In the early 1990s, the clot-busting drug alteplase (intravenous recombinant tissue plasminogen activator or rTPA) revolutionized stroke treatment when it was shown to significantly increase the chances of a good outcome after ischemic stroke when given in the first 4.5 hours since symptom onset. But alteplase is not a miracle drug. In a meta-analysis of 9 randomized trials, rTPA improved [… read more]
Scott Aberegg, M.D., M.P.H. Oh, my, what a predicament. Jahi McMath has been released from Oakland Hospital to the custody of the coroner and her family. She has been issued a death certificate. And she’s being transferred to an undisclosed care center, where it is hoped she will begin receiving artificial nutrition. This is the height [… read more]
No Improvement in Cardiac Arrest Outcomes With Hypothermia Therapeutic hypothermia, or targeted temperature management, has become a standard component of post-cardiac arrest care. The evidence supporting this practice came from two small-to-medium-sized randomized trials, both published in the New England Journal of Medicine in 2002: Among 273 patients with out-of-hospital cardiac arrest due to shockable [… read more]
ICU-related Dysphagia and Swallowing Disorders More than 700,000 people develop respiratory failure requiring mechanical ventilation each year in the U.S. alone, and those that survive are at elevated risk for developing swallowing dysfunction. The aspiration syndromes that follow can be devastating, especially if not recognized and addressed early. Denver’s Madison Macht et al provide a clinical [… read more]
image: Wikipedia Rapid Blood Pressure Control Doesn’t Hurt, May Help in Intracerebral Hemorrhage Strokes caused by intracerebral hemorrhage — sudden bleeding into the brain — are as devastating as they sound. Almost half of people with intracerebral hemorrhage (ICH) die within a month, and most of the survivors end up in nursing homes or needing [… read more]
Intubation for Out-of-Hospital Cardiac Arrest May Harm, Not Help by Blair Westerly, MD Out of hospital cardiac arrest is a major public-health problem, and despite advances in care, survival is still low. Improved survival has been associated with early CPR, rapid defibrillation, and integrated post cardiac arrest care, but pre-hospital “advanced airway management” (i.e., intubation [… read more]
Tranexamic Acid: Underused for Uncontrolled Bleeding? Tranexamic acid is a simple little molecule, just a synthetic derivative of the amino acid lysine. But it’s also a potent pro-hemostatic drug that binds plasminogen and plasmin and stops the degradation of fibrin (the stuff in blood clots). In the U.S., tranexamic acid is sold as Lysteda (oral) [… read more]
Hypertonic Saline & Mannitol for Raised Intracranial Pressure (More PulmCCM Topic Updates) Acute brain injuries of all sorts increase the pressure inside the skull (intracranial pressure). Traumatic brain injury, bleeding in or around the brain, severe ischemic stroke, and acute hepatic failure all raise intracranial pressure, and increased intracranial pressure often becomes the most severe [… read more]
Webb and Samuels (Emory neuro-intensivists) report on a brain-injured patient who, after induced hypothermia and rewarming, had absent brainstem function and a confirmatory apnea test. However, in the O.R. for organ donation 24 hours later, brainstem function transiently returned and the surgery had to be aborted. They urge caution to the rest of us in [… read more]
Targeted temperature management in critical care: A report and recommendations from five professional societies. Nunnally ME et al. Crit Care Med 2011;39:1113-1125. Hypothermia for cardiac arrest guideline. Hypothermia after cardiac arrest review.
Thanks to defibrillators, burly-armed EMTs, speedier cardiac revascularization, and induced hypothermia, the mortality rates after ventricular tachycardia or fibrillation have improved markedly for both in- and out-of-hospital cardiac arrests. But mortality rates after PEA and asystole remain stubbornly steady, seemingly resistant to any of the above interventions. Background: People suffering cardiac arrest in an ICU have the advantage [… read more]
Here’s a free “head-to-head” discussion with arguments for and against implementation of routine mild hypothermia for all patients with out-of-hospital cardiac arrest. The benefits of hypothermia after out-of-hospital ventricular fibrillation cardiac arrests are reasonably well-established, and multiple society guidelines (SCCM’s, AHA’s) advocate the practice. The question is whether to induce mild hypothermia / targeted temperature management in all [… read more]
3% saline infusions have become standard care for increased intracranial pressure at many centers, based on mostly anecdotal evidence. Hauer et al looked retrospectively at 100 patients receiving 3% saline for severe stroke in 2008-2009 (intracerebral hemorrhage, subarachnoid hemorrhage, or ischemic) and compared them to 115 historical controls, 2007-2008 with “equal” underlying disease. Hypertonic saline [… read more]
Tranexamic acid has a small beneficial effect on hemorrhage from trauma or surgery. Among 270 subjects with intracranial hemorrhage due to trauma, those randomized to tranexamic acid showed a trend toward improved outcomes (mortality, hemorrhage extension, new bleeding foci) compared to placebo. Authors propose a large trial to explore further. BMJ 2011;343:d3795. FREE FULL TEXT
Cardiopulmonary arrest and cardiopulmonary monitoring. Sixteen articles, 104 pages. Curr Opin Crit Care 2011;17:211-315. Cardiac arrest review.
Delirium in the ICU, management of: Schiemann A, Curr Opin Crit Care 2011;17:131-140.
Intracerebral hemorrhage, acute management of: Flower O, Curr Opin Crit Care 2011;17:106-114.
Status epilepticus, refractory, treatment of: Holtkamp M, Curr Opin Crit Care 2011;17:94-100.
Subarachnoid hemorrhage, critical care of: Wartenburg KE, Curr Opin Crit Care 2011;17:85-93.
Hooman et al pooled 5 randomized trials with 112 patients, who had 184 episodes of elevated intracranial pressure. They concluded hypertonic saline is better at reducing ICP; but the relative-risk-for-ICP-control confidence interval was 1.0-1.3 and the mean ICP reduction included zero (-1.6 to 5.7 mm Hg). So, maybe. Crit Care Med 2011;39:554-559.