Bartgen/DeWeert    Oral Boards

Pneumothorax re-expansion pulmonary edema

RPE is a possibly life-threatening but relatively little known condition. Therefore its occurrence is often not recognized as a complication of chest drainage after pneumothorax. Signs and symptoms include dyspnea, tachypnea and low saturation levels usually within an hour after intercostal drainage.

Risk factors include younger age, larger pneumothorax or longer existing pneumothorax and maybe a swift drainage of large amounts (>1L) of fluids or air.

To prevent RPE it is advised to drain less than 1L  of air or fluids initially. The disease is often self-limiting and therapy is supportive.

Treat with supplemental O2 or bipap or intubation depending on the severity of pulmonary edema.  Editor's note: For larger pneumos that I drain going forward, I will watch the patient for 1-2 hours in the ED following chest tube placement.

Verhagen M, van Buijtenen JM, Geeraedts LMG. Reexpansion pulmonary edema after chest drainage for pneumothorax: A case report and literature overview. Respiratory Medicine Case Reports. 2015;14:10-12. doi:10.1016/j.rmcr.2014.10.002.

Carlson      Critical Care Toxicology

Capnography is superior to pulse-oximetry to identify early hypoventilation or airway obstruction.    If you only have a pulse-ox to monitor the patient, don't give supplemental oxygen. You basically want to identify oxygen desaturation as a marker for hypoventilation/respiratory depression and supplemental O2 will mask early oxygen desaturation. 

The most common toxicology causes for intubation are ETOH, Benzos, and sedative hypnotics.

Bipap is a problematic strategy for respiratory support in toxic patients due to altered mental status and risk of vomiting.  Andrea's bottom line: BiPap is a no-go for the poisoned patient except for non-cardiogenic pulmonary edema (eg. post heroin overdose patient).

If the patient has salicylate poisoning you have to be very careful to adequately ventilate the patient after intubation. You will need higher tidal volumes like around 10ml/kg and a rate around 30+.  This is very different from usual lung protective ventilatory strategy with tidal volume of 6ml/kg and rates around 15.

The peri intubation period in the Tox patient is very high risk. Be sure to have a well thought-out airway management plan and optimize the patients hemodynamics prior to starting intubation.

First choice vasopressor for Toxin-Induced Cardiogenic Shock (TICS) is epinepherine.  If that doesn't solve the problem you can add norepi BUT there is no mortality benefit shown for using a second pressor.  If the first pressor isn't working you may to start thinking about mechanical CV support like an Impella device or ECMO.

High dose insulin 1 unit/kg is the first line agent for hypotension for beta blocker or calcium channel blocker overdose.  Be sure to supplement glucose and potassium.  You usually don't need high doses of glucose to prevent hypoglycemia because blood sugar doesn't drop that much with insulin therapy in the setting beta blocker overdose.  Editorial advice: Check the sugar q 1 hour if you are using high dose insulin.

Hormese  Pharm D    Management of PE

Treatment of massive PE with TPA showed improved mortality (10mg bolus and then 90mg over 2 hours)

Treatment of sub-massive PE with TPA in the PEITHO Trial 2014 did not show improved mortality.  When investigators combined mortality and hemodynamic instability as the outcome there was benefit.  The study demonstrated a 6% extra-cranial bleed rate and 2% intracranial bleed rate.

Patients less than 65yo with sub-massive PE  do better with TPA than older patients.  Use low dose strategy 10mg bolus followed by 40mg over 2 hours.  Elise comment: there is no right answer for the management of sub- massive PE.  The body of data thus far does not show clear benefit.  Treatment for sub-massive PE is decided on a case by case basis.  In younger patients with worse PE's a better case can be made for it.  Harwood comment: Don't even consider TPA for sub-massive PE unless you have an abnormal echo AND an elevated troponin.  Definitely use low dose strategy and use it in only in patients under 65.  The bleed risk is significant. Use shared decision-making with patient/family/cardiologist/intensivist.

EKOS catheter directed thrombolysis can be considered for both massive and sub-massive PE's.  Here at Christ the Cardiologists are performing this procedure.  If you need an EKOS trained cardiologist call the STEMI Cardiologist on call and they will get the person who can do EKOS.

Cost to patient for TPA is $32,000.

There was a discussion about what to do for the unstable patient who has PE in the DDX but has not had a CT yet.  Everyone agreed that this was a tough decision to give TPA without a confirmatory test. Everyone agreed that bedside echo is the best test to help you in this situation.

HCAP Guidelines

The new HCAP guidelines for ACMC were reviewed.

Friend       Epinepherine dosing in place of an Epipen

We no longer have epipens in the ED.  Dr. Friend discussed our current strategy to administer epinepherine to our patients with anaphylaxis. To prevent dosing errors, Dr. Harwood suggested that in the epi kit there should be 1 vial of epinephrine and 3 insulin syringes.  When the kit is opened. All 3 syringes should be used to draw up 0.3 ml of epinephrine in each syringe.  That gives you 3 doses of 0.3mg of epinephrine to administer.  That way you can't inadvertently give too large of a dose.  Everyone agreed this was an excellent safety strategy. 

Florek    PE/DVT

Dr. Florek discussed the diagnostic strategy for 5 types of patients with suspected PE.

1. Well appearing. Low risk Well's and PERC negative----Done

2. Well appearing  Low risk Well's and PERC positive------Get a D-dimer (age-adjusted) If you are using age adjusted d-dimer you have to scan if pt exceeds the age adjusted limit by even 0.01.

3. Intermediate or High Risk on Well's-----Go straight to CTPE study

4. Peri-Arrest------Get CXR, EKG, bedside Echo.  If high suspicion for PE and dissection is felt to be unlikely then start heparin and consult for EKOS

5. PEA arrest------ Get history and perform bedside echo.  If suspicion for PE is high you can consider TPA 50mg IV bolus.

For pregnant patients use pregnancy adjusted d-dimer and if positive, your initial imaging should be venous dopplers of the legs.  Jeff Kline uses d-dimer cut-offs  of 0.75 in first trimester, 1.0 in second trimester, and 1.25 in third trimester.  He states in his article that if the pregnant patient has low-risk Well's score, no high-risk features, PERC neg, Venous dopplers negative, and d-dimer is under pregnancy-adjusted cut-offs no need to work up further. (Kline JEM 2015)