All posts by Chad Meyers

RaCC/Cardiac Room Orientation

Policies, Protocols

 

The Cardiac Room, also known as the “RACC Room” (Resuscitation and Critical Care) is the critical care area of the Elmhurst ED. The sickest patients in the department are seen here. There are 4 cardiac bays although you may use the adjoining trauma room for 3 additional critical care bays if needed.  When the cardiac room overflows into the trauma room try and leave one available bed for the trauma team unless it is absolutely impossible. Unlike the sides or fast track you do not get to pick up patients at your leisure. You must see each patient immediately when they arrive. Patients either come from Triage or the sides.  Patients who are presented to the cardiac room from the side may have had a partial work-up done by another provider or they may have decompensated prior to be seen by the side team.  You may also be asked to care for patients who are still in the emergency department that have been admitted and are awaiting an inpatient bed but decompensate before leaving the ED.

The Cardiac Room is staffed by one resident and one dedicated attending.  This shift provides you with a lot of one on one time with your attending and makes for great teaching and learning.  This is your best chance to engage your attending and really pick their brain for the intricacies and details of resuscitative care.  In addition the cardiac room provides you with an excellent chance to practice critical procedures.  Try and explore your patients’ pathology in-depth and “wrap them up” as much as possible before releasing them to the floor services partly for the patient’s good and partly for your own learning and practice.

On occasion there may be an intern or medical student shadowing in the cardiac room with you.  This is their introduction to the Cardiac Room and please help make it beneficial for them.  Take them with you as you set up the room (discussed below).  Teach them the basics of ED critical care medicine and show them how to use ventilators and perform essential procedures.  It is also an excellent opportunity to show them the location of all required equipment present in the back.

 

Pre-Shift Preparation

 

At the beginning of your shift. first priority is to prepare the room for the arrival of a potentially critically ill patient.  It is not uncommon that critical patients arrive without EMS pre-notification, therefore all necessary resuscitation equipment should always be immediately available and ready to use.  Review the RACC pre-shift checklist (available in the resource binder next to the attending computer) and begin by preparing the video laryngoscope cart.  The failed airway drawer should be stocked with a scalpel, 6.0mm portex trach, and both sizes of LMA with a syringe. Each resuscitation bay headwall should be standardized with O2 delivery supplies, BVM and face shields.  The ventilator should always have clean tubing connected as well as inline filters attached.  The Zoll defibrillator should be in a visible position beside the bay monitor, connected to defibrillator pads and the Zoll mainstream EtCO2 detector should have a clean adapter.  The ultrasound machine should be in its place, plugged in and charging with adequate supply of gel and chucks.  Is the tox/antidote kit available, stocked and are you familiar with its contents?  Next, review the RACC critical equipment inventory verifying adequate stock of equipment in the Pyxis units, the shelving above the trauma computers and the appropriate bluebin racks.  Keep in mind where each item is located for when you need it.  Finally, check the respiratory equipment stock in the green drawers below the sink. If any items are low stock (eg. only 1 transvenous pacemaker kit left? 2 pigtails? 1 small NIV mask?), contact the appropriate department listed on the inventory contact list. 
 
Ask yourself during prep, “Do I know how to use every item that we have stocked?” Reuben’s general start of shift checklist is a great review of emergency procedures and strategies you should be prepared for during every shift.  Take some time before your shift reviewing procedures you are either unfamiliar with or haven’t done for awhile.  EHCED is a fairly good repository of institution equipment specific procedure tutorials.  Use the search bar to find old posts and tutorials. If you have any questions regarding equipment, supplies or anything else Elmhurst critical care related email cmeyersmd@gmail.com or call 917-749-1004.
Can’t find an item?  Check the RACC critical inventory for location and reference the floor map below. 

Workflow

Patients will arrive from the triage, brought in by EMS, or sent from the sides in extremis.  Unlike your typical side patients, therapeutic intervention often needs to occur in parallel with diagnostic interventions.  When a patient first enters the Cardiac Room perform a rapid focused assessment of the patient’s airway, breathing and ventilatory status, circulatory status, and neurologic/mental status.  All patient should be exposed to look for concerning skin findings.  You may need to intubate some patients on arrival.  Use ultrasound and the RUSH exam liberally to further clarify a patient’s clinical status.

Resuscitative and critical care can be thought of as consisting of two parts.  The first part is action and the second part is detail.  Once you patient is stabilized (or you have assured yourself that they are not in immediate cardiopulmonary or neurologic threat) then turn your attention to detail and begin gathering information pertaining to their present illness and medical history.  Consider forming your assessment of the patient by organ system as you would in an ICU for your most critically ill and complex patients.  Do not forget trauma and toxicology as categories of this assessment unique to emergency medicine.

 

Unique cases include STEMIs and strokes.  For both of these presentations you will work closely with an outside service and page them via the emergency paging system.  This system is reached by dialing 41911 and you should give your name and request a “stroke code” or, for STEMIs, a “C-PORT code” accordingly.  After this you should continue your critical care assessment as usual.  You will be called by the appropriate team (the stroke resident or CPORT fellow) and briefly present the case for them to come to the ED.  A potential pitfall is permitting patients to leave the ER without vascular access due to a desire to expedite their imaging.  Do not allow this to happen even if your consultants request it.  Vascular access (often peripheral or — if that is not possible –central access) is a necessity in order for any critically ill patient to be stable to leave the Cardiac Room and go to imaging.  We are the most skilled specialty in obtaining vascular access and the appropriate tools for doing so are located in the Cardiac Room–not radiology!

 

 

Triage and the Sides

You and your attending will be asked to evaluate patients in triage who are indeterminate in their need for critical care.  Your attending will likely handle this task during your initial shifts but you will be asked to see patients in triage and make a determination on behalf of your attending as the year progresses and your skills develop.   You may begin refusing people to the Cardiac Room as your experience increases, however all patients that are refused need to be run by the Cardiac Room Attending.  Emergency Medical Services may bring patients directly to the cardiac room, bypassing triage, if they are in sufficient extremis.  These patients demand your immediate attention and resuscitative efforts as they are often in cardio-pulmonary distress, experiencing a STEMI, or a stroke.  You will also be asked to receive those patients who decompensate on the side or need closer care.  Your attending will ultimately determine which of these patients are accepted or declined.

Once patients are stabilized and no longer require resuscitation, active critical care, or close monitoring it is important to send them out to the sides as they await their disposition.  Critical care space is limited and it is important to preserve it for new critically ill patients.  However, even though a patient has been sent to the side they remain your responsibility.  Those patients who will ultimately be discharged or require ongoing care before they are admitted should be visited by you for re-evaluation at regular intervals and to update them regarding the progress in their care.

 

Admitted Patients and Sign out in the Cardiac Room

All patients in the cardiac room are actively managed by you regardless of their admission status.  However, the cardiac room functions as an “open” unit in the sense that when patients are admitted but too unstable to leave the cardiac room you provide critical care in coordination with a primary team that will be also entering orders.  Patients who fall into this category are often admitted to stepdown (called A4) as those patients admitted to an ICU tend to leave for beds very quickly.  Coordinate your care with the inpatient team but always remember that you are the final arbiter of care if patients begin to decompensate.  In this case you do not need the primary team’s permission to intervene and have an obligation to do so.  All patients who require transport to an ICU must be accompanied by a physician per Elmhurst policy.  During the day a resident from the receiving unit will often come down for the patient, but at night most units are staffed by only one resident and as such you will need to accompany many of your patients in order to ensure their effective final disposition.

Always ask yourself “who can I downgrade next?” This not only keeps you involved in the care of the admitted patients but optimizes the room for the next patient.  Cardiac room sign out should be task focused but as comprehensive as necessary.  Think in terms of what needs to be done to safely downgrade your patient to the side and free up space.  Is the patient on NIV? When were they last given a chance off NIV?  Is your DKA patient on an insulin drip?  CHF patient still on nitro?  You may find the RACC critical handoff worksheet to be helpful to organize your sign out, copies should be located in the binder next to the attending computer.

EHC COVID-19 Clinical Guidelines Update

Policies

Below are the latest updates to the EHC COVID-19 clinical guidelines.

Summary of major changes:

1. Anticoagulation. In light of the recent NIH announcement, EHC is no longer recommending empiric therapeutic anticoagulation outside of suspected or confirmed DVT/PE or prior AC.   EHC currently recommends either standard or intermediate VTE prophylactic dosing based on clinical risk factors. In the absence of contraindication to anticoagulation, use intermediate VTE ppx dosing for patients who are critically ill or who require respiratory support beyond O2 via NC(eg. HFNC, NIV, MV). Dosing is adjusted for extremes of weight, however most patients will require either enoxaparin 40mg q24h (standard dose) or enoxaparin 40mg q12h (intermediate dose). In the setting of CrCl<30, heparin SQ is preferred for VTE prophylaxis.

2. Immunomodulatory therapy. Reflecting preliminary data from REMAP-CAP suggesting benefit of the IL-6 inhibitor Tocilizumab in critically ill patients requiring organ support, EHC is now recommending early administration of Tocilizumab in patients with confirmed or suspected COVID-19 requiring respiratory support beyond O2 via NRB (eg. HFNC, NIV, MV) or vasopressors without contraindication (see full guidelines).

3. Pregnancy. Recommendations regarding the management of pregnant patients with COVID-19 have been added to corresponding therapeutic subsections.

EHC COVID-19 Clinical Care Guidelines 2-5-21

Any comments, questions or concerns please contact me at cmeyersmd@gmail.com

Acute Stroke Activation

Policies

EHC has now gone live as a thrombectomy center. Below summarizes the workflow for patients with evidence of large vessel occlusion (LVO) who are potential candidates for emergent thrombectomy vs. patients with non-LVO stroke. Stroke and LVO alerts should be activated at the time of EMS pre-notification via the STAT page operator at 4-1911.

Acute Stroke Workflow

Below is a summary of the stroke cardinal sign and LAMS + speech scale, aka SLAMS scale. SLAMS ≥ 4 is concerning for potential LVO stroke.

Stroke SLAMS and cardinal sign nursing practice alert

EHC COVID-19 Clinical Care Guidelines Update

Policies

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 11-11-20

Thank You

Policies

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

Policies

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)

Policies

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.