EMCrit Podcast 136 – Getting Shit Done


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


1. Collection/Universal Capture


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!



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


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


  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



(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


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


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


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

Now on to the Podcast…


EMCrit Podcast – Trauma Thoughts with 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


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


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


Videos from a Prime Author

Hear from Sandra Peake

Recognition-Find em’ Early


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


Treatment-Treat the Source/Perfuse the Tissues

sepsis priorities


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


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


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:


What do you think? Let me know below.

Now on to the Podcast…


EMCrit Podcast 133 – The First Prehospital 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


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.


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…


Podcast 132 – MoTR – Toughness Part I with Michael Lauria


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


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


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

Now on to the Podcast…


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


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

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


Use a Checklist so you are Ready!


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

Cricothyrotomy Lecture Videos

Build a Cric Trainer

Here are My Slides

Now on to the Video…

EMCrit Podcast 130 – Hemodynamic-Directed Dosing of Epinephrine for Cardiac Arrest


Today on the podcast, I address the last little bit from my SMACC lecture on the new management of the intra-arrest: hemodynamic, individualized dosing of epinephrine.

normanparadisadonehThe podcast is interspersed with clips from Professor Norman Paradis

Articles/Posts on Epinephrine by ACLS Guidelines

  • (15306666),
  • http://www.emdocs.net/epinephrine-cardiac-arrest/
  • http://www.jems.com/article/patient-care/new-resuscitative-protocol
  • (24846323)
  • (19934423)

Epinephrine Dosing Based on DBP

Three Swine Study

(Crit Care Med. 2013 Dec;41(12):2698-704)

(Resuscitation. 2013 May;84(5):696-701)

Here is the abstract from the latter study:

AIM: Advances in cardiopulmonary resuscitation (CPR) have focused on the generation and maintenance of adequate myocardial blood flow to optimize the return of spontaneous circulation and survival. Much of the morbidity associated with cardiac arrest survivors can be attributed to global brain hypoxic ischemic injury. The objective of this study was to compare cerebral physiological variables using a hemodynamic directed resuscitation strategy versus an absolute depth-guided approach in a porcine model of ventricular fibrillation (VF) cardiac arrest.

METHODS: Intracranial pressure and brain tissue oxygen tension probes were placed in the frontal cortex prior to induction of VF in 21 female 3month old swine. After 7minutes of VF, animalswere randomized to receive one of three resuscitation strategies: 1) Hemodynamic Directed Care (CPP-20): chest compressions (CCs) with depth titrated to a target systolic blood pressure of 100mmHg and titration of vasopressors to maintain coronary perfusion pressure (CPP)> 20mmHg; 2) Depth 33mm(D33): target CC depth of 33mm with standard American Heart Association (AHA) epinephrine dosing; or 3) Depth 51mm(D51): target CC depth of 51mm with standard AHA epinephrine dosing.

RESULTS: Cerebral perfusion pressures (CerePP )were significantly higher in the CPP-20 group compared to both D33 (p<0.01) and D51 (P=0.046), and higher in survivors compared to non-survivors irrespective of treatment group (P<0.01).Brain tissue oxygen tension was also higher in the CPP-20 group compared to both D33 (P<0.01) and D51 (P=0.013), and higher in survivors compared to non-survivors irrespective of treatment group (P<0.01).Subjects with a CPP>20mm Hg were 2.7 times more likely to have a CerePP>30mm Hg (P< 0.001).

CONCLUSIONS: Hemodynamic directed resuscitation strategy targeting coronary perfusion pressure>20mmHg following VF arrest was associated with higher cerebral perfusion pressures and brain tissue oxygen tensions during CPR. University of Pennsylvania IACUC protocol #803026.

Human Study by Dr. Paradis

Coronary Perfusion Pressure and the Return of Spontaneous Circulation in Human Cardiopulmonary Resuscitation


Coronary perfusion pressure (CPP), the aortic-to-right atrial pressure gradient during the relaxation phase of cardiopulmonary resuscitation, was measured in 100 patients with cardiac arrest. Coronary perfusion pressure and other variables were compared in patients with and without return of spontaneous circulation (ROSC). Twenty-four patients had ROSC. Initial CPP (mean±SD) was 1.6 ± 8.5 mm Hg in patients without ROSC and 13.4 ± 8.5 mm Hg in those with ROSC. The maximal CPP measured was 8.4 ±10.0 mm Hg in those without ROSC and 25.6 ±7.7 mm Hg in those with ROSC. Differences were also found for the maximal aortic relaxation pressure, the compression-phase aortic-to— right atrial gradient, and the arterial Po2. No patient with an initial CPP less than 0 mm Hg had ROSC. Only patients with maximal CPPs of 15 mm Hg or more had ROSC, and the fraction of patients with ROSC increased as the maximal CPP increased. A CPP above 15 mm Hg did not guarantee ROSC, however, as 18 patients whose CPPs were 15 mm Hg or greater did not resuscitate. Of variables measured, maximal CPP was most predictive of ROSC, and all CPP measurements were more predictive than was aortic pressure alone. The study substantiates animal data that indicate the importance of CPP during cardiopulmonary resuscitation.

Good Review on Epinephrine

Epi Review

AHA Cardiopulmonary Resuscitation Quality Statement

by Meaney P. et al (Circulation 2013;128:417)


  • CCF>80%
  • Rate 100-120
  • 5cm depth
  • Full Recoil
  • <12 BPM, Minimal Chest Rise


  • Art/CVP CPP>20
  • Just Art Line DBP>25-30 (I disagree)
  • ETCO2>20 mm Hg

If DBP < 20 optimize compressions or vasopressors (Circulation 2011;123:e236)

CVP can be higher during the poor flow of the arrest state (3970745),(Am J Emerg Med. 1985 Jan;3(1):11-4.), and (3946853) and this one had a mean of 16 (10.1161/01.CIR.80.2.361)

so I would shoot for 35-40 mm Hg

Goal is to give less epineprhine

Hemodynamic-directed CPR Review


Now on to the Podcast…



Podcast 129 – LAMW: The Neurocritical Care Intubation


This is the another of the Laryngoscope as a Murder Weapon lectures; though in this case it is really more of an aggravated assault.

Who is this For?

Semi-elective intubations for patients with presumed or known elevated ICP

In TBI severity of brain injury doesn’t predict the lack of need for pharmacological blunting of increase in MAP or ICP (23511147)

The prototypical case requiring this treatment is a high-grade SAH prior to securing the aneurysm

This is the same way we would intubate an aortic dissection patient


Ap Ox and high-flow fiO2 for the full 3 minutes or longer


Put it on the BVM

Non-Pharmacologic Methods to Blunt Reflex Response

Limit time of laryngoscopy and atraumatic laryngoscopy

Leave the patient upright until the last possible moment, then intubate in 20 degrees head-up

No-touch intubation with video laryngoscopy by the best intubator


Control the BP BEFORE the intubation


While there is evidence that it blunts ICP rise and cough response, there is no good evidence that this has clinical results.(11696494) Literature is pretty good on endotracheal suctioning, but nothing on patient-important outcomes during intubation. Not hemodynamically active in this one study, but I have experienced radical drops in BP. (22633717)

Local is more effective than IV. (10861151)

Lidocaine References (11696494), (17358099), (23683444), (7772359),


Dose 5 mcg/kg (6318605), (7032347)

All equipment meds must be prepared before administration. Someone must be watching the pt. You need to have push-dose epinephrine drawn up at the bedside if you are going to use fentanyl in these doses.


Remifentanil can also be used, but I don’t have so I can’t speak about it


Dose 1.5-2 mg/kg ~ 3min beforehand

Combo of Esmolol and Fentanyl (1363221) (7788827) (9084524),(1672488)


Dose 20 mcg/kg (average 1.4 mg)

(21696933) and (10553821) and Review Article (16978041)

Other Group’s Recs

At this stage, Emergency Airway Course only recommends Lidocaine and Fentanyl: they state prefasiculation is dead

Osmotic Therapy

Probably a good time to give a dose of hypertonic saline

Induction Agents

Etomidate, Propofol, or Propofol/Ketamine (75%/25%). If Thiopental was still available, it would be on the list as well.

Muscle Relaxants

Rocuronium or Succinylcholine at full dose

Post-Intubation Sedation

Propofol and Fentanyl

Post-Intubation Ventilation

Shoot for 95% saturation, use PEEP only if necessary; but if it is necessary it is safe to use

Increase Respiratory Rate until ETCO2 of 35 mm Hg; then send a blood gas

Other Situations

Basilar Stroke and Stuttering Stroke-lower bp=screwed

Review Article

Has anyone found a good one for ICP

Here is a great article for the high-risk vascular intubation

Rich Levitan’s Airway Course

Go here to get the scoop

Now on to the Podcast…



Podcast 128 – Pulmonary Embolism Treatment Options and the PEAC Team with Oren Friedman


OrenFriedmanWe now have way too many treatment options for sub-massive and massive pulmonary embolism (PE) patients who aren’t coding in front of you. How do you decide which one is right for your patient? To help answer this question, I am joined today by Oren Friedman, pulmonary critical care doc and one of the members of the Cornell PEAC team.

Cornell Pulmonary Embolism (PE) Advanced Care Team (PEAC), aka the CLOT Team

Oren Friedman MD, Pulm Crit Care; James Horowitz MD, Cardiology; Arash Salemi MD, Cardiac Surgery; Akhilesh Sista MD, Interventional Radiology

You can shoot the team an email: peadvancedcare at gmail dot com

Who Should We Treat?

Wood 2002 PE Mortality Curve

Wood 2002 PE Mortality Curve

30% normotensive patients have RVD; 10% progressed to shock; 5% in hospital mortality(10859287)

The Better Risk Categories for Pulmonary Embolism

  • Well and Stable Sub-Massive
  • High-Risk Sub-Massive
  • Massive


NEJM 2014;370(15):1402

Full dose tenecteplase with concurrent heparin

  • Death or hemodynamic decompensation occurred in 2.6% of the tenecteplase group as compared with 5.6% of the placebo group
  • Extracranial bleeding occurred in 32 patients (6.3%) in the tenecteplase group and 6 patients (1.2%) in the placebo group (P<0.001)
  • Intracranial Bleed 10 patients (2%) in the tenecteplase group and 1 patient (0.2%) in the placebo group (P=0.003)

Also see my bud, Salim Rezaie’s post on PEITHO and Konstantinides’ prior study (12374874)

Ryan Radecki made some great observations in his post on PEITHO

  • The criteria for myocardial injury was a troponin I >0.06 ?g/L or troponin T >0.01 ?g/L.  These may be relatively inclusive thresholds.
  • Not all placebo patients developing hemodynamic collapse received subsequent thrombolysis; likewise, almost half of those who received open-label thrombolysis had no hemodynamic collapse.
  • Half the deaths in the placebo arm were “sudden unexplained” or “other”, compared with bleeding or stroke complications in the thromboysis arm.


Jeff Kline’s trial was stopped midway through due to an institution change. Complicated primary endpoint with promising, but unusable results (24484241)

For the scoop on this one see the Bottom Line Review post on TOPCOAT


Half-dose alteplase led to a marked reduction in pulmonary hypertension without sig. complications

Sharifi M et al. Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT trial). (J Cardiol 2013; 111: 273)

See this prior EMCrit Wee as well on MOPPETT

Update: This meta-analysis states that the half-dose may be appropriate, effective, and safe (24412030)


Chatterjee et al. have the most current meta-analysis on this topic (JAMA. 2014;311(23):2414-2421)

See the Bottom Line Review post on this study

Nakamura just published another MA this week; see Rory Spiegel’s take on the two here

Is it just in the Oldies?

Markedly lower risk in <75 y/o in PEITHO and <65 in the Meta-Analysis

The Treatment Options

Heparin Alone

tried and true. but even if some degree of resolution of presenting severe symptoms, there is the question of long-term consequences of leaving a large clot burden–namely, loss of exercise tolerance due to chronic pulmonary hypertension

Systemic Thrombolysis

With either full or half-dose alteplase or full-dose tenecteplase

Catheter-Based Intra-Arterial Thombolytic Infusion

Angiography guided placement of pulmonary artery catheters allowing a 24-hour infusion of low dose tPA. (19875060)

A newer therapy is the EKOS catheter. This uses ultrasound to continuously break up the clot during the IA Thrombolysis. Many of us wonder if this is any better than standard catheter-based therapy. (24226805), (23601295) See the PulmCCM Post on the Circulation RCT of EKOS

Interventional Mechanical Clot Disruption



AngioJet-a catheter that breaks up the clot with a high speed jet of saline, heparin, or tPA that then sucks up clot using Bernoulli physics. Very little systemic drug is delivered. Oren’s center doesn’t like the device; other centers use it. This letter is by an adovcate.



AngioVac-This device uses an ECMO-like system to suck up clot and then return the declotted blood to the venous circulation. It requires huge introducer sheaths. Oren alluded to its main benefit being intra-cavitary or vena cavae clots. Some are billing this as a replacement for embolectomy in many cases.

Surgical Embolectomy

Requires the patient to go on cardiopulmonary bypass and have a sternotomy. Recent experience with surgical embolectomy has had much
better results , much lower mortality than historical, (15867775)

Temporary VA ECMO as a bridge to one of these other therapies

See the EDECMO site for more on this therapy

Oren’s Algorithm

Oren's PE Algorithm

Oren’s PE Algorithm

Oren’s Slide Set

We discussed this topic with Jeff Kline a few years ago in Podcast 51

Fibrinolysis in PE with Jeff Kline

Want to know what to do for the rest of resuscitation for these patients?

We’ll have a podcast soon regarding the management of right ventricular failure, until then see this excellent post by Josh Farkas.

If they go into arrest, give tPA (10.1371/journal.pone.0008323)

As to what dose, who knows? Here is a great post on it. I would give tenecteplase.

expert-commentExpert Commentary on the Podcast

Provocative topic. Like it or not, these [PE Treatment Teams] are here to stay. I managed to get one going at Methodist. How? Well, maybe a little by perseverance, knowing the evidence, showing up for meetings, building alliances. Yeah, sure. But what sold it was when I found out for sure that the main competitor hospital, St. Vincents’ Hospital, was setting up the same program and had treated 18 patients with CDT [catheter-directed therapy] the month before. Then, suddenly attitudes changed. So what will be the main driver? The old ‘reducing practice variability’ line will be the party line. The real driver will be market share.

As Vic Tapson said in ATS two months ago “The practice is racing ahead of the evidence.” While I study lytics, and am a proponent of using them in massive and severe submassive, as your speaker advocates, I have to think like a contrarian for a minute. Funny thing is by reducing variability, we may all be doing the wrong thing instead of just some of us.

The standard lines  from most pulmonologists is “All my submassive PE patients do fine with heparin and warfarin. You guys are putting them at risk because there is no mortality benefit.”

Then the JAMA SR [the Chatterjee one mentioned above] came out 3 weeks ago showing mortality benefit and a huge NNH:NNT ratio for age<65 for survival. A huge shift. Now they say “It still increases bleeding risk…and there is no improvement in quality of life.” So I show them TOPCOAT, and they don’t read it except to see that part of the outcome was a survey, and conclude that they don’t believe in surveys (despite similar surveys being the endpoint for many other lung treatments they use; besides, the SF36 was by far the minority driver of the composite endpoint in TOPCOAT). This is going to be like stroke: a substantial number of physicians with ambiguity intolerance syndrome will say the devil you know is better than the devil you don’t. They see the clot in the lungs as better than the bleed that might happen. There are outspoken emergency physicians who still think lytics are dead wrong for stroke, monkey-fisted that position,  and in some sense have marginalized themselves from the mainstream. I suspect as we go forward, about 40% of the pulmonology community will be shaking their heads saying “what are you guys doing.” But, even if the evidence is mixed, market competition will drive this forward.

At this point, I agree with the speaker, who I believe is a pulmonologist. We should be giving systemic lytics to patients<70 years (more or less) with no contraindications, when the RV that is smashing the LV. Whether we should use catheter-directed therapy (CDT), is to me, the real question at this point. CDT offers the advantage of lower lytic dose, and Ekos  just got FDA clearance to market, and has an army of cardiologists behind them. Curiously, IR guys think Ekos is bogus and prefer CDT. But no trial has compared Ekos or general CDT to systemic lytics, and I doubt any CDT advocates will try such an RCT.

Jeffrey Kline [aka the Man]

comments in brackets are EMCrit’s

Update: Great Post on All of the Above from PulmCrit

Now on to the Podcast…



Podcast 127 – The Oxylator with Jim DuCanto


from inter-rescue.de

james-ducantoToday on the show, I talk with my friend Jim DuCanto, MD about the oxylator. Jim is an anesthesiologist extraordinaire with a constant drive to perfect new airway techniques and document them on video along the way.

What is the Oxylator?

A mainly plastic device about the size of your fist with a incredibly quick magnetic valve

It runs on pressurized wall or tank oxygen

Only two main controls, a pressure setting knob and a manual inhalation/automatic mode button

Manual Resuscitator Mode

Press the button and the device will give 30 lpm of inhalation until you let go or it hits the pressure limit you set

Automatic Ventilator Mode

Press in the button and give it a turn and the device switches to automatic ventilation mode. Think of it as a flow-controlled, pressure cycled ventilator in your hand

It gives 30 lpm fixed flow (slow, safe flow) until it hits the user-selectable pressure limit, it then cycles to passive exhalation until it reaches 2-4 cm H20 PEEP and then it begins a new breath

On a patient who is not spontaneously breathing, you can titrate that pressure setting to an inhalation time of 1-2 seconds; this will deliver 500-1000 mls per breath

At those settings, the minute volume will be 10-12 liters/minute

oxylator with mask

from inter-rescue.de


The device indicates when you are obstructing by clicking and tells you when there is a mask seal leak by not cycling to the next breath

It Solves the 5 Problems of the BVM

  1. We give too many breaths
  2. Those breaths are at too high a pressure
  3. The breaths are given too rapidly
  4. We get no feedback on whether the breath went in or it was given against an obstructed airway
  5. In a spontaneously breathing patient, the BVM will give variable FiO2s depending on the exhalation port

How we use it

We both use an inline hepa filter, ETCO2 port, and sometimes extension tubing. If you want to use it on a spontaneously breathing patient, OR mask straps are a great addition.

Two models

EMX (25-45 cm H20) and HD (15-30). There are also specialty models for chemical/explosive situations.

Here is Jim’s Overview on the Device

And here are the Slides from a lecture Jim gave at SAM

Here is an example of the use of the Oxylator for an OR Induction


Nasal CPAP in Unconscious Patient is More Effective than Full-Face Masks

Crit Care. 2013 Dec 23;17(6):R300.

Oxylator Product Page

This is the EMX Model

Disclaimer and COI

Neither Jim nor I take any money, kickbacks, or incentives from the manufacturer. Both Jim and I have been provided with Oxylators to test and research.

Now on to the Podcast…