Target BP in ICH ....

Intracranial hemorrhage is a common medical emergency in ER secondary to hypertension. So it is important to control blood pressure as early as possible. The target SBP in ICH is area of concern, now let us look at the recent evidences.

Recent Evidence

INTERACT 2 RCT (NEJM.2013) was done to assess wether rapid lowering of elevated blood pressure would improve the outcomes in patients with ICH. 2839 patients were randomly assigned to intensive treatment group (SBP <140 mmHg in 1 hour) or guideline recommended treatment (SBP <180 mmHg). The study found that In patients with intracerebral hemorrhage, intensive lowering of blood pressure 

did not result in a significant reduction in the rate of the primary outcome of death or severe disability (OR=0.87; 95%CI, 0.75 to 1; p = 0.06) . An ordinal analysis of modified Rankin scores indicated improved functional outcomes with intensive lowering of blood pressure (OR=0.87; 95%CI, 0.77 to 1; p = 0.04) .

ATACH-2 RCT (NEJM.2016) randomly assigned patients with IC Bleed ( Volume <60cm3 , GCS > or =5) either to intensive treatment group ( 110 -139 mmHg) n= 500 or standard group ( 140 -179 mmHg), n=500.  Patients were treated with IV Nicardipine within 4.5 hours after symptom onset. The study found that intensive treatment to achieve a target target systolic blood pressure of 110 to 139 mm Hg did not result in a lower rate of death or disability (38.7%) than standard reduction to a target of 140 to 179 mm Hg(37.7%) RR : 1.04, 95% CI 0.85 -1.27.

INTERACT 3 (Lancet.2023) is a multicentric, randomised, blinded endpoint study done to asses wether a goal directed care bundle incorporating early intensive bp lowering (SBP <140mmHg) and management algorithms for hyperglycemia, pyrexia and abnormal anticoagulation, implemented in hospital setting could improve outcomes for patients with acute spontaneous ICH.The likelihood of a poor functional outcome was lower in the care bundle group, n=3221 (common odds ratio 0·86; 95% CI 0·76–0·97; p=0·015). Patients in the care bundle group had fewer serious adverse events than those in the usual care group (16·0% vs 20·1%; p=0·0098).

 

Current Recommendation 

• AHA/ASA  recommends to target a SBP of 140mmHg with goal of maintaing a range of 130 -150 mmHg in mild to moderate ICH with SBP of 150 -220 mmHg at presentation. 

• AHA/ASA states that safety and efficacy of intensive BP control in severe ICH has not be well established. 

Post HOC analysis of ATACH-2 Trial has shown that intensive BP targets <130 mmHg in large ICH , severe IVH requiring EVD was associated with increased mortality and poor outcomes due to decreased CPP < 60mmHG. Study has also shown that participants with SBP >220 mmHG reported higher rates of neurological deterioration at 24 hours and renal adverse events until 7 days in intensive treatment group. 

Reference

• Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, Lindley R, Robinson T, Lavados P, Neal B, Hata J, Arima H, Parsons M, Li Y, Wang J, Heritier S, Li Q, Woodward M, Simes RJ, Davis SM, Chalmers J; INTERACT2 Investigators. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013 Jun 20;368(25):2355-65. doi: 10.1056/NEJMoa1214609. Epub 2013 May 29. PMID: 23713578.

• Ma L, Hu X, Song L, Chen X, Ouyang M, Billot L, Li Q, Malavera A, Li X, Muñoz-Venturelli P, de Silva A, Thang NH, Wahab KW, Pandian JD, Wasay M, Pontes-Neto OM, Abanto C, Arauz A, Shi H, Tang G, Zhu S, She X, Liu L, Sakamoto Y, You S, Han Q, Crutzen B, Cheung E, Li Y, Wang X, Chen C, Liu F, Zhao Y, Li H, Liu Y, Jiang Y, Chen L, Wu B, Liu M, Xu J, You C, Anderson CS; INTERACT3 Investigators. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet. 2023 Jul 1;402(10395):27-40. doi: 10.1016/S0140-6736(23)00806-1. Epub 2023 May 25. Erratum in: Lancet. 2023 Jul 15;402(10397):184. doi: 10.1016/S0140-6736(23)01420-4. PMID: 37245517; PMCID: PMC10401723.

• Qureshi AI, Palesch YY, Barsan WG, Hanley DF, Hsu CY, Martin RL, Moy CS, Silbergleit R, Stein T, Suarez JI, Toyoda K, Wang Y, Yamamoto H, Yoon BW; ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016 Sep 15;375(11):1033-43. doi: 10.1056/NEJMoa1603460. Epub 2016 Jun 8. PMID: 27276234; PMCID: PMC5345109.

• AHA/ASA Guideline for the management of spontaneous ICH. 2022

PlateletTransfusion AABBandICTMGInternationalClinical PracticeGuidelines 2025

Prevention of CLABSI

SCAPE

Sympathetic crashing acute pulmonary edema ( SCAPE) is a specific  subset of acute heart failure in which patients present with acute onset of pulmonary congestion and severe dyspnea with severe systolic hypertension due to sympathetic surge.

Pathophysiology

• Catecholamine release during this sympathetic surge leads to an increase in arterial tone and redistribution of fluid causing flash pulmonary edema.Activtion of renin-angiotesin-aldosterone system leads to increase in peripheral vascular resistance, sodium and water resabsorption, which worsens the cardiac function.Hypoxia, dyspnea and further sympathetic surge ensue as the intravascular fluid shifts into the pulmonary interstitium and alveoli.

• The shift of fluid in the lung is the major problem rather than hypervolemia.

Treatment

• NTG

• NTG is converted to nitirc oxide while activating cyclic guanosine monophosphate. This leads to smooth muscle relaxation and thereby reducing the preload due to venodilatation and higher doses reduces afterload by causing arterial dilatation.
• But conventional low dose NTG < 100mcg/min has not been shown to reduce the arterial tone. Studies have shown much higher doses > 100mcg/min  (upto 250 mcg/min) have shown beneficial in reduction in arterial tones.

• Diuretics
• Loop diuretics such as furosemide have been primarily used in the management of acute pulmonary edema. The effect starts in 30 min and peaks by 1.5h. 
• The role of diuretics in SCAPE is doubtful in euvolemic patients as the mechanism is fluid redistribution rather than fluid overload. 

• NIV

• NIV improves oxygenation, opens collpased alveoli. NIV causes reduction of preload and afterload. NIV also reduces the work of breathing.
• NIV should be started with higher PEEP (12-14) and titrated once the patient is stabilised. 

Evidence

• Kelly at al (Am J Emerg Med. 2023) published a retrospective, single centre study done on 41 patients to compare the clinical outcome when using low dose  NTG < 100 mcg/min (n=27)v/s high dose NTG > 100mcg/min (n=14). 8 out of 14 patients in the high dose group reached their BP target within first hour of treatment compared to 6 out of 27 in the low dose group. 

• Houseman et al (Am J Emerg Med. 2023) published a study on 67 patients to assess the clinical outcome on patients receive high dose NTG > (100 mcg/min).Study used median dose of 100 mcg/min with maximum upto 400mcg/min. Study concluded that high dose NTG infusion is safe.

• Levy at (Ann Emerg Med. 2007) published a feasibility and outcome assessment of the treatment of severe decomopensated heart failure with high dose nitroglycerin. Enrolled patients (N=29) were given bolus high dose of NTG (2mg) every 3 minutes upto a total of 10 doses. Patients treated with high dose NTG was assosciated with ET, BiPAP and ICU admisssion less frequently. 

Conclusion

• SCAPE is a important medical emergency and it is important recognise this entity . High dose NTG and NIV are two main treatment modality.

Reference

• Verma A, Jaiswal S, Mahawar A, Lal M, Gupta S, Begum R. Managing Patients With Sympathetic Crashing Acute Pulmonary Edema (SCAPE) Using the SCAPE Treatment Protocol: A Case Series. Perm J. 2024 Jun 14;28(2):116-120. doi: 10.7812/TPP/23.149. Epub 2024 Mar 29. PMID: 38549439; PMCID: PMC11249274.

• Agrawal N, Kumar A, Aggarwal P, Jamshed N. Sympathetic crashing acute pulmonary edema. Indian J Crit Care Med. 2016 Dec;20(12):719-723. doi: 10.4103/0972-5229.195710. PMID: 28149030; PMCID: PMC5225773.

ED Thoracotomy

 Indication

• Patients presenting with penetrating thoracic injury who arrives pulseless, but with myocardial electrical activity.

Benefits

• Evacuation of pericardial clots
• Direct control of exsanguinating intrathoracic hemorrhage
• Open cardiac massage
• Cross clamping of descending aorta

Procedure

• Clamshell thoracotomy : Clampshell technique is considered as preferred method in ED.
• Anterolateral thoracotomy 

Recent Evidence

• Joseph et al (Jamcollsurg.2020) did an observational study from the AORTA registry to compare whether resuscitative thoracotomy done using left anterolateral (AT) or clamshell thoracotomy (CT) was better. Study population was 1218 patients from AORTA registry who underwent RT . Overall survival was 6% (AT 6.6% 59 of 900 v/s CT 4.2% 13 OF 296; P=0.132). Study found that clamshell thoracotomy facilitates thoracic life saving procedures without increased systemic or thoracic complications compared with AT inpatients undergoing RT. 

• Perkins et al (JAMA Surg. 2025) did a retrospective cohort study of all cases of prehospital thoracotomy for Traumatic Cardiac Arrest in London from Jan 1999 to Dec 2019. Study analysed 601 patients who underwent prehospital thoracotomy . They found that 30 patients (5%) survived to hospital discharge, with favourable neurological outcome in 23 survivors. Study also found that survival varied with cause of arrest : 22 of 105 patients (21%) with cardiac tamponade , 8 of 418 patients (1.9%) with exsangunation. Study also noted that there was no survivors beyond 15 minutes of TCA due to cardiac tamponade and 5 minutes after exsanguination. 

Reference

• https://doi.org/10.1016/j.jamcollsurg.2020.09.002

• https://www.ctsnet.org/article/emergency-anterior-bilateral-thoracotomy

Hypocalcemia & Massive Transfusion

• Calcium plays a significant role in coagulation, platelet adhesion and contractility of myocardial and smooth muscle cells. It is required by clotting factors II, VII, IX and X aswell as protein C & protein S for activation at the damaged endothelium. 

• Severe ionised hypocalcemia is defined as Ionised calcium < 0.9 mmol/L and is assosciated with increased mortality in critically ill adults, whereas levels < 0.8 mmmol/L is assosciated with adverse cardiac effects. 

• PRBC, FFP & platelet contains approx 3g of citrate anticoagulant per unit as preservative. This is usually insignificant as 3g is metabolised by liver in 5 minutes. But in hypovolemic shock the combination of rapidly infused blood products and decreased hepatic clerance due to hypoperfusion and hypothermia may impair clearance of citrate.

Recent Evidence

• Ginacarcelli et al (J Surg Res..2016) did retrospective analysis of 156 trauma patients who received massive transfusion  and found 111 (71%) patients had iCa <0.9mmmol/L (Severe hypocalcemia). Patients in the iCa < 0.9 mmmol/l had received more blood products . They also found that mortality was higher in patients with severe hypocalcemia. 

• Potestio et al (cureus. 2022) did a retrospective study on 52 trauma patients requiring massive transfusion and found that incidence of  hypocalcemia was 85 - 97%. They also found that 97% of their patients developed hypocalcemia during first six hours. Nadir occured after median of eight units of blood products were given.

Recommendation

• ATLS 10th Edition donot recommend routine administration of calcium . Calcium supplementation should be guided by level of ionised calcium. 

• Joint Trauma System ( US Defense Health Agency - 2019 updates recommends use of 1gm calcium (30 ml of calcium gluconate ) immediately after first blood transfusion and then again after 4 units.

Conclusion

• Hypocalcemia is found to be common during massive transfusion. But there is lack of clear guidelines on dose and timing of calcium administration. Hence it advisable to monitor calcium at routine intervals and provide supplement based on the values.  

Reference

• https://doi.org/10.1016/j.jss.2015.12.036
• Doi: 10.7759/cureus.22093

Double Lumen Tube

• Lung isolation and one  Lung Ventilation ( OLV )  are used to facilitate surgery on the lungs, thoracic aorta, thoracic spine, esophagus and during minimally invasive cardiac surgery.  They are also used to manage air leak (Bronchopleural fistula) and preventing contamination of healthy lung by blood or infected material.

• It can be achieved by double lumen tracheal tube, bronchial blocker or advancing single lumen tracheal tube into a main bronchus. 

• Modern day DLT are single use, made of PVC. They have a white or clear tracheal lumen and blue bronchial lumen. When correctly inserted tracheal lumen terminates in the distal trachea and the bronchial lumen terminates in the distal main bronchus. When initiating OLV, the connector to the operative lung is clamped and the lumen opened to air, allowing ventilation of the non-operative lung and deflation of the operative lung.

Right sided DLT

Left Sided DLT

Size

• Male : 41 Fr, Small stature :37 Fr
• Female :35

Procedure

Video

Complication

• Hoarsness of throat
• Sore throat
• Trauma to Arytenoids, vocal cord tears and airway rupture

Reference 

• Double-lumen tubes and bronchial blockers Patel, M. et al. BJA Education, Volume 23, Issue 11, 416 - 424 .

FALLS Protocol

FALLS (Fluid Administration Limited by Lung Sonography) protocol is an ultrasound approach done at admission, facilitating causal diagnosis of acute circulatory failures with no obvious cause through seven step.

• Step 1 : Pericardial tamponade
• Step 2 : Look for Right ventricle enlargement ( Pulmonary Embolism )
• Step 3: Look for Lung sliding (Pneumothorax)

• Step 1-3 : Rules out Obstructive Shock

• Step 4: Look for B-Profile of Blue protocol ( Acute Hemodynamic Pulmonary Edema ) (Cardiogenic Shock). B lines between two ribs symmetrically distributed anteriorly and assosciated with lung sliding. 

• Step 5 (FALLS- Profile): Applied when A profile is seen ( Anterior A-lines mostly, with lung sliding). The B-Line appears from pulmonary artery occlusion pressure of 18 mmHg. A lines indicate that PAOP < 18 mmHg and fluids can be administered.  The idea is to partially treat both remaining causes of shock (hypovolemic, distributive), while promptly detecting the transformation from A-lines to B-lines under fluid therapy, a change called the FALLS-profile

• Step 6(Round Falls Protocol):  Here fluid is administrated using traditional rules or until FALLS profile occurs (To correct hypovolemia). If patient responds to fluid he is in hypovolemic shock, whereas there will be no improvement in distributive shock (Septic shock) . FALLS profile indicates need for addition of other measures like vasopressors. 

A FALLS Profile indicates a septal edema (Interstitial edema) which precedes alveolar edema. Intersitial AHPE is a silent development with moderate or no effect on gas exchange.

Limitation

•  A patient presenting with B lines on admission can have no transformation from A lines to B lines.

Reference

• Lichtenstein, D.A., Bar, S. Lung ultrasound for causal diagnosis of shock (FALLS-protocol), a tool helping to guide fluid therapy while approaching fluid tolerance. Some comments on its accuracy. Ann. Intensive Care 14, 88 (2024). https://doi.org/10.1186/s13613-024-01329-8

PECARN C-Spine Rule

Cervical spine injuries are serious but uncommon (<1%) in childrens. NEXSUS and Canadian C-Spine Rule have good sensitivity in adults but they are not well validated in childrens. 

Pediatric Emergency Care Applied Research Network (PECARN) did a multientric prospective observational study of 22,430 childrens with blunt trauma to develop a robust pediatric Cervical Spine Injury (CSI) prediction rule that can be incorporated into an algorithm to guide radiographic screening of children for CSI in ED. 

Study derived a validated CSI prediction rule with >92% sensitivity. Study found that GCS of 3-8, AVPU Score : Unresponsive, Abnormal airway, breathing or circulation findings and focal neurologic deficits were assosciated with high CSI risk. Study found that GCS of 9-14, AVPU score : V or P , substanial head injury, torso injury , midline tenderness is associated with CSI. 

Study also found that CT and plain radiography use would have been decreased from 17.2% to 6.9% and 39.7% to 34.2% respectively.