Community emergency departments account for the vast majority of emergency medicine locations throughout the country, delivering care to a large portion of the patients requiring emergency treatment. Although the practice setting and resources for community physicians and physicians at large academic centers is often very different, the standard of care typically comes from or is heavily influenced by the academic world. Unfortunately, the same resources or approaches (i.e. rapid infusers) may not be available or work in many community emergency departments. Thus, community emergency providers must frequently find different tools or techniques that work efficiently and effectively in their unique setting.
I experienced the contrast between academic and community EM practice first hand when I transitioned from daily academic clinical practice to a pure private practice setting. One of the things I enjoy most about community practice is the opportunity to navigate the challenges of two or more critically ill patients at the same time, often without residents or fellows to delegate to. There is an energy and urgency in effectively juggling those situations that attracts certain physicians and nurses to community practice. There isn’t enough time to focus exclusively on a single patient for long, no matter how sick they are, so we need tools and methods that are effective in a resource-limited environment.
The community EM clinician’s most challenging management scenario might be the septic shock patient. A patient with shock and hypotension requires immediate resuscitation (good write-up here on risks of delaying resuscitation). To make matters worse, many of these patients have challenging vascular access, so often we’re dependent on a 20 or 22 gauge thumb IV. Many studies have shown improved outcomes with early fluid resuscitation in septic shock, but that’s easier said than done in a community ED.1-3 Simply ordering 30 cc/kg of fluids in no way guarantees a patient will get even a drop of fluid in that early critical period. We don’t have a mechanical rapid infuser, but even if we did, it’s unlikely that anyone would know how to set it up. The ideal fluid resuscitation device is one that can be set up and deliver a bolus in minutes, so I can quickly assess and treat the patient before rushing to the next one.
The following is an all-too-common example of a case like this in a community ED:
A 48 year old female with DM, HTN, DVT/PE and prior stroke presents with one day of fever, cough, and complaints of weakness and confusion. Triage shows BP of 83/40 mmHg, RR 22, Temp 101.3 and O2 saturation of 96% on room air. The patient is given Tylenol, but vascular access cannot be obtained despite several attempts. The patient is brought back to a room several minutes later, once a less-ill patient is moved to the hall. On physical examination the patient appears significantly ill, slightly confused and very weak. While two nurses are attempting IV placement in an arm and leg, the EP places an EJ. A blood flash is obtained but the EJ blows.
The patient’s appearance worsens clinically, so an ultrasound machine is pulled in to look for a deeper vein. Due to obesity and chronic problems only a small upper antecubital fossa vein is seen and a 20 gauge IV is placed. It seems to pull back well enough to get some blood and flushes fairly well. A liter of saline is hung. Fluid is infusing slowly and the attending asks for a pressure bag. The single nurse left with the patient, is hooking the patient up to monitors, placing EKG stickers, and pulls out a pressure bag. The pressure bag is hung and pumped up, increasing the rate of fluid flow. After about 150 ccs, the pressure bag has to be pumped up again. The blood pressure cycles showing a systolic of 60 mmHg and the patient is almost unresponsive.
The attending physician is repeatedly inflating the pressure bag while looking for another vein to cannulate. As the patient is suddenly noted to have decreasing respirations, the pulse oximeter tracing fattens out, showing the previous saturation as 88% with a non-rebreather mask. Her blood systolic is now up to 68 mmHg with about 400 cc of saline infused. With no gag reflex present, falling oxygen saturation and an unresponsive patient, the attending makes a decision to intubate. Intubation is successful but the patient has a bradycardic arrest immediately after, requiring CPR and several rounds of ACLS. She is successfully resuscitated and taken to the ICU. Her course is complicated by acute renal injury requiring dialysis and moderate neurological deficits resulting from her arrest. She is eventually transferred to a nursing home.
In this situation, fluid simply could not be infused rapidly enough to correct the patient’s hypotension. As is often the case, the window to rapidly reverse severe hypotension is limited and can close quickly, like it did for this patient. When a patient drops their oxygen saturation and loses consciousness and their airway, little remains but to intubate them. This is the critical point where that continued hypotension intervenes once more. If a patient is hypotensive it greatly increases the odds of an arrest during or immediately after intubation.4
When it came to hypotension and fluid resuscitation in the community EM setting, my biggest challenge early in my transition was getting out of the habit of “fire and forget.” In academics, with residents, fellows, lots of nurses, ultrasound, and many other resources, I was used to saying, “this patient needs 2 liters now” and then moving on to the next patient. This can work well if the patient comes with an easily-flowing 16 gauge IV and you’ve got a large clinical support team, but, as we know, resources are limited in the community ED and such patients with easy vascular access are more exception than the rule. In fact, many of our patients seem to have almost no access.
Delivering a rapid fluid bolus to a hypotensive patient in a community ED can be challenging. We will have to work either through a peripheral IV, central line or possibly an IO. Central lines, unless you place a cordis introducer sheath, are made up of long and narrow tubes. Infusion rates are not much better than small peripheral IVs. While an IV may be placed in seconds, a central line will typically require 30 to 40 minutes or more when you factor in preparation and required clean-up.5 Intraosseous lines can work great but are often underutilized in the community ED. Higher volume infusions are easier when IOs are placed into the proximal femur or humerus.6 Peripheral IVs, unless a 14 gauge is placed into a large vein, will yield flow rates that are rarely impressive. You’ll never be able to deliver fluid via gravity and watch hypotension resolve in front of you. The result for me is standing at the patient’s bedside and repeatedly pumping up a pressure bag to get fluid to flow in faster. I often have to squeeze bags as well; the result: cramping and shaking hands with unclear improvement in flow rates. Few facilities I have worked in while in community practice had readily available Level I or similar infusers and, even if they did, it was typically stored elsewhere (far away). On the practical side, many of my nurses were not cleared to set up a Level I and we had to read instructions each time. Lastly, the set up took forever, made worse by lack of familiarity with the device.
LifeFlow is a hand-operated device for rapid infusion of a fluid bolus. I have read many clinical cases, user testimonials and even watched videos about LifeFlow and how a physician, nurse or tech could easily infuse a liter of saline in minutes through a peripheral IV, not a 14 gauge but an average 20 gauge IV. This is the type of device that’s ideal for a community ED. It’s effective but it doesn’t require a lot of resources or complex training to set up and use. If I could ask my nurse to pump the LifeFlow and definitely know that she or he will quickly infuse the liter (or two) I ordered stat, perhaps I really could walk away to the patient next door. Or I could wait a couple minutes, assess the effects of the rapid fluid bolus and determine the best next step for the patient.
For the community ED practice, different, more effective tools to rapidly diagnose and resuscitate hypotensive patients are needed. It is important to note that this discussion about an early fluid bolus in a hypotensive, shock patient is completely distinct from the arguments in academic circles that warn against the possible harm of fluid overload in septic patients where fluids are administered over several days. A patient who is hypotensive and in shock may not survive to get potential complications if we do not fix their blood pressure immediately.
- Lee SJ, Ramar K, Park JG, Gajic O, Li G, Kashyap R. Increased fluid administration in the first three hours of sepsis resuscitation is associated with reduced mortality: a retrospective cohort study. Chest 2014;146(4):908-15. 10.1378/chest.13-2702.
- Leisman D, Wie B, Doerfler M, Bianculli A, Ward MF, Akerman M, et al. Association of Fluid Resuscitation Initiation Within 30 Minutes of Severe Sepsis and Septic Shock Recognition With Reduced Mortality and Length of Stay. Ann Emerg Med 2016;68(3):298-311.
- Williams JM, Greenslade JH, Dymond CA, Chu K, Brown AFT, Lipman J. Characteristics, treatment and outcomes for all emergency department patients fulfilling criteria for septic shock: a prospective observational study. Eur J Emerg Med 2018;25(2):97-104.
- De Jong A, Rolle A, Molinari N, Paugam-Burtz C, Constantin JM, Lefrant JY, et al. Cardiac Arrest and Mortality Related to Intubation Procedure in Critically Ill Adult Patients: A Multicenter Cohort Study. Crit Care Med 2018;46(4):532-9.
- Keller AS, Melamed R, Malinchoc M, John R, Tierney DM, Gajic O. Diagnostic accuracy of a simple ultrasound measurement to estimate central venous pressure in spontaneously breathing, critically ill patients. J Hosp Med. 2009 Jul;4(6):350-5.
- Lairet J, Bebarta V, Lairet K, Kacprowicz R, Lawler C, Pitotti R, Bush A, King J. A comparison of proximal tibia, distal femur, and proximal humerus infusion rates using the EZ-IO intraosseous device on the adult swine (Sus scrofa) model. Prehosp Emerg Care. 2013 Apr-Jun;17(2):280-4.