EMERGENCIES IN CRITICAL CARE: Edited by Wesley H. Self
Welcome to the Emergencies in Critical Care issue in Current Opinion in Critical Care. This issue focuses on key topics that live within the domain of clinical medicine at the intersection of emergency medicine and critical care medicine – that is, topics relevant to providers caring for acutely and severely ill patients from the prehospital phase of resuscitation through the emergency department and into the early phase of management in the ICU.
Advances in clinical medicine can come in many different forms. Such advances from the invention of new technologies and the development of new pharmaceuticals are frequently celebrated (as they should be). However, learning how to use existing tools better is also essential to improving clinical care, and frequently can have a larger impact than a new technology or drug. For example, oxygen therapy, intravenous fluids, endotracheal intubation, and assisted ventilation have been cornerstones of acute resuscitation for many decades, and at times seem mundane in a world of molecular diagnostics and genetic medicine. Yet, despite being delivered to millions of patients every year around the world, we continue to learn how to administer these core therapies better.
This issue focuses on recent advances in everyday clinical care using tools already available in most emergency departments and ICUs. International experts review recently published data on four of the most commonly used treatments (oxygen, intravenous fluids, noninvasive ventilation, and intubation) and two of the most commonly encountered illnesses (pneumonia and pulmonary embolism) in the emergency department and ICU.
As outlined in the article by Frei and Young (pp. 506–511), oxygen has been used to treat patients since the 18th century. Yet, only recently have the risks of overzealous oxygen use and hyperoxia been widely appreciated. Increasing evidence supports the use of oxygen therapy only to prevent hypoxia and not to drive oxygen to supraphysiologic levels in patients without hypoxia [1,2]. As reviewed by Casey et al. (pp. 512–518), saline (0.9% sodium chloride) has been one of the most common therapies administered to hospitalized patients for over a century. New data now question the routine use of saline and suggest balanced crystalloid solutions are a better choice for intravenous fluid treatment for most patients [3–5]. As recently as last year, many clinicians would have reflexively initiated supplemental oxygen and an intravenous saline bolus as two of the first treatments for an acutely ill patient, even in the absence of hypoxia. Now, we have strong data published in the past year to direct clinicians away from these practices, highlighting the power of conducting comparative effectiveness research for common conditions and treatments.
Frat and Thille (pp. 519–524) and Carlson and Wang (pp. 525–530) review the most recent studies on noninvasive ventilation and intubation, respectively, in the emergency setting. Although the effectiveness of noninvasive ventilation for patients with chronic lung disease presenting with hypercapnic respiratory failure and acidosis is now well established, the role for noninvasive ventilation is unclear for patients with de novo hypoxic respiratory failure – that is, patients without chronic lung disease presenting with an acute pulmonary illness causing hypoxia. Compared with supplemental oxygen administered by high-flow nasal cannula or traditional facemask, noninvasive ventilation may result in higher tidal volumes and thus contribute to lung injury via high transpulmonary pressures [6,7]. Optimal noninvasive strategies to deliver oxygen to patients with acute hypoxic respiratory failure is a key unanswered question that requires additional study. When providers decide to move beyond noninvasive support and pursue intubation, what is the most effective method for consistently achieving endotracheal intubation on the first attempt? The traditional approach involves using an endotracheal tube with a stylet and converting to a bougie only after initial attempts have failed. New data suggest primary use of a bougie for emergency intubation may be the preferred method for maximizing first-pass success rates .
As acute care and critical care specialists, we continue our quest to master the management of pneumonia and pulmonary embolism. As reviewed by Cillóniz et al. (pp. 531–539), new strategies in pneumonia have the potential to improve outcomes and continued efforts are needed to clarify the optimal role for steroids and to fully develop rapid diagnostics and biomarker-based algorithms to guide clinicians on decisions about antibiotics [9–11]. Chodakowski and Courtney (pp. 540–546) review the latest evidence on pulmonary embolism, focusing on indications for thrombolytic therapy. Although current data support the use of thrombolytics for pulmonary embolism with shock (massive pulmonary embolism), its role in the management of intermediate severity pulmonary embolism with right heart dysfunction but without overt shock (sub-massive pulmonary embolism) remains unclear and is an important area for future research [12,13].
Our goal with the following reviews is to help clinicians advance their expertise in the delivery of everyday, routine care by providing the most up-to-date data and informed interpretations of those data. Thank you for your interest in these topics. We hope you find these reviews useful for your practice and for developing research that will continue to advance the science of critical care medicine and improve the care we deliver to our patients.
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Conflicts of interest
There are no conflicts of interest.
1. Hofmann R, James SK, Jernberg T, et al. Oxygen therapy in suspected acute myocardial infarction. N Engl J Med 2017; 377:1240–1249.
2. Chu DK, Kim LH, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet 2018; 391:1693–1705.
3. Semler MW, Self WH, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med 2018; 378:829–839.
4. Self WH, Semler MW, Wanderer JP, et al. SALT-ED InvestigatorsBalanced crystalloids versus saline in noncritically ill adults. N Engl J Med 2018; 378:819–828.
5. Pfortmueller CA, Funk G-C, Reiterer C, et al. Normal saline versus a balanced crystalloid for goal-directed perioperative fluid therapy in major abdominal surgery: a double-blind randomised controlled study. Br J Anaesth 2018; 120:274–283.
6. Frat JP, Ragot S, Coudroy R, et al. REVA networkPredictors of intubation in patients with acute hypoxemic respiratory failure treated with a noninvasive oxygenation strategy. Crit Care Med 2018; 46:208–215.
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8. Driver BE, Prekker ME, Klein LR, et al. Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation: a randomized clinical trial. JAMA 2018; 319:2179–2189.
9. Briel M, Spoorenberg SMC, Snijders D, et al. Capisce Study Group; STEP Study GroupCorticosteroids in patients hospitalized with community-acquired pneumonia: systematic review and individual patient data metaanalysis. Clin Infect Dis 2018; 66:346–354.
10. Huang DT, Yealy DM, Filbin MR, et al. Procalcitonin-guided use of antibiotics for lower respiratory tract infection. N Engl J Med 2018; 379:236–249.
11. Self WH, Balk RA, Grijalva CG, et al. Procalcitonin as a marker of etiology in adults hospitalized with community-acquired pneumonia. Clin Infect Dis 2017; 65:183–190.
12. Konstantinides SV, Vicaut E, Danays T, et al. Impact of thrombolytic therapy on the long-term outcome of intermediate-risk pulmonary embolism. J Am Coll Cardiol 2017; 69:1536–1544.
13. Jiménez D, Martin-Saborido C, Muriel A, et al. Efficacy and safety outcomes of recanalisation procedures in patients with acute symptomatic pulmonary embolism: systematic review and network meta-analysis. Thorax 2018; 73:464–471.