Podcast 139 – Opioid-Free ED with Sergey Motov

heroin

Motov.Sergey.jpg_0x200Today I am joined by a good friend Sergey Motov, MD. Sergey is an EM doc with a particular interest in pain management in the ED. Sergey recently, as part of a approved study, ran an entire ED shift without a single administration of an opioid for pain. Can it be done?

The Pain-Free ED

Sergey has an amazing site, with resources and lectures: The Pain-Free ED

The Concept and Rationale of an Opioid-Free ED: Why do we need alternative to opioids in the ED?

No consensus on optimum opioid doses (weight-based, fixed, nurse initiated?)

Poor titration practices

Overdosing hydromorphone/ under-dosing morphine

Severe side effects ( especially geriatric patients)

Begetting Addiction

Regulatory concerns of prescribing opioids.

Concept of Multimodal Receptor/Channel Targeted Analgesia (RCTA)

Cox Inhibition

COX 1-2 – NSAIDS ( renal colic, back pain; by honoring “Analgesic Ceiling” concept)

COX 2 -Cox 3 – Acetaminophen (as well as TRPV1( capsaicin receprots) , cannabis, endogenous opioids)

NMDA antagonism- ketamine ( IV push, drip, continuous infusion as adjunct to opioids or single agents)

GABA receptors-propofol ( intractable migraine headache), partially gabapentin

Alpha-2 Central Agonists-clonidine, dexmedetomidine

Central calcium receptors- gabapentin, pregabalin

  • http://www.ncbi.nlm.nih.gov/pubmed/25411680
  • http://www.ncbi.nlm.nih.gov/pubmed/22786518
  • http://www.ncbi.nlm.nih.gov/pubmed/21412914
  • http://www.ncbi.nlm.nih.gov/pubmed/19588419

Sodium Channel Blockade-lidocaine, bupivacaine

Local Anesthetic

Topical, myofascial blocks, trigger point injections, paravertebral/paracervical/occipital blocks

Intraarticular Injections

  • http://www.ncbi.nlm.nih.gov/pubmed/10530535
  • http://www.ncbi.nlm.nih.gov/pubmed/21491392
  • http://www.ncbi.nlm.nih.gov/pubmed/25066879
  • http://www.ncbi.nlm.nih.gov/pubmed/22436475
  • http://www.ncbi.nlm.nih.gov/pubmed/18783486

US guided-regional anesthesia

  • http://www.ncbi.nlm.nih.gov/pubmed/21883635
  • http://www.ncbi.nlm.nih.gov/pubmed/18606327
  • http://www.ncbi.nlm.nih.gov/pubmed/22030184
  • http://www.ncbi.nlm.nih.gov/pubmed/17499669
  • http://www.ncbi.nlm.nih.gov/pubmed/?term=Liebmann+O%2C+2006
  • http://www.ncbi.nlm.nih.gov/pubmed/?term=Wathen+JE%2C+2007
  • http://www.ncbi.nlm.nih.gov/pubmed/24343768
  • http://www.ncbi.nlm.nih.gov/pubmed/23758305
  • http://www.ncbi.nlm.nih.gov/pubmed/22494596
  • http://www.ncbi.nlm.nih.gov/pubmed/21570238

Systemic IV lidocaine

Nitrous oxide

Poorly understood as to what receptor it hits–NMDA??

Practical considerations

  • Dual/triple analgesic combinations
  • Different classes of analgesic agents with unique pharmacologic and physiologic actions provide synergistic analgesia
  • Smaller doses of each agent result in decrease potential for drug-related adverse events
  • Less sedation, early ambulation, and decreased LOS in the ED by non-opioid analgesia.
  • Intravenous /intranasal/ subcutaneous routes
  • Transdermal route to go home with (e.g. lidocaine/clonidine patches)
  • Major contribution from Regional Anesthesia/Analgesia
  • IV drips in the ED (2-6h) of ketamine/Lidocaine/Dexmedetomidine
  • Overall patient satisfaction

Future research

  • Creation of solid analgesic algorithms as an alternative to opioid analgesia in the ED
  • Role of compounded pharmaceuticals (creams/ointments) in acute pain management.
  • Cannabis for ED pain management
  • Liposomal Bupivacaine
  • Transdermal PCAs of any of the above meds

 

Opioid-Free Shift in the ED Suggested Protocols

The rational of an opioid–free shift in the ED   is to evaluate the feasibility of controlling acute painful conditions without oral and parenteral opioid analgesics by using alternative  multimodal pain –mediated receptors/channels targeted analgesia(RCTA) as initial treatment modalities. All patients to be eligible for rescue opioid analgesia (morphine, fentanyl, hydromorphone) at 20 min if pain is still severe enough and warrants parenteral analgesia.

Combinations of two or even three medications might be warranted:

Abdominal pain (renal colic)

  1. IV Ketorolac-10-15 mg IVP (or Ibuprofen 400 mg if they can take PO)
  2. IV Acetaminophen-1g over 15 min
  3. IV Lidocaine -1.5 mg/kg of 2% Lidocaine (cardiac) over 10-15 min

Abdominal Pain (non-traumatic)

  1. IV Ketorolac-10-15 mg IVP (or Ibuprofen 400 mg if they can take PO)
  2. IV Acetaminophen-1g over 15 min
  3. IV Ketamine-0.3 mg/kg over 10 min, + IV drip at 0.15 mg/kg /hr

Abdominal Pain (traumatic)

  1. IV Acetaminophen-1 g over 15 min
  2. IV Ketamine-0.3 mg/kg over 10 min, + IV drip at 0.15 mg/kg /hr

Back pain (oral meds)

  1. Ibuprofen-400-800 mg
  2. Acetaminophen -1000mg
  3. Methocarbamol 500 mg-1500 mg
  4. Diazepam-5 mg

Back Pain (parenteral)

  1. IV Ketorolac 10-15 mg (or Ibuprofen 400 mg if they can take PO)
  2. IV Acetaminophen-1 g over 15 min
  3. IV Ketamine-0.3 mg/kg over 10 min, + IV drip at 0.15 mg/kg /hr
  4. IV Lidocaine -1.5 mg/kg of 2% Lidocaine( cardiac) over 10-15 min
  5. IV Clonidine-0.3-2 mcg/kg/hr drip

Headache

  1. IV Metoclopramide -10 mg
  2. IV Diphenhydramine-25-50 mg
  3. IV Prochlorperazine-10mg
  4. IV Ketorolac-10-15 mg (or Ibuprofen 400 mg if they can take PO)
  5. SQ Sumatriptan (migraine)-6mg
  6. IV Propofol (intractable Migraine)-10mg ivp q5 min
  7. IV Haldol-2.5 mg, IV Droperidol -2-5 mg
  8. Refractory cases-Ketamine at 0.2-0.3 mg/kg short infusion ( 10 min)

Musculoskeletal Pain: REGIONAL NERVE BLOCKS( IF SUITABLE)

  1. PO Ibuprofen-400-800 mg
  2. PO Acetaminophen-500-1000mg
  3. PO Naproxen-375 mg
  4. IV Ketorolac-10-15 mg
  5. IV Acetaminophen-1g over 15 min
  6. IV Ketamine-0.3 mg/kg over 10 min, + IV drip at 0.15 mg/kg /hr

Neuropathic Pain

  1. PO Ibuprofen-400-800 mg
  2. PO Gabapentin-100-300 mg
  3. PO Prednisone-25-50 mg
  4. PO Clonidine 0.1-0.2 mg
  5. IV Ketamine-0.3 mg/kg over 10 min, + IV drip at 0.15 mg/kg /hr
  6. IV Lidocaine -1.5.-2.5 mg/kg /hr drip x2-4 h ( 2% cardiac Lidocaine)
  7. IV Dexemedetomidine-0.2-0.3 mcg/kg/hr drip
  8. IV Clonidine-0.3-2 mcg/kg/hr drip

Post-Operative Pain

  1. IV Acetaminophen-1g over 10-15 min
  2. IV Ketamine-0.3 mg/kg over 10 min, + IV drip at 0.15 mg/kg /hr
  3. IV Dexemedetomidine-0.2-0.7 mcg/kg/hr drip

Dental Pain

  1. Dental Blocks
  2. PO Ibuprofen -400-800 mg
  3. PO Acetaminophen-500-1000mg

Burns

  1. PO Ibuprofen-400-800 mg
  2. PO Acetaminophen-500-1000mg
  3. PO Naproxen-375 mg
  4. IV Acetaminophen-1g over 15 min
  5. IV Ketamine-0.3 mg/kg over 10 min, + IV drip at 0.15 mg/kg /hr
  6. IV Lidocaine -1.5.-2.5 mg/kg /hr drip x2-4 h (2% cardiac Lidocaine)
  7. IV Dexemedetomidine-0.2-0.7 mcg/kg/hr drip
  8. IV Clonidine-0.3-2 mcg/kg/hr drip

Sickle Cell Painful Crisis

  1. PO Ibuprofen-800mg
  2. PO Hydroxyurea-100mg
  3. IN Ketamine 1mg/kg (no more than 1ml per nostril)
  4. IV Ketamine-0.3 mg/kg over 10 min, + IV drip at 0.15 mg/kg /hr
  5. IV Lidocaine -1.5.-2.5 mg/kg /hr drip x2-4 h (2% Cardiac Lidocaine)
  6. IV Dexemedetomidine-0.2-0.3 mcg/kg/hr drip

Now on to the Podcast…

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Podcast 138 – Vasopressor Basics

vise

The Basics of Vasopressors

There is a ton to speak about regarding vasopressors, but before we get to the edge cases, we need to set-up a foundation.

Types of Shock

  • Obstructive
  • Hypovolemic
  • Cardiogenic
  • Distributive

It’s all about flow!

  • Should we get rid of blood pressure?

Critical Perfusion Pressures

  • MAP of 50 in non-vasculopath dogs for the brain? (9692450)
  • MAP of 65 for the heart?
  • MAP 65-75 for the Kidneys? (18382191)

When we put someone on a vasopressor, what are we hoping to accomplish?

  • Critical Perfusion Pressures (Heart will get better, but may look worse)
  • Increase Venous Return
  • Avoid Gut Ischemia and Flow Reduction

Norepi Increases Venous Return as well as Constricting Afterload

  • Crit Care Med. 2012;40(12):3146-3153
  • Crit Care Med. 2011 Apr;39(4):689-94
  • Crit Care Med. 2013 Jan;41(1):143-50
  • Critical Care 2007, 11(Suppl 2):P37
  • Critical Care 2010, 14:R142

MAP of 65 or Higher?

No benefit to 80-85 group (24635770)

Vasopressor Flow Chart

Vasopressor FlowChart

Update: The Hinds Perspective

Hinds-Algo

Various Vasopressors

Terminology

  • ‘pressors/catecholamines/inotropes are not so helpful
  • Pure Pressors
  • Inopressors
  • Inodilators (another show)

Why Norepi?

(10966247)

Should become weight based

Should tolerate tiny doses

Why Not Dopamine?

’cause it is crappy

Vasopressin

Phenylephrine

Epinephrine

Effects on Mortality

Early norepi was better than later norepi (25277635), (25072761)

Up and Coming Vasopressors to be Discussed in Future Episodes

Methylene Blue

Angiotensin II

ATHOS Trial

Peripheral Vasopressors

EMCrit Episode 107

Very Good Review Article on the Effects of Vasoactive Agents on Microcirculation

Great Review (20811874)

Review Articles

(12386503) (21097695)

Understanding Venous Return

(24966066)

Must Read Post By Josh Farkas

Early MAP Stabilization

Now on to the Podcast…

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Bibliography

EMCrit Podcast 137 – Delayed Sequence Intubation (DSI) Update

The DSI study is finally published! Listen to this podcast for a discussion of the paper and the things we have learned since the original DSI podcast.

For all of the notes, links to the article and to be able to comment; click over to:

EMCrit.org/DSI

For Mike Stone’s Free DVT book…

Practical Ultrasound: DVT

 

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EMCrit Podcast 136 – Getting Shit Done

get-shit-done-mug-4

So my friend Michelle Lin was kind enough to solicit a “How I Work Smarter” piece on her excellent ALIEM blog. One of the things I mentioned in that piece was a book called Getting Things Done. I’ve since gotten a bunch of questions and comments about the book. I’d like to take a brief diversion from the main topic of EMCrit and discuss a bit about the book and productivity for docs and resuscitationists.

The Books

The Philosophy

A clear mind eliminates stress and allows creativity, so…

Capture all the things that need to get done into a logical and trusted system outside of your head and off your mind, and…

Discipline yourself to make decisions about all the inputs you let into your life, so that you will always have a plan for next actions that you can implement or renegotiate at any moment

(altered from Mindzone Wiki)

Problems with the Book

  1. Mindset of the Author
  2. Based on an erstwhile paper-based world
  3. Can be read as Dogma

The Steps of GTD

Collect/Process/Organize/Review/Do

1. Collection/Universal Capture

Inbox(es)

2. Process

What is it?

Is it an action, spam, or something non-actionable you want to keep?

Action Processing

  • Decide if you want to Do it, Don’t do it, Delegate it, or Put it in your system
  • Is it a project?
  • What is the physical next action that must occur to bring you 1 step closer to completion
Next Actions & Projects

cascading for gtd

Reference Processing

Things you just want to keep or references for actions

Eliminate Paper!

scansnap

 

3. Organize-If you are not doing it right now, put it in the system

  • NirvanaHQ or Omnifocus
  • GCal with Fantastical
  • Add all reference material as links in your system

Calendar

Only things that absolutely must happen at this date/time

Lists on Task Management System

nirvana lists

Especially important to have a someday/maybe list, a waiting list, and have a thorough understanding of scheduled events.

4. Review

Daily

  1. Try to process all email
  2. Kill all paper
  3. Clean off Desktop
  4. Look at Calendar
  5. Look at Focus and Inbox
  6. Make a To-Do Card
  7. Pack for next day

to-do-card

Weekly

(this list is from Mindzone wiki)

  1. Loose Papers
    • business cards, receipts, etc. – put in in basket for processing
  2. Process Your Notes
  3. Previous Calendar Data
    • review for remaining action items, reference information, etc.
  4. Upcoming Calendar
  5. Empty Your Head
    • write down any new projects, action items, etc.
  6. Review “Projects” (and Larger Outcome) Lists
    • ensure that at least one kick-start action is in your system for each
  7. Review “Next Actions” Lists
    • Mark off completed actions & review for reminders of further action steps to capture
  8. Review “Waiting For” List
    • Records appropriate actions for any needed follow-up & check off received items
  9. Review Any Relevant Checklists
  10. Review “Someday/Maybe” List
    • Check for any projects that may have become active and transfer them to “Projects” & delete items no longer of interest
  11. Review “Pending” and Support Files
    • Browse through all work-in-progress support material to trigger new actions, completions, and waiting-fors

Quarterly

Higher Level Goals and a super-thorough version of weekly review

Yearly

Vision, Life, Clean Out All Files, Am I going in the right direction?

5. Doing

Happens naturally if you use the method above. However, I alter the canonical method with my daily to-do card and the focus section of nirvana

The Initial Dump (this comes first, but is being discussed last)

You will fall off the wagon

Not a problem, redo the initial dump and start up again

Flowcharts

Here is a pdf of the simplified workflow from DavidAllenCo.

A more elaborate version is here:

David Allen Workflow

GTD Flow from DavidAllenCo

Other People’s Take

Things to Do Immediately

Please tell me your thoughts on this episode. Use the comments section below

Update: Numerous readers have also recommended doit.im

Now on to the Podcast…

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EMCrit Podcast – Trauma Thoughts with John Hinds

john-hinds

@docjohnhinds is the man behind Cricolol

I recently brought him to our EM Critical Care Grand Rounds at @stonybrookem

He gave two fantastic lectures! I then brought him back to EMCrit Studios to record a few of the take-home lessons from his talks.

See Cases from the Races on the RagePodcast site to see the inspiration for this ‘cast.

Blunt Traumatic Arrest: a Road Racing Doc’s Approach

If the patient is in blunt traumatic arrest, John and his team immediately perform the following before any further assessment:

  1. Intubation using a bougie and confirmed by waveform CO2
  2. Perform Bilateral Finger Thoracostomy
  3. Place Pelvic Compression Device
  4. Straighten Long Bone Fractures to Length
  5. Administer Fluid Bolus (Administer Blood if In-Hospital)

Only then reassess and decide what to do

Impact Apnea

Airway positioning and rescue ventilation can save a life

More on this soon when the Wilson, Hinds, Davies study is published. Until then, see the LiTFL CCC Entry

Central Line Placement

In John’s unit, they use infraclavicular left subclavian for all ICU CVC placements

Play

EMCrit Wee – I Thought This Would be the One, but Nope….

Hug a Researcher

EMCrit specializes in Type 2 Translation and Implementation. That crap wouldn’t exist without the researchers. Go find a Critical Care Researcher today and give them a hug.

But they Weren’t Sick Enough…

SSC Reverses their Stance on EGDT (Sort of…)

What do folks thing EGDT still brings to the table?

Cognitive DeBiasing

Please ask yourself, before you air your viewpoints in public, are you displaying Confirmation Bias

bias-cartoon

Shown to Me by G. Kovacs

 

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Podcast 134 – ARISE has arisen; now where do we stand on Severe Sepsis in 2014

SMACC-Final-Sepsis1

So the Arise Study (Australasian Resuscitation In Sepsis Evaluation) just dropped. The amazing guys at the Bottom Line did a summary (saving me a bunch of work)

Baseline Characteristics

baseline characteristics

Table S5-Therapies in the first 6 hours and 3 days

table-S5

Videos from a Prime Author

Hear from Sandra Peake

Recognition-Find em’ Early

SIRS+

Lactate or Persistent Hypotension (Arise used 1 liter)

I would use STOP Sepsis Campaign Modification of SIRS Critieria, so you don’t need to wait for cbc

SNAG-0016

Treatment-Treat the Source/Perfuse the Tissues

sepsis priorities

Antibiotics

Another trial showing early abx are associated with goodness

If a patient is sick and you don’t know what is going on, just give them appropriate spectrum abx. If a patient is persistently hypotensive and you don’t know why–give them abx.

Source Control

Early, early, early

Don’t box ‘em with the tube

See the Hemodynamic Kills Lecture

The Right Amount of Fluid

Use whatever method you want, but you should probably give between 3-4 liters

Early Vasopressors

Give them peripherally to get them in fast and then you should probably put in a line

If you have given 3-4 liters, the patient probably deserves pressors for venous squeeze before giving more fluid

Check Your Work

Serial lactates?

Put them in a Monitored Setting

b/c of the way septic patients die

Other Stuff

Blood

No role for blood, except in niche cases, until Hb < 7 from the recent TRISS Trial (PMID 25270275)

Fewer pts got blood in EGDT group of either ProCESS or ARISE than the original EGDT study

Dobutamine

who the hell knows

Want to Hear from the Primary Investigator?

Oli Flower did a podcast in which Anthony Delaney addresses many comments from this post. Here’s Oli:

Thanks Scott for your insights on ARISE and the state of play of sepsis management in 2014.

These open discussions that your podcast stimulates are incredibly important and essential for translating research findings into practice, and getting the important messages and critical interpretation of the data to as many people as possible!

Yesterday I interviewed the ARISE PI Anthony Delaney to hear his take, now he’s allowed to finally talk about the results, and I went through a lot of your listener’s comments to get an answer from the horse’s mouth.

The interview is here:
http://intensivecarenetwork.com/delaney-arise-study-emcrit-dogmalysis/

Cheers,
Oli

What do you think? Let me know below.

Now on to the Podcast…

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EMCrit Podcast 133 – The First Prehospital REBOA

field-reboa

A few months ago, we spoke about REBOA-resuscitative endovascular balloon occlusion of the aorta. You might have thought to yourself, “Interesting, but I’ll never be doing that.” Well, not so fast, on today’s podcast we speak to the retrieval doctor that performed the first REBOA in the field.

REBOA in the Field and the ED

Gareth-Davies

In London, the idea of bringing REBOA to the field and the ED was made reality by Gareth Davies. Dr. Davies is Chair and Medical Director of the London Air Ambulance (London HEMS), one of the best HEMS services in the world. In the first part of the podcast, we hear how he conceptualized and enacted the plan to bring REBOA to the field.

REBOA Training at London HEMS

REBOA Training at London HEMS (Photo by Andy Patton @AndyP_91)

The First Prehospital REBOA

JonnyPriceThen we speak with Jonny Price, Anesthesia and Intensive Care registrar doing a secondment in HEMS. At the time of the events of the podcast, he was flying with London HEMS. His story of the first prehospital REBOA is fascinating.

Special thanks to Cliff Reid for making these interviews possible.

EVO-Logo-on-White

SMACC Equipment Videos Online (EVO) Competition

Consider submitting a video and winning a free registration to SMACC Chicago. Go to the SMACC Site and Enter Now.

Now on to the podcast…

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Podcast 132 – MoTR – Toughness Part I with Michael Lauria

pj

Today, I interview Mike Lauria on the concepts of toughness and resilience.

The Rationale of Selection Courses/Indoc

80-90% Attrition for the PJs Indoc

One of the things that people, I think, find distasteful about selection programs in the civilian word is that it uncovers fundamental weaknesses and shortfalls.  This is no commentary on the intrinsic worth of the individual.  It doesn’t necessarily mean that they are smart or dumb.  But it is indicative of some inability or failure to meet a standard.  While it is hard for many civilians (and military members for that matter) to swallow, perhaps not everyone is cut out for a particular discipline.  Maybe we shouldn’t be forcing training, pushing people along, coddling individuals to maintain the outward appearance that a program is “successful” if an individual can’t make it through some sort of initial pipeline.  Perhaps a benefit of selection is making sure that the right people are there to begin with and the individuals that were simply not made for it are directed elsewhere.

I lost the source for the above quote, but I think it describes the process well. If anyone has it, please send me the attribution.

Builds an innate Espirit de Corps and a common thread of self and team-reliance

Residency as the Pipeline

Should we have culmination tests and exercises at the end of residency?

Stress Inoculation/Cognitive Tempering

Mike discusses four stages to do this right:

  1. Conceptualization-give a background of stress responses, why they happen, and what to expect.
  2. Train and educate on the skills and tasks we want to see performed under stress. Then give the tools to deal with the expected stress. The latter is where we may be failing our learners
  3. Do a dry run to train in simulation without added stressors
  4. Run the same training with stress inoculation

How can we make #4 work in EM/CCM?

Sound, distractions, equipment failures, and deliberate poor communications

So what tools can we offer for #2?

Mike offers an acronym: Beat The Stress, Fool

  • B is for Breathe. Breathe tactically. See the On Combat Podcast for a description (and there is an app for that too: Tactical Breather App)
  • T is for Talk. Self Talk. Positive self-talk is used by athletes and any elite performance group.
  • S is for See. Visualization. Visualize yourself performing the task exactly how you want to see it done.
  • F is for Focus. A key word to activate the state you want. Mike has chosen “focus” as his word. We then had a brief discussion of the book, the Art of Learning by Josh Waitzkin. The author creates an entire relaxation and mindset ritual that eventually gets boiled down to a key word or short set of actions. You’ll be hearing more about this book on the podcast.

When Mike asked if I had anything to add to this excellent set of tools, I discussed this TED Video by Dr. Amy Cuddy:

 

So maybe…Beat the Stress, Foolish Padawan with a P for posture??

Too Much Macho Militarization?

Mike posted a Youtube Video Addressing this question

Cliff Reid’s Resus.me Post on Self-Defense

During the intro, I discussed the contentious self-defense post on resus.me

Update

Some Anesthesia programs are already doing a modified interview process–thanks Lauren!

SNAG-0001

Here is the article: (non-tech-skills-interview-process)

Now on to the Podcast…

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EMCrit Podcast 131 – Cut to Air: Surgical Airway from SMACC Gold

machete

This is the resource page for all things Crics (Cricothyroidotomy)

We spoke a ton about cricothyrotomy way back in episode 24; this is an update

Review Article

Especially keen on the parts of this cricothyrotomy article that discuss the failures of non-surgical techniques

Understand the Surgically Inevitable Airway (thanks, Rich)

In appropriate circumstances (prophylactic cricothyroidotomy) has numerous advantages, not least the potential to secure and check the ‘rescue airway’ in a calm and unhurried manner, without hypoxia, before an emergency arises

— NAP4 Study

Anatomy

Use a Checklist so you are Ready!

CricCON2

Click for Full-Size

Click for Full-Size

Here was the original CricCON Wee

Which Trach Should you use?

Needle Cric

I don’t recommend this method, but some just will never feel comfortable cutting the neck

My Current Cric Method

Other Cricothyrotomy Lecture Videos

Build a Cric Trainer

Here are My Slides

Now on to the Video…