POTD: EtomiDate or EtomiHate?

Hi everyone,

For a double dose of learning, today's extra POTD comes at the request of our wonderful PEM attending Dr. Hector Vazquez: should we be using etomidate in rapid sequence intubation (RSI) for septic pediatric patients?

Short answer? No. Long answer? It's complicated, but still no.

Etomidate's theorized effect on adrenal insufficiency = etomidate BAD

Etomidate is a bread-and-butter induction agent for us during intubation in the ED, often utilized for its hemodynamic stability and fast onset of action. However, the story started to really turn on etomidate in 2011 and 2012 when two systematic reviews and meta-analyses demonstrated that etomidate was associated with adrenal insufficiency and increased mortality in septic patients (Albert, Ariyan, & Rather, 2011; Chan, Mitchell, & Shorr, 2012). Why is this adrenal insufficiency thing such a big deal, anyways? It's because cortisol, our body's glucocorticoid that is produced by the adrenal gland, is absolutely vital during critical illness such as sepsis. Cortisol both helps maintain vascular responsiveness (good for blood pressure control in sepsis!) and has anti-inflammatory effects (good for fighting infection in sepsis!). The annoying part is that etomidate works through a cytochrome pathway that blocks conversion of cholesterol to cortisol. So more etomidate = less cortisol = adrenal insufficiency = not a good look.

Most of the adult literature on etomidate = etomidate EH BUT MOSTLY BAD

Honestly, like most of medicine, the data is controversial on the use of etomidate in sepsis in the adult literature. Even though the effect of etomidate on adrenal suppression is pretty well laid out, the question is if it is clinically significant and affects morbidity or mortality. A more recent systematic review and meta-analysis in 2021 reiterated the older meta-analyses findings, stating again an increase in adrenal suppression and mortality in septic patients (Albert & Sitaula, 2021). But, like most of medicine, many of the studies that were analyzed had some bias, some blinding blind spots, and varying definitions of all-cause mortality. A more recent RCT in 2023 even showed that there was no mortality difference between septic patients intubated with a single dose of etomidate vs. ketamine (Srivilaithon et al., 2023). All to say, the data isn't doing etomidate any favors when it comes to its use in septic adults, but it's not straight forward either. It's mostly bad, but we need better data, too. Journey with etomidate at your own risk.

Pediatric Sepsis Guidelines 2020 = etomidate BAD

Which brings us to peds patients. And make no mistake, the pediatric providers are stating it nice and clear for us: do not use etomidate in pediatric septic patients. In 2020, an expert panel released the holy grail for pediatric sepsis management, titled "Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis- Associated Organ Dysfunction in Children." Included in these guidelines are 77 evidence-based statements made up of 6 strong recommendations, 52 weak recommendations, and 9 best-practice statements. 

And here's their recommendation regarding etomidate: We suggest not to use etomidate when intubating children with septic shock or other sepsis-associated organ dysfunction (weak recommendation, low quality of evidence). So no etomidate, but a weak recommendation... why do we even trust that? Well, pediatric patients just simply don't get the same research funding and consideration that adult patients get. A lot of the recommendations thus are based off of scant data, poor data, or adult data. And with such low quality of evidence overall, they only can claim to have weak recommendations. With regards to this recommendation in particular, as of 2020, no RCTs exist in critically ill children comparing etomidate to another sedation agent. But the recommendation is going off of two observational studies that included children in their patient population and four adult RCTs. Is it the cleanest recommendation? Definitely not. But they made an educated decision and pediatric septic patients should not be getting etomidate for RSI based on this recommendation. Maybe try ketamine instead.

So what were the 6 strong recommendations then?

1. In children with septic shock, we recommend starting antimicrobial therapy as soon as possible, within 1 hour of recognition (strong recommendation, very low quality of evidence)

2. We recommend removal of intravascular access devices that are confirmed to be the source of sepsis or septic shock after other vascular access has been established and depending on the pathogen and the risks/benefits of a surgical procedure (strong recommendation, low quality of evidence)

3. In healthcare systems with no availability of intensive care and in the absence of hypotension, we recommend against bolus fluid administration while starting maintenance fluids (strong recommendation, high quality of evidence)

4. We recommend against using starches in the acute resuscitation of children with septic shock or other sepsis-associated organ dysfunction (strong recommendation, moderate quality of evidence)

5. We recommend against the routine use of inhaled nitrous oxide (iNO) in all children with sepsis-induced PARDS (strong recommendation, low quality of evidence)

6. We recommend against insulin therapy to maintain glucose target at or below 140mg/dL (7.8 mmol/L) (strong recommendation, moderate quality of evidence)

To me, it wasn't so interesting to see what was included as strong recommendations, but more to see what was not included. If it's not listed here, but is typically something you would expect to be doing for a septic patient, it is likely listed as a weak recommendation or a best-practice statement. Meaning, lots of things we don't have all the evidence for but we have all collectively decided to do them anyway.

Happy intubating,

Kelsey

Resources:

1) https://pubmed.ncbi.nlm.nih.gov/21373823/

2) https://pubmed.ncbi.nlm.nih.gov/22971586/

3) https://jtd.amegroups.org/article/view/5542/5525#B19

4) https://pubmed.ncbi.nlm.nih.gov/32912050/

5) https://www.acepnow.com/article/should-you-etomidate-me/2/

6) https://www.nature.com/articles/s41598-023-33679-x

7) https://pubmed.ncbi.nlm.nih.gov/32032273/

POTD: Trauma Level 1 vs. Level 2 vs. Level 3

Hi everyone,

Today's Trauma Tuesday POTD is inspired by the upcoming rollout of new trauma activation aka "level" criteria in the MMC ED. Woohoo! Exciting! Change is fun!

In light of this, our main question today is, when EMS brings in a patient with a traumatic injury, how are we determining level 1 vs. level 2 vs. level 3?

As we all know, MMC is an adult level 1 and pediatric level 2 trauma center, and thus we get the whole host of traumatic injuries that roll into our ED, from sprained ankle to traumatic arrest to being on the South Side on a Monday afternoon (just kidding). But how does EMS determine if they are coming to a trauma center at all? How do hospitals determine what level those incoming traumas should be? And, with all that in mind, how is the MMC level criteria changing with our new rollout?

EMS Trauma Criteria

The goal of EMS trauma criteria is to determine the appropriate destination for the patient: trauma center vs. general ED. The criteria is determined by the Regional Emergency Medical Advisory Committee (REMAC - yes, that REMAC!) of New York City. The two main buckets to determine required transport to a trauma center are physical findings and mechanism of injury. The other bucket to determine possible transport to a trauma center is high risk patient. The options for a high risk patient are either transporting or contacting OLMC. The criteria they use is below.

It isn't the job of EMS to determine the level of the trauma or whether or not they are coming to North Side or South Side. Oftentimes they will call for a trauma notification to the North Side if the patient is giving bad vibes, but really their only job is determining transport to a trauma center or not.

Hospital Trauma Activation Criteria

Once a trauma notification is called in, or once the patient arrives to the ED, it is the job of the ED hospital staff to determine what level of trauma activation is indicated. Trauma activation criteria is determined by the hospital itself. This means that, though two hospitals may both be level 1 trauma centers, they may have different criteria that qualifies someone as a level 1 trauma patient. Trauma activation criteria revisions occur every so often after interdepartmental discussions and research-based committee decision-making, with MMC having just completed its own. 

But why are revisions even necessary? Well, both under-triage and over-triage of traumas come with their own risk, so we want to get our triage levels right.

Under-triage means that the patient had more severe injuries than the original level indicated (e.g. the trauma was called as a level 2, but, after assessing injuries, actually met criteria for a level 1). There are obviously serious dangers to under-triage, as the patient may not have the necessary resources, specialties, or expedited care to care for their injuries. Be aware that there are higher rates of under-triage in pediatric and elderly patients. The MMC goal is to have less than 5% under-triage given the morbidity and mortality associated with these cases. 

Over-triage, on the other hand, means that the patient had less severe injuries than the original level indicated (e.g. initially called as a level 1 but later determined to be a level 2). The risk of over-triage may seem less disastrous, but it does come with a cost, mostly with regards to inefficient resource mobilization. The MMC goal is to have 25-50% over-triage. Trauma surgery keeps track of these numbers closely, and the American College of Surgeons reviews our numbers as part of the verification process to remain a trauma center. The goal should really be to triage everyone into the correct trauma level to activate the correct resources immediately, but obviously there is a bit more leeway skewing us to over-triage rather than under-triage.

New MMC Trauma Activation Criteria

So EMS has transported a trauma patient to the MMC ED based on their trauma criteria, and the patient has arrived in the North Side in room 51. What level are we calling it?

Old Criteria

Our old trauma activation criteria is still hung up on the back wall of room 51. I know I still look to these boards as reminder for the detailed criteria. For adult patients, one very generalized way to think of it is that level 1 includes physiologic criteria, level 2 incorporates mechanism criteria, and level 3 is everyone else who likely needs admission for traumatic injury. For pediatric patients, it's quite similar, but blast explosion mechanism earns you a level 1 right off the bat. But what about our new criteria?

New Criteria

Here's the new trauma activation criteria that is being rolled out in the MMC ED, and it will soon physically replace the old criteria on the back wall of room 51. See if you can spot the main differences between the two...

New Criteria Differences from Old Criteria

Ok, I'll tell you.

Adult Level 1

• HR > SBP

  • No longer HR >120

• Respiration rate <10 or >29

  • No longer includes compromised airway

Adult Level 2

• Patients transferred in from outside hospitals should only be activated if they meet the above criteria

  • No longer transfer patients from other hospitals automatically level 2

• **Systolic blood pressure >110 over the age of 65 is a typo and should have always been systolic blood pressure <110 over the age of 65**

Adult Level 3/Consult

• No changes

Pediatric Level 1

• Traumatic arrest

• Significant neurologic deficit

  • No longer suspected spinal cord injury or paralysis

Pediatric Level 2

• No longer major peripheral neurologic deficit (sensory or motor), as was changed to level 1

• No longer drowning associated with trauma, as was changed to level 3

Pediatric Level 3/Consult

• Injured patients with GCS >13

• Hangings and drownings with injury

• Injured patients with bleeding disorders

• Multi-system trauma involving more than one surgical specialty

• Patients with complications of recent injuries

TLDR

As you can see, the old and new criteria are actually quite similar, but it's good to keep in mind the changes in HR and respiratory status criteria for adult level 1, transfer patients no longer automatically being an adult level 2, significant neurologic deficits qualifying as a pediatric level 1, and drowning with trauma qualifying as a pediatric level 3.

Look out for the new trauma activation criteria in room 51 coming soon, and happy leveling,

Kelsey

Resources:

- Dr. Nate Zapolsky's brain

- Dr. Dave Eng's brain, too

- https://www.maimonidesem.org/blog/ems-protocol-of-the-week-general-trauma-care-adult-and-pediatric

- https://www.aast.org/disaster-detail/acs-highlight-trauma-team-activation-optimizing-pr

POTD: MTP and OBH in 123

Happy Friday!

This week's Wellness POTD will be about what keeps all of us well and alive each and every day: blood! Ok so not as flashy and fun, but hopefully this is a relatively quick and dirty review of massive transfusion protocol (MTP) and OB hemorrhage (OBH) at MMC.

TLDR of MTP

• MTP is initiated if there is (1) >4 units of pRBC transfused in 1 hour OR (2) replaced all of the patient's total blood volume in 24 hours OR (3) replaced half the patient's total blood volume in 3 hours OR (4) bleeding faster than 150 ml/min

• MTP is un-crossmatched blood

• Adult MTP 1st round is 4u pRBC + 4u FFP + 1u platelets, then 2nd round is the same + 10u cryoprecipitate

• MTP is activated by an attending physician

• Notify the blood bank of MTP activation by calling 3-8400 or 3-7651

TLDR of OBH

• OBH is defined as (1) >1000 ml blood loss in any delivery OR (2) >500 ml blood loss in vaginal delivery with sxs of hypovolemia

• Call a Code H for concern for OBH

• Stage 1 think IV access/fluids/uterotonics, stage 2 think consult MFM, stage 3 think OR, stage 4 think ACLS

Ok now for the longer and more rambly (but hopefully helpful?!) details within our protocol at MMC...

Massive Transfusion Protocol

I will try to summarize the MTP protocol that Dr. Marshall shared via email, which I am also attaching to this email, and will highlight relevant facts for our clinical use in the ED.

Adult MTP Indication

1) Transfused >4 units of pRBC in 1 hour w/ more blood needed

2) Expected to transfuse >50% of a patient's total blood volume in 3 hours (most adults have around 10-12 pints/units of blood in their body)

3) Expected to transfuse >100% of a patient's total blood volume in 24 hours

4) Bleeding faster than 150 ml/min

Pediatric MTP Indication

1) Expected to transfuse >50% of a patient's total blood volume in 3 hours

2) Expected to transfuse >100% of a patient's total blood volume in 24 hours

3) Bleeding faster than 10% total blood volume/min

MTP Initiation/Termination

• Activated by an attending physician

• Initiate MTP by using the red phone by the North Side charge nurse desk or by calling blood bank at 3-8400 or 3-7651

  • Information that must be included on the call is name, MRN, sex, DOB, location, diagnosis, and contact physician info

• Have a physician fill out the "Emergency Blood Transfusion/Massive Transfusion Request" form, section B, and send it to blood bank by messenger or pneumatic tube

• Send a lavender top blood specimen for ABO antibody screening and crossmatching of continued future transfusions

• Blood bank does their magic prepping and getting us the blood...

• "Crack the fridge" in resus 51 for emergency blood to bridge us while awaiting MTP blood

  • Charge nurse has the code to the fridge

  • ED fridge contains 2 whole blood + 8 units O- pRBC + 4 units O+ pRBC + 4 units FFP (no platelets)

  • The attending physician can decide whole blood vs. components

  • Use O+ for males and O- for females

• Have the attending physician be in close contact with the blood bank to anticipate continued need

• Terminate MTP by the attending physician notifying the blood bank OR automatically terminates 4 hours after MTP started

MTP Components

MTP Tips

• Try to balance your transfusions by hour 1 or 2 into MTP (1:1:1 ratio of pRBC:FFP:platelets)

• The 1 unit of apheresis platelets in MTP is synonymous with ~6 units of individual platelets

• Use blood warmers to prevent hypothermia

• Consider TXA for trauma

• Consider calcium repletion after 3 units of transfusion

OB/Postpartum Hemorrhage

OBH Definition

1) Cumulative blood loss of >1000 ml in c-section or vaginal delivery

2) Cumulative blood loss of >500 ml in vaginal delivery with sxs of hypovolemia

OBH Stages

Stage 1: normal vital signs --> IV, fluids, fundal massage, pitocin, add other uterotonics

Stage 2: normal vital signs but blood loss up to 1500 ml OR pitocin and 2 uterotonics started --> consult MFM, transfuse, add TXA, foley, uterine balloon/packing

Stage 3: abnormal vital signs OR blood loss >1500 ml OR 2 units pRBC transfused --> go to OR, MTP

Stage 4: cardiovascular collapse --> ACLS

"Code H" aka alert the OB troops

Code H is the trigger to get more people involved for any stage OBH. It can be activated by anyone by dialing 33 and stating you have a Code H. The people notified are: OBGYN inside attending, OBGYN outside attending, anesthesia attending, anesthesia resident, chief OB resident, any individual on OB codes list, nursing leadership, blood bank.

OBH Tips 

• Consider the 4 T's of OBH when treating these patients: Tone (uterine atony), Trauma (laceration, hematoma, inversion, rupture), Tissue (retained products), Thrombin (coagulopathy)

• Use the red OB hemorrhage kit in the fridge of resus 52 which has pre-made uterotonic meds and a cheat sheet for when to use each

• Get the pitocin running early

Happy transfusing,

Kelsey

Resources:

- MMC MTP and OBH protocol

- Dr. Nicky Chung POTD from 10/8/24

- Dr. Kat Pattee POTD from 5/15/24