Introduction first, I'm Patrick Marr. I work at Mount Sinai in the mostly ICU, medical ICU. And I'm giving a talk, so moving now from the kind of pre-hospital sphere, so applications within the emergency medicine literature over the past 12 months, maybe with resuscitation implications, focusing mostly within the emergency department itself. So as a disclosure, I do serve on a scientific advisory board, but none of the devices which are made by this company are involved in my studies. The first one that I wanted to go through was a paper published by Driver in the past year in Annals of Emergency Medicine. This was looking at sedative dose in RSI and the occurrence of post-intubation hypotension. Is there an association between this occurrence and can we reduce this with reduced doses of our sedative agents? This was an analysis of the NEAR Registry, the National Emergency Airway Database over a two-year period. And they were able to come up with, in that database, about 12,000 automated intubations and only about 2,000 ketamine intubations. The primary outcome here was hypotension, systolic less than 100 in the first 15 minutes following intubation. Authors were very careful to note this is not a comparison between these two drugs. These are the two drugs studied for this trial. And the idea was that, you know, with certain agents, noticeably propofol and probably even Aslam as well, reducing their intubation dose probably does reduce the occurrence of post-intubation hypotension, but can we find evidence of this within these more frequently used agents within the emergency department today? Within their study, there were, relatively speaking, you know, fewer cases of post-intubation hypotension with the ATOMIDATE group, although once again, not a head-to-head comparison. The groups were similarly sized with regards to their weight, which I think is important given that this is a dosing study. The patients who had the occurrence of post-intubation hypotension were a little bit older. They were also a little bit sicker. And their intubation indications reflected that increased sickness with an increased occurrence of shock and increased medical cardiac arrests, for instance, as the indication intubation reason. The protective factor, I guess, for post-intubation hypotension was unsurprisingly pre-intubation hypertension. And patients who were hypotensive either on or off pressers pre-intubation had higher rates of post-intubation hypotension, which I think was not surprising. Doses that were used in this trial were pretty much as expected for common doses of etomidate and of ketamine used in emergency department intubations. I suspect that many of these were kind of round number doses, but they did correct for weight of the patients. There was a slightly higher amount of patients who did experience post-intubation hypotension who had reduced doses, but this failed to meet significance and they adjusted for it in their final analysis, which is presented here. So the primary analysis failed to find that there was a protective effect of dose reduction of either etomidate or of ketamine in the occurrence of post-intubation hypotension in their multivariable analysis. There was increased rates of post-intubation hypotension for patients who were older, for patients who were female, patients who were intubated immediately, patients who were intubated for shock, or patients who were already hypotensive, but the effect of the sedative dose was not significant in their analysis. They chose to graphically present this in a skitter plot. So this is kind of a measure of density. You see here as the y-axis is the dose, respectively of etomidate or of ketamine, and then it's skittered out so you can just see kind of the density of doses in the patients. The x-axis itself doesn't really mean anything otherwise, but you do see the patients who respectively had intubation hypotension versus not, and pretty similar medians, and pretty similar interquartile ranges within the range of the vertical bar plot next to the skitters. They performed multiple sensitivity analyses, finding that the patients who had excluded patients with hypotension prior to intubation, similar findings. Secondary sensitivity analysis only for patients with shock, similar findings. Sites that just did not appear to use weight-based dosing, but just were kind of round numbering it or maybe using 20 milligrams of etomidate every time, similarly, similar findings. So they concluded, and it seems like the data would support this, that the reduction of your dose of pre-intubation medications does not affect the occurrence of post-intubation hypotension. They've recommended not continuing this practice, particularly given that there are possible risks to patients of reducing these medication doses, notably post-intubation awareness while still paralyzed, and then kind of a failure to do other things which would otherwise mitigate the risks for post-intubation hypotension, things like pre-intubation resuscitation with fluids or with pressers. The next two papers that I wanted to go over both deal with palliative care and the emergency department. So the first of these is published by Auchi et al, and that's an academic emergency medicine also within the past year. This is differences in code status conversations reported by emergency medicine versus palliative care physicians. Focusing as a mixed method study, they conducted a bunch of surveys in about three centers in the Northeast of the United States, and then followed those survey respondents with a series of interviews of which the seven emergency medicine practitioners were included compared to nine palliative care physicians. This was analyzed using a framework analysis for qualitative data. As I mentioned, all of these were in the Northeast of the United States. There was a total of three. And I think importantly, all of the respondents within these surveys and these interviews were attendings, nurse practitioners, or physician assistants, so people who were already fully credentialed to independently practice in emergency medicine in many settings. They obviously were finding that there was differences in the frequency of code status discussions with the emergency medicine physicians reporting that their most frequent box that they fit into would be that they were doing maybe one to six of these per year, which is less than one every two months. Unsurprisingly, the palliative care physicians reported many of these discussions with the most common group being over two per month or over 25 per year. And the differences that they were interested in asking, and this was a hypothetical scenario which they presented as a red cap question and asked, would you ask this particular question or not? The emergency physicians were far more likely to ask procedurally based questions. So things like, do you want your dad to be on a ventilator? Do you want him to get CPR? Do you want him to get central lines? Do you want him to get vasopressors? They were just as likely to estimate the survival probability for these patients, but they were far less likely to do things like ask, ask if they could give a recommendation. They were, much to my chagrin, far more likely to ask questions like, would your father want everything done? Which I feel like is a problematic way to address palliative care in any setting. Respectively though, the palliative physicians asked a lot more values based questions. So they were far more likely to go into questions about the baseline function of the patient. What would your father say if he was here? How much would your father be willing to go through in order to get well? What's their minimum quality of life that they would be willing to live with? And they were way, in this survey, more likely to recommend things to the patient. And so just a real different kind of level of questioning that the palliative care physicians reported when they were faced with the same scenario of comparison to these fully trained, fully fledged emergency clinicians in this study. And I put this next to another paper because I feel like it does dovetail well. So this is a study in which they only analyzed emergency medicine residents. So this is Sanders et al. in Annals of Emergency Medicine, also with 2023. And this is a paper on emergency residents conversations about life-sustaining treatments and critical illness. So kind of a different group, and I think that there are some interesting differences. The authors of this paper noted that emergency discussions are focused upon rapid decisions. These are distinct decisions that need to be made in a pretty fast way, and that they have immediate consequences with regards to whether we're gonna be debating doing CPR on a patient. We fail to have the kind of luxury of time to think about this in a way that we'd like to plan ahead in the emergency department. So their goal, given that, was to do a qualitative exploration of how emergency residents make recommendations around life-sustaining treatments in patients with acute life-threatening clinical presentations. The population of this study was in Canada. It was emergency residents over about a five-month period in 2021. This is the height of the COVID pandemic, and that does filter into their results. They got a total of 17 emergency medicine residents to take part in these surveys. All of these were telephonic in English. They represented nine different Canadian universities over seven different provinces. They purposively sampled out of their group for a year of training, sex of the respondent, and also geography, just to make sure that they had a good swath of Canadian provinces involved. They asked all of them directed interview questions. They also allowed for open-ended answers. They used inductive thematic analysis to then analyze those interviews in order to come up with some themes from the residents about how they're conducting these kinds of discussions. And these were the factors that they found. So basically, with regards to the factors guiding their treatment recommendations, the residents recognized, even I think at their relatively young stage in training, that they have a duty as physicians to make a recommendation to these families. I find this very interesting in comparison to the attending responses in the previous study. However, they recognized some of the factors influencing their comfort that they were still in training. This is the uncertainty part of that pyramid on the bottom of this graph. As a factor affecting the recommendation saw that there was a big importance of the disease burden for a patient and their patient's values when they gave a recommendation, which I think is also critical to see. But affecting their comfort once again, time constraints even was recognized. And then moral distress. Moral distress in this case was twofold as examples that they cited. One was that this was still the COVID pandemic and there was still some treatment rationing which they were concerned about. Is it the right thing to do for this particular patient to offer everything? And then moral distress also in the sense of being trainees, if they recommend, for instance, against intubation, they deprive themselves of an endotracheal tube. And they actually saw that as a conflict of interests when they give recommendations to patients that they will deprive themselves of procedures if they recommend against those procedures. So as emergency critical care physicians, I feel like these two studies are interesting because they display kind of a shift in the way that people maybe think of palliative care in our field from their training stages to their fully trained stages and probably continued role for us in our training pathway to help bridge these two areas and improve the ways that we're doing palliative care downstairs in the ED. Okay, and then the last two papers that I wanted to discuss both deal with procedures within thrombocytopenic patients, particularly central access. First was within the emergency medicine literature, Zurama et al in academic emergency medicine. This was a retrospective study looking at prophylactic platelet transfusion and the risk of bleeding associated with ultrasound guided access in patients with severe thrombocytopenia. Single center out of Columbia, total of 221 patients over eight years. The entry criteria to this cohort was a platelet count of less than 20 and all of these patients received central lines. Some of them had been transfused, a total of 72 in the study and 149 had received central access with no transfusions. These were their two groups for comparison. Their outcome was hemorrhage according to a common criteria for bleeding, which is also used in the last study that I'll discuss. Authors noted that there was multiple guidelines which had been published over the last many, many years from the different organizations offering various guidelines, typically either 20 or 50 at which they'd recommend platelet transfusion prior to participating in central access for a patient who's thrombocytopenic. However, a lot of the data went into these guidelines was prior to the development of a kind of a more widespread use and comfort with ultrasound within critical care and emergency medicine. Platelets are expensive, platelets take time and these are weak recommendations. So comparing patients who did and did not get platelets, patients who got platelets had a slightly lower median platelet count but didn't achieve significance. INRs, they did exclude patients with significant coagulopathy were similar. More patients who did not receive platelets were getting their access in the emergency department in comparison to other settings. For that reason, I think it's unsurprising that most of the patients who also didn't get platelets were getting their lines from emergency physicians in comparison to the patients who received platelets, a slightly higher amount of these getting them up in the ICU or in other settings. Fascinating to me because this kind of goes against something that I've trained my fellows with my entire life is that a lot of these patients were getting subclavian lines, despite once again, a median platelet count of 11. And otherwise though, pretty similar breakdown between the groups. Their findings were that in this study of once again, a retrospective cohort rounds about to 200 patients, 220. No patients had major bleeding according to their standardized criteria. The patients who received minor bleeding were even between these two groups. There was a numerically higher number of hematomas in the patients who had not received platelets that did not see any significance and oozing likewise numerically higher did not meet significance. These authors concluded that platelet transfusions even in these numbers are unnecessary and that we can perform central access safely with ultrasound at these low numbers. The last study that I just wanna mention is not out of the emergency medicine literature, but which is something that I find kind of perhaps an important rebuttal to this. So this is a randomized control trial. This is done in the Netherlands. This is a larger study and a higher level of data. The platelet entry of this was higher though. So this was a platelet count of 10 to 50. It didn't look at the platelet numbers, which we were seeing in the Colombian study. Using similar outcomes though and assessing for bleeding grades two to four. And I've gone ahead and provided the scale here. And all of these providers that were using, that were in the study had done a lot of central lines over 50 and they were all trained in ultrasound and they were all using ultrasound for all the lines in the study. So in this group, platelet counts were similar. INR is similar, RCT was well-matched. Patients were included if they were either in the ICU or the hematology ward. Patients were not included in the emergency departments in this particular study, perhaps affecting some of its applicability and its generalizability to our emergency department population that we see. Catheter types included both large-bore and small-bore, both tunneled and non-tunneled. And also, once again, every site, including at platelet counts of less than 50, rounds abouts of 38% of these patients getting subclavian lines with ultrasound. The bleeding rates were higher on their primary outcome analysis in the patients who had not received platelet transfusions with an effect size odds ratio of 2.4. The group did sub-analyze whether the rates of grades three to four, so grade two is just holding pressure onto it, but grade three and higher is either transfused or something more invasive to try and treat it. So that was not significant, but trended towards a significance and a worse outcome for the no transfusion. Authors similarly noted that many patients who had not initially received platelets as part of their randomized protocol ended up receiving platelets later on within the first 24 hours after their line. That was around 47% of patients. And that the median platelet counts despite those transfusions were still, however, higher in the patients who got them pre-line than after the line. They did a subgroup analysis looking at other things, noting that subclavian risk was a little bit higher for bleeding, particularly in the patients who had not been transfused. Tunneled catheters in their study had a much higher risk of bleeding in comparison to non-tunneled catheters. I don't think we do many tunneled catheters within the emergency department. And then also patients who were receiving their catheters on the hematology wards, probably because of the differences as to the reasons for their thrombocytopenia, had higher rates of bleeding as well. And I'll just say that those authors concluded that this is something which should not be ignored, that there's a lower risk of bleeding, but as to the clinical importance of this in a particular population, there may still be some room for this to be a personalized decision for each and every patient as to whether you think that there's an ability for you to wait and to do platelets, or whether you think that that's necessary, or whether you think that the clinical situation for that particular patient is such that you can give them the central line now and the platelets later if they need it. So thank you all, and I'll let our final speaker go. Thank you.

emergency medicine

resuscitation

rapid sequence intubation

palliative care

thrombocytopenic patients