SMACC Lecture Notes

*****Hemodynamic Kills

Hypotension in the peri-intubation is bad and is a source of mortality. Hemodyanmically unstable or on pressors prior to intubation is the biggest factor assoc. with death and complications. (Schwartz et al. Anesthesiology 1995;82:367) and (J Crit Care 2012 Aug;27(4):417)

Etomidate is probably safe in shock patients (Acad Emerg Med 2006;13:378)

Etomidate can definitely drop Blood Pressure (Crit Care 2012;16:R224)

Ketamine given to patients with horrible ejection fractions (Thangathurai et al.; Anesth 1988;69(3a):A79), in OR anesthetized pts (Prakt Anaesth. 1976 Dec;11(6):397-404) and In-Vitro human-tissue studies show Ketamine to be least cardio-depressant (Anesthesiology 1996;84:397). Another anesthesia study showed no drop from initial values after large and repeated doses (Br J Anaesth 1976;48:1071)

Best study, reasonable doses (CCM 1983;11(9):730) showed excellent stability

A further anesthesia study (Anesth and Analg 1980;58(5):355) 1/12 patients dropped HR with no effect on CI.

Cats did fine (Canad Anesth Soc J 1975;22(3):339)

However if you give 10-100-fold doses to canine heart tissue then maybe (J Cardiovasc Pharmacol 1986;8:414) and (Anesthesiology 1992;76:564), in the latter, dogs got infusions at 25-100 mg/kg/hr.
Best review Article by Morris et al. (Anaesthesia 2009;64:532)

Case report of 2 arrests post-ketamine (J Inten Care Med 2012; Dewhirst et al.)

Ketamine in ICP (emerg med australia 2006;18(1):37-44) and ()

Other References Reviewed:

1. Griesdale D. Etomidate for intubation of patients who have sepsis or septic shock-where do we go from here? Critical Care [Internet] 2012;Available from: http://ccforum.com/content/16/6/189/abstract
2. Heffner AC, Swords D, Kline JA, Jones AE. The frequency and significance of postintubation hypotension during emergency airway management. Journal of critical care [Internet] 2012;27(4):417.e9-13. Available from: http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=22033053&retmode=ref&cmd=prlinks
3. Dewhirst E, Frazier WJ, Leder M, Fraser DD, Tobias JD. Cardiac Arrest Following Ketamine Administration for Rapid Sequence Intubation. Journal of Intensive Care Medicine [Internet] 2012;Available from: http://jic.sagepub.com/cgi/doi/10.1177/0885066612448732
4. Hughes S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: is ketamine a viable induction agent for the trauma patient with …. Emergency medicine journal: EMJ [Internet] 2011;Available from: http://emj.bmj.com/cgi/doi/10.1136/emermed-2011-200894
5. Bruner D, Portsmouth V, Kotoro J. Rapid Sequence Induction in Trauma. Trauma Reports [Internet] 2011;:1-15. Available from: http://xa.yimg.com/kq/groups/14639670/338710043/name/RSI+in+Trauma+2011.pdf
6. Jaber S, Jung B, Corne P, et al. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Med [Internet] 2010;36:248-55. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19921148
7. Morris C, Perris A, Klein J, Mahoney P. Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent? Anaesthesia [Internet] 2009;64(5):532-539. Available from: http://doi.wiley.com/10.1111/j.1365-2044.2008.05835.x
8. Jabre P, Combes X, Lapostolle F, et al. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. The Lancet [Internet] 2009;374(9686):293-300. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0140673609609491
9. Jabre P, Combes X, Lapostolle F, Dhaouadi M. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. The Lancet [Internet] 2009;:1-8. Available from: http://www.sciencedirect.com/science/article/pii/S0140673609609491
10. Malchow RJ, Black IH. The evolution of pain management in the critically ill trauma patient: Emerging concepts from the global war on terrorism. Critical Care Medicine [Internet] 2008;36(Suppl):S346-S357. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00003246-200807001-00014
11. Zed P, Abu?Laban R. Intubating conditions and hemodynamic effects of etomidate for rapid sequence intubation in the emergency department: an observational cohort study. Academic emergency [Internet] 2006;:1-6. Available from: http://onlinelibrary.wiley.com/doi/10.1197/j.aem.2005.11.076/abstract
12. Zed P, Mabasa V, Slavik R, Abu-Laban R. Etomidate for rapid sequence intubation in the emergency department: is adrenal suppression a concern? CJEM [Internet] 2006;:1-4. Available from: http://images.wikia.com/twhicufellows/images/f/fd/Pg347(1).pdf
13. Ebert T. Sympathetic and hemodynamic effects of moderate and deep sedation with propofol in humans. Anesthesiology [Internet] 2005;:20. Available from: http://journals.lww.com/anesthesiology/Abstract/2005/07000/SympatheticandHemodynamicEffectsof_Moderate.7.aspx
14. Reich DL, Hossain S, Krol M, et al. Predictors of Hypotension After Induction of General Anesthesia. Anesthesia & Analgesia [Internet] 2005;101(3):622-628. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00000539-200509000-00002
15. Jackson W. Should we use etomidate as an induction agent for endotracheal intubation in patients with septic shock? A critical appraisal. Chest Journal [Internet] 2005;Available from: https://journal.publications.chestnet.org/article.aspx?articleid=1083167
16. Shafer S. Shock values. Anesthesiology [Internet] 2004;101:567-8. Available from: http://journals.lww.com/anesthesiology/Abstract/2004/09000/Shock_Values.2.aspx
17. Johnson KB, Egan TD, Layman J, Kern SE, White JL, McJames SW. The Influence of Hemorrhagic Shock on Etomidate: A Pharmacokinetic and Pharmacodynamic Analysis. Anesthesia & Analgesia [Internet] 2003;:1360-1368. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00000539-200305000-00022
18. Kim K, Cheong M, Jeon J, Lee J, Shim J. The dose effect of ephedrine on the onset time of vecuronium. Anesthesia & Analgesia [Internet] 2003;:1-5. Available from: http://www.anesthesia-analgesia.org/content/96/4/1042.short
19. Skinner H, Biswas A, Mahajan R. Evaluation of intubating conditions with rocuronium and either propofol or etomidate for rapid sequence induction. Anaesthesia [Internet] 2002;:1-9. Available from: http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2044.1998.396-az0506.x/abstract
20. Yeung J, Zed P. A review of etomidate for rapid sequence intubation in the emergency department. CJEM [Internet] 2002;:1-5. Available from: http://www.cjem-online.ca/v4/n3/p194
21. Ledowski T, Wulf H. The influence of fentanyl vs. s?ketamine on intubating conditions during induction of anaesthesia with etomidate and rocuronium. European journal of anaesthesiology [Internet] 2001;Available from: http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2346.2001.00886.x/full
22. Wilbur K, Zed P. Is propofol an optimal agent for procedural sedation and rapid sequence intubation in the emergency department. CJEM [Internet] 2001;:1-9. Available from: http://www.cjem-online.ca/v3/n4/p302
23. Benson M, Junger A, Fuchs C, Quinzio L. Use of an anesthesia information management system (AIMS) to evaluate the physiologic effects of hypnotic agents used to induce anesthesia. Journal of clinical [Internet] 2000;Available from: http://www.springerlink.com/index/R112389N556H7388.pdf
24. SOKOLOVE P, PRICE D, OKADA P. The safety of etomidate for emergency rapid sequence intubation of pediatric patients. Pediatric emergency care [Internet] 2000;Available from: http://journals.lww.com/pec-online/Abstract/2000/02000/Thesafetyofetomidateforemergencyrapid.5.aspx
25. Heier T, Caldwell J. Rapid tracheal intubation with large-dose rocuronium: a probability-based approach. Anesthesia & Analgesia [Internet] 2000;Available from: http://www.anesthesia-analgesia.org/content/90/1/175.short
26. Robinson B. Mechanisms whereby Propofol Mediates Peripheral Vasolidation in Humans: Sympathoinhibition or Direct Vascular Relaxation? Anesthesiology [Internet] 1997;86:64. Available from: http://journals.lww.com/anesthesiology/Abstract/1997/01000/MechanismswherebyPropofolMediatesPeripheral.10.aspx
27. Schwartz, Matthay M, Cohen N. Death and other complications of emergency airway management in critically ill adults: a prospective investigation of 297 tracheal intubations. Anesthesiology [Internet] 1995;Available from: http://journals.lww.com/anesthesiology/Abstract/1995/02000/DeathandOtherComplicationsofEmergencyAirway.7.aspx
28. Bazaral MG. Con: Ketamine is a useful anesthetic agent for patients undergoing coronary artery bypass surgery. Journal of cardiothoracic and vascular anesthesia [Internet] 1992;6(2):248-51. Available from: http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=1568017&retmode=ref&cmd=prlinks
29. Pagel P, Kampine J, Schmeling W, Warltier D. Ketamine depresses myocardial contractility as evaluated by the preload recruitable stroke work relationship in chronically instrumented dogs with autonomic nervous …. Anesthesiology [Internet] 1992;Available from: http://ukpmc.ac.uk/abstract/MED/1550282
30. Muzi M, Berens RA, Kampine JP, Ebert TJ. Venodilation Contributes to Propofol?Mediated Hypotension in Humans. Anesthesia & Analgesia [Internet] 1992;74(6):877-883. Available from: http://www.anesthesia-analgesia.org/content/74/6/877.abstract
31. Thangathurai D, Elder S, Rodriguez J, ALLEN H. Induction and Maintenance of General Anesthesia Using Ketamine-Midazolam Continuous Infusion in Cardiac Surgical Patients With Low Ejection Fractions. Anesthesiology [Internet] 1988;Available from: http://journals.lww.com/anesthesiology/Abstract/1988/09010/InductionandMaintenanceofGeneral_Anesthesia.79.aspx
32. Donati F. Onset of action of relaxants. Canadian Journal of Anesthesia/Journal canadien d’ [Internet] 1988;Available from: http://www.springerlink.com/index/B869J67J86350PX0.pdf
33. Mccollum JS, Anaesthetics LI, Dundee JW. Comparison of induction characteristics of four intravenous anaesthetic agents. Anaesthesia [Internet] 1986;41(10):995-1000. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3491551
34. LIPPMANN M, APPEL P, MOK M. Sequential cardiorespiratory patterns of anesthetic induction with ketamine in critically ill patients. Critical Care [Internet] 1983;Available from: http://journals.lww.com/ccmjournal/Abstract/1983/09000/Sequentialcardiorespiratorypatterns_of.12.aspx
35. Waxman K, Shoemaker WC, Lippmann M. Cardiovascular Effects of Anesthetic Induction with Ketamine. Anesthesia & Analgesia [Internet] 1980;59(5):355-358. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7189381
36. Savege TM, Colvin MP, Weaver EJ, Bond C, Drake J, Inniss R. A comparison of some cardiorespiratory effects of althesin and ketamine when used for induction of anaesthesia in patients with cardiac disease. British journal of anaesthesia [Internet] 1976;48(11):1071-81. Available from: http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=999767&retmode=ref&cmd=prlinks
37. Wong DHW, Jenkins LC. The cardiovascular effects of ketamine in hypotensive states. Canadian Anaesthetists’ Society Journal [Internet] 1975;22(3):339-348. Available from: http://www.springerlink.com/index/10.1007/BF03004843

*****Path to Insanity

Knowledge

Full list of journals I read

The Pareto Reduction to 12

• Ann Emerg Med – Acad Emerg Med
• Am J Emerg Med
• Emerg Med J
• Br J Anaesth
• Anesthesiology
• Anesth & Analg
• Resuscitation
• J Trauma
• Crit Care Med
• Crit Care
• Intens Care Med

Insight comes from Knowledge (Psychol Sci. 2006 Oct;17(10):882-90. The prepared mind: neural activity prior to problem presentation predicts subsequent solution by sudden insight.)

More

Mastery by Robert Greene Pragmatic Thinking by Andy Hunt

Procedures

More

Siamak Moayedi has one of the best lectures on the topic [http://www.emrapee.com/episodes/how-to-teach-procedures-in-emergency-medicine/]

Critical Thinking

Rhetological Fallacies

http://www.informationisbeautiful.net/visualizations/rhetological-fallacies/

PSYBlogs List of Cognitive Biases

http://www.spring.org.uk/2012/06/the-dunning-kruger-effect-why-the-incompetent-dont-know-theyre-incompetent.php

More

Mastermind by Maria Konnokova Thinking Fast and Slow by Kahneman

Potholes

Dunning-Kruger Effect

1. Dunning D, Johnson K, Ehrlinger J. Why people fail to recognize their own incompetence [Internet]. Current Directions in 2003 Jan.;Available from: http://cdp.sagepub.com/content/12/3/83.short
2. Caputo D, Dunning D. What you don’t know: The role played by errors of omission in imperfect self-assessments [Internet]. Journal of Experimental Social Psychology 2005 Jan.;Available from: http://www.sciencedirect.com/science/article/pii/S0022103104001210
3. Carter T, Dunning D. Faulty Self?Assessment: Why Evaluating One’s Own Competence Is an Intrinsically Difficult Task [Internet]. Social and Personality Psychology 2008 Jan.;Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1751-9004.2007.00031.x/full
4. Ehrlinger J, Johnson K, Banner M, Dunning D. Why the unskilled are unaware: Further explorations of (absent) self-insight among the incompetent [Internet]. Behavior and Human 2008 Jan.;Available from: http://www.sciencedirect.com/science/article/pii/S074959780700060X
5. Difficulties in Recognizing One’s Own Incompetence: Novice Physicians Who Are Unskilled and Unaware of It [Internet]. Academic Medicine 2001 Oct.;76(10):S87.Available from: http://journals.lww.com/academicmedicine/Citation/2001/10001/DifficultiesinRecognizingOnes_Own.29.aspx
6. Edwards R, Kellner K, Sistrom C. Medical student self-assessment of performance on an obstetrics and gynecology clerkship [Internet]. and gynecology 2003 Jan.;Available from: http://ukpmc.ac.uk/abstract/MED/12712114
7. Haun, Zeringue A, Leach A, Foley A. Assessing the competence of specimen-processing personnel [Internet]. Lab Medicine 2000 Jan.;Available from: http://labmed.ascpjournals.org/content/31/11/633.short
8. Duffy F, Holmboe E. Self-assessment in lifelong learning and improving performance in practice [Internet]. JAMA: the journal of the American Medical 2006 Jan.;Available from: http://jama.ama-assn.org/content/296/9/1137.short
9. Kleinpell R. Mirror mirror on the wall: Physician and nurse perceptions of their quality of care for deteriorating patients. Critical Care Medicine [Internet] 2012;Available from: http://journals.lww.com/ccmjournal/Abstract/2012/11000/Mirrormirroronthewall_Physicianandnurse.26.aspx

Meditation

*****Mind of the Resuscitationist

How to Place a Blakemore Tube

http://crashingpatient.com/procedures/emergency-procedures.htm/#blakemore_tube

and

Bibliography