

By flightRNaz - Feb 21 2019
Read more
So excited you have joined IAMED to share your knowledge to even more people!
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REBEL Cast

Latest release on Feb 12, 2020

The Best Episodes Ranked Using User Listens

Updated by OwlTail 3 days ago

Warning: This podcast is a series podcast

This means episodes are recommended to be heard in order from the very start. Here's the 10 best episodes of the series anyway though!

Rank #1: REBEL Cast Ep 55 – Hyperoxia in the Critically Ill

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Background: Critically ill patients come to the ED all the time and it is almost reflexive to liberally administer oxygen in these acutely ill patients.  Many...

The post REBEL Cast Ep 55 – Hyperoxia in the Critically Ill appeared first on REBEL EM - Emergency Medicine Blog.

Jul 09 2018

12mins

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Rank #2: REBELCast Ep62 – US Guided PIVs with Jacob Avila, MD

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Welcome back to REBELCast.  In this episode we talked with Jacob Avila about US guided PIVs. Difficult IV access in an already busy department can be...

The post REBELCast Ep62 – US Guided PIVs with Jacob Avila, MD appeared first on REBEL EM - Emergency Medicine Blog.

Feb 07 2019

45mins

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Rank #3: REBEL Cast Ep56 – PARAMEDIC-2: Time to Abandon Epinephrine in OHCA?

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Background: Epinephrine(adrenaline) has been used in advanced life support in cardiac arrest since the early 1960s. Despite the routine recommendation for its use, evidence to support...

The post REBEL Cast Ep56 – PARAMEDIC-2: Time to Abandon Epinephrine in OHCA? appeared first on REBEL EM - Emergency Medicine Blog.

Jul 20 2018

27mins

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Rank #4: REBEL Core Cast 3.0 – Asthma, COPD + PNA

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Take Home Points Single dose oral dexamethasone is an excellent choice for asthma exacerbations. It takes away the compliance issue for patients who have trouble...

The post REBEL Core Cast 3.0 – Asthma, COPD + PNA appeared first on REBEL EM - Emergency Medicine Blog.

Jan 23 2019

14mins

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Rank #5: REBEL Core Cast 15.0 – Syncope Literature Updates

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Take Home Points There is no real distinction between syncope and near syncope. Older folk with near syncope or syncope should be treated the same....

The post REBEL Core Cast 15.0 – Syncope Literature Updates appeared first on REBEL EM - Emergency Medicine Blog.

Aug 07 2019

8mins

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Rank #6: REBEL Core Cast 18.0 – DKA Tips and Tricks

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Take Home Points When looking at pH and bicarb, the differences between VBG and ABG are miniscule. For DKA patients, stick with the VBG as...

The post REBEL Core Cast 18.0 – DKA Tips and Tricks appeared first on REBEL EM - Emergency Medicine Blog.

Sep 25 2019

10mins

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Rank #7: REBEL Cast Episode 65: Optimal Order of Drug Administration in Rapid Sequence Intubation

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Background Information: The sequential administration of a sedative and neuromuscular blocking agent (NMBA) to facilitate the passage of an endotracheal tube is a common method of...

The post REBEL Cast Episode 65: Optimal Order of Drug Administration in Rapid Sequence Intubation appeared first on REBEL EM - Emergency Medicine Blog.

May 09 2019

22mins

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Rank #8: REBEL Core Cast 4.0 – RSI Cheat Codes

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Take Home Points Bed Up Head Elevated (BUHE) position is a simple intervention that can reduce the rate of intubation-related complications. The bougie should be...

The post REBEL Core Cast 4.0 – RSI Cheat Codes appeared first on REBEL EM - Emergency Medicine Blog.

Feb 06 2019

6mins

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Rank #9: REBEL Core Cast 21.0 – ECG in Syncope

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  REBEL Core Cast 21.0 – ECG in Syncope Click here for Direct Download of Podcast Sample ECGs Post Peer Reviewed By: Salim R. Rezaie,...

The post REBEL Core Cast 21.0 – ECG in Syncope appeared first on REBEL EM - Emergency Medicine Blog.

Nov 13 2019

9mins

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Rank #10: REBEL Cast Ep73: Are Peripheral Vasopressors Safe?

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Background: Traditionally, vasopressors have been given through central venous catheters (CVCs) in the critically ill.However, the time it takes to place a CVC is time a patient could potentially remain hypotensive. Early initiation of vasopressors may be associated with reduced mortality by increasing end-organ perfusion. Therefore, there has been a growing trend to use vasopressors through peripheral IVs (PIVs).  Running pressors through a peripheral IV has a couple of important benefits including faster time to pressor initiation and no need for invasive procedures (i.e. CVC). There islittle evidence to support the safety of this practice other than one systematic review which included case reports and small case series. Now we have two more papers that evaluate this very question…are peripheral pressors safe?

REBEL Cast Episode 73: Are Peripheral Vasopressors Safe?

Click here for Direct Download of Podcast

Tian DH et al 2019 [1]

What They Did:

  • Systematic review evaluating the safety of delivering vasopressor medications via PIVs
  • Performed a literature search of prospective and retrospective studies of vasopressor infusions in adults

Outcomes:

  • Primary: Adverse events related to the use of peripheral vasopressors (i.e. extravasation, skin necrosis, limb ischemia, compartment syndrome, infection, and any other reported complications that required treatment)
  • Secondary:
    • Details of administration protocols, policies, and guidelines regarding the management of the infusion (i.e. frequency of observation)

Inclusion:

  • Randomized clinical trials
  • Prospective and retrospective cohort trials
  • Case series that included at least 20 participants
  • Continuous infusions of vasopressor medications (noradrenaline, adrenaline, metaraminol, phenylephrine, dopamine, and vasopressin) delivered via a PIV that included at least 20 patients and reported incidence of adverse events

Exclusion:

  • Studies with <20 participants
  • Studies using peripherally inserted central catheters (PICC)
  • Patients not in shock (i.e. laboratory studies, cardiac arrest, use of push-dose vasopressors or intraoperative use of vasopressors)
  • Non-English language
  • Review articles

Results:

  • 7 studies identified including 1382 patients and 1436 episodes of peripheral vasopressor administration
    • Studies published between 2009 – 2018
    • Number of patients per study ranged between 20 – 734
    • Most catheters were either 18 or 20g in size (Due to low event rate, association between complications and PIV size could not be reliably assessed)
  • Most commonly administered agents:
    • Noradrenaline: n = 702 episodes
    • Phenylephrine: n = 546 episodes
    • Dopamine: n = 108 episodes
    • Metaraminol: n = 74 episodes
    • Vasopressin & Adrenaline: < 5 patients
  • Mean duration of infusion = 22h (95% CI 8 – 36hrs)
  • Extravasation events* = 35 events = 3.4% (95% CI 2.5 – 4.7%)
    • No reported episodes of tissue necrosis or limb ischemia
    • All extravasation events were managed conservatively or with vasodilatory medications

*Looking at table 3 of the paper there were 38, not 35 extravasation events out of 1434, not 1436 infusions, which equals an extravasation rate of 2.6%, NOT 3.4%

Strengths:           

  • Predefined inclusion criteria to provide an estimate of the incidence of adverse events associated with the use of vasopressors via a peripheral catheter
  • Extensive search strategy ensuring a low chance of missing studies

Limitations:

  • All included studies were observational or case series without comparison groups (i.e. no RCTs)
  • Paucity of studies examine the use of peripheral vasopressors
  • Duration of vasopressor use in the included studies is relatively limited with all but two studies receiving <24hrs of infusion. Therefore, we are unable to draw conclusions regarding the safety of more prolonged infusions
  • Variations in the dose and concentrations of vasopressors, variation in the sites and gauge size of peripheral catheters, and monitoring protocols preclude definitive recommendations regarding what constitutes safe medical practice
  • 6 of 7 studies were single center
  • 5 of 7 studies were unclear regarding consecutiveness of patient inclusion
  • 3 of 7 studies did not report competing interests
  • Scarcity of primary outcomes precluded sub-group analysis of higher-quality studies
  • Only 4 of 7 studies detailed their protocols for peripheral IV insertion

Discussion:

  • This study makes it reassuring that the rate of extravasation events is low with the use of peripheral vasopressors, with the caveat that the quality of studies included are not that great.
  • It is important to remember that the use of peripheral vasopressors is a bridge to something else and not prolonged infusions. This would either mean the patient improves and comes off vasopressors or does not improve in which case a CVC should be placed.

Author Conclusion: “Reports of the administration of vasopressors via PiVCs, when given for a limited duration, under close observation, suggest that extravasation is uncommon and is unlikely to lead to major complications.”

Clinical Take Home Point: There is clearly a need for further high-quality research in this area. Until that time, the practice of peripheral vasopressors appears to make pragmatic sense to help expedite time to vasopressor infusions. If using this practice, there should be clinical monitoring protocols and protocols for management of extravasation as the adverse event rate is not zero.

Pancaro C et al 2019 [2]

What They Did:

  • Multicenter, retrospective cohort study of a perioperative database from the University Hospitals in Amsterdam and Utrecht in the Netherlands
  • Estimate the rate of occurrence of drug-related adverse effects (i.e. skin necrosis requiring surgical management) when dilute norepinephrine (20ug/mL) peripheral extravasation occurs in patients undergoing elective surgery under general anesthesia
  • Standard peripheral norepinephrine infusions used in this study were constituted at a concentration of 0.002% in NS so that the final dilution is 20ug/mL (Initial infusion dose of 0.01 – 0.02ug/kg/min and titrated as per desired targeted BP)

Outcomes:

  • Primary: Adverse drug event linked to peripheral norepinephrine administration (i.e. extravasation associated with tissue injury requiring medical or surgical intervention)

Inclusion:

  • Query of EMR of patients receiving perioperative norepinephrine
  • Age ≥18 years of age
  • General anesthesia used

Exclusion:

  • Patients not receiving peripheral norepinephrine

Results:

  • 14,385 patients received norepinephrine via a peripheral continuous infusion
  • Drug extravasation observed in 5 patients
  • 5/14,385 = 0.035% (95% CI 0.011% – 0.081%)
    • 1 – 8 events/10,000 patients
  • Zero related complications requiring surgical or medical intervention (95% CI 0% – 0.021%)
    • 0 -2 events/10,000 patients
  • Of the 5 extravasation events:
    • Dose range 0.02 – 0.05 ug/kg/min
    • Total median infusion time 20 min (range 20 – 25min)
    • Median norepinephrine dose administered 40 ug (range 35 – 50ug)
    • Total estimated norepinephrine that extravasated 33 – 80ug (volume range 1.67 – 4mL)

Strengths:

  • Large observational trial of >14,000 patients
  • Assesses and important question where there is a paucity of high-quality data

Limitations:

  • Retrospective chart review, which means the data reviewed is only as good as the information that was entered into the EMR. In other words, the study may not have captured all complications leading to underreporting (i.e. selection bias)
  • Low extravasation event rate does not allow for defining risk factors
  • IVs placed in elective surgical patients are inherently different than those placed in emergency crashing patients
  • Time from extravasation to detection was short in this study, resulting in low volume of extravasate. This may not extrapolate to patients receive infusions for longer periods of time

Discussion:

  • Critically ill patients are different than elective surgical cases:
    • Hypotentsion can affect tissue perfusion and the effect of extravasation in critically ill patients
    • Patients are monitored much more closely in the OR setting than what is possible in critically ill patients in the ED or ICU
    • IV placement is more difficult in critically ill patients, which means they have more potential to have extravasation
  • The incidence of peripheral vasopressor extravasation in critically ill patients is higher than what is quoted in this study (i.e. 3 – 6%) of non-critically ill patients, but the incidence of tissue damage is also low.

Author Conclusion: “In the current database analysis, no significant association was found between the use of peripheral intravenous norepinephrine infusions and adverse events.”

Clinical Take Home Point: In this study, the use of diluted norepinephrine administered by peripheral IV did not result in any complications requiring surgical or medical intervention. However these were small, diluted doses of norepinephrine and therefore not surprising we are not seeing skin necrosis. It is impossible to extrapolate the results of this study to critically ill patients.

Reversal of Extravasation Checklist (From EMCrit) [3]:

Although extravasation events are rare, if you are using peripheral pressors you should have a plan to treat extravasation events.

Initial Mangement

  1. Switch Pressor to another IV, IO, or CVC
  2. Leave cannula in and suck out as much as you can

SC & IV Phentolamine (Regitine)

  1. Use 25g or smaller needle
  2. Administer SC around the extravasation site (Place 5mg/1mL in 9mL of NS)
  3. Through the catheter use 0.1 – 0.2 mg/kg (up to a max of 10mg)

Topical Nitroglycerin

  1. 4mm/kg of 2% ointment to affected area
  2. Can repeat dose in 8hrs

Terbutaline

  1. Digital Extravasation: 0.5mg (1mg/mL) SC into area of extravasation
  2. Extremity Extravasation: 1mg (1mg/10mL) SC into area of extravasation
  3. Can repeat dose in 15min

Clinical Bottom Line:

In patients who are critically ill and requiring vasopressor treatment, the use of peripheral IVs are relatively safe with several caveats:

  • Use an antecubital fossa or more proximal IV (These are generally larger veins which allow for larger IVs (i.e. 18g)
  • Do not run the infusion for >2 – 4hrs
  • Use as dilute a concentration as possible
  • Use as small a volume as possible
  • Have an IV observation protocol
  • Have an extravasation protocol

References:

  1. Tian DH et al. Safety of Peripheral Administration of Vasopressor Medications: A Systematic Review. EMA 2019. PMID: 31698544
  2. Pancaro C et al. Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study. Anesth Analg 2019. PMID: 31569163
  3. Plum M et al. Alternative Pharmacological Management of Vasopressor Extravasation in the Absence of Phentolamine. PT 2017. PMID: 28890646

For More Thoughts on This Topic Checkout:

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)

The post REBEL Cast Ep73: Are Peripheral Vasopressors Safe? appeared first on REBEL EM - Emergency Medicine Blog.

Jan 02 2020

27mins

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Rank #11: REBEL Core Cast 20.0 – Takotsubo’s Cardiomyopathy

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Take Home Points   Stress cardiomyopathy looks like ACS/STEMI, with patient presenting with chest pain, dyspnea or maybe syncope. It looks like ACS and should be...

The post REBEL Core Cast 20.0 – Takotsubo’s Cardiomyopathy appeared first on REBEL EM - Emergency Medicine Blog.

Oct 31 2019

12mins

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Rank #12: REBEL Cast Ep70 – Time to Antibiotics in Sepsis

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Background: Antibiotics are one of the cornerstones of therapy in the treatment of sepsis/septic shock, however according to the Surviving Sepsis Campaign (SSC) guidelines, time to...

The post REBEL Cast Ep70 – Time to Antibiotics in Sepsis appeared first on REBEL EM - Emergency Medicine Blog.

Aug 19 2019

24mins

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Rank #13: REBEL Core Cast 22.0 – Decompensated Liver Disease

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Take Home Points    End stage liver disease patients have fragile baseline physiology. Minor insults can have profound effects Always start with the basics –...

The post REBEL Core Cast 22.0 – Decompensated Liver Disease appeared first on REBEL EM - Emergency Medicine Blog.

Nov 27 2019

14mins

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Rank #14: REBEL Cast Ep 61: Diagnostic Questions in Urinary Tract Infections in the Elderly

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Introduction: Beyond the Data The evolution from eminence-based to evidence-based care has come to define bedside emergency medicine, with rigorous skepticism and scholarly consideration accelerated...

The post REBEL Cast Ep 61: Diagnostic Questions in Urinary Tract Infections in the Elderly appeared first on REBEL EM - Emergency Medicine Blog.

Jan 03 2019

18mins

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Rank #15: REBEL Crit Cast Episode 1.0 – Overview of Targeted Temperature Management (TTM) Post Cardiac Arrest

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Therapeutic Hypothermia (also called targeted temperature management (TTM)) is a deliberate reduction of the core body temperature to 32 – 34°C, in patients who suffer cardiac arrest with return of spontaneous circulation, but also don’t regain consciousness.  In REBEL Crit Cast episode 1, I will go through the evidence for cooling adults and children, potential adverse effects, and what temperature to shoot for.

REBEL Crit Cast Episode 1.0 – Overview of Targeted Temperature Management (TTM) Post Cardiac Arrest

Click here for Direct Download of Podcast

Evidence for Cooling in Adults and Children:

HACA Trials (New England Journal of Medicine 2002) [1]

  • 275 patients suffering out of hospital arrest with shockable rhythm
  • Evaluated 32 – 34°C vs standard normothermia
  • Improved survival rate with good neurologic outcome at 6 months (55% vs. 39%)
  • Decreased mortality rate at 6 months (41% vs. 55%)
  • Used Cerebral Performance Category score (CPC) to classify good neurological outcome
    • 1 = Returning back to baseline with mild deficits
    • 2 = Moderate disability, able to return to work and living
    • 3 = Indicating severe disability
    • 4 = Persistent vegetative state
    • 5 = Brain dead

Bernard Trial (New England Journal of Medicine 2002) [2]

  • 77 patients suffering out of hospital arrest with shockable rhythm
  • Evaluated 33°C vs standard normothermia
  • Improved survival rate with good neurological outcome at discharge (49% vs 26%)
  • Questioned if improved survival rate was secondary to prevention of fever which in turn provided neurological protection

Targeted Temperature Management (TTM) (2013) [3]

  • 939 patients, with out-of-hospital cardiac arrest over 36 ICUs
    • 80% shockable rhythms, 20% were PEA and asystole
  • Evaluated which “dose” (temperature) was more effective, 36°C vs 33°C
  • Also used CPC and modified Rankin scores
  • Findings suggested NO difference in mortality rate at end of trial (50% vs 48%)
  • No difference at 6 months, or survivability with favorable CPC
  • Updated ILCOR (International Liaison Committee on Resuscitation) guidelines state that a range of treatment between 32° – 36°C is acceptable

Hyperion Trial (2019) [4]

  • 584 patients from 25 different ICUs
    • Non-shockable rhythms (i.e. PEA or asystole)
  • Compared 90-day mortality and outcome of 33°C vs 37°C
  • Rate of survivability with good outcome was statistically significant in 33°C (10.2% vs. 5.7%)
  • No difference in mortality rate between target temperatures (85%)

THAPCA [5][6]

  • In-Hospital: 257 children aged >48hrs and <18 years of age
    • Compared therapeutic hypothermia (33.0°C) vs therapeutic normothermia (36.8°C)
    • Primary efficacy outcome: Survival at 12 months after cardiac arrest with a score of 70 or higher on the Vineland Adaptive Behavior Scales, second ed (VABS-II, on which scores range from 20 to 160, with higher scores indicating better function)
    • Trial terminated early due to futility
    • No difference in primary outcome (Hypothermia = 36% vs Normothermia = 39%)
  • Out of hospital: 260 children, aged >48hrs and <18 years (Average age of 1 – 2 years)
    • 70% of patients had a respiratory cause of cardiac arrest; ½ had chronic medical conditions
    • Compared 33°C (Therapeutic hypothermia) vs. 37°C (Therapeutic normothermia)
    • Primary efficacy outcome: survival at 12 months after cardiac arrest with a Vineland Adaptive Behavior Scales, second ed (VABS-II)
    • No significant difference in primary outcome between therapeutic hypothermia (20%) vs therapeutic normothermia (12%)
    • There was a trend towards improvement of neurological outcome using 33° C, however not statistically significant

Cochrane Neonatal HIE Review 2012 [7]

  • Pediatrics with Hypoxic-ischemic encephalopathy (HIE) recommended to cool to 33 – 35°C for infants at 34-36 wks
  • 7 trials including 1214 newborns
  • Cooling helps to improve survival with good neurological outcome
  • Less data for pediatrics, personally recommend 33°C

Brain Injury and Therapeutic Hypothermia:

Mechanism

  • Global ischemic injury occurs during cardiac arrest
  • Once brain injury sets in, it can be irreversible
  • Providers may have one chance at preventing secondary brain injury
  • After obtaining ROSC, ischemia reperfusion injury (IRI) takes place
  • Post-cardiac arrest, mitochondria switch from aerobic to anaerobic metabolism causing:
    • Acidemia
    • Increased phosphate and lactate production
    • Influx of calcium ions
      • Apoptosis
      • Glutamate release, which increases the risk of seizures 5-20%

How Does Therapeutic Hypothermia Work?

  • A few of the major neuroprotective mechanisms of hypothermia include:
    • Decrease in cerebral metabolic rate
    • Decrease in acidemia and calcium influx
    • Decrease in glutamate release, which may decreases risk of seizures
    • Decrease in cerebral edema
    • Decrease in free radical production which causes cellular injury and death
    • Decrease in cytokine release which can lead to fever even days after arrest

Adverse Effects of Targeted Temperature Management (33°C)?

There is NO difference in major adverse events between cooling to 33°C vs 36 or 37°C. This is just a myth!

Increased Risk of Coagulopathy

  • Some patients may come in with major life threatening bleeding already, ( intracranial or GI)
  • ILCOR guidelines offers dosing range of 32 – 36°C; target 36° for these patients to decrease risk of further bleeding

Arrhythmia

  • Can cause bradycardia
  • Monitor blood pressure and perfusion
  • Possible use of low dose vasopressors
  • If too unstable, increase temperature until satisfactory

Increased Insulin Resistance

  • Typically treated with insulin infusion: goal 140-180 mmol/L
  • Can also use high dose insulin as acceptable
  • If continued hyperglycemia, despite high dose insulin infusion, then increase temperature
  • Tight glucose control can lead to hypoglycemia, which can also lead to poor neurologic outcomes

Electrolyte Abnormalities

  • Cold-induced diuresis caused by vasoconstriction, leading to increased urine output
  • Hypokalemia, hypomagnesemia, hypophosphatemia, hypocalcemia
  • Hypokalemia is main concern because it can cause dysrhythmias
  • Monitor potassium closely as patients can become hyperkalemic during rewarming
  • Tip: Keep potassium low normal prior to rewarming to avoid hyperkalemia

Drug Metabolism

  • Hypothermia can affect the liver and its ability to metabolize certain drugs
  • Possible prolonged effects of analgesics and sedation medeications

Infection Risk

  • Ventilator associated pneumonia
  • Can decrease leukocyte function
  • Literature does not report this or sepsis as increased risk

Musculoskeletal

  • Shivering increases oxygen demand and consumption
  • Treat aggressively with sedation or paralytic
  • Sedation preferred over paralysis as goal is to decrease oxygen consumption

Therapeutic Hypothermia from Beginning to End:

  • Expedite cooling to 33° C within the first 4 hours (podcast I stated 6 hours, but faster the better)
  • Keep at targeted temperature for 12-24 hours (ICECAP Trial enrolling patients soon to determine duration of cooling)
  • Use of intravascular cooling device (closed-loop feedback) offers tightest control
  • Slowly rewarm by 72 hours, be mindful of this stage as patients can still spike fevers
  • Target normothermia for a few days after rewarming

References:

  1. Hypothermia After Cardiac Arrest Study Group. Mild Therapeutic Hypothermia to Improve the Neurologic Outcome After Cardiac Arrest. NEJM 2002. PMID: 11856793
  2. Bernard SA et al. Treatment of Comatose Survivors of Out-of-Hospital Cardiac Arrest with Induced Hypothermia. NEJM 2002. PMID: 11856794
  3. Nielsen N et al. Targeted Temperature Management at 33°C Versus 36°C After Cardiac Arrest. NEJM 2013. PMID: 24237006
  4. Lascarrou JB et al. Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm. NEJM 2019. PMID: 31577396
  5. Moler FW et al. Therapeutic Hypothermia After In-Hospital Cardiac Arrest in Children. NEJM 2017. PMID: 28118559
  6. Moler FW et al. Therapeutic Hypothermia After Out-of-Hospital Cardiac Arrest in Children. NEJM 2015. PMID: 25913022
  7. Tagin MA et al. Hypothermia for Neonatal Hypoxic Ischemic Encephalopathy: An Updated Systematic Review and Meta-Analysis. Arch Pediatr Adolesc Med 2012. PMID: 22312166

References:

  1. Hypothermia After Cardiac Arrest Study Group. Mild Therapeutic Hypothermia to Improve the Neurologic Outcome After Cardiac Arrest. NEJM 2002. PMID: 11856793
  2. Bernard SA et al. Treatment of Comatose Survivors of Out-of-Hospital Cardiac Arrest with Induced Hypothermia. NEJM 2002. PMID: 11856794
  3. Nielsen N et al. Targeted Temperature Management at 33°C Versus 36°C After Cardiac Arrest. NEJM 2013. PMID: 24237006
  4. Lascarrou JB et al. Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm. NEJM 2019. PMID: 31577396
  5. Moler FW et al. Therapeutic Hypothermia After In-Hospital Cardiac Arrest in Children. NEJM 2017. PMID: 28118559
  6. Moler FW et al. Therapeutic Hypothermia After Out-of-Hospital Cardiac Arrest in Children. NEJM 2015. PMID: 25913022
  7. Tagin MA et al. Hypothermia for Neonatal Hypoxic Ischemic Encephalopathy: An Updated Systematic Review and Meta-Analysis. Arch Pediatr Adolesc Med 2012. PMID: 22312166

Post Transcribed By: Corinthia Stephanas Gonzales

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

The post REBEL Crit Cast Episode 1.0 – Overview of Targeted Temperature Management (TTM) Post Cardiac Arrest appeared first on REBEL EM - Emergency Medicine Blog.

Jan 13 2020

36mins

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Rank #16: REBEL Core Cast 24.0 – Stroke Update 2019

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Take Home Points

  • Important as front line providers to know research and data behind stroke care
  • Patients eligible for endovascular care are those with large vessel occlusion in the anterior circulation – anterior cerebral artery, middle cerebral artery, distal intracranial carotid artery and they have to have perfusion mismatch (small infarcted core with a large penumbra).

REBEL Core Cast 24.0 – Stroke Update 2019

Click here for Direct Download of Podcast

Brief History of Stroke Care

  • 2015 – Suspected stroke: NCHCT, if onset of symptoms < 3-4.5 hours consider thrombolytics
  • 2015 – IMS 3, Mr Rescue and Synthesis did not show any benefit to interventional care. Showed potential worse outcomes
  • 2015 – MR CLEAN study – showed benefit in large vessel obstruction specifically anterior circulation strokes MCA, ACA and distal intracranial carotid AA.  NNT 5 for benefit
  • There are 8 subsequent studies looking at the same question, all looking at patients with large vessel occlusions and 7 out of 8 found benefit to interventional therapy.

How did they identify large vessel occlusions

  • MR CLEAN used NIHSS scale
  • In some of the later studies they switched to perfusion imaging
  • The window of time got larger and larger in the studies

Shortcomings of the studies

  • All studies stopped early except for MR CLEAN
  • The problem with stopping early is that it probably overestimates the benefit of the therapy
  • None of the studies were blinded and all industry sponsored

All these studies have been expanding the time window for the intervention. DAWN and DEFUSE 3 trial pushing it back all the way to 24 hours.

2018 AHA/ACC Stroke Guidelines

  • NCHCT within 20 minutes of arrival
  • If suspicious for large vessel occlusion – order CTA
  • If positive finding on CTA – get CT perfusion study or MRI perfusion study

How to identify large vessel occlusion

  • NIHSS stroke scale greater than or equal to 6
  • VAN score
    • Not yet externally validated but good sensitivity and specificity

Take Home Points

  • Important as front line providers to know research and data behind stroke care
  • Patients eligible for endovascular care are those with large vessel occlusion in the anterior circulation – anterior cerebral artery, middle cerebral artery, distal intracranial carotid artery and they have to have perfusion mismatch (small infarcted core with a large penumbra).

For More on This Topic Checkout:

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

The post REBEL Core Cast 24.0 – Stroke Update 2019 appeared first on REBEL EM - Emergency Medicine Blog.

Dec 18 2019

8mins

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Rank #17: REBEL Core Cast 14.0 – Superficial Venous Thrombosis

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Take Home Points on SVT Superficial venous thrombosis refers to a clot and inflammation in the larger, or “axial” veins of the lower extremities and...

The post REBEL Core Cast 14.0 – Superficial Venous Thrombosis appeared first on REBEL EM - Emergency Medicine Blog.

Jun 26 2019

10mins

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Rank #18: REBEL Cast Ep72: Systemic Alteplase in Stroke Mimics is Safe?

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Background: Currently, alteplase is the mainstay of treatment of acute ischemic stroke.  Advocates of alteplase suggest that the benefit of alteplase is greatest when given early...

The post REBEL Cast Ep72: Systemic Alteplase in Stroke Mimics is Safe? appeared first on REBEL EM - Emergency Medicine Blog.

Oct 30 2019

21mins

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Rank #19: REBEL Core Cast 7.0 – Oncologic Emergencies

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Take Home Points on Oncologic Emergencies: Hyperviscosity Syndrome happens when elevated WBCs or severe hyperproteinemia cause high serum viscosity and micro-circulatory problems in patients with Waldenstrom’s macroglobulinemia, multiple myeloma or...

The post REBEL Core Cast 7.0 – Oncologic Emergencies appeared first on REBEL EM - Emergency Medicine Blog.

Mar 20 2019

9mins

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Rank #20: REBEL Core Cast 16.0 – Decompensated Hypothyroidism

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Take Home Points Myxedema coma is severe, decompensated hypothyroidism with a very high mortality. Classic features include: decreased mental status, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia,...

The post REBEL Core Cast 16.0 – Decompensated Hypothyroidism appeared first on REBEL EM - Emergency Medicine Blog.

Aug 21 2019

13mins

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