Separating The Wheat From Separating The Wheat From

The ChaffThe Chaff

Making 2012 Sense Of Acute Making 2012 Sense Of Acute

Resuscitation In The EDResuscitation In The EDInadequate Perfusion, Access, Fluids, Inadequate Perfusion, Access, Fluids,

Ventilatory SupportVentilatory Support

Restore Perfusion, Identify Insult And Restore Perfusion, Identify Insult And Remove Or Relieve, ReassessRemove Or Relieve, Reassess

Dave Milzman, MD , FACEP MILZMAND@GEORGETOWN.EDU (202) 210-8018 (202) 210-8018

Professor of Emergency MedicineProfessor of Emergency MedicineAdjunct Professor of Pharmacology/ PhysiologyAdjunct Professor of Pharmacology/ PhysiologyAssistant Dean for Student ResearchAssistant Dean for Student ResearchMedical Director for Community OutreachMedical Director for Community OutreachGeorgetown University School of MedicineGeorgetown University School of MedicineSenior Advisor PreHealth Sciences, Georgetown Senior Advisor PreHealth Sciences, Georgetown UniversityUniversity

Medical Director, DC Sports Concussion CenterMedical Director, DC Sports Concussion CenterResearch  Director Georgetown U./Washington Research  Director Georgetown U./Washington Hospital  Center Emergency Medicine ResidencyHospital  Center Emergency Medicine Residency

What Do I Really Want?What Do I Really Want?

Tuition BenefitsTuition Benefits

Objective: Objective: Primum non Primum non nocere, and Save Livesnocere, and Save Lives

"To Separate The To Separate The Wheat From The Wheat From The Chaff” Chaff” Matthew3.0Matthew3.0

To Separate Things To Separate Things of Value From of Value From things of NO things of NO VALUE!!VALUE!!

What Works in the ED?What Works in the ED? Talking To and Making Actual Contact with Talking To and Making Actual Contact with

Patient and FamilyPatient and Family

Pain ControlPain Control

Controlling HemorrhageControlling Hemorrhage

Suturing Wound, Removing FB, Reducing Suturing Wound, Removing FB, Reducing Dislocation, I and D, Asthma RX, Appendectomy,..Dislocation, I and D, Asthma RX, Appendectomy,..

Works Sometimes: Airway Control, CPR, PCI, Works Sometimes: Airway Control, CPR, PCI, Central Access, Treating PID and Central Access, Treating PID and

RESUSCITATIONRESUSCITATION

EGDT is on the TableEGDT is on the Table

Everyone NEED Understand the Concept: Everyone NEED Understand the Concept: Inadequate Perfusion (Shock) is Best Inadequate Perfusion (Shock) is Best Treated Early (Cryptic Shock) and Treated Early (Cryptic Shock) and Aggressively (EGDT)!Aggressively (EGDT)!

EGDT Original RecipeEGDT Original Recipe

Warning!! Warning!! toys not toys not Included, Included, cost extracost extra

EGDT in 2012EGDT in 2012

What we Know? What we Know?

Treat in the ED, Maybe EMSTreat in the ED, Maybe EMS

Early Aggressive Fluid Resuscitation:Early Aggressive Fluid Resuscitation:

Large catheter, or IO Crystalloid then BloodLarge catheter, or IO Crystalloid then Blood

Improve Oxygenation: Mechanical Improve Oxygenation: Mechanical Ventilation, ContractilityVentilation, Contractility

Remove Insult: Antibiotics, Operation, Remove Insult: Antibiotics, Operation,

Re-AssessRe-Assess

EGDT in 2012EGDT in 2012What we Don’t Know?What we Don’t Know?

Best Marker to FollowBest Marker to Follow

Endpoints of ResuscitationEndpoints of Resuscitation

QUANTITATIVE RESUSCITATION

(HEMODYNAMIC OPTIMIZATION OR GDT) Lactate Clearance Monitoring Lactate Clearance Monitoring (10% reduction) (10% reduction)

Is A Superior Therapeutic Target To Oxygen-Is A Superior Therapeutic Target To Oxygen-derived Variables Such As Scvoderived Variables Such As Scvo2 2 (>70%)(>70%)

Multicenter Studies Have Failed To Show The Multicenter Studies Have Failed To Show The Use Of SvoUse Of Svo22 As A Resuscitation As A Resuscitation

Ability To Clear Lactate Has Consistently Ability To Clear Lactate Has Consistently Predicted Better SurvivalPredicted Better Survival

Its EasierIts Easier Chest Jones 2011Chest Jones 2011

Dr Rivers RespondsDr Rivers Responds It Is Common Knowledge That Many Septic It Is Common Knowledge That Many Septic

Patients Develop Multiple Organ Failure And Die Patients Develop Multiple Organ Failure And Die Despite Normal Blood Lactate Levels Despite Normal Blood Lactate Levels Levraut Et Levraut Et Al CCM2003Al CCM2003

Be Careful Of Non-inferiority Studies: Smaller Be Careful Of Non-inferiority Studies: Smaller Numbers Bias Toward Non-inferiority. …. Still Numbers Bias Toward Non-inferiority. …. Still Waiting On Waiting On ProcessProcess

10% Drop In Lactate Has Different Implications 10% Drop In Lactate Has Different Implications If The Initial Value Is If The Initial Value Is 12 Mmol/L 12 Mmol/L Than Than 4 Mmol/L4 Mmol/L

““Today's Prudent Clinician Will Use Both Today's Prudent Clinician Will Use Both Normalization Of ScvoNormalization Of Scvo22 And Lactate Levels To And Lactate Levels To Guide Resuscitation Rather Than Rely On One Guide Resuscitation Rather Than Rely On One Parameter Alone.”Parameter Alone.”

Rivers et al Chest 2011Rivers et al Chest 2011

Last Word and Take-Away Last Word and Take-Away PointPoint

In Rivers. Patients had much higher lactate, In Rivers. Patients had much higher lactate, much lower ScvOmuch lower ScvO22, and much higher mortality , and much higher mortality …patients in Detroit between 1997 - 2000 …patients in Detroit between 1997 - 2000 were markedly different in the world's were markedly different in the world's literature and/or …selection bias was a literature and/or …selection bias was a significant problem in …study. significant problem in …study. Jones Chest Jones Chest part 2, 2011part 2, 2011

LACTATES study reported no significant LACTATES study reported no significant concordance in achieving lactate clearance concordance in achieving lactate clearance and ScvOand ScvO22 goals goals Jones, shapiro Trzeciak JAMA Jones, shapiro Trzeciak JAMA 20102010

FEW ED Resuscitation Actually Using GDTFEW ED Resuscitation Actually Using GDT

Jones et al 2006 CCM, 2007 AEMJones et al 2006 CCM, 2007 AEM

ED ResucitationsED Resucitations

What We Think We DoWhat We Think We Do

And And

What usually HappensWhat usually Happens

SIRS CriteriaSIRS Criteria

Gets a LactateGets a Lactate

2 L IVF2 L IVF

And ICU ConsultAnd ICU Consult

What IS Most Important What IS Most Important during Acute ED during Acute ED

ResuscitationResuscitation What to Follow:What to Follow:

Vitals NO Shock Index Trend Vitals NO Shock Index Trend

Lactate YesLactate Yes

CVP YesCVP Yes

Scv02 Not ProvenScv02 Not Proven

What we can do What we can do tomorrow in the EDtomorrow in the ED

Jones Kline, Trzeciak, Et Al. Acad EM 2006Jones Kline, Trzeciak, Et Al. Acad EM 2006

Only 2/36 Academic Programs surveyed Only 2/36 Academic Programs surveyed routinely used EGT routinely used EGT

Most Don’t Have Team Or Effective Most Don’t Have Team Or Effective Protocol: If Its Not You What Do Most Protocol: If Its Not You What Do Most EP Do??EP Do??

Get A Lactate Give 2 L Start Pressors, Give Get A Lactate Give 2 L Start Pressors, Give Blood, Blood,

Mech Vent If NeededMech Vent If Needed

Monitoring Invasive Vs Follow BiomarkersMonitoring Invasive Vs Follow Biomarkers

SGO 1904 Use of ‘Suit’ in Surgery, SGO 1904 Use of ‘Suit’ in Surgery, Inflated when BP droppedInflated when BP droppedDeflated after Operation, Marked Deflated after Operation, Marked inproved survival 25-40% inproved survival 25-40% What Else did Dr. Crile Do:…..What Else did Dr. Crile Do:…..1.1.Administration Of Oxygen Under Administration Of Oxygen Under Pressure For Gas Casualties, Pressure For Gas Casualties, 2.2.Epinephrine For Patients In Shock, Epinephrine For Patients In Shock, 3.3.Diluted Sea Water Infusions To Support Diluted Sea Water Infusions To Support Victims Of Massive Trauma.Victims Of Massive Trauma.

Shock: Catching up to Shock: Catching up to the last Century: Dr. Crilethe last Century: Dr. Crile

Prevention Of Shock Was Of Far Greater Prevention Of Shock Was Of Far Greater Importance Than Its TreatmentImportance Than Its Treatment

Successfully Used Saline Solutions And Successfully Used Saline Solutions And Epinephrine To Treat Patients Seemingly In Epinephrine To Treat Patients Seemingly In Extremis. Extremis.

1903 Crile Had Realized That Saline Solutions Were 1903 Crile Had Realized That Saline Solutions Were Of Limited Benefit To Prevention And Treatment Of Of Limited Benefit To Prevention And Treatment Of Shock, And He Was One Of The First To Use Blood Shock, And He Was One Of The First To Use Blood Transfusions Regularly In SurgeryTransfusions Regularly In Surgery

1903 Crile Had Realized That Saline Solutions Were 1903 Crile Had Realized That Saline Solutions Were Of Limited Benefit In The Prevention And Of Limited Benefit In The Prevention And Treatment Of Shock, And He Was One Of The First Treatment Of Shock, And He Was One Of The First To Use Blood Transfusions Regularly In SurgeryTo Use Blood Transfusions Regularly In Surgery

Moratorium Wards" Where Soldiers Were Taken To Die Be Moratorium Wards" Where Soldiers Were Taken To Die Be Redesignated "Resuscitation Wards," Where Soldiers Would Redesignated "Resuscitation Wards," Where Soldiers Would Be Given Whole Blood To Resuscitate Them Instead Of Be Given Whole Blood To Resuscitate Them Instead Of Morphine To Ease Their Deaths.Morphine To Ease Their Deaths.

Early Invasive MonitoringEarly Invasive Monitoringpart Deux part Deux

Geriatric Blunt Multiple Trauma: Improved Survival With Early Invasive Monitoring. Scalea et al J Trauma 1990

optimize patients to a cardiac index : 4 L / min / M[2]

 or an oxygen consumption index of 170 cc / min / M[2]

statistically significant differences between optimized cardiac output and systemic vascular resistance in survivors compared with non-survivors.

early use of invasive hemodynamic monitoring will identify this deficit and afford the opportunity to help improve survival.

Scalea Way Ahead in Scalea Way Ahead in 19861986

Central venous oxygen Central venous oxygen saturation: An early accurate saturation: An early accurate measurement of volume measurement of volume during hemorrhage. J during hemorrhage. J Trauma1988;28:725-732. 29. Trauma1988;28:725-732. 29. Scalea TM, Simon HM, Duncan Scalea TM, Simon HM, Duncan AO. .AO. ...

Gastric TonometryGastric Tonometry

Gastric Mucosal pHi Is Measured According To Gastric Mucosal pHi Is Measured According To An Equation That Assumes That Arterial An Equation That Assumes That Arterial Bicarbonate Is Equal To Intramucosal Bicarbonate Is Equal To Intramucosal Bicarbonate Bicarbonate Lancet 1992 Guitierrez et al. Lancet 1992 Guitierrez et al.

pHpHii-Guided Resuscitation May Help Improve Outcome In Such -Guided Resuscitation May Help Improve Outcome In Such

Patients By Preventing Splanchnic Organ Hypoxia And The Patients By Preventing Splanchnic Organ Hypoxia And The Development Of A Systemic Oxygen Deficit.Development Of A Systemic Oxygen Deficit.

Could identify patients with increased Could identify patients with increased mortality but not successful as mortality but not successful as marker to treatmarker to treat

Easy to Place But Hard to Easy to Place But Hard to UseUse

pHi Vs Parameters in pHi Vs Parameters in SurvivalSurvival Gastric Tonometry*The Hemodynamic Monitor of

Choice Chest 2003

J Heard

Nagdev AD, et al. Emergency department Nagdev AD, et al. Emergency department bedside ultrasonographic measurement of bedside ultrasonographic measurement of

the caval index for noninvasive the caval index for noninvasive determination of low central venous determination of low central venous

pressure. Ann Emerg Med 2010pressure. Ann Emerg Med 2010

Fig 1- IVC diameter at end inspire Fig 2- IVC diameter at end expire. The Caval Index calculation is (expire IVC diameter – inspire IVC diameter) / expire IVC diameter and the Caval Index Percentage = caval index x 100

Lessons Learned from Lessons Learned from EMSEMS

•Immed VS Delayed Immed VS Delayed Resus had lower Resus had lower Survival 62% VS 70% P Survival 62% VS 70% P <0.04<0.04•No Difference In BloodNo Difference In Blood•But Increased ICU and But Increased ICU and Total LOS Total LOS •OverResus with Fluid OverResus with Fluid leads to ALI leads to ALI

Lessons Learned from Lessons Learned from EMSEMS

•Not Exactly NO Fluid Not Exactly NO Fluid PrehospitalPrehospital•And Some Fluid Given And Some Fluid Given In EDIn ED•No Difference In OR No Difference In OR RequirementsRequirements•No Difference In Blood No Difference In Blood Products Intra OPProducts Intra OP•Only Rate Of Only Rate Of Administration In OR Administration In OR Was DifferentWas Different

The Prognostic Value Of Blood The Prognostic Value Of Blood Lactate Levels Relative To That Of Lactate Levels Relative To That Of

Vital Signs In The Pre-hospital Vital Signs In The Pre-hospital Setting: Setting:

Jansen Et Al. 2008 Crit CareJansen Et Al. 2008 Crit Care

PreHospital Predictors of PreHospital Predictors of Outcome:Lactate Better then Outcome:Lactate Better then

SBPSBP

Non-Inferiority in our Non-Inferiority in our MonitorsMonitors

Sublingual CapnographySublingual Capnography

Marik chest 2001Marik chest 2001

Blood Products in ED Blood Products in ED 20122012

When to Transfuse: When to Transfuse:

1. There is No Absolute Level1. There is No Absolute Level

2. J Trauma 1992 Editorial Stop 2. J Trauma 1992 Editorial Stop Transfusion a Hct30 , ongoing ischemia is Transfusion a Hct30 , ongoing ischemia is indication and hemorrhageindication and hemorrhage

3. Acute Resus New Formula 1:1:1 pRBC: 3. Acute Resus New Formula 1:1:1 pRBC: FFP: PltFFP: Plt

JB Holcomb Hematology 2010JB Holcomb Hematology 2010

multiple large military and civilian retrospective single and multicenter studies that associate a high ratio of plasma and platelets to RBCs with improved survival in MT trauma patients. Because the majority of these reports are retrospective and subject to bias, particularly survivorship bias, they must be interpreted with caution

Between July 2009 and October 2010, PROMMTT screened 12,561 trauma admissions and enrolled 1245 patients who received one or more blood transfusions within 6 h of Emergency Department (ED) admission. A total of 297 massive transfusions were observed over the course of the study at a combined rate of 5.0 massive transfusion patients/week.

Capnography in the ED

monitor C02 production, pulmonary perfusion and alveolar ventilation as well as respiratory patterns

End tidal CO2

normal values of  ETCO2 is around 5% or 35-37 mm Hg. The gradient between the blood CO2 (PaCO2) and exhaled CO2 (end tidal CO2 or PetCO2) is usually 5-6 mm Hg.  PetCO2 can be used to estimate PaCO2 in patients with essentially normal lungs.

Shock index A comparison of the shock index and A comparison of the shock index and

conventional vital signs to identify acute, conventional vital signs to identify acute, critical illness in the emergency critical illness in the emergency department. department. Ann Emerg Med October 1994;24:685-Ann Emerg Med October 1994;24:685-690. Rady Rivers et al.690. Rady Rivers et al.

patients who were triaged to a priority patients who were triaged to a priority requiring immediate treatment (23 versus requiring immediate treatment (23 versus 45; 45; P<.01) and required admission to the P<.01) and required admission to the hospital (35 versus 105; P<.01) and hospital (35 versus 105; P<.01) and continued therapy in an ICU (10 versus 13; continued therapy in an ICU (10 versus 13; P<.01P<.01

Shock index Shock index (SI) (heart rate/systolic blood Shock index (SI) (heart rate/systolic blood

pressure; normal range, 0.5 to 0.7) pressure; normal range, 0.5 to 0.7) ABORMAL > 0.9ABORMAL > 0.9

Shock index: a re-evaluation in acute Shock index: a re-evaluation in acute circulatory failurecirculatory failure Resuscitation Rady Resuscitation Rady 19921992

a non-invasive means to monitor a non-invasive means to monitor deterioration or recovery of LVSW during deterioration or recovery of LVSW during acute hypovolemic and normovolemic acute hypovolemic and normovolemic circulatory failure and its therapycirculatory failure and its therapy

Shock index: Wheat or Shock index: Wheat or ChaffChaff

Yealy and delbridge Ann EM 1994 editorialYealy and delbridge Ann EM 1994 editorial

All that glitters…All that glitters…

Despite Negative Editorial and Loss for a Despite Negative Editorial and Loss for a decadedecade

It is definitely useful Birrkram et al Am J It is definitely useful Birrkram et al Am J EM 2007EM 2007

Proved change in blood donation study Proved change in blood donation study

Boys and their toys part Boys and their toys part 22

Biomarkers Get Rapid Biomarkers Get Rapid ResultsResults

Which Markers Really WorkWhich Markers Really Work

Lactate all the time

Annals of Surgery 1971

What lactate what about cytokines

I wanna go fast

Insert pix, play clip

Size of molecule 90 daltons vs 7000 vs bigger

mrna

Time to disuse out

Time to clear post acute insult

Do we always need to Do we always need to get invasiveget invasive

Does Non invasive really work

Monitor Wizards

Vital Signs aloneVital Signs alone Shock index final yea or neaShock index final yea or nea

Controlling for HRControlling for HR

Do we learnDo we learn

Who do you believe : me or your Who do you believe : me or your lying eyeslying eyes

Rapid US learning from FAST Yes Ultrasound is ImportantYes Ultrasound is Important

Not Just to find Vessels , Babys and FASTNot Just to find Vessels , Babys and FAST

Rapid assessment of Fluid statusRapid assessment of Fluid status

Cardiac contractility in CPR and even StEMI NSTEMICardiac contractility in CPR and even StEMI NSTEMI

Volume Status in HypovolemiaVolume Status in Hypovolemia

Accuracy in PneumothoraxAccuracy in Pneumothorax

If you don’t have these skills, you better get them or If you don’t have these skills, you better get them or will not be able to care for your patients as will not be able to care for your patients as well.

Final Answer? Cystalloid or Colloids

Favors Crystalloids Favors Colloids

Endpoints and outcomes

Have we really improved survival

Do fewer patients die of sepsis

Do fewer patients die from shock

Do they die of other causes

Costs VS Outcomes

Is it worth it?

WHAT GETS REIMBURSED

WHAT CAN I TELL MY CHAIR?CLINI DIRECTOR

Multicenter Study of Noninvasive Multicenter Study of Noninvasive Monitoring Systems as Alternatives to Monitoring Systems as Alternatives to

Invasive Monitoring of Acutely III Invasive Monitoring of Acutely III Emergency PatientsEmergency Patients Shoemaker et al Chest 1998

Monitor Wizards

Monitoring Wizards or Monitoring Wizards or Wizards MonitoringWizards Monitoring

The main endpoints evaluated for The main endpoints evaluated for accuracy were:accuracy were:

Accuracy-absolute bias compared Accuracy-absolute bias compared to the reference methodto the reference method

Precision Sensitivity and Precision Sensitivity and specificity to detect directional specificity to detect directional changes in COchanges in CO

Time ResponsivenessTime Responsiveness