Resuscitation: News, Updates, Pearls and Practice Changers

Dennis Djogovic MD, FRCPC

Objectives

Hit you with theme based short snappers that (hopefully) shed light on some recent changes or controversies in CRIT/ER practice

Financial disclosures

None to report

Thanks to everyone for attending

A little bit about your directors

Too Hot or Too Cold?

Too Hot

Be ready for the increasing number of severe methamphetamine, cocaine, ecstasy and PMMA exposures in our region

Medication induced hyperthermia Neuroleptic malignant syndrome Malignant Hyperthermia Serotonin syndrome

They kind of look the same But they are actually very different Because they are different, the ideal

treatments are different▪ Or are they?

MH Congenital calcium repolarization problem at SR▪ Increased intracellular calcium▪ Tx: abolish contraction-excitation coupling in muscle

(Dantrolene) NMS

Dopamine blockade (low dopamine state)▪ Tx: DA agonist (bromocryptine)

SS Xs serotonin ▪ Tx: 5HT antagonist (cryproheptadine)

Would dantrolene work in SS (ecstacy, meth, cocaine)?

Traditional thinking says no Muscle release (calcium lowering) would

not help serotonin problem 5HT antagonist for a 5HT problem

Too Hot?

MDMA and dantrolene Controversial Published data: case reports mostly

SR 53 articles 71 cases Dantrolene use in 26 cases

Survivors dantrolene group 21/26

Survivors non dantrolene group 25/45

Temp >42C Temp 40-42C

Dantrolene use 8/13

survivednon Dantrolene use 0/4 survived

Dantrolene use10/10

survivedNon Dantrolene

15/27 survived

Transient hypoglycemia One case

Minimal risk to use?

Too Cold?

Too Cold?

Resuscitated VF/VT patients should undergo therapeutic hypothermia for potential treatment of anoxic brain injury ILCOR Level I recommendation ACC/AHA

Likely any patient who has suffered anoxic brain injury from resuscitated cardiac arrest should be considered for TH

Based on two landmark NEJM studies in early 2000s

BUT…

Targeted Temperature Management at 33C vs 36C after Cardiac Arrest (TTM) NEJM, Nielsen et al

Big study Well done No difference in outcome

What now?

What does it mean? Maybe patients don’t have to be THAT

cool for benefit Maybe its easier to start TTH vs TH,

therefore, more accessible Hyperthermia and normothermia are

NOT acceptable

So what should we do? TTM should be considered for

resuscitated cardiac arrest Challenges

Tougher to get patient to 33C, but easier to keep them there

Easier to get patient to <36C, but harder to keep them there

Pump or Squeeze?

Pump or Squeeze?

ER docs treat shock There are no evidence based

guidelines to assist in which pressor/trope to use in shock

VICE has created a document to address that CAEP standards committee CJEM

Shavaun MacDonald Rob GreenAndrea Wensel Osama LoubaniJames Lee Patrick ArchambaultJaneva Kircher Simon BordeleauKatherine Smith Adam SzulewskiJon Davidow Sara GrayDennis Djogovic Jean Marc Benoit

David

Messenger Dan Howes

What are inotropes?

Any agent that augments heart PUMP ▪ Ie emptying

Inotropy Chronotropy Decrease afterload

What are vasopressors?

Any agent that augments SQUEEZE

Systemic vasoconstriction

Inotropes VasopressorsIntra aortic Balloon Pump

PhenylephrineDobutamine Ephedrine Isoproteronol

Norepinephrine Epinephrine Dopamine Milrinone Nitroprusside Digoxin

VICE Highlights

For ED patients in shock, what are the side effects of vasopressors and inotropes?

Dopamine increases the risk of tachyarrhythmia compared to norepinephrine. ▪ (Grade A).

Epinephrine increases metabolic abnormalities compared to norepinephrine.▪ (Grade A).

Which vasopressors and inotropes should be used in the treatment of ED patients with cardiogenic shock?

Recommendation: Cardiogenic shock patients in the ED should receive norepinephrine as the first-line vasopressor▪ (Strong)

Which vasopressors and inotropes should be used in ED patients with distributive shock?

Recommendations: Norepinephrine is the first line vasopressor for use in septic shock▪ (Strong)

Recommendation: Dobutamine should be used for septic shock with low cardiac output despite adequate volume resuscitation▪ (Strong)

Which vasopressors and inotropes should be used in ED patients with distributive shock?

Recommendation: Epinephrine infusion is the preferred agent for anaphylactic shock that does not respond to intramuscular or intravenous bolus epinephrine. ▪ (Strong)

Which vasopressors and inotropes should be used in ED patients with undifferentiated shock?

Recommendation: In undifferentiated shock not responding to fluid resuscitation, norepinephrine should be the first-line vasopressor. ▪ (Strong)

Stay Together or Break Up?

Stay Together or Break Up?

Small PE IV heparin or LMWH

Massive unstable PE Thrombolyze (tPA)

Massive “stable” PE ????????????????

Massive “stable” PE May have

Dilated right ventricle▪ On TTE or CT

Septum: flat or bowed Elevated troponin▪ Suggesting right heart ischemia/strain

Elevated BNP hypoxia

30% of normotensive patients have RV dysfunction

10% progress to shock 5% mortality

▪ Of those who have survived this far

Recent studies to muddy the waters PEITHO MOPPET Chatterjee JAMA Meta-analysis

Dilemma

If you lyse Risk of bleed▪ 20% major bleed▪ 3-5% intracranial bleed

If you don’t lyse Pulmonary HTN, exercise tolerance Higher chance recurrent thromboembolic

disease

MOPETT, J Cardiol 2013 ½ dose tPA for moderate (submassive)

PE

No difference in survival▪ No difference in death

Less pulmonary hypertension if tPA▪ 16 vs 57%▪ ???

PEITHO, NEJM 2014 1000 patients, moderate PE, tenecteplase

No mortality difference 30 days Less hemodynamic decompensation and death in

7 days Bleeding

More extracranial bleeding▪ 6.3 vs 1.2%

More hemorrhagic stroke▪ 2.0 vs 0.2%

If >75 ya, more extracranial bleeding (11 vs 4%, but not significant)

Chatterjee, JAMA 2014 Meta analysis, thrombolysis in PE ▪ But includes ALL thrombo given for ALL PEs

16 trials 1/4 trials accounted for ¾ of patients

Mortality 2.2 vs 3.9%

Major bleeding 9.2 vs 3.4%▪ Major bleeding if >65ya: 12.9 vs 4.1%▪ Major bleeding if <65 ya: 2.8 vs 2.3%

ICH 1.5 vs 0.2%

So, what to do?

If you have a submassive but scary PE, you should talk to someone Not really time emergent but time

urgent therapy▪ 12-24hrs?

What do I do?

IF CT shows extensive clot TTE shows right heart failure Positive troponin Elevated BNP “soft” BP <65 years age NO bleeding risks identified in history No access to interventional radiology

THEN I might give half dose thrombolytic

4 or 10? Which and When?

4 or 10? Which and When?

Burn resuscitation Dilemma

Too little fluid▪ End organ dysfunction (renal failure, gut

hypoperfusion, acidosis) Too much fluid

▪ Compartment syndromes▪ Chest: cant ventilate▪ Worsen limb compartments▪ Abdomen: decompressive laparotomy

Huge increase in mortality

Parkland formula Current standard 40 years old Many burn centres quickly move away

from Parkland numbers Many centres also start using colloid at

8-12 hr mark Parkland likely overresuscitates most

large burns

Parkland formula 4cc/kg/%TBSA burned

4cc x BW in kg x “number” of percent Split into half Give the first half in 8 hours, last half in

16 hours

High potential for confusion, miscalulations

Is there an easier way?

What are the goals of burn resuscitation?

Rule of Tens USAISR

10 x percent TBSA / hr

If >80 kg BW, add 100cc/hr for every additional 10kg of BW

Titrate to urine output (30-50cc/hr)

Example with Parkland

50 yr old male in house fire, 60% TBSA burn Body weight 90 kg

4 x 90 x 60 = 21600cc Half of this = 10800cc

Half in first 8 hrs = 10800/8 =1350cc/hr

Second half in next 16 hours=10800/16 =675cc/hr

Example with Rule of Tens

50 yr old male in house fire, 60% TBSA burn Body weight 90 kg

10 x 60=600cc/hr + 100 cc/hr

▪ (for his extra 10kg in BW above 80 kg)

700 cc/hr IV Ringers lactate

In conclusion

Too hot, too cold Pump or squeeze Stay together or break up 4 or 10, which and when

Its not easy being a CRIT/ER!