Clinical Pearls from ACEP 2017 – Washington D.C.

This year ACEP 2017 took place in Washington D.C. from Oct. 29^th – Nov 1^st, 2017.   There were lots of amazing speakers and topics as was evidenced by the eruption of everyone’s twitter feeds with the #ACEP17 hashtag.  I was fortunate enough to attend this amazing conference and approached by several attendees if I would put together a list of my favorite pearls from this conference.  I decided to put a top 10 list together, in no particular order.

Pearl #1: The Diagnostic Performance of Computer Programs for Interpretation of of ECGs[1]

• What They Did: Comparison of 9 ECG computer programs vs 8 cardiologists interpreting 1220 clinically validated cases of various cardiac disorders
• Control patients = 382
• LVH = 183
• RVH = 55
• Anterior MI = 170
• Inferior MI = 273
• Median Correct Diagnosis:
  • Computer Programs: 91.3%
  • Cardiologists 96.0%
  • p < 0.01
• Median Sensitivity to Diagnose Anterior MI
  • Computer Programs: 77.1%
  • Cardiologists: 84.9%
  • p < 0.01
• Median Sensitivity to Diagnose Inferior MI:
  • Computer Programs: 58.8%
  • Cardiologists 71.7%
  • p < 0.001
• The median total accuracy level (percentage of correct classifications was 6.6% lower for computer programs than cardiologists (69.7% vs 76.3%)
• Study Bottom Line: Don’t rely on the computer for ECG interpretations

Pearl #2: Hyperkalemia is the “Syphilis” of ECGs [2]

• What They Did: Collected 188 ECGs of patients with severe hyperkalemia (K+ ≥6.5mEq/L)
• Adverse events occurred within 6 hours in 28 patients (15%)
  • Symptomatic Bradycardia in 22 patients (12%)
  • Death in 4 patients (2%)
  • Ventricular Tachycardia in 2 patients (1%)
  • CPR in 2 patients (1%)
• All adverse events occurred prior to treatment with calcium
• Most Common ECG Findings Predicting Adverse Outcomes:
  • QRS prolongation 79%
  • Bradycardia (HR <50 bpm) 61%
  • PR Prolongation 50%
  • Junctional Rhythm 39%
  • Peaked T Waves 25%
• We have written about this before on REBEL EM: ECG Changes of Hyperkalemia
• Study Bottom Line: When ACLS is not working, think tox or hyperK+ (i.e. In a code situation, just give Calcium prior to K+ level as there is really no downside to doing this)

Pearl #3: Tidal Volume on the Ventilator is Based off IDEAL BODY WEIGHT not Actual Body Weight

• Lung Size for a 250lb and 100lb patient of the same height are essentially the same

• For a great resource on this checkout MDCalc: Endotracheal Tube (ETT) Depth and Tidal Volume Calculator

Pearl #4: If you Have a Critical Patient and Can’t Get IV Access Consider These Options [3] [4]

• What They Did: 16 Cadavers underwent a 5 minute bolus infusion of fluid via three IO access sites:
  • Flow Rates:
    • Sternum: 93.7 mL/min
    • Proximal Humerus: 57.1mL/min
    • Proximal Tibia: 30.7 mL/min
  • Sternum access requires special IO needle not always available at institutions and could affect CPR quality
  • Tibial Access had the greatest number of insertion difficulties

• What They Did: Multicenter prospective observational trial to evaluate the efficacy and safety of the Easy IJ in 74 patients
  • Initial Success Rate: 88%
  • Mean Procedure Time: 4.4 min
  • Number of Skin Punctures: 1 (75%), 2 (19%), 3 – 5 (6%)
  • Complications: Pneumothorax, Line Infection, Arterial Puncture (0%); Loss of Patency (10/73 – 14%)
  • We Have Written About This Before on REBEL EM: The Easy IJ – Another Option for Difficult IV access in Stable Patients?
• Study Bottom Line: If you are having difficulty getting IV access in your critically ill patient, consider, IO access Proximal Humerus > Proximal Tibia or the Easy IJ

Pearl #5: Nitroglycerin NOT Furosemide Should Be First-Line in Treatment of CHF and Pulmonary Edema

• The goals of treatment in cardiogenic pulmonary edema

1. Decrease Preload
2. Decrease Afterload
3. Improve LV Function

• Initial treatment should therefore focus on fluid redistribution not fluid removal
• Morphine associated with increased intubation, Increased ICU admission, and Increased mortality; No role in treatment of cardiogenic pulmonary edema [5]
• Diuretics: Due to increased afterload, effects are often delayed 30 – 120 minutes; Not effective in anuric ESRD patients; May also decrease CO during first 90 minutes [6]
• Nitroglycerin: Rapid, reliable preload reduction and effective afterload reduction at higher doses, so be aggressive 100 – 400mcg/min [7]
• NIPPV; Decreases preload and afterload which help increase CO
• More than 50% of patients with cardiogenic pulmonary edema are euvolemic [8]
• Summary of Treatment Options in Cardiogenic Pulmonary Edema:

1. NIVPPV – First line treatment
2. Nitroglycerin – First line agent
3. ACE-Inhibitors – Second line agent
4. Furosemide – Third Line Agent

Pearl #6: Remember the Rule of 15’s for Pre-Oxygenation Prior to RSI to Prevent Oxygen Desaturation

• Back Up Head Elevated (BUHE) Intubation [9]:
  • 528 Intubations
  • Primary Outcome: Composite of Any Intubation Related Complication (Difficult Intubation ≥3 Attemps or >10 min, Hypoxemia <90% O2 Sat, Esophageal Intubation, or Esophageal Aspiration)
    • Standard Supine Intubation: 22.6%
    • BUHE Intubation 9.3%

• Flush Rate O2 for Pre-Oxygenation [10]:
  • Crossover trial with healthy volunteers with:
    • NRB at 15L/min (NRB-15)
    • NRB with Flush Rate (>40L/min) O2 (NRB-Flush)
    • BVM Device with O2 at 15L/min (BVM-15)
    • Simple Mask with Flush Rate (>40L/min) O2 (SM-Flush)
  • Forced Expiratory O2 in a single Exhaled Breath (FeO2) After 3 Min Pre-Oxygenation:
    • NRB-15: 54%
    • NRB-Flush: 86%
    • BVM-15: 77%
    • SM-Flush: 72%

• Apneic Oxygenation RCT in the ED [11]:
  • Single Institution RCT of 200 patients randomized to Apneic Oxygenation vs No Apneic Oxygenation
  • Lowest Mean O2 Saturation:
    • Apneic Oxygenation: 92%
    • Usual Care: 93%
  • Caveats: 70% of patients intubated by 60 seconds, 80% by 80 seconds, 90% by 100 seconds, and 100% by 195 seconds
  • All patients pre-oxygenated for ≥ 3minutes

• In patients with shunt physiology (Pneumonia, Pulmonary Edema, PE), remember that oxygenation will not help as much as PEEP (Recruit Atelectatic Alveoli)
• For all causes of hypoxia NC>15LPM + BVM 15LPM _ PEEP Valve 15cmH20 = Best PreOx, ApOx, and ReOx currently available
• Bottom Line of Studies:

Pearl #7: Radiologists are NOT “All-Seeing” [12]

• “The Invisible Gorilla Strikes Again”
• 24 radiologists had up to 3 minutes to freely scroll through lung CTs searching for nodules
• A Small Gorilla was also superimposed on the CTs as an experiment of inattentional bias
• 20/24 (83%) radiologists failed to see the gorilla
• Study Bottom Line: ALWAYS look at all radiology images that you order and not just the radiology read

Pearl #8: NPO Status in Pediatric Patients Prior to Sedation/Anesthesia Outside the Operating Room [13]

• What They Did: Pediatric Sedation Research Consortium evaluated >139,000 procedural sedation/anesthesia encounters from 42 institutions
• Evaluated Aspiration Episodes and Composite Major Adverse Events (Aspiration, Death, Cardiac Arrest, Unplanned Hospital Admission) with respect to NPO status
• Aspiration:
  • NPO = 8/82,546 (0.01%)
  • Non-NPO = 2/25,401 (0.008%)
• Composite Major Adverse Events:
  • NPO = 46/82,546 (0.06%)
  • Non-NPO = 15/25,401 (0.06%)
• 0 Deaths
• Study Bottom Line: There is no association between NPO status and aspiration or composite major adverse events in sedation procedures outside the OR

Pearl #9: Regional Nerve Blocks for Hip Fractures [14]

• What They Did: Multicenter RCT of 161 geriatric patients with hip fractures with US Guided Single Injection Femoral Nerve Block and then randomized to:
  • Fascia Iliaca Block (FIB) by Anesthesiology within 24 hours
  • Conventional Analgesics
• Fascia Iliaca Block Superior to Conventional Analgesics
  • Improved Pain Control at 2 Hours
  • Pain Scores at Rest, With Transfers out of Bed, and With Walking on POD 3 Improved
  • At 6 Weeks Improved Walking and Stair Climbing Ability
  • Required 33 – 40% Fewer Parenteral Morphine Sulfate Equivalents
• Study Bottom Line: Femoral nerve blocks result in superior outcomes in geriatric patients with hip fractures compared to parenteral pain medications

Pearl #10: Some Fun with Number Needed to Treat

• ASA in STEMI:
  • NNT for Mortality = 42
  • NNH for Minor Bleeding = 167
• NIPPV for COPD Exacerbation:
  • NNT for Mortality = 8
  • NNT for Avoiding Intubation = 5
• Abx for COPD Exacerbation:
  • NNT for Mortality = 8
  • NNT for Preventing Tx Failure = 3
• NIPPV for Acute Pulmonary Edema
  • NNT for Mortality = 13
  • NNT for Preventing Intubation = 8
• Heparin for ACS
  • NNT to Prevent Nonfatal Heart Attack = 33
  • NNH for Major Bleeding = 25

References:

1. Willems JL et al. The Diagnostic Performance of Computer Programs for the Interpretation of Electrocardiograms. NEJM 1991. PMID: 1834940
2. Durfey N et al. Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short-term adverse Events? West J Emerg Med 2017. PMID: 28874951
3. Pasley J et al. Intraosseous Infusion Rates Under High Pressure: A Cadaveric Comparison of Anatomic Sites. J Trauma Acute Care Surg 2015. PMID: 25757113
4. Moayedi S et al. Safety and Efficacy of the “Easy Internal Jugular (IJ)”: An Approach to Difficult Intravenous Access. JEM 2016. PMID: 27658558
5. Peacock WF et al. Morphine and Outcomes in Acute Decompensated Heart Failure: An ADHERE Analysis. Emerg Med J 2008. PMID: 18356349
6. Ikram et al. Haemodynamic and Hormone Responses to Acute and Chronic Furosemide Therapy in congestive Heart Failure. Clin Sci 1980. PMID: 7002435
7. Wilson SS et al. Use of Nitroglycerin by Bolus Prevents Intensive Care Unit Admission in Patients with Acute Hypertensive Heart Failure. Am J Emerg Med 2017. PMID: 27825693
8. Chaudry SI et al. Patterns of Weight Change Preceding Hospitalization for Heart Failure. Circulation 2007. PMID: 17846286
9. Khandelwal N et al. Head-Eleavted Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesth Analg 2016. PMID: 26866753
10. Driver BE et al. Flush Rate Oxygen for Emergency Airway Preoxygenation. Ann Emerg Med 2017. PMID: 27522310
11. Caputo N et al. EmergeNcy Department use of Apneic Oxygenation Versus Usual Care During Rapid Sequence Intubation: A Randomized Controlled Trial (The ENDAO Trial). Acad Emerg Med 2017. PMID: 28791755
12. Drew T et al. “The Invisible Gorilla Strikes Again: Sustained Inattentional Blindness in Expert Observers.” Psychol Sci 2014. PMCID: PMC3964612
13. Beach ML et al. Major Adverse Events and Relationship to Nil per Os Status in Pediatric Sedation/Anesthesia Ouside the Operating Room: A Report of the Pediatric Sedation Consortium. Anesthesiology 2016. PMID: 26551974
14. Morrison RS et al. Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial. J Am Geriatr Soc 2016. PMID: 27787895

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

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