Month: September 2024

Under Pressure: Abdominal Compartment Syndrome

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Abdominal compartment syndrome is an elusive diagnosis that can cause or worsen multi-organ failure in your sickest patients. How can we avoid missing it? It’s a classic case of “if you don’t think of it, you can’t diagnose it.” Dr. Ruben Geeraert, PGY-3 and future critical care fellow, breaks down how we can recognize and treat it.

Guest: Ruben Geeraert, MD
Host: Kim Bambach, MD
Editor: Kim Bambach, MD

Key Take-Aways:

What is it? Abdominal compartment syndrome is sustained pressures > 20 mm Hg in the abdomen with evidence of end-organ damage. End-organ damage can occur with abdominal hypertension > 16 mm Hg.

What’s the pathophysiology? Compressing structures in the abdomen ultimately leads to decreased cardiac output and multi-organ failure due to hypoperfusion.

Why is it so easy to miss? These patients can be easy to miss because they are already critically ill, and multi-organ failure might be attributed to a different cause. Consider it in patients receiving massive fluid resuscitation, massive transfusion protocols (MTP), polytrauma patients, septic patients, patients with an acute abdomen, and any mechanically ventilated patient. It is shockingly common in MICU and SICU patients.

Can’t I just tell based on abdominal exam? Unfortunately, you can’t. It’s important to recognize a tense abdomen, but the abdominal exam is unreliable—only 50% sensitive for this diagnosis!

How do you measure abdominal pressure? Assess for abdominal compartment syndrome by taking a bladder pressure, which you can do with a Foley catheter and arterial line setup.

How is it treated? Initial management is medical (treating the underlying disease process), but the patient may ultimately require decompressive laparotomy. Evidence is limited on the optimal timing of this procedure.

References:

  1. Masneri DA, O’Brien M. Acute Abdominal Pain. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020. Accessed February 07, 2024.
  2. EMCrit Project. “Abdominal Compartment Syndrome.” Accessed September 27, 2024. https://emcrit.org/ibcc/abdominal-compartment-syndrome/.
  3. Popowicz, Patrycja, Nalin Dayal, Richard K. Newman, and Elvita Dominique. “Abdominal Compartment Syndrome.” In StatPearls. Treasure Island (FL): StatPearls Publishing, 2024. http://www.ncbi.nlm.nih.gov/books/NBK430932/.
  4. Reintam Blaser, Annika, Adrian Regli, Bart De Keulenaer, Edward J. Kimball, Liis Starkopf, Wendy A. Davis, Patrick Greiffenstein, and Joel Starkopf. “Incidence, Risk Factors, and Outcomes of Intra-Abdominal Hypertension in Critically Ill Patients—A Prospective Multicenter Study (IROI Study).” Critical Care Medicine 47, no. 4 (April 2019): 535. https://doi.org/10.1097/CCM.0000000000003623.
  5. Regli, Adrian, Paolo Pelosi, and Manu L. N. G. Malbrain. “Ventilation in Patients with Intra-Abdominal Hypertension: What Every Critical Care Physician Needs to Know.” Annals of Intensive Care 9, no. 1 (April 25, 2019): 52. https://doi.org/10.1186/s13613-019-0522-y.

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Peds Airway Pearls: Status Epilepticus

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In this peds airway pearls segment, we’ll walk through a case of a nine year old in status epilepticus. She’s hypoxic and you need to optimize pre-oxygenation and ultimately intubate her in the ED. Dr. Runkle gives her peds airway pearls as we walk through the case!

Guest: Anne Runkle, MD. Host: Lizzy Hellmann, MD and Kim Bambach, MD. Editor: Kim Bambach, MD and Ben Ostro, MD.

Key Take-Aways:

  1. Optimize pre-oxygenation for this patient: look at positioning (ear to sternal notch), bagging technique, use airway adjuncts, suctioning, elevating the head of the bed. A PEEP valve on your BVM or temporary NIPPV are additional options.
  2. Choose the right blade: “Mac 3 in 3rd grade”. If the patient is 8 years old or 30 kilos, consider starting with a Mac 3 because the longer blade will help you reach the vollecula and you could also use the Mac blade as a Miller and lift the epiglottis. iI the 8-10 year old range you are at a transition point from pediatric to adult airway anatomy.
  3. Have multiple tube sizes (one size smaller) prepped and ready: remember cuffed ETT size is 3.5 + age/4. Having a smaller tube available will help if there are copious secretions (which is likely if the patient is seizing) or edema.
  4. Have an LMA available: this may help with bagging the patient if you need a second attempt. i-Gel supraglottic airways have a suction port that can be used with a suction catheter (but be mindful that the pt cannot be bagged simultaneously and active vomiting is a contraindication to LMA).
  5. RSI med choice: Ketamine is the ideal sedative choice in this case, as propofol is difficult to obtain in pediatric EDs.

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Sub Zero: Managing Hypothermia

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Hypothermia can be deadly and as the weather turns colder, we need to be ready to treat it. In this episode, Dr. Close (PGY-3 Chief Resident) and Dr. Kaide (Professor of EM) teach us how to manage the spectrum of hypothermia from mild cases to cardiac arrest.

Guest: Colin Kaide, MD. Host: Alex Close, MD. Editor: Kim Bambach, MD.

Key Take-Aways:

  1. Hypothermia= core body temp <95* F (35* C)
  2. Risk factors: environmental exposure (winter sports, lack of shelter), ethanol use, extremes of age, underlying illness with impaired thermoregulation (ex. sepsis)
  3. Hypothermia can progress to altered mental status/CNS depression and cardiac arrest due to arrhythmia 
  4. Have a high index of suspicion for trauma, concomitant injuries (ex: SDH after fall and prolonged time down, C spine injury in the submerged patient) 
  5. Loss of shivering is an ominous sign of moderate-severe hypothermia.
  6. For mild hypothermia rewarming may be passive external: warm environment, blankets. Remove any wet clothing. For moderate hypothermia: initiate active external measures like warm blankets/Bair hugger, warm IVF, heated humidified oxygen, targeted temperature management (ex. Zoll catheter). For the critically ill patient with severe hypothermia such as a post arrest patient: chest tube placement for thoracic lavage, consider ECMO. In a lower resource setting consider hemodialysis.
  7. In cardiac arrest the key to obtaining ROSC is high quality CPR and rewarming. Anti-arrhythmic medications have limited efficacy. Common arrhythmias are sinus bradycardia, atrial fibrillation with slow ventricular rate, VF, VT, systole. Look for Osbourne waves on EKG: a positive deflection at the J point in precordial and true limb leads. 
  8. While it is true that hypothermia can slow metabolism CPR should not be terminated until the patient has a core temp of 90*F (>32 *C) “warm and dead”, there are some exceptions such as hyperkalemia >10-12 mmol/L, arrest occurred prior to insult, obvious signs of irreversible death/major trauma, patient is rigid to the extent compressions are not possible.
  9. Always make sure you have a documented core temperature for a patient who is altered or bradycardic- it just might be due to hypothermia! 
  10. Editors note: It is also critical to obtain a finger stick glucose STAT- hypoglycemia and hypothermia frequently co-occur! 

References:

  1. Brown DA. Hypothermia. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020. Accessed September 12, 2024. https://accessemergencymedicine-mhmedical-com.proxy.lib.ohio-state.edu/content.aspx?bookid=2353&sectionid=220746470
  2. Kuhl E, Yamane D. . Accidental Hypothermia and Cardiac Arrest: Physiology, Protocol Deviations, and ECMO. ALiEM. December 12, 2018. Accessed September 12, 2024. https://www.aliem.com/accidental-hypothermia-cardiac-arrest-physiology-protocol-deviations-ecmo/
  3. Furgurson M. EM@3AM: Hypothermia. emDOCs.net – Emergency Medicine Education. December 19, 2020. Accessed September 12, 2024. https://www.emdocs.net/em3am-hypothermia-2/
  4. Hypothermia. Core EM. Accessed September 12, 2024. https://coreem.net/core/hypothermia/
  5. Hypothermia. EMCrit Project. Accessed September 12, 2024. https://emcrit.org/ibcc/hypothermia/

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Diversity, Equity, and Inclusion

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Diversity, Equity, and Inclusion. Those words are found on many university websites throughout the country. What does DEI mean and why is it important within medicine and specifically here within our residency? In this episode, Dr. James and Dr. Young discuss DEI at OSU- what it means, how the DEI committee is engaging with the community, and how you can get involved!

Guest: Henry Young, MD. Host: Edleda James, MD. Editor: Kim Bambach, MD.

Key Take-Aways:

  1. The why behind DEI: The US is constantly becoming more diverse and it’s important that we have a diverse work force. It improves patient outcomes and health disparities disproportionally affect communities of color and underserved communities. Enhancing our own cultural competency also helps care for diverse patients. Inclusion of colleagues makes the ED somewhere we all want to work and inclusion of patients make the ED a place people will feel comfortable seeking care.
  2. So many ways to get involved: There are many community outreach events, DEI committee activities, health fairs, recruitment fairs, book club, summer immersion opportunities, visiting student electives, and much more to get involved! Reach out to Dr. Young directly or to the EM education admin team to find out how you can get connected.

References:

  1. Why Choose Ohio State for EM Residency | Ohio State College of Medicine. Accessed September 5, 2024. https://medicine.osu.edu/departments/emergency-medicine/education/residencies/em-residency/why-choose-ohio-state

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