Sono Pro Tips and Tricks for Evaluation of Elevated Intracranial Pressure

**Written by:** Emma Greever (NUEM ’25) **Edited by:** Maurice Hajjar, MD (NUEM ’22)
**Expert Commentary by**: John Bailitz, MD

Welcome to the NUEM SonoPro Tips and Tricks Series where Local and National Sono Experts team up to take you scanning from good to great for a particular diagnosis or procedure.

For those new to the probe, we recommend first reviewing the basics in the incredible FOAMed Introduction to Bedside Ultrasound Book, 5 Minute Sono, and POCUS Atlas. Once you’ve got the basics beat, then read on to learn how to start scanning like a Pro!

Did You Know?

Ocular ultrasound is a quick procedure which can be done at the bedside to help differentiate between various ophthalmologic emergencies including retinal detachment, vitreous detachment, vitreous hemorrhage, lens detachment, and presence of foreign bodies. Indications for ocular ultrasound include eye pain, acute changes in vision, eye trauma, and suspicion of elevated intracranial pressure, or if there is swelling of periorbital tissue that inhibits direct visualization of the eye. The one absolute contraindication for ocular ultrasound is any suspicion for globe rupture, as placing any pressure on the globe can worsen extrusion of intraocular contents.

Ocular ultrasound can also be used to evaluate for elevated intracranial pressure (ICP). The optic nerve sheath communicates directly with the subarachnoid space. Cerebrospinal fluid flows between the intracranial space and orbit within the subarachnoid space; therefore, increased intracranial pressure is transmitted to the optic nerve sheath. Elevation of ICP is reflected by dilation of the optic nerve sheath. This can be quantified by measuring optic nerve sheath diameter (ONSD). Dilation of the optic nerve sheath often occurs with anterior bulging of the optic disc, seen as optic disc elevation (ODE) on ultrasound. Bulging of the optic disc is seen as papilledema on fundoscopic exam. Both ONSD and ODE measurements are ways to assess for elevated ICP.

If there is concern for elevated ICP, it is not always possible to do a dilated fundoscopic exam, invasive monitoring, or other imaging such as a CT. Point of care ultrasound (POCUS) allows for quick evaluation. Furthermore, POCUS allows for monitoring dynamic changes in ICP as doing serial fundoscopic exams and CTs is not feasible. It is also less invasive than other intra-cranial monitoring. When comparing ONSD (with a cut-off value of >5 mm) with findings of increased ICP on CT, sensitivity and specificity are 95.6% and 92.3%, respectively.

Beyond the emergency department, where else can a SonoPro scan for increased ICP?:

Aside from patients in the emergency department, POCUS for elevated ICP can be used in critically ill children in the PICU, adults in the Neurocritical ICU, and on the battlefield with handheld ultrasounds in combat medicine. ONSD changes within minutes of ICP changing. Studies have demonstrated that the change in ONSD or ODE is strongly correlated with changes in ICP, implying that POCUS could be used to dynamically detect real-time changes in ICP. In neuro-critically ill children, POCUS cannot replace invasive ICP monitoring but can be used as a screening tool in the ICU for intermittent monitoring of ICP when invasive methods are unavailable. It can allow for accurate dynamic evaluation of ICP, which is important in children with traumatic brain injury as fluctuations are common. Additionally, POCUS can be used in many different environments in which imaging is not readily available, such as on the battlefield or in-flight.

How to scan like a Pro:

Place the head of the bed at 45 degrees.
Apply a large, waterproof transparent film dressing (such as a Tegaderm) over the eye you are going to ultrasound, making sure the eye is closed. Make sure to get as much air out from under the Tegaderm as you can.
Apply a large amount of water-soluble ultrasound gel on top of the dressing.
Using a high-frequency linear probe set to ocular mode, place the probe over the eye with the indicator to the patient’s right. It is important to use very minimal pressure on the eye. To have control over the probe and to be able to make small movements with minimal pressure on the eye, rest the side of your hand on the patient’s cheek or bridge of the nose to stabilize your hand.
Ensure the probe is oriented in the transverse plane.
Tell the patient to look straight forward, to the left or right, up, or down as needed to obtain the best view.
Be sure to scan both eyes when concerned for elevated ICP.

What to Look For:

Identify the following structures: anterior chamber, lens, vitreous, retina, and optic nerve.

Use the rule of 3x5 to measure optic nerve sheath diameter:

Find the posterior aspect of the globe overlying the optic nerve
From that point measure 3 mm posteriorly (point A)
Maximal sheath distension occurs at 3 mm behind the papilla

Measure the diameter of the optic nerve from the second point (point B, 3 mm deep)
- Measure from outer wall to outer wall
- < 5mm is normal, 5-6 mm is indeterminate, >6 mm is elevated

Assess for papilledema – measure optic disc elevation (ODE)
- Measure area between the fundus and dome of the papilla

ODE >0.6 mm predicts presence of fundoscopic optic disc edema (sensitivity 82%, specificity 76%); if using the threshold of 1.00 mm then sensitivity is 73% and specificity 100%

This sign can take a couple days to develop and may not appear at the same time as elevated ocular disc diameter

How to interpret:

Determine if ICP is elevated:
- < 5 mm = Likely normal ICP
- >6 mm = Indicates elevated ICP
- Many causes of this, next steps are to identify what is causing the elevation in ICP
- 5-6 mm = Indeterminate range
If elevated, further evaluation for etiology of elevated ICP and treatment of cause.
If indeterminate, assessing for papilledema by measuring the ODE can help in the indeterminate range, although absence of papilledema does not indicate normal ICP.
It is important to note that there is significant variation from person to person regarding ONSD. In other words, >6 mm does not necessarily indicate increased diameter and <5mm does not necessarily mean normal. The SonoPro must use clinical judgement while assessing the ONSD.

Where to Learn More (References)

Where to Learn More (Hyperlinked References):
https://coreem.net/core/ocular-ultrasound/
https://www.coreultrasound.com/onsd/
https://emcrit.org/pulmcrit/pulmcrit-algorithm-diagnosing-icp-elevation-ocular-sonography/
Lin JJ, Chen AE, Lin EE, Hsia SH, Chiang MC, Lin KL. Point-of-care ultrasound of optic nerve sheath diameter to detect intracranial pressure in neurocritically ill children - A narrative review. Biomed J. 2020;43(3):231-239. doi:10.1016/j.bj.2020.04.006
Richards E, Mathew D. Optic Nerve Sheath Ultrasound. [Updated 2021 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554479/
Teismann N, Lenaghan P, Nolan R, Stein J, Green A. Point-of-care ocular ultrasound to detect optic disc swelling. Acad Emerg Med. 2013 Sep;20(9):920-5. doi: 10.1111/acem.12206. PMID: 24050798.
https://www.thepocusatlas.com

Expert Commentary

Thank you for providing this outstanding NUEM Blog Post! Ocular ultrasound for ICP has been a hot topic for over a decade in the EM, PEM, and ICU POCUS literature.

For a full review of my approach to ocular ultrasound, please refer to our 2018 Post - Ocular Ultrasound: From Floaters to Fogginess!

Since that post ,additional literature has been posted questioning the need for Tegaderms over the eye for the reasons we discussed in 2018. Bottomline, if the patient is reliable and can keep their eyes closed for five minutes, then you can skip the Tegaderm. But when the patient is less reliable, then the extra step may still make sense. When locating and measuring the Optic Nerve Sheath (ONS), be absolutely sure to stabilize your hand on the patient's face or forehead particularly when you are over-caffeinated or tired. Then be careful to rock the probe about 15 degrees laterally (illustrated here) to visualize the ONS parallel to the probe’s center US beams, and thereby avoid any edge artifact from visualizing at an angle. Even with the best technique, our local teaching, clinical use, and pilot research has consistently confirmed the need for obtaining multiple measurements of the small optic nerve sheath. Then averaging the best three to obtain the most accurate measurement.

Thank You Dr. Greever (NUEM ’25) and Dr. Hajjar, MD (NUEM ’22) for helping to improve patient care and MedEd through POCUS! Happy scanning everyone.

John Bailitz, MD

Vice Chair for Academics, Department of Emergency Medicine

Professor of Emergency Medicine, Feinberg School of Medicine

Northwestern Memorial Hospital

How To Cite This Post:

[Peer-Reviewed, Web Publication] Greever, E. Hajjar, M. (2024, Sep 11). Sono Pro Tips and Tricks for Evaluation of Elevated Intracranial Pressure. [NUEM Blog. Expert Commentary by Bailitz, J]. Retrieved from http://www.nuemblog.com/blog/sonopro-tips-and-tricks-for-evaluation-of-elevated-intracranial-pressure

Becoming a New Mom and New Resident

Written by: Courtney Premer-Barragan, MD, PhD (NUEM ‘25) Edited by: Saabir Kaskar, MD (NUEM ‘23)
Expert Commentary by: Ivonne H. Schulman, MD

As I am sitting here, pondering how to adequately share my experiences of becoming a brand-new mom and intern, what better time than when I’m recovering from family “Sienna-itis” as we like to call it ("Sienna-itis” being the many fevers, coughs, and colds she has brought our way). The adage goes, get lots of sleep, rest, and hydration to fight sickness, and wow, does that sound great! However, when you have a child crying inconsolably because they have a 104.5* fever, and simultaneously you have fever, body aches, and feel miserable, your child comes first. You suppress all your aches and ignore your need to recover deferring to motherly instincts that demand your baby feel safe and loved. This is a slightly harsh metaphor of what it’s like to be an intern with a new baby. There is no such thing as rest and recovery. I am responsible for another human. Finally, a day off the MICU. Want to lounge around all day? Watch TV and relax? Nope! Just got off a night shift. Want to sleep all day to recover? Nope. Hey, I don’t work until 2pm, let me sleep in. Nope. It’s a constant rollercoaster that none of my co-interns can relate to, and that makes it even more challenging. But would I do it all over again? Look at this face. Yes! She makes everything worth it. So how did I get here and what have I learned along the way?

Let’s start where it all started, medical school…

I decided during medical school that I was ready to start a family. Previous lengthy graduate school years enhanced the sense of growing older and moving past my prime reproductive years. Looking at the literature, a career in medicine and motherhood seemed daunting. “Pregnant trainees and those contemplating pregnancy often report stress related to faculty and coworker attitudes, rigid and intense educational requirements, long work hours, unpredictable work demands, altered schedules, guilt over colleagues’ increased workloads, and concern for maternal–fetal well-being.” 2 I scoured the internet to find support groups or at least supportive views showing that you can equally be an attentive mom and thrive in your medical residency, albeit this view was scant. Literally every article mentioned medical trainees felt sentiments of guilt, vulnerability, overworked, judged, and feelings of inadequacy1-6. I ultimately decided that I wanted a family, and medicine and family shouldn’t be mutually exclusive. So, I was pregnant at the end of my 3rd year. I did the all-important EM rotation in my 2nd trimester of pregnancy, took Step 2 in my 3rd trimester, did all my residency interviews feeling like I was about to pop (7-8 months pregnant), and matched at my dream program.

On to residency….

The transition to residency, while embracing my new reality as a mom, was tough. You’re stepping into a new role in your life, learning to be a new doctor, and then compounding that with trying to figure out how to take care of another human. Sleep deprivation. Guilt. FOMO. Sadness. Happiness. Isolation. Joy. Every day seemed like a new feeling. As I watched my co-residents all go out together, enjoying fun times when off shift, forging close bonds, I was increasingly feeling sad and isolated, as it was often impossible for me to join. This was heightened by having no family in Chicago as a support network. But then, full stop! There’s the utter feeling of fulfillment. Coming home to Sienna with her blazing smile and her unconditional love is sheer bliss. Lying next to her as she crawls, stands, and slobbers all over me is pure joy. Hearing her laugh permeate the room. Watching her dance with no care in the world. Her self-clap when she takes a new step. So many priceless moments. Again, it’s a rollercoaster of emotions, lots of highs and lots of lows, lots of feeling like the most loved person in the world while also feeling completely isolated. I’m sharing my experiences with all its vulnerabilities to add another perspective to the scant literature and lack of advice to hopefully help fill in the void.

Some lessons I learned along the journey…

1. There’s never going to be a perfect time.

I was so thankful to have a mentor who ingrained in my brain, “never wait for the right time to have kids, because you always find an excuse.” But I’m about to do residency interviews. I can’t show the program I’m pregnant. But I’m just starting my intern year. It’s a huge challenge and draining, and it’s crazy to add a child into the mix. But I’m a senior resident running the department. Let me wait a couple more years until my career is established. Although I’m a new Attending, I need to start my career strong. I’m applying for a promotion. Now is not the right time. But here’s the thing: you name the time, and there will ALWAYS be an excuse. Understanding that there will NEVER be a right time and learning how to make your time the right time, is fundamental.

2. This goes against the common convention but talk about family life/being pregnant/wanting to get pregnant in interviews, during residency, or whatever stage of your career you are at.

I received very mixed advice regarding this point while going through residency interviews. Some attendings were shocked that I wanted to be so open about my pregnancy. Some were like, “heck yes!” Is there still bias against women in medicine having children? 100%! With this in mind, I wanted to find a program that I knew would support an arduous journey I was about to embark upon. I was appalled by a couple of residency interviews and how they responded to me being pregnant. And boy, was I thankful they transparently showed their colors. I can’t imagine if I would have kept my pregnancy a secret and then have been stuck in an unsupportive environment. Thankfully, most of my interactions were very positive and gave me hope that medicine and babies can mix. When I matched at Northwestern and they sent Sienna a little snow hat, I instantly knew my family would be supported. All my fear and anxiety surrounding being the intern with the baby dissipated.

3. Support is everything (family, co-residents, friends).

Lean on EVERYONE for help, because man, do you need it! My mother moved here for the first month of residency, and that support was everything. Don’t be shy to ask for help. Unless you also have a baby, you can’t imagine how incredibly difficult it is to be an intern and a mom. Let yourself be vulnerable and relish in all the support. If someone offers to help watch the baby, heck yes! If someone offers to bring you groceries because they know you’re struggling with every task, let them bring you the groceries.

4. It’s okay to take mini breaks to survive long rounds.

As women, we put a lot of pressure on ourselves to not show any weakness. That pressure is only heightened when pregnant, trying to show that we are just as strong as everyone else. But guess what? It’s not a sign of weakness to take that little break on 4 hours of grueling rounds because your back is breaking. Grab that hospital orange juice if you’re feeling light-headed or weak. Run to the bathroom multiple times if that’s what’s calling. I was so thankful that I did my internal medicine rotation with my best friend who consistently reminded me that I needed to take care of myself, and I’ll still look like a rockstar medical student, even if I silently disappear for a minute here or a couple minutes there. At the end of the day, while we think the attending and co-medical students/co-residents are judging us for doing those little things, get over it! They’re not! So, take care of you and you’ll still shine.

5. Advocate for your breastfeeding journey.

Let me reinforce this vital tenant: advocate for yourself and your baby. I cannot stress that statement enough. If you are breastfeeding and therefore pumping at work, don’t be embarrassed/shy to take those pumping breaks. And, for the love of everything, don’t feel like a burden for taking those 20-minute breaks while your co-residents are working. You are balancing being a mother and a physician. No one else can possibly fathom the overtime amount of work you are doing both at work and at home. (Pro tip: if pumping multiple times per shift, put all the parts in the fridge so you don’t have to clean everything between each pump session. It saves sooo much time!)

6. Embrace the emotions.

You’re going to have the happiest of days. You’re going to have the darkest of days. AND THAT’S OKAY! Talk about when you’re feeling sad. But also share those glorious happy moments. Celebrate all the wins that make it so incredibly worth it. It’s really important to normalize all your feelings.

7. Most importantly…. Take care of you!

In case all the above did not sufficiently convey that balancing residency and parenthood can be quite exhausting, and make it so easy to forget about yourself, it’s vital to remember you need time to decompress and recharge. Go on that hour run by yourself. Get your nails done. Go on a date. Take a long bath. When you have a list of things that need to get done on your day off, look at that list, and think, “is this really the priority? Will life fall apart if I clear my mind at the gym instead of doing 20 Rosh Review questions and cleaning the bathroom?” To be a good mother, an engaged resident, and a good wife, you need to also take care of you. Period.

References

1. Attieh, E., Maalouf, S., Chalfoun, C., Abdayem, P., Nemr, E., & Kesrouani, A. (2018). Impact of female gender and perspectives of pregnancy on admission in residency programs. Reproductive Health, 15(1), 1-5.

2. Blair, J. E., Mayer, A. P., Caubet, S. L., Norby, S. M., O’Connor, M. I., & Hayes, S. N. (2016). Pregnancy and parental leave during graduate medical education. Academic Medicine, 91(7), 972-978.

3. Finch, S. J. (2003). Pregnancy during residency: a literature review. Academic Medicine, 78(4), 418-428.

4. Peters, G. W., Kuczmarska-Haas, A., Holliday, E. B., & Puckett, L. (2020). Lactation challenges of resident physicians-results of a national survey. BMC pregnancy and childbirth, 20(1), 1-8.

5. Sandler, B. J., Tackett, J. J., Longo, W. E., & Yoo, P. S. (2016). Pregnancy and parenthood among surgery residents: results of the first nationwide survey of general surgery residency program directors. Journal of the American College of Surgeons, 222(6), 1090-1096.

6. Walsh, A., Gold, M., Jensen, P., & Jedrzkiewicz, M. (2005). Motherhood during residency training: challenges and strategies. Canadian Family Physician, 51(7), 990-991.

Expert Commentary

The decision to begin having children during medical school or residency is one that preoccupies many women, even before they decide to pursue a career in medicine. This is in sharp contrast to men, who although now consider work/life balance and parental responsibilities more than before, still benefit from societal gender roles that place the bulk of the parenting and domestic responsibilities on women.

The number of female physicians has continuously increased over the past few decades, with women now comprising just over half of the medical students in the United States (1). Despite increasingly egalitarian societal attitudes toward gender roles, female physicians still struggle to balance a medical career and a family. Female physicians, particularly young ones, are much more likely to reduce their work hours than males, a gap that emerges immediately following medical training.

Moreover, significant gender differences in the time spent on parenting and domestic responsibilities among physicians are still evident (2). There is evidence that traditional gender roles impact female physicians’ medical specialty choices, representation in academic and professional societies, original and invited authorships, leadership positions, compensation, full time vs. part time work status, and promotion and retention in academic medicine. These findings highlight the importance of increasing awareness and expanding social and institutional support for work-family balance for female and male physicians. Until policies and a culture allowing women and men to be both parents and physicians are created, women are less likely to be retained and to advance in medicine. Proposals for solutions include availability and affordability of childcare services, maternity and paternity leave, and advocating, through mentorship, leadership courses, and support groups, for changes in social norms, such as sharing of household and child care responsibilities and creating an environment conducive to work-life

balance for all genders (3).

References

1. AAMC. The Majority of U.S. Medical Students Are Women, New Data Show. Association of American Medical Colleges; www.aamc.org; 2019.

2. Frank E, Zhao Z, Sen S, Guille C. Gender Disparities in Work and Parental Status Among Early Career Physicians. JAMA Netw Open. 2019;2(8):e198340.

3. Dandar VM, Lautenberger DM, Garrison GE. Promising Practices for Understanding and Addressing Salary Equity at U.S. Medical Schools. Association of American Medical Colleges; 2019. Disclosure: The opinions expressed in this paper are those of the author and do not necessarily reflect those of the National Institute of Diabetes, Digestive and Kidney Diseases, the National Institutes of Health, the Department of Health and Human Services, and the government of the United States.

Ivonne H. Schulman, MD

Senior Scientific Advisor for Acute Renal Failure and Renal Pathophysiology

Program Director, Translational and Clinical Studies of Acute Kidney Injury

Division of Kidney, Urologic & Hematologic Diseases (DKUH)

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

National Institutes of Health (NIH)

University of Miami Miller School of Medicine

How To Cite This Post:

[Peer-Reviewed, Web Publication] Premer-Barragan, C. Kaskar, S. (2024, Jul 29). Becoming a New Mom and New Resident. [NUEM Blog. Expert Commentary by Schulman, I]. Retrieved from http://www.nuemblog.com/blog/new-mom-and-new-resident

Posterior Reversible Encephalopathy Syndrome (PRES)

Brief overview of posterior reversible encephalopathy syndrome (PRES) and how it may present in the Emergency Department. This blog has been written and peer-reviewed by emergency physicians.

Vagal Maneuvers Simplified

**Written by:** Keara Kilbane, MD (NUEM ‘25) **Edited by:** Maren Leibowitz, MD (NEUM ‘23)
**Expert Commentary by**: Danielle M McCarthy, MD

Vagal Maneuvers Simplified

https://acls-algorithms.com/rhythms/supraventricular-tachycardia/

Introduction to Vagal Maneuvers:

Vagal maneuvers are considered the first line treatment for hemodynamically stable supraventricular tachycardia (SVT).
Studies demonstrate up to a ~40% success rate in converting patients back into normal sinus rhythm.
Benefits of vagal maneuvers:

Safe for most patients*
Avoids use of adenosine, a medication that is associated with side effects like lightheadedness, chest discomfort, vomiting, and severe anxiety, all of which can be very concerning to patients.

*see contraindications to specific vagal maneuvers below

Brief Physiology of Vagal Maneuvers:

https://www.hopkinsmedicine.org/health/conditions-and-diseases/anatomy-and-function-of-the-hearts-electrical-system

Normal sinus rhythm starts with an electrical impulse at the sinoatrial (SA) node → atrial tissue → atrial contraction → AV node → His-Purkinje system → ventricular myocardium → ventricular contraction

https://www.cprseattle.com/blog/slow-down-youre-going-too-fast-svt-and-the-modified-valsalva-maneuver

SVT (specifically AVRT/AVNRT) is most commonly caused by a re-entry conduction pattern involving a retrograde accessory pathway from the ventricles to the atrium, bypassing the SA node.

Vagal maneuvers work by stimulating the vagus nerve, which slows the impulse at the sinus node, conduction at the AV node, and lengthens the AV node refractory period.
Initially, pressure against a closed glottis results in increased intrathoracic pressure → increase in blood pressure → increased aortic pressure → baroreceptor activation → increased parasympathetic output to the heart via the vagus nerve → decreased heart rate.

Ghazal, S.N. Valsalva maneuver in echocardiography. *J Echocardiogr* 15, 1–5 (2017).

During the straining period of the vagal maneuver, there is a prolonged period of increased intrathoracic pressure → decreased venous return → decreased cardiac output → reflexive increase in HR to maintain stroke volume.
When the maneuver is stopped, there is sudden decrease in intrathoracic pressure → increased venous return and right atrial pressure → increased blood pressure and aortic pressure → reflexive decrease in heart rate and termination of SVT

Types of Vagal Maneuvers:

http://healthcaresciencesocw.wayne.edu/cnm/8_2.htm

The Valsalva Maneuver
- Main take away: creating pressure against a closed glottis
- Success rate: 5 – 20%
- Contraindications:

https://www.medicalnewstoday.com/articles/322661

Methods:
- Gag
- Cough
- Have patient plug nose, close mouth, and try to blow air out for 15 seconds
- Blow on a 10mL syringe for 15 seconds
- Bear down and strain by trying to push the air out of the lungs while closing nose and mouth. Attempt for 15 seconds

with 45 seconds of passive leg raise
https://www.ecgmedicaltraining.com/wp-content/uploads/2016/06/REVERT-Trial-SVT.jpg

The Modified Valsalva Maneuver (REVERT Trial)

Main take away: Valsalva using 10mL syringe + passive leg raise to improve venous return

Success Rate: In the RCT REVERT, the modified valsalva maneuver demonstrated 43% success rate, significantly more than valsalva maneuver alone (only 17%).
Contraindications: same as the valsalva maneuver
Methodology:
- Place patient in a sitting position
- Have patient blow into a 10mL empty syringe for 15 seconds (~40mmHg)
- After 15 seconds, immediately recline patient into supine position with 45 seconds of passive leg raise

https://www.grepmed.com/images/10366/algorithm-tachycardia-treatment-management-peds

Ice Water on the Face
Main take away: In pediatric patients who cannot follow directions, placing a bag of ice water over their forehead and eyes is the first line vagal maneuver. This stimulates the vagus nerve via activating a “diving reflex”, causing the child to valsalva.
Success rate: 33-63%
Contraindications:
- Unstable SVT
Methodology: Place a bag of iced water over an infant's eyes and forehead and hold for 15-30 seconds. Do not cover the infant's nose or mouth

Carotid Massage
Main take away: Stimulates the carotid sinus, which stimulates vagus nerve, activating parasympathetic response and slows impulse at SA node. Generally, it has fallen out of favor given the risk of precipitating stroke in patients with carotid stenosis.
Contraindications:
- Unstable SVT
- Carotid bruit
- Prior TIA or CVA in past 3 months
- Pediatric patients
Methodology: Patient in a supine position with the neck extended, and applying pressure to one carotid sinus for approximately 10 seconds

References:

1. Appelboam A, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomized controlled trial. The Lancet 2015; 386 (10005): 1747-1753.

2. Ghazal, S.N. Valsalva maneuver in echocardiography. J Echocardiogr 15, 1–5 (2017). https://doi-org.turing.library.northwestern.edu/10.1007/s12574-016-0310-8

3. Manole MD, Saladino RA. Emergency department management of the pediatric patient with supraventricular tachycardia. Pediatr Emerg Care. 2007 Mar;23(3):176-85; quiz 186-9. doi: 10.1097/PEC.0b013e318032904c. PMID: 17413437.

4. Niehues LJ, Klovenski V. Vagal Maneuver. [Updated 2021 Jul 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551575/

5. Patti L, Ashurst JV. Supraventricular Tachycardia. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441972/

6. Salim Rezaie, "The REVERT Trial: A Modified Valsalva Maneuver to Convert SVT", REBEL EM blog, September 14, 2015. Available at: https://rebelem.com/the-revert-trial-a-modified-valsalva-maneuver-to-convert-svt/.

Expert Commentary

Thank you for this excellent review of the non-pharmacologic options for managing SVT in the ED. At one point or another in my career, I have tried them all…. and I think one of the most important things to remember about these options is: there are very few harms that can result from giving them a try.

Although the individual success rate of each maneuver is not high, there is not a lot to be lost in attempting one (or more) of these techniques while other activities are in-motion to start pharmacologic therapy should the non-pharmacologic maneuvers fail. I typically do not delay having nursing establish an IV and pulling medications in preparation for pharmacologic management given that the maximal reported success rate is 43%; however, assuming no contra-indications, it doesn’t hurt try. Even in the most highly functioning EDs, it takes a few minutes to get a patient on a monitor, get continuous EKG set up and get pharmacy / nursing colleagues to bedside for administration of adenosine (or other meds) with real-time EKG tracing. It is during those minutes that I make use of these maneuvers to see if the pharmacologic therapy can be avoided.

Pre-2015, I could count on one hand the number of times I’d been successful with a vagal maneuver; however, since publication of the REVERT Trial, I have personally found using Modified Valsalva Maneuver to be more successful than Valsalva alone and have been able to avoid adenosine for numerous patients. Consider reviewing the prior NUEM blog post that discusses the REVERT Trial results in detail.

Since starting to personally use this Modified Valsalva technique in ~2016, I have adopted a few practices that may be helpful. First, I explain to the patient that we are going to ask them to do some stuff that may seem silly, but it might help them to avoid medications and I caution them that it only works ~40% of the time. Second, I’ve taken to holding up my phone with the digital timer facing the patient so they can see the seconds counting down. I’ve subjectively found that it helps them to “hang in there” and maintain the breath hold longer than without looking at a timer. Without a timer, we (doctors/nurses) tend to unintentionally “speed-up” our pace of counting as we see the patient fatiguing and therefore don’t achieve a full 15 second count. Similarly, I advocate for using your phone or a wall-clock to maintain the leg raise for a full 45 seconds. This adherence to the time intervals ensures that you’re sticking to the true technique of the maneuver rather than approximating the technique and potentially diminishing its effect. Third, if it works, I review the steps with them again and send them home with an empty syringe (and they think you’re a magician). If it fails, you already counseled them that it would likely fail; you’ve lost neither time nor trust.

Finally, I have noticed that successful or not, having a few doctors and nurses cheer a patient on to maintain the breath hold builds a spirit of trust and camaraderie. This trust is hopefully helpful to the patient…particularly when we start to explain how we are going to give a medicine that will temporarily stop their heart and make them feel transiently terrible.

In conclusion, give it a try. If these maneuvers fail, then move on. In the stable patient, consider adenosine or calcium channel blockers (see NUEM blog post on CCB as an alternative to adenosine in SVT here).

Danielle M McCarthy, MD

Vice Chair for Research, Department of Emergency Medicine

Associate Professor, Emergency Medicine

Northwestern Memorial Hospital

How To Cite This Post:

[Peer-Reviewed, Web Publication] Kilbane, K, Leibowitz, M (2024, Jul 14). Vagal Maneuvers Simplified. [NUEM Blog. Expert Commentary by McCarthy, M]. Retrieved from http://www.nuemblog.com/blog/vagal-maneuvers-simplified

Initial Resuscitation in ARDS

Quick infographic review of initial resuscitation in ARDS. This blog is written and reviewed by emergency physicians.

Symptomatic Bradycardia: Considering the Differential Diagnosis

**Written by:** Keara Kilbane (NUEM ‘25) **Edited by:** Eric Power (NUEM ‘24)
**Expert Commentary by**: Seth Trueger, MD, MPH, FACEP

THE HEART CONDUCTION SYSTEM

"Normal” adult heart rates range from 60-100 beats per minute (BPM), with bradycardia defined as a heart rate of less than 60 BPM. Electrical impulses for each heartbeat begin at the sinoatrial (SA) node, then propagate through the atrium to the atrioventricular (AV) node, continuing down the Bundle of His, and lastly to each bundle branch, causing the ventricles to contract. Bradycardia can be physiologic, such as in individuals who have high levels of cardiovascular training. However, pathologic and/or symptomatic bradycardia results from a disruption in this electrical circuit [1].

What is symptomatic bradycardia [1-2]?

Defined as the presence of bradycardia, resulting in debilitating symptoms with lack of alternate explanation.

The most common symptoms include:

Lightheadedness
Syncope
Chest pain
Exercise intolerance
Fatigue

**Important note: The heart rate at which patients experience symptoms may vary based on their ability to increase stroke volume.

CARDIAC OUTPUT = STROKE VOLUME X HEART RATE

Treatment Algorithm for Symptomatic Bradycardia [2-4]:

What are common causes of symptomatic bradycardia [2]?

Myocardial Infarction
Medication
Sinus node dysfunction
Infectious Disease
Hypothermia
Metabolic Abnormalities (hypothyroidism, hyperkalemia, ect.)
Elevated intracranial pressure (ICP)
Genetic Conditions

Myocardial Infarction

Bradyarrhythmias occur in up to 25% of patients with an acute myocardial infarction, especially those involving the right coronary artery (RCA) which supplies the SA node in up to 60% of patients.

Treatment for bradycardia secondary to myocardial infarction is standard care for an occlusive MI, including emergent cardiology consult and cath lab activation, and loading the patient with anti-platelet medications [5-7].

Common Medications and Mechanisms of Causing Bradyarrhythmias

Beta Blockers and Non-Dihydropyridine Calcium Channel Blockers (Diltiazem and Verapamil)

Inhibit the automaticity of the SA node

Antiarrhythmics (Amiodarone, Adenosine, Flecainide)

Inhibits the SA and AV node

Acetylcholinesterase inhibitors (Donepezil, Neostigmine, Pyrodostigmine, Physostigmine)

Activates the parasympathetic nervous system which leads to inhibition of the automaticity of the SA node

Clonidine

Stimulation of central alpha-2-receptors, reducing the norepinephrine

Antidepressants (Citalopram, Escitalopram, Fluoxetine)

Sodium and calcium channel inhibition

Digoxin

Increases vagal tone

Anesthetics (Bupivacaine, Propofol)

Reduces sympathetic activity

Treatment depends on the medication involved. If high suspicion or known overdose, involve and consult your local Poison Center [8].

Sinus Node Dysfunction (Sick Sinus Syndrome) [9-10]:

Sick sinus syndrome is most commonly due to aging of the sinus node and surrounding atrial myocytes. It is often associated with severe bradycardia (HR<50 bpm. It is also associated with sinus pauses, arrests, and SA node block, and or a junctional escape rhythm. Treatment includes permanent pacemaker placement [9].

Hypothermia

Moderate to severe hypothermia can cause significant bradycardia leading to hypotension. Treatment includes removing all wet clothing, externally rewarming with bair huggers and warm blankets, administering warm IV fluids, active core rewarming including bladder and thoracic irrigation with warmed fluids). It is also important to remember that the differential to hypothermia itself is broad itself and not just limited to environmental exposure. For example, hypothyroidism, adrenal insufficiency, sepsis, neuromuscular disease, malnutrition, thiamine deficiency, hypoglycemia can all lead to hypothermia [11-13].

Decompensated Hypothyroidism (Myxedema Coma)

Classic symptoms of myxedema coma include:

Decreased mentation or delirium
Hypothermia
Bradycardia
Hyponatremia
Hypoglycemia
Hypoventilation
Hypotension

Common triggering events:

Infection
Medication non-adherence
Surgery or trauma
Myocardial infarction
CHF exacerbation
Cerebral Vascular Accident
GI bleed

Treatment includes IV atropine if unstable while treating the underlying condition (IV steroids, IV levothyroxine) [14].

Increased Intracranial Pressure

Classic triad of bradycardia, respiratory depression, and hypertension (Cushing reflex), concerning for brainstem compression and/or herniation [15].

Treatment includes treating the underlying condition, and stabilization through maneuvers including [15]:

Hyperventilation
Head of the bed elevation to maximize venous outflow
Ensure neck braces (c-collar) is appropriately placed (not too tight)
Hypertonic solutions like mannitol or hypertonic saline
Emergent craniotomy

Other Etiologies of Symptomatic Bradycardia [15-16]

Prolonged hypoxia
Severe electrolyte derangements (hyperkalemia)
Vagal response
Severe obstructive sleep apnea
Genetic channelopathies

References:

Spodick, D. H., Raju, P., Bishop, R. L., & Rifkin, R. D. (1992). Operational definition of normal sinus heart rate. The American Journal of Cardiology, 69(14), 1245–1246. https://doi.org/10.1016/0002-9149(92)90947-w
UpToDate. (n.d.). Www.uptodate.com. https://www.uptodate.com/contents/sinus-bradycardia?search=Bradycardia&source=search_result&selectedTitle=1~150&usage_type=default&disp
Spodick, D. H. (1992). Normal sinus heart rate: Sinus tachycardia and sinus bradycardia redefined. American Heart Journal, 124(4), 1119–1121. https://doi.org/10.1016/0002-8703(92)91012-p
ACLS Bradycardia Algorithm. (n.d.). ACLS Medical Training. https://www.aclsmedicaltraining.com/adult-bradycardia-algorithm/
A. A. J. Adgey, Geddes, J. S., Mulholland, H., Keegan, D., & Pantridge, J. F. (1968). INCIDENCE, SIGNIFICANCE, AND MANAGEMENT OF EARLY BRADYARRHYTHMIA COMPLICATING ACUTE MYOCARDIAL INFARCTION. The Lancet, 292(7578), 1097–1101. https://doi.org/10.1016/s0140-6736(68)91577-8
UpToDate. (n.d.). Www.uptodate.com. Retrieved June 11, 2024, from https://www.uptodate.com/contents/sinus-node-dysfunction-clinical-manifestations-diagnosis-and-evaluation?search=bradycardia&source=
ROTMAN, M., WAGNER, G. S., & WALLACE, A. G. (1972). Bradyarrhythmias in Acute Myocardial Infarction. Circulation, 45(3), 703–722. https://doi.org/10.1161/01.cir.45.3.703
Tisdale, J. E., Chung, M. K., Campbell, K. B., Hammadah, M., Joglar, J. A., Leclerc, J., & Rajagopalan, B. (2020). Drug-Induced arrhythmias: A scientific statement from the american heart association. Circulation, 142(15). https://doi.org/10.1161/cir.0000000000000905
Kusumoto, F. M., Schoenfeld, M. H., Barrett, C., Edgerton, J. R., Ellenbogen, K. A., Gold, M. R., Goldschlager, N. F., Hamilton, R. M., Joglar, J. A., Kim, R. J., Lee, R., Marine, J. E., McLeod, C. J., Oken, K. R., Patton, K. K., Pellegrini, C. N., Selzman, K. A., Thompson, A., & Varosy, P. D. (2019). 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and
Cardiac Conduction Delay. Journal of the American College of Cardiology, 74(7), e51–e156. https://doi.org/10.1016/j.jacc.2018.10.044
Farkas, J. (2021, October 1). Hypothermia. EMCrit Project. https://emcrit.org/ibcc/hypothermia/
UpToDate. (n.d.). Www.uptodate.com. Retrieved June 11, 2024, from https://www.uptodate.com/contents/accidental-hypothermia-in-adults?search=hypothermia&source=search_result&selectedTitle=1~150&usage_type=default&display_r
Näyhä, S. (2005). Environmental temperature and mortality. International Journal of Circumpolar Health, 64(5), 451–458. https://doi.org/10.3402/ijch.v64i5.18026
Decompensated Hypothyroidism (“Myxedema Coma”). (n.d.). EMCrit Project. https://emcrit.org/ibcc/myxedema/#treatment_of_cause
UpToDate. (n.d.). Www.uptodate.com. Retrieved June 11, 2024, from https://www.uptodate.com/contents/evaluation-and-management-of-elevated-intracranial-pressure-in-adults?search=increased%20intracranial%20pressure&source=search_result&selectedTitle=2~150&usage
UpToDate. (n.d.). Www.uptodate.com. https://www.uptodate.com/contents/sinus-bradycardia?search=Bradycardia&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=

Expert Commentary

Thank you for this nice review of the differential diagnosis of bradycardia. As emergency physicians, it’s easy to slip into the default of “symptomatic/unstable” vs “asymptomatic/stable” and slip past the underlying causes, and with bradycardia (as with many things), patients are often not divided quite so neatly.

Similarly, the context matters considerably: what resources are available? Is a cardiologist who can place a permanent pacer upstairs and ready with a staffed lab? Or is “definitive care” hours away (eg, requires transfer, or the cardiology team needs to come in from home). A patient with bradycardia from an acute MI will need the cath lab regardless, but in settings that require a transfer that may require transvenous pacemaker prior to transfer. On the other hand, a patient being whisked upstairs to a cath lab requires a different conversation with the cardiology team, eg preparing for transcutaneous pacing while getting the patient from the door to the balloon in a handful of minutes.

The differential can also be helpful when considering other logistics. For example, while I am happy to place a transvenous pacemaker for a patient who needs it for, say, a high degree AV block from Lyme disease, I may consider if the patient is stable enough to have a transvenous pacer placed more elegantly by the cardiology team as the patient may keep the TVP for 2 weeks but not need a permanent pacemaker.

Of course there are also secondary causes of bradycardia that need other, non-cardiac, definitive treatments, eg, overdose, hypothermia, Cushing’s response, and of course, hyperkalemia; keeping the differential in mind is part of the reason why we have not yet been replaced by robots.

Seth Trueger, MD, MPH, FACEP

Associate Professor of Emergency Medicine

Northwestern Memorial Hospital

How To Cite This Post:

[Peer-Reviewed, Web Publication] Kilbane, K. Power, E. (2024, Jun 17). Symptomatic Bradycardia: Considering the Differential Diagnosis. [NUEM Blog. Expert Commentary by Trueger, S]. Retrieved from http://www.nuemblog.com/blog/symptomatic-bradycardia

Homeward Bound: Acute Hospital Care at Home

Written by: Pranav Kaul, MD (NUEM ’25) Edited by: Gabrielle Bunney, MD, MBA (NUEM ’22)

Expert Commentary by: Luke Neill, MD, MBA (NUEM ’20)

Hospitals and acute care medicine are historically inseparable. However, with hospital-based care totaling nearly one-third of national health expenditures in the United States annually, increasingly limited bed capacity1, and evidence suggesting hospitalizations are unsafe for many elderly patients2, it is no surprise that administrators and policymakers are seeking innovative alternatives to inpatient medicine. 

Currently, for some of the most common conditions, that alternative exists. The acute hospital care at home or “AHCaH” model seeks to bring acute care services (e.g. continuous monitoring, 24-hour provider availability, intravenous medications) to the patient’s home in an effort to allocate health system resources more appropriately relative to patient needs. New evidence suggests that the “hospital at home” model may have cost and quality benefits over traditional hospitalization, strengthening the push for this approach to be adopted more widely. Today, we examine a 2020 randomized-controlled trial from Annals of Internal Medicine comparing the impact of a home hospitalization pilot program on cost and quality of care. 

Study: Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial 

Study Design: Parallel design, randomized controlled trial 

Population: 

91 adults (43 home and 48 control) admitted via the emergency department with selected acute conditions

Intervention: 

Acute care at home including nurse and physician home visits, intravenous medications, remote monitoring, video communication, and point-of-care testing

Outcome Measures: 

Primary: total direct cost of acute care episode (sum of non-physician labor, supplies, medications, and diagnostic tests) 
Secondary: health care use, physical activity during the episode and at 30 days

Results: 

Primary: 38% lower adjusted mean cost for home patients vs control including fewer diagnostics and consultations. 
Secondary: Smaller proportion of day spent sedentary or lying down; fewer 30-day readmissions (7% vs 23%)

Discussion/Conclusions: 

This study sought to compare cost, quality, and experience outcomes between patients who received “home hospital care” and those who were admitted to the hospital. Using broad inclusion and exclusion criteria that incorporated physician judgment, patients were enrolled and randomized to either the intervention (home hospital care) or control (inpatient hospital) at admission.

When comparing costs, the intervention group had a 38% lower adjusted means cost than the control, including fewer laboratory orders, imaging studies, and consultations. Moreover, patients who received acute care at home had significantly lower 30-day readmission rates (7% vs. 23%). Overall, quality and patient satisfaction outcomes were largely similar between the two groups. 

Despite these promising results, home hospital care is an evolving field of research that warrants further investigation. While this study suggests that cost and readmission reductions can be achieved without compromising care quality, it is important to recognize its limitations. Inclusion and exclusion criteria were dependent on subjective assessments by admitting providers, which limits generalizability of the findings. Without a standardized protocol to select appropriate patients, it will be challenging to implement. Among patients that were selected for inclusion, approximately 63% opted out of the study. A broad set of conditions were included without any stratification, and patients were carefully selected for “low risk of clinical deterioration.” Consequently, the small sample size and case distribution may have also limited the study’s power and ability to accurately capture safety events in either group.

Home hospital care presents many possible advantages to patients, payors, and providers, but it continues to seek comprehensive and generalizable data to support its widespread implementation. Studies such as this one provide a strong foundation for further research into this area through larger trials and systematic reviews. 

References:

1 Horwitz LI, Green J, Bradley EH.US emergency department performance on wait time and length of visit. Ann Emerg Med. 2010;55:133-41.  [PMID:  19796844]  doi:10.1016/j.annemergmed.2009.07.023 

2 Hung WW, Ross JS, Farber J, et al.Evaluation of the Mobile AcuteCare of the Elderly (MACE) service. JAMA Intern Med. 2013;173:990-6. [PMID: 23608775] doi:10.1001/jamainternmed.2013.478 

3Levine DM, Ouchi K, Blanchfield B, Saenz A, Burke K, Paz M, Diamond K, Pu CT, Schnipper JL. Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Ann Intern Med. 2020 Jan 21;172(2):77-85. doi: 10.7326/M19-0600. Epub 2019 Dec 17. PMID: 31842232.

Expert Commentary

Launched in 2020 by the Center for Medicare and Medicaid Services (CMS), the Acute Hospital Care at Home program allows patients to receive inpatient level care within their own home.  A patient can be admitted to home through two main mechanisms:

The Patient can be admitted directly to home from the Emergency Department
A patient who was initially admitted to the floor can be transferred early to acute inpatient care at home to finish the remainder of their admission.

In order to begin enrolling patients in the program, each individual hospital must submit an Acute Hospital Care At Home Waiver to CMS and receive approval. Northwestern Memorial Hospital received approval for the waiver back on March 27th of 2021 and after spending a year building the infrastructure of the program, admitted the first patient into both our program and within Chicago on March 27th of 2022.    

As of February 2024, there are now 131 systems including 313 hospitals in 37 states, and CMS closely monitors these programs. Health systems interested in the program can learn more here.

Unequivocal Program Benefits: 

  Acute Care at Home Models Reduce Costs - In general, acute care at home programs have realized savings of 30 percent or more per admission, while maintaining equivalent or better outcomes.1

  Acute Care at Home Models Improve Quality – Quality results for care in the home are comparable to or better than those realized for facility-based care. Programs have demonstrated a reduction in readmissions, mortality, complications, and emergency department visits.2,3

 Consumers Prefer to Receive Care in the Home – Home-based care is preferred by the overwhelming majority.4

 Home-Based Models Contribute to Improving Disparities and Trust – Home-based models provide marginalized communities the option to conveniently receive care at home, which helps to reduce barriers to facility-based care such as access to transportation. Home-based care also promotes trust and communication between the patient and provider by removing institutional barriers and placing the interaction in a familiar setting.4

References

Adams D, et al. Initial Findings From an Acute Hospital Care at Home Waiver Initiative. JAMA Health Forum. 2023;4(11)Levine DM, et al. Acute Hospital Care at Home in the United States: The Early National Experience. Ann Intern Med. 2024 Jan;177(1):109-110. 
Levine DM, et al. Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Ann Intern Med. 2020 Jan 21;172(2):77-85.
Federman AD, Association of a Bundled Hospital-at-Home and 30-Day Postacute Transitional Care Program With Clinical Outcomes and Patient Experiences. JAMA Intern Med. 2018;178(8):1033–1040.
Leff B et. al. Satisfaction with hospital at home care. J Am Geriatr Soc. 2006 Sep;54(9):1355-63

Luke Neill, MD, MBA

Director, Hospital at Home Program

Emergency Medicine

Northwestern Memorial Hospital

How To Cite This Post:

[Peer-Reviewed, Web Publication] Kaul, P, Bunney, G (2024, May 20). Acute Hospital Care at Home. [NUEM Blog. Expert Commentary by Neill, L. Retrieved from http://www.nuemblog.com/blog/hospital-care-at-home

Accidental Tracheostomy Decannulation

**Written by:** Chezlyn Patton, MD (NUEM ‘27) **Edited by:** Keara Kilbane, MD (NUEM ‘25)
**Expert Commentary by**: Matt McCauley, MD (NUEM ‘21)

Introduction

Tracheostomy is a common procedure in the US with over 110,000 trachs placed annually (1). Complications occur at a rate of approximately 40-50%, however most complications are minor, with only 1% being catastrophic (1). Of these devastating complications, 90% occur within the first 10 days of placement. Overall approximately 15% of tracheostomies will be decannulated accidentally, and in a critical care setting, 50% of airway related deaths were associated with accidental tracheostomy decannulation (1, 2).

One way to approach a decannulated tracheostomy tube could be with the acronym, IRMI; Investigate, Recannulate, Monitor, and Intubate (if you must).

Investigate: How long ago was the tracheostomy tube placed? How long has it been out? What is the size of the trach? Is it cuffed or uncuffed? Why was the trach placed initially?

Cuffed vs. uncuffed: Is there a pilot balloon present? If yes, that indicates the trach is a CUFFED tracheostomy tube.
Size of tracheostomy tube: ALWAYS labeled on the neck flange.

Figure 1: Size of trach tube identification on flange. Borrowed from https://tracheostomyeducation.com/tracheostomy-tubes/.

Figure 2: Tracheostomy tube parts labeled, borrowed from *©Linda L. Morris and M. Sherif Afifi,* https://www.trachresource.com/table-of-contents/

Recannulate: Oxygenate from above with non-rebreather or by blow by oxygen over the tracheostomy stoma if the patient is spontaneously breathing. If they are in respiratory distress or not spontaneously breathing, bag-valve-mask (BVM) oro-nasopharyngeal or over the stoma. You can use a pediatric mask to fit over the stoma or a LMA. Ensure to occlude the stoma if BVM from above or close the mouth if BVM from the stoma to prevent air leakage. Note, if the patient is ventilator dependent, you need a CUFFED tracheostomy tube. Obtain one tracheostomy tube of appropriate size, and a tube that’s a size down, as a stoma may begin to close the longer it’s out. For stomas less than 10 days old, grab a fiberoptic scope, as these will require recannulization under direct visualization. This is to minimize the risk of creating a false passage.

Figure 3: Depiction of creation of false passage through subcutaneous tissue when replacing tracheostomy tube. Borrowed from: Morris, L.L., Whitmer, A., & McIntosh, E. (2013). Tracheostomy care and complications in the intensive care unit. *Critical care nurse, 33 5*, 18-30 .

Otherwise, you can place blindly for the initial insertion. Ensure the obturator is placed inside the outer cannula tracheostomy tube prior to insertion, as it blunts the hard edge of the tracheostomy tube that can damage the membranous wall of trachea. If you meet any resistance, size down immediately, as the stoma has likely started to heal (even with a matured tracheostomy). Then remove the obturator and inflate the cuff to maintain placement (3,4).

Monitor: Once the trach tube is reinserted, it is important to monitor for appropriate placement and gas exchange. Continuous capnography is the gold standard for this. Additionally, the tube should be confirmed to be in the trachea through direct fiberoptic visualization of the trachea and carina. Be sure to assess for complications such as creation of a false lumen, which could manifest as subcutaneous emphysema (5).

Intubate if you must: If faced with a scenario where the tracheostomy tube cannot be passed through the stoma, and your patient is developing respiratory distress, you can intubate your patient orotracheally if they have a patent upper airway. The only exception to this is a patient who has had a laryngectomy, as those patients cannot be intubated orally and are obligate neck stoma breathers (6).

References

1.Bontempo, Laura J., and Sara L. Manning. "Tracheostomy emergencies." Emergency Medicine Clinics 37.1 (2019): 109-119.

2. Cheung, Nora Ham-Ting and Lena M. Napolitano. “Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes.” Respiratory Care 59 (2014): 895 - 919.

3. Rajendram, R., and N. McGuire. "Repositioning a displaced tracheostomy tube with an Aintree intubation catheter mounted on a fibre-optic bronchoscope." BJA: British Journal of Anaesthesia 97.4 (2006): 576-579.

4. Shah RK, Lander L, Berry JG, et al. Tracheotomy outcomes and complications: a national perspective. Laryngoscope 2012;122(1):25–9

5. Riley, Christine M.. “Continuous Capnography in Pediatric Intensive Care.” Critical care nursing clinics of North America 29 2 (2017): 251-258 .

6. McGrath B, Bates L, Atkinson D, et al, National Tracheostomy Safety Project. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia 2012;67(9):1025–41.

Expert Commentary

Thank you for this concise summary of tracheostomy management. While most of the immediate complications of tracheostomy will occur in the ICU, these patients still frequent our emergency department with and without tracheostomy related emergencies. Despite this, patients with tracheostomy can be intimidating there is a general lack of knowledge about tracheostomy among healthcare professionals in general and emergency medicine trainees in specificity.1,2

As you have outlined, understanding both the chronicity of the tracheostomy as well as the indication for the procedure are key history when managing a displaced tube. A patient who underwent tracheostomy for failure to liberate for the ventilator likely has a patent upper airway while one placed following an ENT surgery likely poses a significant challenge for orotracheal intubation! Obtaining this history (and handing off this key information when transitioning care) can be lifesaving. Significant care should be taken when replacing a tracheostomy through an immature stoma, the usual cited maturity date being 10 to 14 days old. These should always be replaced over a fiber-optic scope with visualization of the tracheal rings and carina prior to cuff inflation and ventilation by BVM or ventilator. Failure to do so can result in severe pneumomediastinum, pneumothorax, subcutaneous emphysema, and respiratory arrest if placement into a false tract is not recognized3 . Replacement of a tracheostomy tube into a mature tract can be done blindly with an obturator in place but care should also be taken if there are any signs of trauma or bleeding. When in doubt, play it safe and obtain fiber optic visualization!

While trach replacement can be stressful under the wrong circumstances, patients with tracheostomy tubes can present with enumerable other emergencies. As with any high stress situation in resuscitation, it helps to fall back onto our ABCs, airway being of principle importance here. The immediate assessment of any patient with a tracheostomy tube in extremis should be focused on a singular question: can I ventilate the patient through this tube? In order for a patient to be effectively bagged or ventilated through a tracheostomy tube three things must be true. The tube must be patent and endotracheally placed, the tube must be cuffed, and the cuff must be inflated. Patency can be quickly assessed with passage of a flexible suction catheter. If this is unsuccessful, removal of the inner cannula (if present) and replacement with a fresh inner cannula can often resolve obstruction by secretions. If obstruction is unable to resolve, you should oxygenate from above while preparing to replace the tracheostomy tube as you have elegantly outlined.

The presence of a cuffed tube will be indicated by the presence of a pilot balloon, no reading of numbers or brand names needed! Finally, cuff inflation can be confirmed by palpation of the pilot balloon and assessing for any speech production or gurgling hear though the mouth. If the patient can phonate then the balloon is not properly inflated! If gentle inflation of the cuff does not resolve the air leak assume a ruptured cuff and replace the tracheostomy.

Tracheostomy tube care and emergencies can be very intimidating but this procedure is a valuable tool for ICU and ventilator liberation. As emergency physicians, we need to be familiar with the nuances of these devices so we can safely manage the airway just as we would any sick patient.

References

1. Whitcroft KL, Moss B, Mcrae A. ENT and airways in the emergency department: national survey of junior doctors’ knowledge and skills. J Laryngol Otol. 2016;130(2):183-189. doi:10.1017/S0022215115003102

2. Darr A, Dhanji K, Doshi J. Tracheostomy and laryngectomy survey: do front-line emergency staff appreciate the difference? J Laryngol Otol. 2012;126(6):605-608; quiz 608. doi:10.1017/S0022215112000618

3. Long B, Koyfman A. Resuscitating the tracheostomy patient in the ED. Am J Emerg Med. 2016;34(6):1148-1155. doi:10.1016/j.ajem.2016.03.049

Matt McCauley, MD

Assistant Professor, Division of Critical Care

UW BerbeeWalsh Department of Emergency Medicine

Associate Medical Director

UW Organ and Tissue Donation

How To Cite This Post:

[Peer-Reviewed, Web Publication] Patton, C. Kilbane, K. (2024, Apr 15). Accidental Tracheostomy Decannulation. [NUEM Blog. Expert Commentary by McCauley, M]. Retrieved from http://www.nuemblog.com/blog/tracheostomy-decannulation

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Posted on April 15, 2024 by NUEM Blog and filed under Critical care, ENT and tagged tracheostomy difficult airway ENT.

Molar Pregnancy

Written by: Conner Morton, MD (NUEM ‘26) Edited by: August Grace (NUEM ‘24)

Expert Commentary by: Dana Loke, MD, MS

Expert Commentary

Thank you to Drs. Morton and Grace for this excellent infographic highlighting molar pregnancy and its relevance to Emergency Medicine providers. While rarer than other pregnancy issues seen in the Emergency Department, molar pregnancy is an important diagnosis for Emergency Medicine providers to be able to recognize, understand, and treat. As listed in the above post, symptoms of molar pregnancy can be similar to viable pregnancy and its complications, so it is important to obtain a timely ultrasound in any patient with unknown pregnancy location or if considering molar pregnancy. While molar pregnancy is not a difficult diagnosis to make as long as an ultrasound is done, it is important to be wary of its complications and treat appropriately. This includes monitoring vitals, specifically in consideration of hemorrhage and pre-eclampsia, with resuscitation and transfusion as needed. Consultation with OB/GYN should occur in the Emergency Department for immediate next steps, which will include procedural management. When updating the patient about the diagnosis and next steps, make sure to sensitively explain that molar pregnancy is nonviable. Lastly, make sure to complete a comprehensive review of systems and physical exam; molar pregnancy is associated with choriocarcinoma, which is known to spread widely and aggressively throughout the body.

Dana Loke, MD, MS

Assistant Professor

Emergency Medicine

University of Wisconsin-Madison

How To Cite This Post:

[Peer-Reviewed, Web Publication] Morton, C. Grace, A. (2024, Apr 1). Molar Pregnancy. [NUEM Blog. Expert Commentary by Loke, D. Retrieved from http://www.nuemblog.com/blog/molar-pregnancy

TXA in the Trauma Bay

Expert Commentary

Unlike many of the treatments and interventions we use in the Emergency Department and the trauma bay, tranexamic acid (TXA) has rather robust studies to guide usage. Like many interventions, however, even when there are studies with large numbers of patients and positive results, there are still barriers towards implementation. TXA is no different.

Working at a Level 1 Trauma Center and frequently interacting closely with the trauma surgeons through the Trauma Quality Management Committee, I often follow their lead when it comes to promising trauma innovations through the years such as TXA, REBOA, permissive hypotension, and so on. What I have observed is that our trauma surgeons tend to believe that there is benefit to properly timed TXA in the right trauma patients and that we do not use it enough. Yet use of TXA in trauma at our hospital has not been protocoled.

Why not? Some possibilities:

Someone usually (but not always) thinks to give it to patients who would benefit despite there not being a protocol (thanks ED pharmacists!).
The patients who need it most also need something else even more – source control of hemorrhage. Anything that slows or distracts from that may be counterproductive. It may not seem like a simple TXA infusion would delay anything. But keep in mind the multiple lines sick trauma patients may need and the often already chaotic nature of “the bay” getting the sickest patients the tubes, meds, lines, products, studies, and, ultimately, proper disposition during their “golden hour”. The nurses have many tasks, to say the least. But maybe this is an argument for why use of TXA should just be protocolized.

I bounced this off of our trauma section head to make sure I was not misrepresenting their thoughts. As a result, we are looking into protocolling its use. Thanks NUEM Blog!

Matthew Levine, MD

Associate Professor of Emergency Medicine

Department of Emergency Medicine

Northwestern Memorial Hospital

How To Cite This Post:

[Peer-Reviewed, Web Publication] Shimberg, J. Lima, R. (2024, Mar 11). TXA in the Trauma Bay. [NUEM Blog. Expert Commentary by Levine, M]. Retrieved from http://www.nuemblog.com/blog/txa-trauma

Breastfeeding Pharmacy: Analgesics

Expert Commentary

“Pump and dump” is definitely the easy way out for the emergency medicine provider, but this practice can have detrimental effects on the baby and on the mother. There is a false pretense that many medications are harmful to the breastfeeding infant, but this is not the case. The other consideration to have when thinking about medication use in breastfeeding is the medication effects on the mother’s lactation and the medication impact on breast milk production.

Ibuprofen by far has the most supporting evidence for use in breastfeeding women and this is a reasonable first line agent for treating many types of pain. Ketorolac is used frequently immediately after delivery and limited amount of drug is excreted in colostrum, but more may be excreted as milk supply increases thus increasing the risk of bleeding in the infant. Aspirin is excreted into breastmilk, and long-term use of high doses may cause bleeding along with metabolic abnormalities in the infant. That said, long-term use of low dose aspirin is likely safe.

If opioids are required for pain control, fentanyl is a reasonable choice for immediate pain control. Combination hydrocodone and acetaminophen is also an option when oral pain medications need to be utilized. The jury is (sort of) out on if oxycodone is safe during breastfeeding, and the baby should be monitored closely if oxycodone is selected for pain management.

Local anesthetics are very poorly absorbed by the infant, but still remain diligent about checking the specific maximum recommended dose for adults. My favorite database to find information on medications in lactation is LactMed, a database funded by the NIH. It is always safest to check this database before prescribing a medication to a lactating patient.

Kelsea Caruso, PharmD

Clinical Pharmacist

Department of Emergency Medicine

Northwestern Memorial Hospital

How To Cite This Post:

[Peer-Reviewed, Web Publication] Premer-Barragan, C. Payne, A. (2023, Jul 31). Breastfeeding Pharmacy Analgesics. [NUEM Blog. Expert Commentary by Caruso, K]. Retrieved from http://www.nuemblog.com/blog/breastfeeding-pharm-analgesics

Breastfeeding Pharmacy: Antibiotics

Expert Commentary

Emergency Medicine practitioners may be quick to recommend patients to “pump and dump” when on antibiotics, but this can have downstream detrimental effects on the baby and on the mother. With the numerous indications for antibiotics, including some dealing with breastfeeding itself, it is imperative that EM providers recognize that most antibiotics are considered safe.

Most beta-lactam antibiotics are considered safe in breastfeeding women and can be used to treat many infections. Depending on the type of infection, anaerobic coverage may be warranted. Case reports have documented the potential for metronidazole to cause Candida infections and diarrhea in the infant. Clindamycin has the highest potential to cause GI issues in the breastfed infant. If these medications are indicated, it is best to have a risk-benefit discussion with the patient about the best option.

Tetracyclines have historically been feared in breastfeeding mothers due to the potential for bone deposition and staining of the dental enamel. As more literature has reviewed their safety, tetracyclines are considered safe for short term use, but limit courses to fewer than 21 days. Tetracycline absorption is also inhibited by calcium, which is contained in breast milk, so the amount actually absorbed by the infant should be low.

My favorite database to find information on medications in lactation is LactMed, a database funded by the NIH. Always the safest bet is to check this database before prescribing a medication to a lactating patient.

Kelsea Caruso, PharmD

Clinical Pharmacist

Department of Emergency Medicine

Northwestern Memorial Hospital

How To Cite This Post:

[Peer-Reviewed, Web Publication] Premer-Barragan, C. Payne, A. (2023, Jul 25). Breastfeeding Pharmacy Antibiotics. [NUEM Blog. Expert Commentary by Caruso, K]. Retrieved from http://www.nuemblog.com/blog/breastfeeding-pharm-antibiotics

COVID-19 and Mental Health

**Written by:** Evelyn Huang, MD (NUEM ‘24) **Edited by:** Julian Richardson (NUEM ‘21)
**Expert Commentary by**: Tyler Black, MD, FRCPC

COVID-19 has been difficult for everyone. Deaths, isolation, loss of work, and countless other hardships abound. With this, comes the concern for mental health crises. In a survey from June 2020, 11% of adults reported thoughts of suicide in the past 30 days [1]. It can be hypothesized that the pandemic has increased suicide rates. However, does this bear out in the literature? As frontline workers, and oftentimes the only interaction that patients have with the healthcare system, it is particularly important that we identify the impact of COVID-19 on the mental health of the patients that we see every day.

In Japan, researcher used a cross-sectional study to analyze national suicide rates during the COVID-19 pandemic. They found that suicide rates in 2020 were increased in October and November for men and in July through November for women when compared to 2016-2019. Increases in suicide rates were more pronounced with men and women that are younger than 30 [2]. This supports the idea that suicide rates increased as a result of the pandemic, especially with the younger population.

However, the trends in the United States are different. A study conducted in the US looked at suicide rates in Massachusetts from March to May 2020. Excluding data from pending death investigations, they found that the incident rate for suicide death was 0.67 per 100,000 person-months for the pandemic period as compared to 0.80 in the corresponding period in 2019. The researchers point to a sense of shared purpose, connections via video platforms, anticipated government aid, and mental health awareness campaigns as possible explanations for the stable rate of suicide deaths [3]. Another study looked at United States suicide related searches during the beginning of the pandemic. Researchers found that internet searches for suicide decreased during the early stages of the COVID pandemic (March to July 2020). While this may be surprising, there is literature that shows that catastrophic events can be associated with increased social support and reduce suicidal outcomes [4]. However, as the pandemic lengthens, more research is needed to see the trends in the data.

The next question is whether the same trend of decreased suicidality also applies to the pediatric population. A pediatric emergency department in Texas looked at the resulted of their routine suicide risk screenings for patients aged 11-21. They found a significantly higher rate of suicidal ideation in March and July 2020 and a higher rate of suicide attempts in February, March, April, and July 2020 when compared to the same months in 2019 [5]. It has also been cited that prior to the pandemic, suicide was the 10th leading cause of death in the United States, but the 2nd leading cause of death among people aged 12-17 [1]. This makes our interactions with the pediatric population even more important and argues for suicide risk screening for every patient.

Looking historically, there are differing trends for different global catastrophes. One researcher found that World War I did not influence United States suicide rates, whereas the great Influenza Epidemic increased suicide rates [6]. Another study looked at suicide rates in Hong Kong during the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003. They found an increase in older adult suicide in April 2003 when compared to 2002. These researchers cited loneliness and disconnectedness in the older community as a possible explanation [7]. While there are many different factors that go into increased suicidality, trends seen in the past can help guide policy and actions today.

Research is still needed to look at the current trends of suicide rates. The question is whether suicide rates will change as the pandemic continues to lengthen and the sense of shared purpose wanes and social isolation continues. The mental health of our patients is likely to be impacted long after the pandemic ends.

A study conducted in California found that emergency department patients presenting with deliberate self-harm or suicidal ideation had an increased risk of suicide or other mortality during the first year after their initial presentation in the emergency department [8]. This is a troubling trend, but also presents an opportunity for improvement. As emergency physicians, it is also important that we keep vigilant and take the time to talk about mental health. A common fear is that asking about suicide will prompt suicidal ideation, but research has shown that this is not the case [9]. There are several suicide screening tools that can be used in the ED, such as the Suicide Assessment 5‐step Evaluation and Triage (SAFE‐T) and American College of Emergency Physicians ICAR2E [9]. What is important is to ask, because patients will often reveal things to us that they do not mention to their loved ones. Build suicide screenings into your general practice, watch out for risk factors, and support those that are seek help.

References

1. Panchal, Nirmita, et al. The Implications of COVID-19 for Mental Health and Substance Use. Kaiser Family Foundation, 10 Feb. 2021, www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/.

2. Sakamoto H, Ishikane M, Ghaznavi C, Ueda P. Assessment of Suicide in Japan During the COVID-19 Pandemic vs Previous Years. JAMA Netw Open. 2021;4(2):e2037378. doi:10.1001/jamanetworkopen.2020.37378

3. Faust JS, Shah SB, Du C, Li S, Lin Z, Krumholz HM. Suicide Deaths During the COVID-19 Stay-at-Home Advisory in Massachusetts, March to May 2020. JAMA Netw Open. 2021;4(1):e2034273. doi:10.1001/jamanetworkopen.2020.34273

4. Ayers JW, Poliak A, Johnson DC, et al. Suicide-Related Internet Searches During the Early Stages of the COVID-19 Pandemic in the US. JAMA Netw Open. 2021;4(1):e2034261. doi:10.1001/jamanetworkopen.2020.34261

5. Hill RM, Rufino K, Kurian S, Saxena J, Saxena K, Williams L. Suicide ideation and attempts in a pediatric emergency department before and during COVID-19. Pediatrics. 2020; doi: 10.1542/peds.2020-029280

6. Wasserman IM. The impact of epidemic, war, prohibition and media on suicide: United States, 1910-1920. Suicide Life Threat Behav. 1992 Summer;22(2):240-54. PMID: 1626335.

7. Cheung YT, Chau PH, Yip PS. A revisit on older adults suicides and Severe Acute Respiratory Syndrome (SARS) epidemic in Hong Kong. Int J Geriatr Psychiatry. 2008 Dec;23(12):1231-8. doi: 10.1002/gps.2056. PMID: 18500689.

8. Goldman-Mellor S, Olfson M, Lidon-Moyano C, Schoenbaum M. Association of Suicide and Other Mortality With Emergency Department Presentation. JAMA Netw Open. 2019;2(12):e1917571. doi:10.1001/jamanetworkopen.2019.17571

9. Brenner, J. M., Marco, C. A., Kluesner, N. H., Schears, R. M., & Martin, D. R. (2020). Assessing psychiatric safety in suicidal emergency department patients. Journal of the American College of Emergency Physicians Open, 1(1), 30-37.

Expert Commentary

This review is a comprehensive summary of the challenges and nuances of suicide epidemiology. Though it goes against the narrative many hold, in the United States we have preliminary but reliable data for suicides two years into the pandemic, we have not seen an increase in suicide rate in any age group (Figure 1) [1,2]. This reassuring news is tempered by the knowledge that prior to the pandemic, a decade-long trend of increasing suicide rates has maintained, and children, adults, and older adults are much more likely to die of suicide now in America than they were in 2010 [3].

**Figure 1.** Odds ratio for suicide, by age groups (A = under 18 years; B = 18 to 64 years; C = above 64 years). Years are grouped to match with the onset of the pandemic (March 2020), such that each data point represents April of that year to the following March (instead of the typical January to December presentation). The comparator for each year’s odds of suicide is a sum of the odds between April 2017 and March 2020. The shaded vertical lines represent the 95% confidence interval for odds ratio, and they are hidden behind the markers for the adult group due to the small confidence interval.

Whenever considering suicide risk, it is crucial to remember that there are not direct links between suicidal thinking, suicide attempts or visits to the emergency department, and deaths by suicide. Up to 60% of people die of suicide on their first attempt, and the vast majority (95%) of people who attempt suicide do not die of suicide, so while it is important to see the danger in suicidal presentations to emergency department, it is crucial to be aware of the challenges in predicting who will live and who will die by suicide and focus on a person-centered approach to understanding an individual’s risk and protective factors[4, 5].

I applaud the authors for encouraging all clinicians to consider suicide risk in all patients and to become comfortable with routine screening. This may never demonstrate a reduction in suicide rates in rigorous research, but we have ample evidence that having open, genuine discussions about psychological, social, and health problems regarding suicide risk is beneficial to the patients we care for [6].

References

1. Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 1999-2020 on CDC WONDER Online Database, released in 2021. Data are from the Multiple Cause of Death Files, 1999-2020, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/ucd-icd10.html on Dec 1, 2022.

2. Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Provisional Mortality on CDC WONDER Online Database. Data are from the final Multiple Cause of Death Files, 2018-2020, and from provisional data for years 2021-2022, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/mcd-icd10-provisional.html on Dec 1, 2022

3. Centers for Disease Control and Prevention. (2022, June 28). Suicide data and statistics. Centers for Disease Control and Prevention. Retrieved December 1, 2022, from https://www.cdc.gov/suicide/suicide-data-statistics.html

4. Bostwick, J. M., Pabbati, C., Geske, J. R., & McKean, A. J. (2016). Suicide attempt as a risk factor for completed suicide: Even more lethal than we knew. American Journal of Psychiatry, 173(11), 1094–1100.

5. Hawton, K., Lascelles, K., Pitman, A., Gilbert, S., & Silverman, M. (2022). Assessment of suicide risk in mental health practice: shifting from prediction to therapeutic assessment, formulation, and risk management. The Lancet Psychiatry.

6. Dazzi, T., Gribble, R., Wessely, S., & Fear, N. T. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence?. Psychological medicine, 44(16), 3361-3363.

Tyler Black, MD, FRCPC

Assistant Clinical Professor

Department of Psychiatry

The University of British Columbia

How To Cite This Post:

[Peer-Reviewed, Web Publication] Huang, E. Richardson, J. (2023, Jan 2). COVID-19 and Mental Health. [NUEM Blog. Expert Commentary by Black, T]. Retrieved from http://www.nuemblog.com/blog/covid-mental-health

EMTALA and Patient Transfers

Expert Commentary

While EMTALA was first enacted to address issues with “patient dumping”, it has had broad influence on how patients are treated, dispositioned, and transferred in emergency department and hospital settings. In addition, EMTALA law has taken on almost mythic proportions among healthcare workers and administrators, likely due to high-profile cases, the fear of potential violation of the law and subsequent penalties, the potential for it to bolster civil malpractice claims, misunderstanding of it by healthcare personnel, and variability in interpretation by regulatory bodies.

Emergency physicians are often called upon to make decisions as the default expert in EMTALA for patients presenting for emergency care or in fielding hospital transfer calls. Unfortunately, on-call specialty physicians involved in the acceptance of transfers, and even hospital transfer centers, may not have a good understanding of the statue. As such, emergency physicians who are not versed in EMTALA can put both the hospital and themselves at risk.

The infographic by Dr. Tandlich gives an excellent summary of EMTALA. In addition, it is imperative that hospitals and emergency departments establish clear processes and appropriate documentation for EMTALA-related situations. More specifically, important concepts to consider include:

When conducting a medical screening exam (MSE), approach it as a process with consistent implementation for all patients and understand this often includes more than just a physical exam
When accepting transfers from outside hospitals, do not solely rely on on-call physicians to make the decisions
When transferring patients to outside hospitals, make clear the reasoning, the patient status, and the risks and benefits

It behooves emergency physicians, emergency department staff, and transfer centers to understand the basic concepts around EMTALA. Overall, the best advice is to do that which is in the best interest of the patient, as this will usually lead to the right decision.

Michael Schmidt, MD

Chief of Staff

Department of Emergency Medicine

Northwestern Memorial Hospital

How To Cite This Post:

[Peer-Reviewed, Web Publication] Tandlich, M. Feiger, D. (2022, Oct 31). EMTALA. [NUEM Blog. Expert Commentary by Schmidt, M]. Retrieved from http://www.nuemblog.com/blog/emtala-transfers

Health Insurance Basics

**Written by:** Evelyn Huang, MD (NUEM ‘24) **Edited by:** Vytas Karalius, MD, MPH (NUEM ‘22)
**Expert Commentary by**: Cedric Dark, MD, MPH

Health Insurance: The Basics Every Doctor Should Know

A Brief History of Insurance in the U.S.

In 1929, teachers in Dallas contracted with Baylor University Hospital to have monthly payments in exchange for up to 21 days of inpatient care a year. By 1937, there were 26 similar plans that all combined to form the Blue Cross network. In the 1930s, physicians also formed a network of insurance plans known as Blue Shield [1].
During World War II, wage controls prevented employers from raising salaries. As a result, they started to offer health insurance. The IRS added that employers and employees did not have to include these costs in their taxable income [1].
In 1944, President Franklin Roosevelt called for an “Economic Bill of Rights” that included the right to medical care that was never passed. President Truman proposed national health insurance for all Americans that was unpopular due to anti-communist sentiment [1, 2].
In 1965, Medicare and Medicaid were created. In 1972, Medicare was extended for people under 65 who had long-term disabilities and/or end-stage renal disease [2].
In 2010, the Patient Protection and Affordable Care Act (ACA) was passed [2].

Medicare Basics

As of 2019, Medicare covers approximately 61.4 million people [4]. Medicare is federally-run and has four parts:

Part A: inpatient services, nursing care, home health
Part B: outpatient services, ED visits
Part C: “Medicare Advantage,” enrolling in Medicare benefits through private insurers
Part D: prescription medications

Medicaid Basics

As of 2019, Medicaid covers approximately 75.8 million people and includes low-income adults, pregnant, and children [4]. Medicaid is unique from Medicare in that it is state-run with set federal regulations. The Affordable Care Act expanded eligibility to households with income up to 138% of the federal poverty level [2]. To date, 39 states including DC have adopted this expansion and 12 states have not, as seen in the map below [5].

Medicaid also includes the Children’s Health Insurance Program (CHIP) for children living in households that are under 200% of the federal poverty level and is state-run [2]. As of 2019, CHIP covers approximately 7.2 million children [4].

Patients that come to the emergency room are also able to apply for emergency Medicaid if they are currently uninsured. The details of this vary from state to state.

The Affordable Care Act

Signed into law 2010, the Patient Protection and Affordable Care Act had three main goals: expanding healthcare coverage, decreasing health care costs, and improving health care delivery.

Expanding healthcare coverage
- Medicaid expansion
- Individual mandate (discussed in “Private Insurance Basics”)
- Requirements for employers to offer health insurance plans
- Dependent coverage for children up to age 26
- Removed insurance exclusions for patients with pre-existing conditions
Decreasing health care costs
- Tax credits for small business employers that purchase health insurance for employees
- Creation of health insurance exchanges
- Insurance market rules, such as limiting deductibles and prohibiting lifetime limits of coverage
- Discounts for prescription drugs for patients covered by Medicare
Improving health care delivery
- National quality improvement strategies
- Required health plans to cover preventative services
- Bonus payments for primary care physicians
- Grants for wellness programs
- Required chain restaurants to disclose nutritional content

For more information on the ACA, visit this website.

Private Insurance Basics

The ACA enacted an individual mandate, which required Americans to have health insurance or face a tax fee. However, the individual mandate penalty was repealed starting in 2019. Private insurance can be purchased individually, through an exchange/marketplace (third-party markets created by the ACA) or is provided by employers [2].

The ACA also set up 10 essential health services that must be covered with insurance plans. This includes hospitalizations, ambulatory services, lab tests, prescriptions, and emergency services [7].

There are different types of private health insurances, and it is important to have a basic knowledge of this when caring for your patients [9]:

HMO (Health Maintenance Organization): you choose a primary care physician (PCP) that is in-network, you will need a PCP referral for any specialists, no out-of-network care is covered
PPO (Preferred Provider Organization): you can choose in-network providers (typically lower cost) or out-of-network providers, no referral needed for specialists
EPO (Exclusive Provider Organization): does not cover out-of-network providers, but do not need a referral for specialists
POS (Point of Service): you have a PCP that is in-network and that must give you a referral to see a specialist, but you can also access out-of-network options for a higher cost
Catastrophic plan: only available for people under 30 or with a hardship exemption (affordability exemption), low premium and high deductible, theoretically only used for serious illness

Insurance plans on the marketplace also have different metal tiers to their plans. As you go up in tiers, the insurance company pays more when you get healthcare, with a higher associated monthly premium. If someone utilizes a lot of health care, a higher tier choice is better [8].

Bronze: lowest premium, higher cost that you must pay when obtaining care, high deductible
Silver: moderate premium, moderate cost when obtaining care
Gold: high premium, low cost when obtaining care, low deductible
Platinum: highest premium, lowest cost when obtaining care, low deductible

Insurance Definitions You Should Know

Premium: monthly payment to insurance company regardless of whether you use the insurance
Deductible: how much you pay for health services before insurance starts to pay
- Plans with lower premiums typically have higher deductibles
- Usually, you will still need to pay copays and coinsurance if you reach your deductible until you meet your out-of-pocket maximum
Out-of-pocket maximum: after this level, insurance will pay for 100%
- Includes deductible, copay, and coinsurance
- The ACA established that policies must include an out-of-pocket maximum
  - For 2020: $8,150 for an individual and $16,300 for a family [9]
Copay(ment): fixed payment for specific service or medication
- E.g. You pay $20 every time you see your PCP
Coinsurance: Percentage of cost that you pay before the out-of-pocket maximum
- E.g. You pay 20% every time you see your PCP

Part of medical care is knowing that there is an associated cost with every test and treatment that we use. Medical insurance is essential to this, and it is important to know the basic ideas and language surrounding insurance, so that we can better serve our patients.

References

1. Moseley III GB. The U.S. Health Care Non-System, 1908-2008. AMA Journal of Ethics. 2008;10(5):324-331.

2. Schlicher N, Haddock A. Emergency Medicine Advocacy Handbook. 5th ed. Irving: Emergency Medicine Residents’ Association; 2019:1-8.

3. What's Medicare?. Medicare.gov. https://www.medicare.gov/what-medicare-covers/your-medicare-coverage-choices/whats-medicare. Accessed August 18, 2020.

4. CMS Fast Facts. Cms.gov. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMS-Fast-Facts. Published 2020. Accessed August 18, 2020.

5. Status of State Medicaid Expansion Decisions: Interactive Map. KFF. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/. Published 2020. Accessed August 18, 2020.

6. Summary of the Affordable Care Act. KFF. https://www.kff.org/health-reform/fact-sheet/summary-of-the-affordable-care-act/. Published 2013. Accessed November 10, 2020.

7. Norris L. Obamacare's essential health benefits. healthinsurance.org. https://www.healthinsurance.org/obamacare/essential-health-benefits/. Published 2020. Accessed August 18, 2020.

8. The 'metal' categories: Bronze, Silver, Gold & Platinum. HealthCare.gov. https://www.healthcare.gov/choose-a-plan/plans-categories/. Published 2020. Accessed September 8, 2020.

9. Lalley C. Health insurance basics: The 101 guide to health insurance. Policygenius.com. https://www.policygenius.com/health-insurance/learn/health-insurance-basics-and-guide/. Published 2020. Accessed August 18, 2020.

10. Out-of-pocket maximum/limit. HealthCare.gov. https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/. Published 2020. Accessed August 18, 2020.

Expert Commentary

Every year, I instruct our medical students and residents on the “Anatomy & Physiology of the United States Health Care System” using a historical journey from the first Blue Cross plan in Dallas crafted for schoolteachers until the modern era of the Affordable Care Act. Along the way, we have added in a piecemeal fashion to our nation’s health care system such that seniors and low-income Americans have coverage carved out for them. Everyone else is reliant upon employer insurance for coverage or must purchase for themselves. Because of our country’s surprisingly involvement in financing health care for its citizens – over 36 percent is paid by the federal government – some commentators have declared the U.S. is an “insurance company with an army.”

While national health expenditures and financing our system are big picture items everyone in the health care sector should understand, we must also understand the small details that are most relevant to patients, such as common terminology regarding their insurance types and the payments they are required to pay at the point of service.

Cedric Dark, MD, MPH

Assistant Professor

Department of Emergency Medicine

Baylor College of Medicine

How To Cite This Post:

[Peer-Reviewed, Web Publication] Huang, E. Karalius, V. (2022, Oct 10). Health Insurance Basics. [NUEM Blog. Expert Commentary by Dark, C]. Retrieved from http://www.nuemblog.com/blog/health-insurance-basics

Debriefing in the ED

**Written by:** Diana Halloran (NUEM ‘24) & Andrew Long (NUEM ‘25) **Edited by:** Nick Wleklinski (NUEM ‘22)
**Expert Commentary by**: John Bailitz, MD

Introduction

The Emergency Department is a challenging work environment for a variety of reasons. It is not surprising that unpredictable work hours mixed with frequent interactions with patients undergoing physical and emotional trauma can cause spillover into the personal lives of ED staff. However, in the recent years there has been an increasing body of literature that highlights the challenges that we face as ED personnel.

The American Heart Association even recommends a “hot” debrief for every cardiac arrest attended by a healthcare professional. We know debriefing has concrete and tangible advantages. Previous studies have shown that debriefing immediately after an event can improve individual and team performance by 20-25%, issues can be identified for interventions, and mental health and emotional trauma can be addressed. It is well-documented that ED physicians have historically high rates of burnout compared to other specialties as well as a high incidence of post-traumatic stress disorder (PTSD) compared to the general population. PTSD is 2 times more prevalent in physicians (14.8%), with EM resident physicians falling in the range from 11.9%-21.5%.

As a field, we are now starting to design and implement interventions to preserve our own mental wellbeing. In fact, debriefing has been shown to be one method for managing PTSD. One article described an initiative that implemented an immediate (also known as “hot”) debrief protocol immediately following all cardiac arrests during which 90% of participants felt they benefited psychologically, and 100% felt it improved their clinical practice. In this post, we will give a brief overview of a landmark study in the ED debrief literature, which advocates for a “hot” debrief model in resuscitation cases using the STOP5 model.

Study Analysis

This study published in 2019 designed, tested, and developed the STOP5 model to facilitate safer patient care, team development, and quality improvement within the Emergency Department. The STOP5 model, the first widespread debriefing tool, was designed as a “hot debrief”: “an interactive and structured team dialogue that takes place either immediately or very shortly after a clinical case”. Any team member of the resuscitation may lead the hot debrief.

Figure 1: The STOP5 Model Debriefing Framework (proposed by CA Walker et al 2020)

After an initial check-in the team moves to a group discussion and follows the STOP framework above: Summarize the case, Things that went well, Opportunities to improve, and Points to action and responsibilities. Inclusion criteria for these hot debriefing cases were major traumas, deaths in resuscitation, and any cases upon request by any staff member. No potential resuscitation cases were formally excluded.

After 18 months the ER staff was re-surveyed to ascertain STOP5 rating scores, the number of staff involved in the debriefs, any possible benefits or barriers to team performance, and if staff believed there should be more or less hot debriefing in the ER. In this 18-month review all STOP5 debriefs were rated “good” to “excellent”, suggesting the debriefing was highly valued. 98% of respondents believed that there should continue to be more hot debriefs in the emergency department. In a 12-month review there were 10 process and equipment changes (“hard outcomes”) as a direct result of the STOP5 hot debriefs and 14 additional opportunities for improvement. The hot debrief allowed for concrete actions to be taken about these issues and for a dedicated plan of action for correction. These hard outcomes identified issues such as those listed below which allowed for concrete solutions for all the identified problems.

Shortage of resuscitation room equipment
Drug stocking issues
Drug preparation/infusion regime for vital but rarely used medications difficult for staff to find
Faulty equipment (doors, machines)

Reported barriers to enacting hot debriefs include time constraints, workload, low staff confidence in leading the debrief, or absence of team members (consultants who might have left the department, change of shift). For these reasons hot debriefing is still not standard practice. However, a hot debrief such as STOP5, with a concrete checklist, is an inexpensive and quick way to enhance team performance, improve patient care, and assist with emotional trauma and mental check-ins for the team. Debriefing is a valuable and important aspect of our medical career. We hope to bring more of a focus to debriefing within our institution by beginning to enact the STOP5 based hot debriefing after clinical events.

Expert Commentary

Whether working in a community or academic Emergency Department, recurrent extraordinary cases threaten the well-being of the clinical team during that shift and after. Although resources often exist for individual employee assistance after a difficult shift has ended, few interventions have been described to help the team regroup and recover during that particular shift. Furthermore, department level morbidity and mortality conferences or hospital level quality assurance reviews focus more on the technical case details and less on team wellness.

With the primary purpose of quickly restoring team performance and wellness, hot debriefs at NUEM provide the opportunity for our ED teams to have a structured yet brief meeting immediately after an extraordinary case. Using STOP5, team leaders have a step-by-step plan to quickly yet effectively help every clinician on the team properly mentally frame the case, share gratitude, and then identify and assign opportunities for immediate improvement. Building on life support courses and residency training, specific education on the STOP5 framework quickly prepares senior clinicians to lead hot debriefs. Utilizing change management principles to identify and address logistical barriers helps to create a culture that supports immediate debriefing. Successful strategies in our NUEM ED include protocols to pause new inflow and cover existing patient demands, designating meeting spaces, adding positive program reminders to clinical areas and recurring meetings, and tracking and celebrating program success.

References

1. Get With The Guidelines - Resuscitation Clinical Tools. (2021, August 16). Www.Heart.Org. https://www.heart.org/en/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-resuscitation/get-with-the-guidelines-resuscitation-clinical-tools

2. Gilmartin, S., Martin, L., Kenny, S., Callanan, I., & Salter, N. (2020). Promoting hot debriefing in an emergency department. BMJ Open Quality, 9(3), e000913. https://doi.org/10.1136/bmjoq-2020-000913

3. Tannenbaum, S. I., & Cerasoli, C. P. (2012). Do Team and Individual Debriefs Enhance Performance? A Meta-Analysis. Human Factors: The Journal of the Human Factors and Ergonomics Society, 55(1), 231–245. https://doi.org/10.1177/0018720812448394

4. Vanyo, L., Sorge, R., Chen, A., & Lakoff, D. (2017). Posttraumatic Stress Disorder in Emergency Medicine Residents. Annals of Emergency Medicine, 70(6), 898–903. https://doi.org/10.1016/j.annemergmed.2017.07.010

5. Walker, C. A., McGregor, L., Taylor, C., & Robinson, S. (2020). STOP5: a hot debrief model for resuscitation cases in the emergency department. Clinical and Experimental Emergency Medicine, 7(4), 259–266. https://doi.org/10.15441/ceem.19.086

John Bailitz, MD

Vice Chair for Academics, Department of Emergency Medicine

Professor of Emergency Medicine, Feinberg School of Medicine

Northwestern Memorial Hospital

How To Cite This Post:

[Peer-Reviewed, Web Publication] Halloran, D. Long, A. Wleklinski, N. (2022, Sept 12). Debriefing in the ED. [NUEM Blog. Expert Commentary by Bailitz, J]. Retrieved from http://www.nuemblog.com/blog/debriefing-ED

Proper Preparation for Mass Casualty Incidents

**Written by:** August Grace, MD (NUEM ‘24) **Edited by:** Andrew Rogers, MD, MBA (NUEM ‘22)
**Expert Commentary by**: Andra Farcas, MD (NUEM ‘21)

Introduction

In the setting of trauma, most hospitals are adept at treating and managing patients with a variety of injuries. However, the ability of a hospital to handle a mass casualty incident (MCI) requires a completely different approach and, most importantly, adequate triage and pre-planning. An MCI is defined as “an event that overwhelms the local healthcare system, where the number of casualties vastly exceeds the local resources and capabilities in a short period of time [7].” MCI events can include anything from hurricanes, earthquakes, and other natural disasters to terrorism or other man-made situations that include the use of explosive or biological weapons, mass shootings, or dysfunction in modes of transportation (car, plane, train crash) [3]. Although this is just a short list of the possibilities, each hospital must prioritize its response preparedness to match the likelihood of events that it could receive. For example, as a major urban center, Chicago is more likely to encounter events such as mass shootings, biological terrorism, or explosive injuries. Mobile, Alabama, on the other hand, must have adequate preparation for hurricanes and floods [4]. This post will discuss a brief overview of hospital planning and operational setup with key elements of a disaster response from events that cause high numbers of blunt trauma, penetrating trauma, burns or crush injuries that may be seen following explosive events, mass shootings, or large scale motor vehicle collisions, to name a few.

Casualty Planning & Staffing Considerations

Arguably the most important step in an MCI is the planning that occurs before a single patient is even seen. In most events, hospitals have communication with EMS personnel that are on scene allowing them to have some sort of estimation of the scale of the event and type of disaster encountered. If the mechanism and scale are appropriate, a properly planned disaster response should be initiated and set in motion a sequence of coordinated events.

In creating a disaster response plan, the first step is the designation of the Disaster Medical Officer (DMO). This person should be the most senior ED attending physician and he/she oversees available hospital medical personnel and resources [1]. This person will have no role in patient care and instead will be in charge of all ED operations, delegating tasks, and problem solving issues that arise in the future.

The first task of the DMO is to get help and get it now. Approximately half of all casualties will arrive at the hospital within a one hour window, with 50-80% arriving within 90 minutes. Time begins after the first patient arrives at the hospital [8]. Therefore, getting the appropriate staff to the hospital as quickly as possible is vital to saving lives. How much staff is needed? This can be gauged by the type of disaster encountered and with assistance from EMS personnel at the scene. A five-car motor vehicle collision (MVC) will not require as much additional staff as a collapsed high rise building. The DMO will delegate the task of calling available staff to maximize the number of staff present in the ED and hospital. Contacting surgeons, scrub techs, anesthesiologists, and nurses to get as many ORs operational is invaluable to saving lives.

Continuous staffing adjustments can be monitored and made by using the casualty predictor tool (Figure 2). When in doubt, it is better to have more staff available than needed. To reiterate, the most important part of any disaster situation is to GET HELP.

Triage/ED Setup

Once the process is underway for increasing the level of resources available, the next step is hospital setup and triage. The most important part of this step is creating enough space to allow for the massive influx of patients and maintaining proper flow throughout the ED. It is well known that most hospitals in large population centers already operate at or near full capacity [4]. This makes it even more challenging when presented with an acute influx of patients in a short period of time. There is not much that can be done in the acute setting about patients that are already admitted; however, the ED can be restructured to account for the increased surge. Patients currently in the ED with a condition deemed to be stable (will likely not require an acute intervention in the next 24 hours) can be moved to a different area (green triage area, discussed below). The patients who have a more acute condition can be triaged and recategorized using the same criteria as the incoming casualties.

One current method of triaging patients is the tagging method. In this system, patients are tagged with a red, yellow, or green identification that categorizes patients based on acuity. Other things listed on tags can be a patient’s name, bar code, MRN or other tracking criteria. These patients are then able to be treated based on the level of care needed. In theory, this is a good way for patients to be tracked and accounted for. However, some experts believe that when there is a large volume of patients, this can slow the triage process and extend the amount of time it takes the patient to receive care that may be lifesaving. Another limitation is that it does not allow for a dynamic system, it provides a false sense of security, and can cause confusion. For example, a patient may have a green tag when initially triaged but could decompensate to a yellow or red tag [6]. Thus, there should be an appropriate system for re-evaluation if resources allow.

One system that could be used instead is a tag zone. In this system, the ED could be set up into different zones that would correlate with the tag color and acuity of the condition. Who should triage? The second most senior ED attending physician. The zone system could be set up as follows:

Red zone: Patients that need immediate medical or surgical attention. This includes patients presenting with an acute airway, circulatory or neurologic problem, multi-system involvement, or penetrating injuries to the head, neck, or chest. These patients are likely to need the vast majority of resources and staff.

Orange zone: Not originally categorized in the tag system. These patients are expected to decompensate within the hour but did not need immediate resuscitation [2].

Yellow zone: Patients that are relatively stable that will likely not decompensate within the hour. Extremity injuries or conditions that have time to be worked up.

Green zone: Patients with minor injuries that are unlikely to decompensate. “Walking wounded.” Will not require vast amounts of resources or staffing to be cared for.

The different zones allow for a dynamic system. Patients in each zone will be cared for by a team of physicians and nurses with the majority of staffing located in Red and Orange zones. Patients can be moved “up” a zone (from yellow to orange) if their condition deteriorates or could be moved “down” a zone (from yellow to green) if they are able to be stabilized [1, 2, 3]. The “black tag” patients were not categorized into a zone as they were patients who were either already dead, or not likely to survive given the current staffing and resources available. Figure 3 shows a brief triaging algorithm (without the orange designation). This is one possible system to triage patients and get them to an appropriate level of care rapidly. The hospital system is now ready for the rapid influx of critical patients.

Implementation

All patients should enter through a single triage area. Multiple points of entry can cause confusion and overwhelm each area by not knowing the number of patients entering from each point [4]. As the number of patients in each zone starts to fill up, adequate communication about the space and number of resources available should be communicated to the DMO and charge nurse. Once patients are able to be stabilized in each zone, the goal is to get them to the OR for immediate surgery if needed, or to move them down a zone (yellow to green) in order to make space for additional critically injured patients.

Who are the first patients to arrive? The “dual wave phenomenon” explains how patients usually present to the hospital following MCIs. The first wave of casualties are described as the “walking wounded” or those who are able to self-ambulate and usually only require minor care. These patients begin to arrive within 15-30 minutes of the incident depending on the distance from the scene to the hospital. It is important that these patients do not take up too many hospital resources or staff as they are likely well enough to survive with minimal therapeutic interventions. These patients can easily overwhelm the system and prevent proper care to more critical patients. The second wave includes the patients that arrive via EMS or other assistance from bystanders as they are not well enough to transport themselves. These are the patients who will require a vast majority of hospital staffing, resources, and time in order to prevent deaths [3, 4].

Summary

The first step to preparing for an MCI is having a plan in place.
GET HELP. If you only have time to do one thing it should be this. It does not matter how many resources you have or how much space is available if you do not have enough staff to use them.
Have a triage plan. Create zones of various acuity with the majority of staff occupying the higher acuity areas. Patients can always be moved to a higher zone if they need more care or a lower zone if they have been stabilized.
Get patients to the proper provider. If the patient needs surgery, get them to the OR. This also creates space for new patients to be seen.
Have one single area of entry. This allows the system to maintain consistency and flow.

References

Emergency Safety Officer Management Plan For Mass Casualty. Kings County Hospital Center, www.downstate.edu/emergency_medicine/pdf/KCHCSection03.pdf.
Menes, Kevin. “How One Las Vegas ED Saved Hundreds of Lives After the Worst Mass Shooting in U.S. History: Emergency Physicians Monthly.” EPM, 5 Apr. 2020, epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooting-u-s-history/.
Hospital Medical Surge Planning for Mass Casualty Incidents. Florida Department of Health, www.urmc.rochester.edu/MediaLibraries/URMCMedia/flrtc/documents/WNY-Hospital-Medical-Surge-Planning-For-Mass-Casualty-Incidents.pdf.
Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. https://doi.org/10.17226/11621
“SALT Mass Casualty Triage Algorithm - CHEMM.” U.S. National Library of Medicine, National Institutes of Health, chemm.nlm.nih.gov/salttriage.htm.
“Report: Mass Casualty Trauma Triage Paradigms and Pitfalls .” Journal of Emergency Medical Services , Office of the United States Assistant Secretary for Preparedness and Disaster Response.
DeNolf, Renee L. “EMS Mass Casualty Management.” StatPearls [Internet]., U.S. National Library of Medicine, 15 Oct. 2020, www.ncbi.nlm.nih.gov/books/NBK482373/.
“Mass Casualty Predictor .” Homeland Security Digital Library , Centers for Disease Control and Prevention .

Expert Commentary

This is a great review of MCI management in the Emergency Department by Drs. Grace and Rogers. Although the past few years of the COVID-19 pandemic have felt like we’ve been working in a perpetual MCI, these are important principles to review on a regular basis, as they are not something we necessarily practice every day in the emergency department.

The authors do a good job of emphasizing the importance of preparing for an MCI ahead of time. Another important aspect of preparation is decontamination. An ED disaster response plan should incorporate how to effectively put patients (both walk-ins and EMS arrivals) through decontamination if the disaster at hand requires it. The authors emphasize the importance of having patients enter through a single triage area, and the decontamination station should be similarly set up nearby allowing for one-directional flow of patients through the decontamination process. This is not only vital to patient treatment but also to ensuring staff safety. Additionally, it is necessary to ensure that the ED has sufficient and adequate level Personal Protective Equipment and that the appropriate staff are trained on donning/doffing procedures.

In addition to gathering the staffing resources, there should also be an emphasis on gathering disaster-specific supplies: alerting the blood bank if it is a traumatic MCI, amassing antidotes if it is toxicological in nature, compiling medical equipment (such as ventilators) as applicable, etc. Additionally, alerting other EDs in the system as to the impending influx of patients as well as reaching out to disaster-specific specialty centers (ie, hyperbarics facility for a structure fire for carbon monoxide treatment) can also help take pressure off and allocate more resources.

Finally, the importance of a hotwash or after-action review cannot be emphasized enough. This is a process by which participants can have an open and honest professional discussion about what went well and what can be improved in the future. It centers around four main questions (What was supposed to happen? What did happen? What caused the difference? What can we learn from this?) and is vital for building an ED’s capacity for conducting an adequate emergency response to an MCI.

References

Blackwell, T.H., DeAtley, C., Yee, A. (2021). Medical support for hazardous materials response. Cone, D.C. (ed). Emergency Medical Services Clinical Practice and Systems Oversight; Volume 2: Medical Oversight of EMS. (3rd edition, p339-351). UK: John Wiley and Sons, Ltd.
Greenberg, T., Adini, B., Eden, F., Chen, T., Ankri, T., Aharonson-Daniel, L. An after-action review tool for EDs: learning from mass casualty incidents. Am J Emerg Med. May 2013;31(5):798-802. Doi 10.1016/j.ajem.2013.01.025. Epub 2013 Mar 6. PMID: 23481154.
Metz, T. How to Facilitate an After-Action Review (AAR or Hot Wash): Agenda and Tips. MG Rush Facilitation Training & Meeting Design. https://mgrush.com/blog/after-action-review/.
Salem-Schatz, S., Ordin, D., Mittman, B. Guide to the after action review. Center for Evidence-Based Management. Oct 2010. https://www.cebma.org/wp-content/uploads/Guide-to-the-after_action_review.pdf.

Andra Farcas, MD

Emergency Medicine & EMS Physician

CU Department of Emergency Medicine

University of Colorado School of Medicine

How To Cite This Post:

[Peer-Reviewed, Web Publication] Grace, A. Rogers, A. (2021, Apr 26). Proper Preparation for Mass Casualty Incidents. [NUEM Blog. Expert Commentary by Farcas, A]. Retrieved from http://www.nuemblog.com/blog/mass-casualty-incident-preparation

Nephrolithiasis: Ultrasonography versus Computed Tomography

**Written by:** Kishan Ughreja , MD (NUEM ‘23) **Edited by:** Ade Akhentuamhen, MD (NUEM ‘21)
**Expert Commentary by**: Tim Loftus, MD, MBA

Journal Club: Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis

A 70-year-old man with BPH s/p TURP, hypertension, hyperlipidemia and stroke presents to the ED with acute onset of intermittent sharp left flank pain radiating into the groin that awoke him from sleep. He endorses nausea without vomiting and denies fever. He also endorses slightly decreased urination with “dribbling.” His urinalysis shows >100 RBC and no signs of infection. Nephrolithiasis is likely high on your differential diagnosis. How do you proceed?

What is your initial imaging test of choice, ultrasound (US) or non-contrast CT, and why?

Would you be satisfied with only US and no follow-up CT?

Would you be confident in a point-of-care-ultrasound evaluation or a formal ultrasound?

Do outcomes for patients with suspected nephrolithiasis differ based on the initial imaging?

Should your medical decision-making change if the patient has a history of nephrolithiasis?

What would you do if the same patient presented again with persistent pain from a previously diagnosed stone?

Pain from suspected nephrolithiasis is a very common complaint in the ED and the incidence of the disease continues to increase. The estimated incidence over the past two decades is up to 340 visits per 100,000 individuals.1 Low-dose non-contrast abdominal CT has become the gold standard for diagnosis as it has become readily available in emergency departments nationwide, with some studies touting sensitivity and specificity of 97% and 95%, respectively.2 However, low dose CT still exposes the patient to radiation and may increase their risk of cancer, as many nephrolithiasis patients often undergo repeat imaging because of recurring pain or urological intervention. Additionally, CT scans prolong average ED lengths of stay. However, with ultrasonography becoming more prevalent in EDs, it may be possible that initial imaging may avoid this radiation risk and still have similar outcomes for patients. Let’s analyze this NEJM article comparing US to CT for the assessment of nephrolithiasis.

Study design: a multicenter, pragmatic, randomized comparative effectiveness trial

Population

N = 2759
ages 18- 76 yo
reported flank or abdominal pain that the treating physician wished to order imaging to establish or rule out a primary diagnosis of nephrolithiasis
not considered at high risk for serious alternative diagnoses e.g. cholecystitis, appendicitis, aortic aneurysm, or bowel disorders
no pregnant patients
no men >129 kg, no women >113 kg
no history of single kidney, renal transplantation, undergoing dialysis

Patient selection

Intervention protocol

patients randomized to 3 groups each using a different initial imaging modality (POCUS vs. Radiology US vs. CT)
patients contacted at 3, 7, 30, 90, and 180 days after randomization to assess study outcomes

Outcome measures

Primary Outcomes

high-risk diagnoses with complications that could be related to missed or delayed diagnoses — within 30 days of ED visit, including:
AAA w/rupture, PNA w/sepsis, appendicitis w/rupture, diverticulitis w/abscess or sepsis, bowel ischemia or perforation, renal infarction, renal stone w/abscess, pyelonephritis w/urosepsis or bacteremia, ovarian torsion w/necrosis, aortic dissection w/ischemia
cumulative radiation exposure from all imaging within 6 months after randomization
total cost (not reported in this study, ongoing analysis)

Secondary Outcomes

serious adverse events (FDA definition)
serious adverse events related to study participation
delayed diagnosis, like acute cholecystitis, appendicitis, bowel obstruction
return ED visits
hospitalizations after being discharged from ED
self-reported pain scores
diagnostic accuracy for nephrolithiasis
by comparing ED diagnosis at discharge to reference standard of confirmed stone by patient’s observation of passage or report of surgical removal

Results

no significant differences among groups in terms of pain scores, medical history, physical exam findings, and ED physician’s assessment of the likelihood of other diagnoses (Table 2)
POCUS and US groups had significantly lower cumulative radiation exposure over 6 months than the CT group (difference attributed to initial ED visit’s imaging choice)
11 patients (0.4%) had high risk diagnoses with complications during first 30 days after randomization, with no significant difference among the 3 groups
no difference when stratified by patients with a history of nephrolithiasis
no significant difference among groups in the number of patients with serious adverse events; total of 466 SAE in 316 patients (91.4% were hospitalizations during f/u period; 26.4% involved surgical treatment of complications of nephrolithiasis)
5 reported deaths (occurred between 38 and 174 days after randomization) — none thought to be related to study participation
the proportion of patients with a confirmed stone diagnosis within 6 months was similar in all 3 groups (POCUS 34.5% vs. US 31.2% vs. 32.7% CT)
diagnostic accuracy based on result of initial imaging modality
- POCUS sensitivity 54% [48 - 60]; specificity 71% [67 - 75]
- US sensitivity 57% [51 - 64]; specificity 73% [69 - 77]
- CT sensitivity 88% [84 - 92]; specificity 58% [55 - 62]

Interpretation

The US group was exposed to less radiation than the CT group and had no significant differences in the incidence of high-risk diagnoses with complications, total serious adverse events, or related serious adverse events.
There also were no significant differences in pain scores, hospitalizations, ED readmissions among the groups.
Many patients in the ultrasound groups did get additional imaging, but this was not the majority.
Patients with a history of nephrolithiasis were less likely to undergo additional imaging with CT if they already had an ultrasound first (31% vs 36%). They did not have poorer outcomes than patients without a history of nephrolithiasis.
Patients only undergoing POCUS and no other testing had a significantly shorter ED stay (1.3 hours)
It is safe to pursue ultrasound as the initial imaging of choice for suspected nephrolithiasis (with additional imaging ordered as necessary at clinical discretion), though it should not necessarily be the only testing performed.

Strengths

large size, diversity in ED settings, randomized design, assessment of clinically important outcomes, a high follow-up rate

Weaknesses

no blinding of investigators, physicians, or patients as this was a pragmatic trial design
independent review was used to characterize serious adverse events related to study participation
strict reference standard for stone diagnosis which was unbiased, but prone to error based on the patient’s memory of self-reporting of stone passage

Internal/external validity

Given the aforementioned strengths of this study and its pragmatic design, these findings appear both internally and externally valid and may be applied to daily clinical practice

Take-Home Points

What is your initial imaging test of choice, ultrasound (US) or non-contrast CT, and why?

Ultrasound is a good choice for initial imaging as most patients do not end up requiring additional imaging during their visit. This leads to reduced cumulative radiation exposure.

Would you be satisfied with only US and no follow-up CT?

In this study, 40.7% of those in the POCUS group and 27% in the formal ultrasound group underwent subsequent CT. Follow up CT should depend on the patient and ultrasound operator. Keep in mind that this study excluded patients with kidney disease, pregnant patients, and obese patients. They also excluded patients who were high risk for other pelvic and abdominal diseases. Lastly the POCUS operators were ED physicians with training “recommended by ACEP.”

Would you be confident in a point-of-care-ultrasound evaluation compared to a formal ultrasound?

Yes. Sensitivity and specificity between these groups were similar.

Do outcomes for patients with suspected nephrolithiasis differ based on the initial imaging?

No. There was no significant difference in subsequent adverse events, pain, return visits or hospitalizations, or delayed diagnoses of other serious conditions.

Should your medical decision-making change if the patient has a history of nephrolithiasis?

In this study, patients with a history of nephrolithiasis were less likely to undergo additional imaging with CT if they already had an ultrasound first. They did not have poorer outcomes than patients without a history of nephrolithiasis. This suggests that it is safe to avoid ordering a CT in patients with recurrent stones.

What would you do if the same patient presented again with persistent pain from a previously diagnosed stone?

The majority of patients with adverse outcomes were due to infectious causes. Consider alternative diagnoses such as pyelonephritis. Additionally, although rare, renal infarct can present with acute flank pain and is diagnosed with a contrast CT.

References

Fwu, C. W., Eggers, P. W., Kimmel, P. L., Kusek, J. W., & Kirkali, Z. (2013). Emergency department visits, use of imaging, and drugs for urolithiasis have increased in the United States. Kidney international, 83(3), 479-486.
Coursey, C. A., Casalino, D. D., Remer, E. M., Arellano, R. S., Bishoff, J. T., Dighe, M., ... & Leyendecker, J. R. (2012). ACR Appropriateness Criteria® acute onset flank pain–suspicion of stone disease. Ultrasound quarterly, 28(3), 227-233.
Smith-Bindman, R., Aubin, C., Bailitz, J., Bengiamin, R. N., Camargo Jr, C. A., Corbo, J., ... & Kang, T. L. (2014). Ultrasonography versus computed tomography for suspected nephrolithiasis. New England Journal of Medicine, 371(12), 1100-1110.

Expert Commentary

Thank you very much to Dr.’s Ughreja and Akhetuamhen for an excellent blog post on a very relevant clinical topic. This is a great summary of the landmark randomized trial published in NEJM in 2014 assessing CT vs two types of US for patients with suspected renal colic in the ED setting. It is worth mentioning that this study was a multicenter study based in the US with representation from ED, Radiology, and Urology. The above study was well summarized and bears repeating that, in this multicenter randomized study assessing CT vs POCUS vs radiology performed US in patients with suspected renal colic in the ED setting, initial US reduced radiation exposure without adversely affecting patient-centered outcomes. It is worth mentioning several additional considerations and placing emphasis on others elucidated from this journal club review.

First, a subsequent systematic review (1) incorporating multispecialty (ED, Radiology, Urology) expert panel consensus recommendations has reiterated that in younger patients without a high suspicion for alternative diagnoses or complicating features of nephroureterolithiasis (such as fever, pyelonephritis, solitary kidney, dialysis, etc), US should be the initial diagnostic imaging modality of choice, if any. It's a great paper, worth reading (and appreciating who the authors are), and worth recalling for bedside teaching to junior learners in the ED.

Additionally, this paper brings to mind my second point, and something that is worth shouting from the hilltops -- a kidney stone is a clinical diagnosis! Now, of course, this is exclusive of those patients with high-risk or complicating features (e.g. pediatrics, pregnancy, solitary kidney, fever, unstable/critically ill, unrelenting pain, atypical features, etc). You don’t need any imaging to tell you the diagnosis in the vast majority of patients. US or CT are helpful in confirming the diagnosis when there is uncertainty or non-trivial pretest probability of alternative diagnoses, excluding alternative diagnoses, and identifying exact stone location and size, which can be used to help counsel patients at the bedside regarding the anticipated clinical course and next steps in management.

Third, for those with proper training, and with some exceptions (see the systematic review paper for case vignettes that highlight these), POCUS is non-inferior to radiology-performed US. And, it's not a “formal” US. I can’t remember the last time I attended a black-tie ultrasonography session, but that's just me.

Fourth, it's worth mentioning that although CT use can lead to the identification of incidental findings more commonly than US, identification of these incidental findings still happens rather often with POCUS (a common example is a renal cyst). Please ensure that you document and discuss with the patient accordingly.

Finally, a burden on us as EM clinicians is training in and awareness of clinical practice guidelines and recommendations from specialties outside of EM. As it relates to the diagnostic evaluation of suspected renal colic in the ED setting, the Choosing Wisely recommendations endorsed by the AUA are worth perusing as are the European/EUA guidelines, both of which suggest US as the initial diagnostic imaging modality of choice, for pediatric (CW) and non-high-risk patients without complicating features (EUA).

The bottom line is that CT is helpful for older patients or those in whom you are less sure about the diagnosis of renal colic. For younger or low-risk patients, suspected renal colic is a clinical diagnosis and often needs no imaging, but ultrasound would be an evidence-based first step. Thanks again toDr.’s Ughreja and Akhetuamhen.

References

1) Moore et al. Imaging in suspected renal colic: a systematic review of the literature and multispecialty consensus. J Urol 2019. 202(3):475-483.

Tim Loftus, MD, MBA

Assistant Professor of Emergency Medicine

Fellowship Director of the Clinical Operations and Administration Fellowship Program, Northwestern Department of Emergency Medicine

Medical Director of Emergency Services Northwestern Lake Forest Hospital and Grayslake Emergency Center

How To Cite This Post:

[Peer-Reviewed, Web Publication] Ughreja, K. Akhentuamhen, A. (2022, May 16). Journal Club: Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis. [NUEM Blog. Expert Commentary by Loftus, T]. Retrieved from http://www.nuemblog.com/blog/nephrolithiasis-ultrasonography-versus-computed-tomography.

Neuroleptic Malignant Syndrome

Expert Commentary

This is an awesome, focused review of neuroleptic malignant syndrome (NMS). NMS is hard to diagnose because it's rare. There is no gold standard with respect to its definition, and it requires a medication history (which we typically don't do very well in the emergency department). A tricky cause of NMS is the removal of a dopamine agonist. For this reason, carbidopa/levodopa should never be discontinued during hospital admission - or ED boarding. [1]

Supportive care is more important than antidotal therapy during NMS management. The most acute cause of death from NMS is hyperthermia, which is induced both by D2 receptor antagonism leading to rigidity and impaired thermoregulation from the striatum and hypothalamus. Any life-threatening hyperthermia should be treated immediately with an ice bath.[2] Rigidity will lead to rhabdomyolysis with subsequent hyperkalemia and myoglobin-induced renal failure. Therefore, fluid resuscitation and maintenance are important. Profound immobility can precipitate DVT, so anticoagulation may be necessary.

In terms of pharmacotherapy, benzodiazepines are universally used. Dantrolene inhibits calcium-mediated muscle contraction to reduce muscle rigidity. However, it doesn't address the underlying central D2 antagonism, and its efficacy has only been shown in case reports. Bromocriptine acts more centrally as a dopamine agonist but should be used cautiously in patients with psychiatric diseases as it may exacerbate psychosis. Overall, benzodiazepine use and supportive care should get you through most cases of NMS, though additional therapies may be necessary in severe cases.

References

1. Institute for Safe Medication Practices. Delayed Administration and Contraindicated Drugs Place Hospitalized Parkinson’s Disease Patients at Risk. 12 March 2015. Accessed February 11, 2022.

2. Juurlink JN. Antipsychotics. In: Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. eds. Goldfrank's Toxicologic Emergencies, 11e. Page 1037-1039. McGraw Hill; 2019. Accessed February 11, 2022.

Zachary Schmitz, MD

Toxicology Fellow

Ronald O. Perelman Department of Emergency Medicine

NYU Langone Health

How To Cite This Post:

[Peer-Reviewed, Web Publication] Leibowitz, M. Wleklinski, N. (2022, May 9). Neuroleptic Malignant Syndrome. [NUEM Blog. Expert Commentary by Schmitz, Z]. Retrieved from http://www.nuemblog.com/blog/neuroleptic-malignant-syndrome.

Beyond the Burns: Toxic House Fire Gases

Expert Commentary

Congratulations to Drs. Payne and Wessling on an excellent post.

Management of toxic gas exposure from a house fire is essential knowledge for all emergency physicians. The two major toxic gases of interest are carbon monoxide and hydrogen cyanide; it is important to note that fires in other environments, such as factories or industrial sites, may result in alternative exposures based on the nature of the fire and materials present. The post goes into detail on the pathophysiology, signs, symptoms, and diagnosis of both carbon monoxide and cyanide poisonings, so this commentary will focus on the clinical approach.

I recommend the following simplified process to streamline diagnosis and treatment decision making:

1. Start high flow oxygen (15L NRB) immediately (or, if intubated, give 100% FiO2)

High flow oxygen reduces the half life of carbon monoxide from ~5 hours to ~90 minutes. Oxygen can be discontinued once carboxyhemoglobin normalizes (<2%)

2. Obtain a carboxyhemoglobin level, lactic acid level, and a venous blood gas (arterial is unnecessary unless oxygenation is also a concern) as soon as possible

Unfortunately, there is some disagreement as to what constitutes a “toxic” carboxyhemoglobin level. Weaver, et al. established 25% as an inflection point for the development of severe sequelae, which is now a commonly used (though not universally agreed upon) threshold value. Also, when evaluating a carboxyhemoglobin level, it is essential to consider the time period prior to the level being drawn to avoid false reassurance. For example, a level drawn after 90 minutes of high flow oxygen will be reduced by roughly 50% and interpreted accordingly. Further, do not rely on external co-oximeters alone to rule out carbon monoxide poisoning given limited sensitivity at the moment (though the technology will likely improve over time).

3. Treat with hydroxocobalamin empirically if symptomatic and/or if lactic acid elevated

Hydroxocobalamin is a low risk intervention with significant potential therapeutic benefit, so it should be given early if there is any clinical concern. The other major cyanide antidote, sodium thiosulfate, should only be used if hydroxocobalamin is not available as it has no efficacy advantage and an undesirable side effect profile. It is essential to avoid using nitrites, as inducing methemoglobinemia in the setting of coincidental carbon monoxide poisoning can dramatically worsen tissue hypoxia.

An elevated lactic acid is a surrogate for cyanide poisoning, specifically a level of 8-10 mmol/L or greater is sensitive and should prompt intervention. More modest lactic acid elevations are less likely to be related to cyanide poisoning and should not prompt intervention, especially in an asymptomatic patient, unless the level is persistently elevated despite adequate resuscitation. Cyanide levels, while diagnostic, are of no acute clinical utility since they are rarely available in a timely manner.

4. Consider hyperbaric oxygen therapy (HBOT) if readily available

HBOT for the treatment of carbon monoxide poisoning is controversial. While HBOT reduces the half life of carbon monoxide to roughly 20-30 minutes, HBOT is not used for this purpose alone. In fact, HBOT is primarily used to reduce associated cognitive, behavioral, and neurologic changes (collectively known as delayed neuropsychiatric sequelae). There is lower quality evidence for reduced myocardial infarction and mortality risk as well.

However, several factors limit HBOT use. Primarily, it is not universally available at most institutions, incurring the risk and cost of transport to a distant site. The benefit is thought to be highest when the treatment is performed early (ideally within six hours of exposure), which adds to the logistical burden. Additionally, many chambers are not operated on nights and weekends, and of those available at off hours, many are unable to accommodate intubated patients. Recognizing the controversial nature of HBOT, the 2016 ACEP position statement noted that HBOT or high flow, normobaric oxygen can be used to treat carbon monoxide poisoning; though it likely carries clinical benefit in certain situations, at this time HBOT is not the standard of care for severe carbon monoxide poisoning. Rather, it should be offered if it can be readily and reasonably arranged.

Keeping this in mind, the following are generally accepted indications for HBOT in the setting of carbon monoxide poisoning

Loss of consciousness associated with exposure
Altered mental status
Focal neurologic changes
Evidence of end organ ischemia (pH ≤ 7.1, EKG changes, elevated troponin, angina)
Pregnancy (with some resources citing a level ≥20%)
Carboxyhemoglobin level ≥25%

Importantly, these are not hard and fast rules and there is no firm guideline mandating when HBOT should or should not be used. As a result, it is prudent to involve a medical toxicologist early in the process.

In summary, a few key take home points:

Carbon monoxide and cyanide are strongly associated with house fires – assume exposure to both until proven otherwise
It is reasonable to treat any undifferentiated, symptomatic patient with high flow oxygen and hydroxocobalamin empirically; asymptomatic patients can wait safely for blood work on high flow oxygen alone
The decision making regarding use of HBOT, in particular, is complex – early consultation with a medical toxicologist is strongly encouraged

Justin Seltzer, MD

Toxicology Fellow

Department of Emergency Medicine

University of California, San Diego

How To Cite This Post:

[Peer-Reviewed, Web Publication] Payne, A. Wessling, E. (2022, May 2). Toxic House Fire Gases. [NUEM Blog. Expert Commentary by Seltzer, J]. Retrieved from http://www.nuemblog.com/blog/toxic-house-fire-gases

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