All posts by Chad Meyers

Thank You

Thank you to everyone who supported us during the Covid-19 pandemic.

Your donations of PPE, food, accommodations, transportation, comfort items for staff and patients, your messages of support and much more, all helped us cope through a very difficult time.

Thank you so much,

The Staff of the Elmhurst Hospital Emergency Department

http://ehced.org/thank-you/

Video created by Sujin Chung and Lillian Wong

EHC COVID-19 Clinical Care Guidelines

The guidelines below are a collaborative effort between the EHC departments of internal medicine, infectious disease, pulmonary critical care, surgery, emergency medicine, cardiology, nursing and physical therapy.

As practice guidelines continue to evolve we will continue to update treatment recommendations.  Any suggestions, questions or concerns please email me cmeyersmd@gmail.com

 

EHC COVID-19 Clinical Care Guidelines 5-1-20

Airway Pressure Release Ventilation (APRV)

updated 5-1-20

The following is a tutorial on basic airway pressure release ventilation (APRV) setup and troubleshooting.

There are multiple theoretical advantages of APRV over conventional ventilator strategies (see review articles below) however some of the benefits specific to the COVID-19 patient population is the prevention of derecruitment and encouragement of spontaneous breathing with consequent decreased need for deep analgosedation.  While APRV can be set up directly in the newly intubated patient, it is perhaps easier to transition from more a more familiar conventional modality such as AC/VC.

  1.  After RSI, place pt on ACVC utilizing low tidal ventilation strategy per ARDSnet protocol. Initiate analgesia and sedation strategy.
  2. Once PEEP has been titrated per ARDSnet PEEP/O2 tables, paralysis has worn off and the patient is spontaneously breathing, consider transition to APRV
  3. Set Pressure high (Phigh). While still on ACVC, perform inspiratory hold and measure Plateau Pressure.  The plateau pressure will be your starting  Phigh in APRV.  Values are typically between 20-35 cmH20
  4. Set Time high (Thigh)* in post-op patients and those with normal lungs, Thighs are  typically between 4-6s.  Longer Thigh in general will increase oxygenation.  However, in the setting of COVID-19 an alternative rescue strategy utilizing shortened breath cycles may be preferable.  See below for setting Thigh as a rescue strategy, APRV time controlled adaptive ventilation (TCAV), in which Thighs will be much shorter, between 1-3s.
  5. Set Pressure low (Plow) to 0** (see discussion below)
  6. Set Time low (Tlow).  APRV relies on autopeep(iPEEP) to prevent derecruitment of alveoli, therefore your release time or Tlow is critical.  The longer the Tlow, the lower the iPEEP and the greater the likelihood of alveolar collapse.  In order to adjust Tlow we need to observe the patients expiratory flow waveform on the ventilator, targeting >50% to 75% T-PEFR (see below).  This will typically be between 0.2-0.8s in restrictive lung disease and 0.8-1.5s in obstructive lung disease.  The shorter the Tlow, the greater the mean airway pressure which will generally increase oxygenation.
  7. Spontaneous Breathing in APRV.  While traditional long Thigh (4-6s) APRV requires spontaneous breathing to maintain normal minute ventilation, rapid cycling TCAV with shortened Thigh (1-3s) will provide adequate ventilation without additional patient efforts even in the setting of paralysis.  In COVID-19, there is concern that abnormal respiratory drive and large Vt spontaneous breathing may be injurious.  TCAV with shortened respiratory cycles can be helpful in minimizing patient efforts without the need for exceptional doses of analgesics/sedatives.  During weening trials, cautious reintroduction of spontaneous breathing may be considered.  On the draeger ventilator, automatic tube compensation (ATC) can be added to provide assistance overcoming the resistance of the endotracheal tube.  On other vent models (PB 840, vela, servo-i) leave off pressure support outside of spontaneous breathing trials during weening.
  8. Troubleshooting Hypoxemia in traditional APRV (for TCAV rescue see below)  Overall, to improve oxygenation we need to increase mean airway pressure and/or recruit atelectatic alveoli.  Assuming your FiO2 is already 100%, consider the following steps:
    1. shorten Tlow up to T-PEFR 75%
    2. increase Phigh and Thigh simultaneously.  Phigh >35 may be required in the morbidly obese
  9. Troubleshooting Hypercapnia in traditional APRV (for TCAV rescue see below)  Mild hypercapnia without severe acidemia can be tolerated in these patients.  Optimizing ventilation should be performed cautiously in a way that does not compromise oxygenation.
    1. Lighten sedation to encourage spontaneous ventilation.
    2. Increase Phigh and Thigh simultaneously.
    3. Lengthen Tlow by 0.05-1s increments up to 50% T-PEFR.  (while this will increase tidal volumes during release, this will also decrease mean airway pressure and likely worsen oxygenation)
    4. Increase Phigh while decreasing Thigh (not recommended).  while this will increase minute ventilation, it will also decrease mean airway pressure and worsen oxygenation.

Below is the table from the Habashi review article which details setup as well as troubleshooting. I highly encourage everyone to read the review prior to your first attempts using APRV.

 

T-PEFR – ventilator flow waveform (resusreview.com)

 

Great Review article by Nader Habashi on APRV

 

APRV by Habashi

 

Thigh – APRV time controlled adaptive ventilation (TCAV) as RESCUE* While Thighs are routinely set at 4-6s in the postop or trauma population, in patients with COVID-19 Dr. Habashi recommends shortening the respiratory rate considerably to improve bulk ventilation.  Transitioning from conventional modalities use the following formula to calculate Thigh.  As discussed above, short Thighs may also suppress spontaneous breathing in COVID-19 patients with abnormal respiratory drive and may potentially protect patients from self injury.

(60/current rate) – TLow   (if RR 20, then 60/20=3 , if Tlow 0.5s then rescue Thigh is 2.5s)

The full APRV Rescue protocol is below from http://www.APRVnetwork.org

APRV TCAV Rescue Strategy Strategy Guidelines 2020

 

Alternative approach to Tlow/Plow settings**. (skip this part until comfortable with Habashi method) An alternative strategy for APRV has been proposed by Zhou et al.  The Zhou method is notably different in their approach to determining Tlow which is determined by starting with a Tlow of ~1s, multiplied by the time constant (resistance*compliance) and then targeting T-PEFR >50%.  In addition, Zhou also utilizes a starting Plow of 5 cmH20, while Habashi recommends Plow of 0.  Many pulmonary physiologists criticize APRV because it relies on autoPEEP(iPEEP) to prevent derecruitment of alveoli.   iPEEP does not uniformly affect the lung.  iPEEP will recruit healthy alveoli with increased compliance preferentially over diseased low compliant alveoli which could potentially worsen atelectatrauma.  With that in mind,  per the starling resistor model extrinsic PEEP and iPEEP are not additive unless extrinsic PEEP exceeds iPEEP.  Adding additional extrinsic PEEP with the ventilator (eg. Plow 5 cmH20) would likely not affect healthy alveoli already stented by iPEEP  but may prevent the full derecruitment of diseased/low compliance/stiff alveoli.  Adding Plow may prolong the release time necessary to reach T-PEFR 50-75%.

Below is Zhou’s alternative APRV initiation and titration strategy taken from their study protocol.  Of note, Zhou utilized Puritan Bennett ventilators (like our 840s) which likely explains some of the differences in initiation/setup.  While 840s can be used to provide APRV, the setup is less straight forward than on the VELAs and Draegers.

 

Zhou ARPV

 

More recent review article summarizing trials as well as reviewing alternative strategy by Zhou.

APRV review

EMCRIT post on APRV

https://emcrit.org/emcrit/aprv-primer/

another site with tutorial based on Habashi APRV strategy

https://resusreview.com/2013/aprv-ventilation-mode-introduction-basic-use-management-and-advanced-tips/

Any questions about setting this up? Grab me while I’m working clinically and I’ll walk you through it or call me anytime with questions 917-749-1004.

EHC COVID-19 EMERGENCY AIRWAY MANAGEMENT GUIDELINES

Some suggestions in terms of workflow for airway management.

The following  in an ongoing collaboration with Nick Caputo at Lincoln as we are attempting to develop a unified approach between sites to allow us all to learn from one another’s success and mistakes.  Check back frequently for updates as our supplies and what we know about the disease changes.

ED_COVID_RSI_Protocol v3-28

 

Ventilator shortage.  The hospital is facing a significant ventilator shortage.  In addition to our 7 VELA ventilators, there are 3 transport ventilators in radiology and 11 anesthesia machines in the OR.  1 transport ventilator should remain in radiology for use with patients requiring CT.  If OR ventilators are required, contact anesthesia for assistance in initial setup and questions.

We have 50 emergency transport ventilators with extremely limited capabilities.  Specifically, they are asynchronous and provide a maximum PEEP of 5cmH20 which makes them of limited value in the setting of severe ARDS.   The devices are a bit tricky to use, so look over the following visual guide and watch the video beforehand.  There is a ventilator in the admin office connected to a test lung and O2 cannister to practice with.

Instructions_VORTRAN Automatic Resuscitator VAR MODEL RC

Dual Ventilation Strategy

Dual ventilation strategy should only be considered as a last resort.  If attempting to do so, the following protocol may improve safety.

Ventilator-Sharing-Protocol-Dual-Patient-Ventilation-with-a-Single-Mechanical-Ventilator-for-Use-during-Critical-Ventilator-Shortages (1)

Non-invasive ventilation. In light of impending ventilator shortage, it is prudent that we avoid any unnecessary intubation.  If clinical history suggests that there may be a reversible component of failure (eg. CHF, asthma) then it may be reasonable to attempt at short trial of NIV.  A few guidelines for NIV:

-NIV should only be attempted with our closed circuit ventilators with a non-vented facemask.  The single limb dedicated BiPAP machines have a vent in the mask which will aerosolize droplets into the room when the patient exhales
-Attach HEPA filter at the mask prior to Y connection of the tubing
-Place patient in isolation tent
-Ensure tight mask fit prior to initiation of ventilation
-If albuterol administration required, administer via MDI adapter or aerogen nebulizer as pictured below

GUIDANCE OF ADMINISTRATION OF ALBUTEROL TO VENTILATED BIPAP EDIT

 

Any questions don’t hesitate to contact me anytime.  text/call 917-749-1004.

How to administer albuterol via MDI or aerogen nebulizer in patients requiring non-invasive or mechanical ventilation

To minimize potential aerosolization during administration of albuterol we are trying to utilize MDIs primarily.  For intubated patients or those requiring NIV you can administer albuterol MDIs via inline adapter.  Alternatively, the aerogen device also minimizes leak compared to the typical acorn nebulizers but it’s effect on droplet dispersal is unknown.

GUIDANCE OF ADMINISTRATION OF ALBUTEROL TO VENTILATED BIPAP EDIT

in-line MDI adapters and aerogen nebulizers are located on the respiratory cart behind the cardiac workstation, located on the same shelf as the VL blades.

Thank to Suzi Bentley for putting together the visual guide.

Alcohol Withdrawal Syndrome Guidelines

Below are the updated AWS guidelines for the EHC emergency department. Note that chlordiazepoxide/librium is favored in all patients who are able to take oral medications and who are not severely agitated (RASS ≥3).  The goal of therapy is a calm to drowsy patient (RASS 0 to -1) regardless of HR/BP.  If a patient remains tachycardic despite adequate sedation, strongly consider concurrent or alternative pathology, eg. sepsis. 

EHC AWS algorithm 11-28

 

In addition, use of the non-benzodiazepine (BZD) adjuncts such as dexmedetomidine/precedex is not advised unless the patient is refractory to BZD and barbiturate therapy.  The refractory AWS pathway (pg2) outlines a suggested strategy for those patients in whom adequate control cannot be obtained despite diazepam 200mg and phenobarbital 390mg.  In these patients the overall goal is to avoid intubation unless absolutely necessary.  The suggested non-BZD adjunct in this scenario is ketamine, which is more strongly supported by evidence.

The goal of management in AWS is to determine the dosage of benzodiazepine that is required to control a patient (calm/alert to slightly drowsy or RASS 0 to -1) for at least 1hr from last administration of medication.

In addition to admission to a unit capable of appropriate level of care, evaluate patients for co-morbid conditions such as trauma, sepsis, pancreatitis, DKA/AKA,  etc.  Strongly consider the supplementation of multivitamin/thiamine/folate to patients at risk for malnutrition. 

These guidelines were adopted from Bellevue’s AWS protocol  and updated with the assistance of our EHC/MSSM toxicologists Alex Manini, Rachel Shively and Beth Ginsburg.  Any questions or concerns please feel free to contact me at cmeyersmd@gmail.com

Sexual Assault Survivor Protocols and Documents

Below are updated resources for the management of sexual assault survivors.  Permanent links to the documents can also be found under the guidelines tab.

Sexual assault checklist

Sexual-Assault-Checklist

 

HIV PEP follow up information

HIV PEP Follow-up Information

 

HIV PEP starter pack information

HIV PEP Starter Pack Information

 

Tip sheet for ordering HIV PEP

Tip Sheet for Ordering HIV PEP

 

FRE form

FRE Form

 

SART bill of rights

SART BIll of Rights (1)

proBNP cutoffs

A few people were asking for a quick reference regarding age related proBNP cutoffs.

Embedded below are links to both the PRIDE and ICON-RELOADED trials which investigated proBNP cutoffs in the emergency department.

In summary:

The optimal age-independent cutoff for ruling out acute heart failure is <300 pg/ml

The optimal age-adjusted cutoffs for ruling in acute heart failure are:

<50 years old – 450 pg/ml

50-75 years old – 900 pg/ml

>75 years old – 1800 pg/ml

doi_10.1016_j.amjcard.2004.12.032

Accidental Hypothermia

Given the current weather it seems appropriate to post some guidance for patients suffering significant cold exposure. Below are concise guidelines from OSU medical center  and the Wilderness Medical Society (pre-hospital).  Both have useful information in regards to management along the spectrum of exposure. 

OSU Management of Accidental Hypothermia

ECMO TRANSFERS

At this time we are referring all all ECMO transfers to Montefiore’s Cardiothoracic Surgical ICU.  Although most ECPR cases are not typically candidates for on-site cannulation and transfer, in some rare hypothermic cases (eg. young patient, short downtime) there may be an exception. 

To initiate possible transfer first call 718-920-ECMO and provide the following: Patient name, Diagnosis and Location.  The transfer center will connect you with a CT surgeon with whom you can discuss the case and decide whether the patient is a candidate for potential transfer.

If ECMO is deemed appropriate, next call the AOD in order to initiate the emergency credentialing process for the surgeon.

EXCLUSIONS to CPR

Appropriate situations in which to terminate efforts for performing CPR in hypothermic patients with cardiac arrest:

  • Body is frozen solid (cannot perform chest compressions, no chest recoil)
  • Obvious non-survivable injury (eg. Decapitation, truncal transection, incineration/decomposition of whole body)
  • Airway obstruction (snow/ice) with downtime greater than 1 hour (more for avalanche victims than urban recoveries)

PROCEDURES

Thoracic lavage should be reserved only for pulseless patients.  A few variations of the procedure are possible including single and dual tube methods.  A good review can be found here THORACIC LAVAGE

Thank you to Neil Dubey and Mark Andreae for their help with this post.

ELMHURST UPDATES – WELCOME TO BLOCK 4, TRAUMATIC BRAIN AND SPINAL INJURY PROTOCOLS

Changes, Updates, Important Information

  • When you are on a cardiac room shift or trauma shift, please arrive a few minute early to check that your supplies are well stocked and airway boxes are ready to go. When you use supplies and airway boxes, don’t forget to reset.
  • ​If a patient leaves during evaluation (this means “provider in” is clicked, orders of any kind are placed, any note is written by a midlevel or attending provider) please indicate “Left During Evaluation” and NOT “Eloped” or “LWBS…”in the Dispo section of the chart.
  • Current drug shortages: kayexelate, epipen
  • Psychiatry consults: (Do not use the paging operator, amion is not yet updated)
    • ​Mon-Fri 8a-5p call 6-6934 (cordless); OR as backup page 40524 for the consult attending
    • Mon-Fri 5p-8a, weekends, holidays page 15094 – consult resident; OR as backup call the Bell attending 6-4750 (cordless)
Discharges
  • Patients from Rikers Island who are discharged back to Rikers should have printed copies of their:
    • (1) H&P and consultant notes (i.e. psych notes);
    • (2) “ED to PCP summary” (i.e. results of diagnostic studies); and
    • (3) AVS (i.e. clear discharge instructions with medication recommendations)
    • (4) placed in a sealed envelope and handed to the Corrections Officer, NOT the patient​
  • Please provide “Procedural Sedation” and “Stroke and TIA Prevention”  discharge instructions to patients as appropriate.
  • Please take the time to schedule appropriate follow up appointments for patients. This is especially important for our Elmhurst population with generally poor health literacy.
  • All patients diagnosed and treated or suspected and treated for a sexually transmitted illness (STI) MUST be followed up in the Sexual Health Clinic (SHC).  Discharge clerks can schedule appoints as early as the next business day. This includes women treated for possible PID, men with confirmed or suspected GC/Chlamydia and anyone with suspected/confirmed syphilis.  
  • Newly diagnosed HIV positive patients are to be referred to the ID clinic NOT to the SHC.  There are resources in the SHC for face-to-face patient counseling, HIV pre-exposure prophylaxis (PreP) medication and partner surveillance.  They’ll also refer female patients to the gynecologic clinic, if necessary, after they’ve met with these patients.
  • ​​Do NOT overbook Proctology Clinic.  If there is no availability, in the timeframe you need, then send the patient to the General Surgery clinic.
  • Patients with suspected ectopic pregnancy should follow up in GYN Surgery clinic. ​
​​Transfers
  • ​​Transfer formsMUST be completed on all transfer patients regardless of the service requesting the transfer.You’ll find the Transfer Form after you’ve selected “Transfer to Another Facility” on the Disposition Tab >> TRANSFER/EMTALA Forms >> complete the form – especially the ACCEPTING HOSPITALand ACCEPTING ATTENDING PHYSICIAN (not resident)! Then save, print, and give the form to the sending RN.  
​​Radiology
  • For radiology studies select an indication AND include a brief comment on the reason for exam
  • When ordering PLAIN X-ray imaging place a patient transport request in EPIC. On the main tracking board select the patient, click on “patient transport”, select “EL Radiology” as the location and priority “high”.  
Admissions​​
  • If you change the admitting service or level of care, you need to (1) change the admission service order in EPIC AND (2) also call Admitting
  • The ED attending makes the final admission decision, please check with them before admitting.
  • Any patient with a traumatic injury MUST be admitted to a surgical service. If they need telemetry or have complex medical diagnoses, the SICU fellow or attending should be consulted for SICU or surgical step down bed assignment.
Epic Quirks 
  • ​​Please use the “quick lists” to order medications. These are set up to have appropriate dosing, administration and titration instructions for the ED. In addition the IV push doses of relevant medications have now been added to this list
  • Click the provider in button and indicate the time you first saw the patient for every patient you see (if it has not already been done).
  • Uses the physical exam checkboxes in EPIC to document guaiac results.​
Misc

  • ​​Vaginal ultrasound probe cleaning (Trophon)/use monitoring: Name-sticker placed in the black folderwhen we use the pelvic ultrasound probe.  This must be done every time by either the ED provider, chaperoning PCA, or the Gyn consultant.
  • Ultrasounds: Please clean the ultrasounds and plug them in after use. Please order, save images, and read all ultrasounds performed in the ED.
  • We have Naloxone kits available for free distribution to at risk patients. Most of the attending physicians have completed the training to dispense the kits. Please consider this for your patients and ask the attendings when appropriate.
​Trauma/Cardiac
  • Apply a patient label or baxter label to the EMS notification sheet when applicable. Continue to place these sheets in the bin by the phones. ​
  • ​Continue to save all ultrasounds, especially all FAST exams done during trauma to Q-path. These should be linked to ​​the patient in Q-path, interpreted by the resident and signed by the attending. 
Sepsis
  • ​​​P​lease help us meet sepsis treatment criteria. We are missing sepsis marker primarily because of these four things: 
    • Blood cultures not marked as collected prior to antibiotic being marked as given – REMIND YOUR RN;
    • Time to fluid and antibiotic administration – We have 3 hours from arrival;
    • Failure to repeat elevated lactate by 6 hours;
    • Failure to write a sepsis reassessment note after fluids are given.

Colleen and Moira

​FULL BLOCK 4 UPDATE  Elmhurst Updates SEPTEMBER 2018

2016 EHC ANTIBIOGRAM 2016 EHC Antibiogram
The most recent EHC Traumatic spine and brain injury protocols. Both can be found permanently linked under the cardiac/trauma tab