Critical Care in the No conflicts to disclose Emergency Department - - PDF document

▶
critical care in the
SMART_READER_LITE
LIVE PREVIEW

Critical Care in the No conflicts to disclose Emergency Department - - PDF document

Jan 01, 2023 162 likes •249 views

5/29/2014 Disclosures Critical Care in the No conflicts to disclose Emergency Department Jenny Wilson MD, MS May 29, 2014 ED Critical Care By The Numbers Overview ED critical care by the numbers Scope of practice

slide-1
SLIDE 1

5/29/2014 1

Critical Care in the Emergency Department

Jenny Wilson MD, MS May 29, 2014

Disclosures

  • No conflicts to disclose

Overview

  • ED critical care by the numbers
  • Scope of practice
  • Collaborations
  • Current controversies
  • New directions

ED Critical Care By The Numbers

slide-2
SLIDE 2

5/29/2014 2 What percentage of ICU patients are admitted from the ED?

A.

20-40%

B.

40-60%

C.

60-80%

Lilly CM, Zuckerman IH, Badawi O, et al. Benchmark data from more than 240,000 adults that reflect the current practice of critical care in the United States. Chest. 2011; 140:1232–1242.

Median ED LOS for Critically Ill?

  • A. <1 hr

B.

1-2 hrs

  • C. 2-3 hrs
  • D. 3+ hrs

Herring AA, Ginde AA, Fahimi J et al. Increasing Critical Care Admissions from US Emergency Departments, 2001-2009. Crit Care Med 2013;41: 1197-1204.

Scope of Practice What the ED can do for you . . .

  • Resuscitate the undifferentiated critically ill

patient

  • -lines, tubes, electricity, fluid, blood
  • Diagnose life-threatening conditions
  • -e.g. stroke, MI, CHF, dissection, bleeding,

acute abdomen, sepsis

  • Initiate critical treatment early
  • -e.g. TPA, ASA, heparin, afterload reduction,

antibiotics

  • Triage to appropriate service/unit
  • Begin communication with family
slide-3
SLIDE 3

5/29/2014 3 What the ED (Often) Can’t Do

  • Focus 100% of resources on one patient

for extended periods

  • Individualize initial work-up and

treatment for all critically ill patients

  • Establish longitudinal therapeutic

relationships

Which Patient Do You See First?

A.

2 week old infant with fever and lethargy

B.

82 yo woman in Afib with BP of 85/60

C.

42 yo man with sore throat, hot potato voice, and pooling secretions

slide-4
SLIDE 4

5/29/2014 4 Collaborative Care Collaborations

  • Trauma
  • -Regionalization, ATLS
  • ACS
  • -STEMI centers, protocols to minimize DTB time
  • Stroke
  • -Stroke centers, EM/rad/neuro collaboration
  • Sepsis
  • -Protocols/bundles
  • Post-Arrest Care
  • -Cardiac Arrest Centers, targeted temperature

management, invasive monitoring, etc.

Controversies Controversies

  • Prehospital airway management
  • Ambulance diversion
  • Limits of focused cardiac ultrasound
  • Epinephrine/early defib in cardiac arrest
  • Bypassing ED for cath lab activation
  • Target temperature in post-arrest patients
  • Sepsis care since ProCESS
  • Antifibrinolytic agents and transfusion ratios in trauma
slide-5
SLIDE 5

5/29/2014 5

Hasegawa K, Hiraide A, Chang Y, Brown DF. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of- hospital cardiac arrest. JAMA. 2013 Jan 16;309(3):257-66. Shen YC and Hsia RY. Association between ambulance diversion and survival among patients with acute myocardial infarction. JAMA. 2011 Jun 15;305(23):2440-7.

slide-6
SLIDE 6

5/29/2014 6 New Directions New Directions

  • ED ECMO
  • Novel decision rules, clinical scoring

systems, and biomarkers

  • The ED ICU

Sakamoto T et al. Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: A prospective observational study Resuscitation 85 (2014) 762–768

slide-7
SLIDE 7

5/29/2014 7

Goto Y, Maeda T, Goto YN. Termination-of-resuscitation rule for emergency department physicians treating out-of-hospital cardiac arrest patients: an observational cohort study. Crit Care. 2013 Oct 13;17(5):R235.

ED-Critical Care Pathways References

1.

Bellezo JM, Shinar Z, Davis DP et al. Emergency Physician-Initiated Extracorporeal Cardiopulmonary

  • Resuscitation. Resuscitation 2012;83:966.

2.

Callaway CW. Epinephrine for cardiac arrest. Curr Opin Cardiol. 2013 Jan;28(1):36-42.

3.

Cha WC, Lee SC, Shin SD, et al. Regionalisation of out-of-hospital cardiac arrest care for patients without prehospital return of spontaneous circulation. Resuscitation. 2012 Nov;83(11):1338-42. doi: 10.1016/j.resuscitation.2012.03.024. Epub 2012 Mar 23.

4.

Goto Y, Maeda T, Goto YN. Termination-of-resuscitation rule for emergency department physicians treating out-of-hospital cardiac arrest patients: an observational cohort study . Crit Care. 2013 Oct 13;17(5):R235.

5.

Hasegawa K, Hiraide A, Chang Y, Brown DF. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest. JAMA. 2013 Jan 16;309(3):257-66.

6.

Herring AA, Ginde AA, Fahimi J et al. Increasing Critical Care Admissions from US Emergency Departments, 2001-2009. Crit Care Med 2013;41: 1197-1204.

7.

Shen YC and Hsia RY. Association between ambulance diversion and survival among patients with acute myocardial infarction. JAMA. 2011 Jun 15;305(23):2440-7.

8.

Lilly CM, Zuckerman IH, Badawi O, et al. Benchmark data from more than 240,000 adults that reflect the current practice of critical care in the United States. Chest. 2011; 140:1232–1242.

9.

Sakamoto T et al. Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: A prospective observational study Resuscitation 85 (2014) 762–768

10.

Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011 Dec;71(6):1869-72.

11.

Weingart SD, Sherwin RL, Emlet LL et al. ED Intensivists and ED intensive care units. American Journal of Emergency Medicine 31 (2013) 617–620.