#emergencymedicine Archives

On this episode, host Jason Woods speaks with Dr Nelson Sanchez-Pinto, pediatric intensivist, about an article he co-authored that was just e-published in the last week! The article concerns a retrospective analysis of the use of HAT therapy (hydrocortisone, ascorbic acid, thiamine) at a single center PICU for the treatment of pediatric septic shock. The e-pub link is below and this post will update when it is published in print. This topic has caused significant controversy and strong emotions for the last several years, and I expect that to continue. Please take a look at the additional resources below, as well as Dr. Sanchez-Pinto’s twitter feed (@nelsonspinto), for even more information.

E-publication link: https://www.atsjournals.org/doi/pdf/10.1164/rccm.201908-1543LE

The highlights:

Study details
- Single center, retrospective, propensity score matched
- 557 septic shock patients in the PICU
- 43 received HAT, 181 hydrocortisone alone, 333 neither
- HAT patients matched 1:1 with the other groups
Results
- HAT patients had lower mortality at 30-days (9 vs 28%, P=0.03) and 90-days (14 vs 37%, P=0.01) compared to no HAT or hydrocortisone
- Similar results comparing mortality in HAT to those with hydrocortisone alone – 30-day (9 vs 30%, p=0.01) and 90 day (14 vs 37%, p=0.01)
- No difference at 30 days in vasoactive free days or hospital free days

Guests

Nelson Sanchez-Pinto MD, Assistant Professor of Pediatrics and Preventative Medicine, Northwestern University, Feinburg School of Medicine

Pediatric Intensivist, Anne and Robert H. Lurie Children’s Hospital of Chicago

References

1. Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest. 2017;151(6):1229-1238.

2. Wilson JX. Mechanism of action of vitamin C in sepsis: ascorbate modulates redox signaling in endothelium. Biofactors. 2009;35(1):5-13.

3. Fowler AA, 3rd, Syed AA, Knowlson S, Sculthorpe R, Farthing D, DeWilde C, et al. Phase I safety trial of intravenous ascorbic acid in patients with severe sepsis. J Transl Med. 2014;12:32.

4. Spoelstra-de Man AME, Elbers PWG, Oudemans-van Straaten HM. Making sense of early high-dose intravenous vitamin C in ischemia/reperfusion injury. Crit Care. 2018;22(1):70.

5. Zabet MH, Mohammadi M, Ramezani M, Khalili H. Effect of high-dose Ascorbic acid on vasopressor’s requirement in septic shock. J Res Pharm Pract. 2016;5(2):94-100.

6. Wald EL, Sanchez-Pinto LN, Smith CM, Moran T, Badke CM, Barhight MF, Malakooti MR. Hydrocortisone-Ascorbic Acid-Thiamine Use Associated with Lower Mortality in Pediatric Septic Shock. Am Journal Respr and Crit Care Med. E-pub ahead of print. PMID: 31916841. DOI: https://doi.org/10.1164/rccm.201908-1543LE

7. Fowler AA, Trust JD, Hite RD. Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients With Sepsis and Severe Acute Respiratory Failure – The CITRIS-ALI Randomized Clinical Trial. JAMA. 2019;322(13):1261-1270. doi:10.1011/jama.2019.11825

Additional Resources

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On this episode, host Jason Woods speaks with Dr. TJ Doyle, medical director of the communicaton center at the University of Pittsburgh Medical Center (UPMC) and medical director for STAT-MD, a ground based consulting group for airlines. The discussions encompasses that frequency and types of in-flight medical emergencies (IME), what is in the medical kit on airplanes, what resources are available in-flight, and the legal ramifications for medical vounteers.

The highlights:

Worldwide ~ 2.75 billion persons fly annually.
IME occur in roughly 1 per 604 US flights, or 24-130 IME per 1 million passengers.
1. 69% had EMS requested, 25% transported to hospital, 8.6% admitted, 0.3% died.
2. Aircrafts divert in about 4$ of IME
Airplane cabins are pressurized to between 5000 and 8000 ft altitude
Minimum equipment in the US (see graphic)

AED
- Hemorrhage control
- IV line
- Gloves
- Medications to treat “basic conditions”
  1. Pain
  2. Allergic reactions
  3. Bronchoconstriction
  4. Hypoglycemia
  5. Dehydration
  6. “Some” cardiac conditions
- Equipment for initial assessment
Most common IME
- Syncope or near 32.7%
- GI 14.8%
- Resp 10.1%
- CV 7.0 %
Medical volunteer role
- Individual airline policies may have different guidance
- Not generally required to carry proof of medical license
- Primary role is to gather info, provide assessment, and communicate with ground support. May need to admin medicines or perform procedures but direction of care is by ground medical.
Legal and ethical issues
- US Aviation Medical Assistance Act
  1. Protects passengers who provide medical assistance from liability except in cases of negligence or willful misconduct.
  2. Medical volunteers who seek compensation for this service may jeopardize their protections under this law, though now lawsuit of such has been filed
- Duty to respond
  1. In US, Canada, England, Singapore, no legal duty
  2. In Australia, many European countries, physicians are required to render assistance.
- Other countries may have different protections or no protections at all

Guests

Thomas J. Doyle, Clinical Assistant Professor of Emergency Medicine, University of Pittsburgh Medical Center; Associate Medical Director, STAT MedEvac; Medical Director, Command Center, STAT-MD.

References

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Little Big Med

Little Patients, Big Medicine

#emergencymedicine

Episode 24: Metabolic Resuscitation for Pediatric Septic Shock

Episode 19: In-flight Emergencies