The Abortion Pill

Pregnancy termination is now very difficult to get in many regions. The abortion pill–medication abortion–is one dose of the antiprogesterone mifepristone followed by one or more doses of the prostaglandin misoprostol. The therapy is well studied and unequivocally safe and effective up to 10 weeks gestation.

For women who have access to both medication and surgical abortion, there are plusses and minuses to each but the main difference is that a surgical abortion is a brief procedure requiring anesthesia and uterine instrumentation, whereas a medication abortion occurs over several days in the patient’s home.

But medication abortion allows women without access to surgical abortion to  safely terminate pregnancy. In the US, federally authorized abortion pills are highly restricted for reasons that are political, not medical. So a network of activists have developed robust programs for getting this treatment into the hands of women who need it.

The role of emergency providers in managing women who request elective termination of pregnancy depends on the resources available in your community, but all of us need to know about medication abortion, if for no other reason than it is a rising therapy and you’re going to get asked. Especially if you practice in an area where surgical abortion is poorly available or unavailable, familiarize yourself with the relevant options so you can properly counsel appropriate patients. This is another way that emergency clinicians stretch the scope of their practice to meet the changing needs of the patients they serve.

Plan C

Aid Access

New York Times, Farhad Manjoo

Narcotica podcast

Ketamine-Only Breathing Intubation

This 9 minute video demonstrates the strengths and weaknesses of an intubation strategy that relies on dissociation with ketamine.

The essential strength, compared to RSI, is that a breathing technique keeps the patient breathing during laryngoscopy, which transforms the procedure from high-adrenaline to highly controlled. You see in this video that my (fabulous) resident was able to take his time, try different blades, slowly advance and adjust while using view optimization techniques as the patient continued to breathe. This is an extremely powerful way to add safety to the riskiest procedure commonly performed in acute care. We would have been able to carry on with his attempts for longer, had we not been inconvenienced by the arrival of a trauma patient.

Keeping the patient breathing during intubation has a long history in emergency medicine, starting with the brutal and often unsuccessful blind nasal intubation, which, fortunately, is now seldom performed. Many of us learned to do operating room style awake intubation, which relies on thorough local anesthesia using atomized/nebulized/topicalized/regionalized lidocaine, so the patient can remain truly awake and breathing during the procedure. Lidocaine-focused awake intubation is a fabulous technique that requires expertise and equipment not available to all acute care providers, but also–depending on your level of skill–time and patient cooperation. Time and cooperation is something we may not have downstairs or on the side of the road,* but what we lack in time and cooperation, we can make up for in ketamine.

When we use dissociative-dose ketamine to do the heavy lifting in allowing the patient to tolerate laryngoscopy, we obviate much of the needed topicalization expertise/supplies, abbreviate the needed time, and add cooperation with ketamine, cooperation in a vial.  The patient becomes dissociated, breathing but unconscious, which is why I use the term breathing intubation rather than the much more accepted term awake intubation to describe it.

Many patients who receive dissociative-dose ketamine without a paralytic will have some muscle rigidity, and some will develop laryngospasm (which is glottic muscle rigidity).  The patient in this video had some rigidity, which resolved and was not a problem, and this is usually the case. But patients who get ketamine to facilitate laryngoscopy are at much higher risk than procedural sedation patients (who are not having their airway instrumented) to develop laryngospasm and occasionally jaw rigidity, which, together, can cause an immediately dangerous cannot intubate cannot ventilate scenario. Anytime KOBI is being undertaken, a paralytic must be immediately available, ideally drawn up in a syringe, so that the procedure can be converted to a paralyzed technique at any point.

How KOBI fits into our expanding airway toolkit is expertly described by Andrew Merelman and Michael Perlmutter in this WJEM paper.

 

 

 

*some airway experts disagree

 

Postoperative Neck Hematoma

Postoperative neck hematoma is not often discussed in emergency medicine but behaves a lot like neck trauma, because it is neck trauma. These patients should be managed with a high-resource approach and discharged reluctantly, after careful deliberation.

Adapted from Bittner, MD.

ED Chest Pain Evaluation Pathway

full pathway as png and pdf

This pathway was agreed upon by a hospital consortium; it is completely unsubstantiated by science and is only intended to serve as a supplement to your otherwise excellent clinical judgment.

Strengths: it reminds you to consider the 7 dangerous causes of chest pain, not just ACS. It’s pretty straightforward and based on well-validated decision tools.*

Weaknesses: chest pain is a complex problem that cannot be reduced to a pathway, even a pathway designed by smart, good-looking people. Don’t turn your brain off when using this or any other decision tool. Decision tools don’t take care of patients, you do.

credits: bradley shy, marc probst, nick genes and the HIC consortium.

 

*except the ADD score, which is not well validated and remains controversial. Nobody knows who needs a scan for dissection. Make sure you scan the patients who have very suggestive presentations, even though the vast majority of them will not have dissection. Think about dissection when patients have features in the score. Understand that you will eventually miss dissection because sometimes it presents in crazy atypical ways, and that if you try to catch very atypical dissections you will do more harm than good by overuse of CT.

Low Threshold Buprenorphine

 

Sustained comprehensive addiction care is the goal, but until then, most OUD patients should get buprenorphine in the ED and/or a script. Every hour a street opioid user is therapeutic on bup is an hour they’re safe from withdrawal, cravings, and overdose, and is an hour they can contemplate recovery.

The Paper Throat: A Lo-fi, DIY Laryngoscopy Simulator

 

Laryngoscopy involves a series of unnatural movements and hand-eye skills that are not easily learned while simultaneously caring for a dying patient. The Paper Throat is a low fidelity but high yield direct laryngoscopy training tool that is easily assembled and practiced. The hope is that routine use will generate laryngoscopy muscle memory so that training providers can focus on other aspects of airway management when called upon to intubate IRL.

Conceived and produced by Jonas Pologe.

Pulse Ox Lag

Folks put a lot of stock in the pulse oximeter, as they should, because the pulse ox is an awesome feat of engineering and patient safety. But the pulse ox lags.

Here, the inestimable Dr. Jonas Pologe (rhymes with apology) demonstrates pulse ox lag with a breath hold.

Breath hold starts at 0:11, sat is 100%
Saturation starts to drop at 0:48
Breathing commences at 1:25, sat is 82% at this point
Saturation continues to drop until 1:46, then recovers from its nadir of 77%
At 1:58, saturation reaches 100% again

 

Lessons:

1. When the sat is on its way down, the patient is more hypoxic than the pulse ox shows. This is another reason why, when laryngoscopy is not producing an acceptable view of the glottis, you should come out and reestablish ventilation/oxygenation earlier than you think. A more important reason to come out and bag early is described here.

2. When you are reestablishing oxygenation (using a bag mask, laryngeal mask, or endotracheal tube), do not use the pulse ox to judge the adequacy of ventilation, use capnography. That means the capnogram should be attached to the bag mask/LMA/ETT before the first breath is given. If the capnogram is good, ventilation is good, and the pulse ox will catch up, so relax and stop bagging so quickly.

Petition to retire the surviving sepsis campaign guidelines

Friends,

Concern regarding the Surviving Sepsis Campaign (SSC) guidelines dates back to their inception.  Guideline development was sponsored by Eli Lilly and Edwards Life Sciences as part of a commercial marketing campaign (1).  Throughout its history, the SSC has a track record of conflicts of interest, making strong recommendations based on weak evidence, and being poorly responsive to new evidence (2-6).

The original backbone of the guidelines was a single-center trial by Rivers defining a protocol for early goal-directed therapy (7).  Even after key elements of the Rivers protocol were disproven, the SSC continued to recommend them.  For example, SSC continued to recommend the use of central venous pressure and mixed venous oxygen saturation after the emergence of evidence that they were nonbeneficial (including the PROCESS and ARISE trials).  These interventions eventually fell out of favor, despite the slow response of SSC that delayed knowledge translation.

SSC has been sponsored by Eli Lilly, manufacturer of Activated Protein C.  The guidelines continued recommending Activated Protein C until it was pulled from international markets in 2011.  For example, the 2008 Guidelines recommended this, despite ongoing controversy and the emergence of neutral trials at that time (8,9).  Notably, 11 of 24 guideline authors had financial conflicts of interest with Eli Lilly (10).

The Infectious Disease Society of America (IDSA) refused to endorse the SSC because of a suboptimal rating system and industry sponsorship (1).  The IDSA has enormous experience in treating infection and creating guidelines.  Septic patients deserve a set of guidelines that meet the IDSA standards.

Guidelines should summarize evidence and provide recommendations to clinicians.  Unfortunately, the SSC doesn’t seem to trust clinicians to exercise judgement.  The guidelines infantilize clinicians by prescribing a rigid set of bundles which mandate specific interventions within fixed time frames (example above)(10).  These recommendations are mostly arbitrary and unsupported by evidence (11,12).  Nonetheless, they have been adopted by the Centers for Medicare & Medicaid Services as a core measure (SEP-1).  This pressures physicians to administer treatments despite their best medical judgment (e.g. fluid bolus for a patient with clinically obvious volume overload).

We have attempted to discuss these issues with the SSC in a variety of forums, ranging from personal communications to formal publications (13-15).  We have tried to illuminate deficiencies in the SSC bundles and the consequent SEP-1 core measures.  Our arguments have fallen on deaf ears.

We have waited patiently for years in hopes that the guidelines would improve, but they have not.  The 2018 SSC update is actually worse than prior guidelines, requiring the initiation of antibiotics and 30 cc/kg fluid bolus within merely sixty minutes of emergency department triage (16).  These recommendations are arbitrary and dangerous.  They will likely cause hasty management decisions, inappropriate fluid administration, and indiscriminate use of broad-spectrum antibiotics.  We have been down this path before with other guidelines that required antibiotics for pneumonia within four hours, a recommendation that harmed patients and was eventually withdrawn (17).

It is increasingly clear that the SSC guidelines are an impediment to providing the best possible care to our septic patients.  The rigid framework mandated by SSC doesn’t help experienced clinicians provide tailored therapy to their patients.  Furthermore, the hegemony of these guidelines prevents other societies from developing better guidelines.

We are therefore petitioning for the retirement of the SSC guidelines.  In its place, we would call for the development of separate sepsis guidelines by the United States, Europe, ANZICS, and likely other locales as well.  There has been a monopoly on sepsis guidelines for too long, leading to stagnation and dogmatism.  We would hope that these new guidelines are written by collaborations of the appropriate professional societies, based on the highest evidentiary standards.  The existence of several competing sepsis guidelines could promote a diversity of opinions, regional adaptation, and flexible thinking about different approaches to sepsis.

We are disseminating an international petition that will allow clinicians to express their displeasure and concern over these guidelines.  If you believe that our septic patients deserve more evidence-based guidelines, please stand with us.

Sincerely, 

Scott Aberegg MD MPH

Jennifer Beck-Esmay MD

Steven Carroll DO MEd

Joshua Farkas MD

Jon-Emile Kenny MD

Alex Koyfman MD

Michelle Lin MD

Brit Long MD

Manu Malbrain MD PhD

Paul Marik MD

Ken Milne MD

Justin Morgenstern MD

Segun Olusanya MD

Salim Rezaie MD

Philippe Rola MD

Manpreet Singh MD

Rory Speigel MD

Reuben Strayer MD

Anand Swaminathan MD

Adam Thomas MD

Scott Weingart MD

Lauren Westafer DO MPH

References
  1. Eichacker PQ, Natanson C, Danner RL. Surviving Sepsis – Practice guidelines, marketing campaigns, and Eli Lilly.  New England Journal of Medicine  2006; 16: 1640-1642.
  2. Pepper DJ, Jaswal D, Sun J, Welsch J, Natanson C, Eichacker PQ. Evidence underpinning the Centers for Medicare & Medicaid Services’ Severe Sepsis and Septic Shock Management Bundle (SEP-1): A systematic review.  Annals of Internal Medicine 2018; 168: 558-568.
  3. Finfer S. The Surviving Sepsis Campaign:  Robust evaluation and high-quality primary research is still needed.  Intensive Care Medicine  2010; 36:  187-189.
  4. Salluh JIF, Bozza PT, Bozza FA. Surviving sepsis campaign:  A critical reappraisal.  Shock 2008; 30: 70-72.
  5. Eichacker PQ, Natanson C, Danner RL. Separating practice guidelines from pharmaceutical marketing.  Critical Care Medicine 2007; 35:  2877-2878.
  6. Hicks P, Cooper DJ, Webb S, Myburgh J, Sppelt I, Peake S, Joyce C, Stephens D, Turner A, French C, Hart G, Jenkins I, Burrell A.The Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008.  An assessment by the Australian and New Zealand Intensive Care Society.  Anaesthesia and Intensive Care 2008; 36: 149-151.
  7. Rivers ME et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock.  New England Journal of Medicine 2001; 345: 1368-1377.
  8. Wenzel RP, Edmond MB. Septic shock – Evaluating another failed treatment.  New England Journal of Medicine 2012; 366: 2122-2124.
  9. Savel RH, Munro CL. Evidence-based backlash:  The tale of drotrecogin alfa.  American Journal of Critical Care  2012; 21: 81-83.
  10. Dellinger RP, Levy MM, Carlet JM et al. Surviving sepsis campaign:  International guidelines for management of severe sepsis and septic shock:    Intensive Care Medicine 2008; 34:  17-60.
  11. Allison MG, Schenkel SM. SEP-1: A sepsis measure in need of resuscitation?  Annals of Emergency Medicine 2018; 71: 18-20.
  12. Barochia AV, Xizhong C, Eichacker PQ. The Surviving Sepsis Campaign’s revised sepsis bundles.  Current Infectious Disease Reports 2013; 15: 385-393.
  13. Marik PE, Malbrain MLNG. The SEP-1 quality mandate may be harmful: How to drown a patient with 30 ml per kg fluid! Anesthesiology and Intensive Therapy 2017; 49(5) 323-328.
  14. Faust JS, Weingart SD. The past, present, and future of the centers for Medicare and Medicaid Services quality measure SEP-1:  The early management bundle for severe sepsis/septic shock.  Emergency Medicine Clinics of North America 2017; 35: 219-231.
  15. Marik PE. Surviving sepsis:  going beyond the guidelines.  Annals of Intensive Care 2011; 1: 17.
  16. Levy MM, Evans LE, Rhodes A. The surviving sepsis campaign bundle:  2018 update. Intensive Care Medicine. Electronic publication ahead of print, PMID 29675566.
  17. Kanwar M, Brar N, Khatib R, Fakih MG. Misdiagnosis of community-acquired pneumonia and inappropriate utilization of antibiotics: side effects of the 4-h antibiotic administration rule.  Chest 2007; 131: 1865-1869.