Bicarb Bicarb is too good or bad ???

Metabolic acidosis is common in critically ill patients with sepsis, shock or renal failure and is associated with impaired myocardial contractility, reduced catecholamine response and high risk of AKI & use of RRT and death.

Sodium bicarbonate has used to treat metabolic acidosis since decades in crtitically ill patients. Though sodium bicarbonate is a life saving drug there has several concerns with regard to blanket use of sodium bicarbonate to treat all critically ill patient. 

BICAR-ICU Trial. The Lancet.2018 is a multicentric, open label, phase 3, RCT trial done to evaluate whether sodium bicarbonate improves the outcome of critically ill patient. Patient were assigned to control group or 4.2% sodium bicarbonate to achieve a pH of >7.3. Study found that the composite death from any cause by day 28 days was 138 (71%) of 194 patients in control group and 128 (66%) of 195 in bicarbonate group (p=0.24). Study also found in predefined subgroup analysis of AKIN with score of 2 or 3 , kaplanmeier method estimate of survival by day 28 between control (63% mortality) v/s bicarbonate group (46% mortality) which is significant. Study concluded that sodium bicarbonate has no effect on composite outcome though it showed survival benefit in predefined stratum of patients with AKI.

BICARICU2 Trial. JAMA.2025 is a open label ,RCT done to determine whether sodium bicarbonate infusion is associated with 90 day all cause mortlaity in pateints with severe metabolic acidemia (pH≤7.2) and moderate to severe acute kidney injury .day 90 all-cause mortality was 195 of 314 patients (62.1%) in the bicarbonate group and 193 of 313 (61.7%) in the control group (absolute difference, 0.4;95% CI, −7.2 to 8.0; P = .91). There was no evidence of a group effect on day 28 or day 180

all-cause mortality. Study concluded that patients with severe metabolic acidemia and moderate to severe acute kidney injury, intravenous sodium bicarbonate did not affect mortality.

SODa-BIC Trial. NEJM 2026 is a pragmatic, multicentric (55 ICU across 7 countries) , double blinded, randomised trial to asses the benefit of sodium bicarbonate in adult patients with metabolic acidosis (pH < 7.3) receiving vasopressors in ICU.Renal-replacement therapy was used within 30 days in 16.8% of the patients in the sodium bicarbonate group and in 20.9% of those in the placebo group (adjusted difference, −3.9 percentage points; 95% CI, −10.6 to 2.7). In-hospital mortality by day 30 was 25.4% in the sodium bicarbonate group and 24.0% in the placebo group (adjusted difference, 1.8 percentage points; 95% CI, −5.6 to 9.2). Study also found that RRT was used within 30 days in 16.8% of bicarbonate group v/s 20.9 in placebo group. Four patients (1.6%) in the sodium bicarbonate group had an adverse effect, as compared with none in the placebo group (P=0.06). Study concluded thatThe use of sodium bicarbonate in critically ill patients with metabolic acidosis 

receiving vasopressors did not lead to a lower risk of major adverse kidney events within 30 days than placebo.

BIHCA Trial. JAMA.2026 is a randomised, double blinded trial done to determine whether administrator of sodium bicarbonate during in hospital cardiac arrest increases the proportion of ROSC. Study found that at 30 days 45 (12%) patients in bicarbonate and 37 (9.1%) in the placebo group was alive (risk ratio, 1.25 [95% CI, 0.84-1.88]).Alkalosis and hypernatremia after cardiac arrest were more common in the sodium bicarbonate group. Study concluded that there was no significant difference in sustained return of spontaneous circulation between sodium bicarbonate and placebo in adults with in-hospital cardiac arrest.

Recommendation

• AHA 2025 guidelines donot recommend routine administration in cardiac arrest. 
• Sepsis guidelines 2026  recommends sodium bicarbonate therapy for patients in septic shock, severe metabolic acidosis pH < 7.2 and AKIN score of 2 or 3 .
• Sepsis guidelines 2026 suggest against using sodium bicarbonate in septic shock and hypoperfusion induced lactic acidemia or to reduce vasopressor requirement. 
• Routine administration in DKA is not recommended. Bicarbonate infusion can be considered if acidosis is severe with pH <7. 
• Sodium bicarbonate infusion is recommended in severe NAGMA.

Conclusion

Yes, sodium bicarbonate is still a main stay of treatment in metabolic acidosis, but routine use of sodium bicarbonate does not improves the outcome.Recent studies have shown that bicarbonate administration in AKI may reduce the need for RRT, but more evidence is required .So administration of bicarbonate needs to be based on evidence and recommendation.

Reference

• Jaber S, Paugam C, Futier E, Lefrant JY, Lasocki S, Lescot T, Pottecher J, Demoule A, Ferrandière M, Asehnoune K, Dellamonica J, Velly L, Abback PS, de Jong A, Brunot V, Belafia F, Roquilly A, Chanques G, Muller L, Constantin JM, Bertet H, Klouche K, Molinari N, Jung B; BICAR-ICU Study Group. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial. Lancet. 2018 Jul 7;392(10141):31-40. doi: 10.1016/S0140-6736(18)31080-8. Epub 2018 Jun 14. Erratum in: Lancet. 2018 Dec 8;392(10163):2440. doi: 10.1016/S0140-6736(18)33040-X. PMID: 29910040.
• Jung B, Jabaudon M, De Jong A, Bitker L, Audard J, Klouche K, Sarton B, Guitton C, Lasocki S, Rieu B, Canet E, Jeantrelle C, Roquilly A, Mayaux J, Verdonk F, Pottecher J, Ferrandiere M, Riu B, Garcon P, Assefi M, Detouche P, Forel JM, Roger C, Bourenne J, Jacquier S, Bougon D, Rolle A, Corne P, Benchabane N, Richard JC, Asehnoune K, Chanques G, Reignier J, Belafia F, Fosset M, Huguet H, Futier E, Molinari N, Jaber S; BICARICU-2 Study Group. Sodium Bicarbonate for Severe Metabolic Acidemia and Acute Kidney Injury: The BICARICU-2 Randomized Clinical Trial. JAMA. 2025 Dec 9;334(22):2000-2010. doi: 10.1001/jama.2025.20231. PMID: 41159812; PMCID: PMC12573113.
• SODa-BIC Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group; Serpa Neto A, McNamara M, White K, Cooper DJ, Fujii T, Higgins AM, Hodgson CL, Navarra L, Nichol A, Peake S, Réa-Neto A, Secombe P, Osborne F, Burrill H, See E, Young M, Zampieri FG, Plummer M, Christie C, Nunnink L, Mackay J, McGuinness S, Marmol J, Tiruvoipati R, Bailey M, Young PJ, Bellomo R, Udy A. Sodium Bicarbonate for Critically Ill Adults with Metabolic Acidosis and Shock. N Engl J Med. 2026 Jun 12. doi: 10.1056/NEJMoa2600526. Epub ahead of print. PMID: 42283370.

Whole blood or Component therapy in trauma ?

History of blood transfusion

Oswald robertson serving with British and American expeditionary forces during World War I pioneered the use of stored, type specific whole blood, demonstrating for the first time that hemorrhagic shock could be treated with transfusion.  During the world war II whole blood was used for transfusion . By 1980's  following vietnam war  component therapy started to replace the whole blood due to its storage advantage of various components and same donated bloods can be used for multiple recipients. SInce then for neary 4 decades component therapy was used for resuscitation.

Why whole blood now ? 

Recent military conflits in Iraq and Afganistan renewed the interest in use of whole blood transfusion. During war the shortage of components and short life of platelet forced the military hospitals to fresh whole blood from walking blood banks. As evidence evolved the US military implemented a cold stored low titre whole blood program for transfusion in austere settings. This has now lead to recent interest for whole blood transfusion in civilian setting.

Recent Evidences

• Spinella et al. J Trauma. 2009  did a retrospective study from US Military combat patients who received ≥1 Warm Fresh Whole Blood (WFWB) to assess whether WFWB transfusion is associated with improved survival compared with component therapy. Study found that 24 hr and 30 day survival was higher in WFWB group 96 of 100 (96%) v/s 223 0f 254(88%) in component therapy group (p= 0.018). Study concluded that in patients with trauma WFWB transfusion may improve 30 day survival. 

• Gurney et al. Transfusion. 2020  did a retrospective analysis of casualities treated by role 2 surgical team in Afghanistan who received 1 or more units Fresh Warm Blood( FWB). The Kaplan-Meier plot demonstrated that survival was similar between FWB (79.1%) and no-FWB (74.5%) groups (p = 0.46); after stratifying patients by the combat mortality index, the risk of mortality (Critical patients)  was increased in the no-FWB group (hazard ratio:2.8; 95% confidence interval, 1.2-6.4) compared to the FWB cohort.

• Torres et al. JAMA Surg. 2024 did a retrospective cohort study from American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2019,to December 31, 2020, for adult patients presenting to US and Canadian adult civilian level 1 and 2 trauma centers with systolic blood pressure less than 90 mm Hg, with shock index greater than 1, and requiring MTP who received a WB transfusion within the first 24 hours of emergency department (ED) arrival.  In this cohort study, receipt of a WB transfusion earlier at any time point within the first 24 hours of ED arrival (adjusted hazard ratio, 0.40; 95% CI, 0.22-0.73; P = .003) was associated with improved survival in patients presenting with severe hemorrhage.

• SWiFT Trial. NEJM.2026 did a phase III , pragmatic, multicentric, unblinded, radomised superiority trial on patients with  major traumatic hemorrhage across 10 air ambulance services in England. Patients were assigned to whole blood was transfused 2 units and  to standard groups was transfused upto 2 units of PRBC and plasma each. 48.7% (153/314) patients in whole blood group and 47.7% (144/302) in standard care group died within 24 hours after randomization ( RR 1.02; 95% CI 0.80 to 1.31; P=0.84. Study concluded that whole blood transfusion was not superior to standard care in reducing death or massive transfusion in 24 hours. 

• TOWAR. NEJM.2026 is a pragmatic, multicentric (44 air medical bases), cluster randomised trial doen to assess transfusion with whole blood is more beneficial than blood components in prehospital setting. Patients were either received 2 units of whole blood or blood components as indicated. Study found that mortality in whole blood (n=695)  was 25.9% compared to component group (n= 298) 20.5%(adjusted odds ratio, 1.24; 95% confidence interval [CI], 0.87 to 1.76; P=0.24).Study concluded that use of whole blood for prehospital transfusion did not result in lower 30 day mortality. 

Recommendation

• ATLS 11th Edition recommends to prefer whole blood over component therapy if available. 

Conclusion

• Although ATLS recommends to prefer whole blood for resuscitation based on military experience, but recent landmark civilian studies haven't shown any superiority over component therapy. More evidences are required to make a final conclusion, till then both the strategies can be followed based on institutional policies and availability of resources. 

Reference

• Torres CM, Jenkins D, Sakran JV. Whole-Blood Transfusion From Empiricism to Evidence: A Narrative Review. JAMA Surg. Published online July 08, 2026. doi:10.1001/jamasurg.2026.2574
• Back to the future: Whole blood resuscitation of the severely injured trauma patient. McCoy et al. SHOCK. 2021.DOI: 10.1097/SHK.0000000000001685
• Gurney J, Staudt A, Cap A, Shackelford S, Mann-Salinas E, Le T, Nessen S, Spinella P. Improved survival in critically injured combat casualties treated with fresh whole blood by forward surgical teams in Afghanistan. Transfusion. 2020 Jun;60 Suppl 3:S180-S188. doi: 10.1111/trf.15767. Epub 2020 Jun 3. PMID: 32491216.
• Spinella PC, Perkins JG, Grathwohl KW, Beekley AC, Holcomb JB. Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries. J Trauma. 2009 Apr;66(4 Suppl):S69-76. doi: 10.1097/TA.0b013e31819d85fb. PMID: 19359973; PMCID: PMC3126655.

Early Vasopressors in sepsis .Is it beneficial ?

Starting vasopressors early in the management of sepsis, is it beneficial or harmful ?  This question has been haunting the Emergency Physician for quiet some time. Lets look at what the evidence tells us 

CENSER Trail AJRCCM.2019 was a single centre, randomised, double blinded, placebo controlled trial was done to evaluate if early low dose norepinephrine in adults with sepsis with shock improves shock control by 6 hours compared with standard care. Median time from emergency room arrival to norepinephrine  administration was significantly shorter in the early norepinephrine group (93 vs. 192 min; P , 0.001). Shock control rate by 6 hours was significantly higher in the early norepinephrine group (118/155 [76.1%] vs. 75/155 [48.4%]; P , 0.001). The 28-day mortality was not different between groups: 24/155 (15.5%) in the early norepinephrine group versus 34/155 (21.9%) in the standard treatment group (P =0.15). The early norepinephrine group was associated with lower incidences of cardiogenic pulmonary edema (22/155 [14.4%] vs. 43/155 [27.7%]; P = 0.004) and new-onset arrhythmia (17/155 [11%] vs. 31/155 [20%]; P = 0.03).Early norepinephrine was significantly associated with increased shock control by 6 hours.

CLOVERS Trail NEJM.2023 was done to asses whether a early restrictive fluid strategy ( Prioritizing vasopressors and lower IV fluid volumes) or a liberal fluid management was beneficial for sepsis induced hypotension.

Study found that the restrictive fluid group administrated -2134ml of IV Fluids less than liberal fluid group and vasopressor use was more longer in restrictive use. Death from any cause before discharge home by day 90 occurred in 109 patients (14.0%) in the restrictive fluid group and in 116 patients (14.9%) in the liberal fluid group (estimated difference −0.9 percentage points; 95% CI, −4.4 to 2.6; P=0.61).

Among patients with sepsis-induced hypotension, the restrictive fluid strategy that was used in this trial did not result in significantly lower (or higher) mortality before discharge home by day 90 than the liberal fluid strategy. 

ARISE Fluids Trail NEJM. 2026 randomly assigned adult patients who presented to the emergency department with septic shock to receive either fluids at restricted volumes and early vasopressor therapy (vasopressor group) or higher volumes of fluids and later vasopressor therapy (fluids group) for at least 6 hours and up to 24 hours. 

In the first 24 hours after randomization, patients in the vasopressor group received less intravenous fluid than those in the fluids group (median difference, −1108 ml; 95% confidence interval [CI], −1395 to −850). The percentage of patients who received vasopressors was  higher by 18.9 percentage points (95% CI, 13.3 to 24.5) in the vasopressor group. The median number of days alive and out of the hospital at day 90 was 76 (interquartile range, 55 to 83) in the vasopressor group and 76 (interquartile range, 55 to 82) in the fluids group (difference, 0.0 days; 95% CI, −2.7 to 2.7; P=1.00). Adverse events occurred in similar percentages of patients in the two groups, except 

for pulmonary edema (0.6% in the vasopressor group vs. 5.0% in the fluids group; P<0.001).

The study concluded that Among adult patients who presented to the emergency department with septic shock, an approach that involved restricted fluid volume and early vasopressors didnot result in a greater number of days alive and out of the hospital at day 90 than an approach involving greater fluid volume and later administration of vasopressors.

Conclusion

Evidences from these studies shows that early vasopressors may help to achieve  shock stabilisation early but studies have failed to show mortality benefit . At the same time liberal use of fluids have shown to be associated with adverse effects like pulmonary edema. 

But we need to understand that sepsis induced hypotension can be due to decrease in vascular resistance, capillary leak, cardiac dysfunction, decreased circulatory volume or combination of all. So what suits to one patient may not be suitable for another. So now the world is moving towards personalised hemodynamic resuscitation.

SOFA 2 Score

Acute dysfunction of vital organs is the hallmark of critical illness. The SOFA score, most widely used to describe organ dysfunction has not been updated in 30 years during which the treatment of organ dysfunction in critically ill has advanced.

Why we need SOFA 2 ?

•  The SOFA score validated since 1996 describes 6 organ system - Neurological,Cardiovascular, Hepatic, Respiratory, Renal and Coagulation using clinical and biochemical variables.  SOFA score failed to capture the contemporary intervention like drugs and devices that provide support for failing organs.

What is SOFA 2 ?

• SOFA 2 was developed and validated in 10 international multicenter cohort of 3.3 million adult ICU patients. The SOFA -2 Score includes 6 organ system with a total score of 0 - 24. The updated score incorporates commonly used drugs and mechanical organ supports used at present era.
• SOFA 2 score considered inclusion of immune and GI systems but later avoided due to inability of candidate variables to satisfy both content and predictive validity
• The  total score ranges from 0-24 . Higher the score indicates worse organ dysfunction.

SOFA 1 V/s SOFA 2

• Development and validation SOFA 2 Score (JAMA.2025) found that SOFA 2 is better in describing organ dysfunction and mortality.
• The predictive validity of SOFA2 and SOFA1 for ICU mortality was similar (SOFA2 AUROC 0.79;95%CI V/s SOFA 1 AUROC 0.77,95%CI). 
• The study also found that median SOFA 2 score among patients expired at ICU was 9.

         Click on the image for better view.

Reference 

• Ranzani OT, Singer M, Salluh JIF, Shankar-Hari M, Pilcher D, Berger-Estilita J, Coopersmith CM, Juffermans NP, Laffey J, Reinikainen M, Neto AS, Tavares M, Timsit JF, Arias Lopez MDP, Arulkumaran N, Aryal D, Azoulay E, Celi LA, Chaudhuri D, De Lange D, De Waele J, Dos Santos CC, Du B, Einav S, Engelbrecht T, Fazla F, Ferrer R, Finazzi S, Fujii T, Gershengorn HB, Greene JD, Haniffa R, Hao S, Hasan MS, Hollenberg S, Ippolito M, Jung C, Kirov M, Kobari S, Lakbar I, Lipman J, Liu V, Liu X, Lobo SM, Magatti D, Martin GS, Metnitz B, Metnitz P, Myatra SN, Oczkowski S, Paiva JA, Paruk F, Pekkarinen PT, Piquilloud L, Pölkki A, Prescott HC, Blaser AR, Rezende E, Robba C, Rochwerg B, Ruckly S, Samei R, Schenck EJ, Secombe P, Sendagire C, Siaw-Frimpong M, Simpkin AJ, Soares M, Summers C, Szczeklik W, Takala J, Tanaka S, Tricella G, Vincent JL, Wendon J, Zampieri FG, Rhodes A, Moreno R. Development and Validation of the Sequential Organ Failure Assessment (SOFA)-2 Score. JAMA. 2025 Dec 16;334(23):2090-2103. doi: 10.1001/jama.2025.20516. PMID: 41159833; PMCID: PMC12573119.

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.