Resuscitation: News, Updates, Pearls and Practice Changers

1. Dennis Djogovic MD, FRCPC Resuscitation: News, Updates, Pearls and Practice Changers

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

3. Financial disclosures • None to report

4. Thanks to everyone for attending • A little bit about your directors

8. Too Hot or Too Cold?

9. Too Hot • Be ready for the increasing number of severe methamphetamine, cocaine, ecstasy and PMMA exposures in our region

10. 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?

11. 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)

12. 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

14. Too Hot? • MDMA and dantrolene • Controversial • Published data: case reports mostly • SR • 53 articles • 71 cases • Dantrolene use in 26 cases

15. Survivors dantrolene group • 21/26 • Survivors non dantrolene group • 25/45

17. Transient hypoglycemia • One case • Minimal risk to use?

18. Too Cold?

19. 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

20. Based on two landmark NEJM studies in early 2000s • BUT…

21. 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?

22. 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

23. 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

24. Pump or Squeeze?

25. 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

26. Shavaun MacDonald Rob Green Andrea Wensel Osama Loubani James Lee Patrick Archambault JanevaKircher Simon Bordeleau Katherine Smith Adam Szulewski Jon Davidow Sara Gray Dennis Djogovic Jean Marc Benoit David Messenger Dan Howes

27. What are inotropes? • Any agent that augments heart PUMP • Ie emptying • Inotropy • Chronotropy • Decrease afterload

28. What are vasopressors? • Any agent that augments SQUEEZE • Systemic vasoconstriction

29. InotropesVasopressors Intra aortic Balloon Pump Phenylephrine Dobutamine Ephedrine Isoproteronol Norepinephrine Epinephrine Dopamine Milrinone Nitroprusside Digoxin

30. VICE Highlights

31. 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).

32. 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)

33. 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)

34. 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)

35. 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)

36. Stay Together or Break Up?

37. Stay Together or Break Up? • Small PE • IV heparin or LMWH • Massive unstable PE • Thrombolyze (tPA) • Massive “stable” PE • ????????????????

38. 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

39. 30% of normotensive patients have RV dysfunction • 10% progress to shock • 5% mortality • Of those who have survived this far

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

41. 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

42. 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% • ???

43. 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)

44. 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%

45. 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?

46. 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

47. THEN • I might give half dose thrombolytic

48. 4 or 10? Which and When?

49. 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: decompressivelaparotomy • Huge increase in mortality

50. 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