EMCrit Podcast 30 – Hemorrhagic Shock Resuscitation

This week we discuss the resuscitation of the hemorrhagic shock patient with Dr. Richard Dutton, MD.

Rick was director of trauma anesthesia at the Shock Trauma Center when I trained there. He is an incredible teacher, clinician, and researcher.

Here are the take home points:

  • Induction agent choice does not matter in these patients; what matters is DOSE! Reduce dose to 1/10 of full intubating dose.
  • Blood products need to be available in the trauma bay for when these patients arrive. If you need to give crystalloid while awaiting the products, give only small amounts just to keep the patients heart beating.
  • A systolic of 80 with good perfusion and normal sized vessels is very different than that same SBP in a patient who is clamped down. The former is a resuscitated state, the latter =spiral of death.
  • The resuscitation fluid for trauma is equal parts PRBC and FFP.

To read more of Dr. Dutton’s thoughts, go to this article:

ITACCS Damage Control Anesthesia

Update: This article is even better (Br J Anaes 2012;109(s1):139)

photo from trauma.org
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EMCrit Podcast 29 – Procedural Sedation, Part II

It seems the government and other specialties are trying hard to make sedation as difficult as possible in the ED. We must persevere to provide the best procedural sedation to allow maximal comfort and safety for our patients. This continues the discussion started in Part I, where we discussed etomidate, ketamine, and versed/fentanyl. In this podcast, I discuss propofol, ketofol, and dexmedetomidine.

the emcrit procedural sedation chapter has tons of references for all of this

Propofol

great propofol articles:

Ann Emerg Med 2008;52:392-398
Ann Emerg Med. 2007;50:182-187

Start with fentanyl 1-1.5 mcg/kg

Then give propofol 0.5-1 mg/kg

may need additional injections of 0.5 mg/kg

When patient is where you want them, begin the procedure

May need to give additional 20-30 mgs if the patient becomes too light

Burns on injection, you can precede with 20-40 mg of lidocaine to numb the vessels

Ketofol

read more here: (Ann Emerg Med. 2007;49:23-30)

1:1 mix of ketamine and propofol

In 20 ml syringe, place 10 ml of propofol (10 mg/ml)

And 10 ml of ketamine at a concentration of 10 mg/ml

Note: your ketamine may come in a different concentration, if so dilute down to 10 ml of 10 mg/ml

Shake like a martini

Dexmedetomidine

Precede with fentanyl 1 mcg/kg

Start with 0.5-1 mcg/kg over 10 minutes for loading dose

then use an infusion 0f 0.2-1 mcg/kg/hr

Beware in the bradycardic, hypotensive or patients with heart blocks

May need to supplement with 1-2 mg of midazolam

Procedural Sedation Checklist

here it is

Stay tuned for part III coming to you some time in the future.

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Procedural Sedation Guidelines Update

This is a piece I wrote for the excellent Emergency Medicine Practice Guidelines Update, edited by my friend, Reuben Strayer.

 

Read

Procedural Sedation, Part I (Audio Only)

The audio only version of Part I of the sedation talk.

Remember to check out Part II next…

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Procedural Sedation – Part I

It seems the government and other specialties are trying hard to make sedation as difficult as possible in the ED. We must persevere to provide the best procedural sedation for the maximal comfort and safety for our patients. This brief lecture was originally posted on the defunct EMCrit Lecture Site on 8/7/2009.

I’m reposting it here so I can post part II sometime this week.

This episode, Part I, covers general concepts on sedation as well as ketamine and etomidate/fentanyl.

Part II will cover propofol, ketofol, and dexmedetomidine.

Part III, to be done some time in the future, will cover really difficult sedations.

My friend Reub Strayer has a great PSA checklist as well

 

 

 

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EMCrit Podcast 28 – Severe CNS Infections

Severe CNS Infections are time dependent diagnoses! You must have a high index of suspicion, a good plan for your work-up, and rapid provision of treatment. After seeing a severely ill meningitis patient, I figured I would do a podcast on some tips and pearls on this topic.

When to Suspect

Here is the article I mentioned on establishing pretest prob:

http://pmid.us/15509818

What Antibiotics

Ceftriaxone 2g as empiric therapy in any suspected meningitis patient

If high risk or LP results are positive, also give

  • Vancomycin 1 G
  • Ampicillin 2g if age > 50 y/o
  • Acyclovir 10  mg/kg if high RBC count, obtundation, seizures, or focal neurologic deficit
  • Dexamethasone 10 mg
  • Cefepime or Imipenem if hospitalized or neurosurgery patient

listen to the podcast for more and see the EMCrit chapter for more.

photo by Lapoland
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EMCrit Podcast 27 – Calcium Channel Blocker Overdose

This week, I am joined by Leon Gussow, MD of the excellent blog: The Poison Review (TPR). TPR is my source for new toxicology articles; I highly recommend it as an incredible read. I got to meet Leon for a few beers a month ago; he is a great guy.

My Canadian pal, Ram, suggested calcium channel blocker OD as a podcast episode. Ram, here you go.

Calcium Channel Blocker OD

CCB Classes

Nifedipine and other dihydropyridines (amlodipine, felodipine, isradipine, nicardipine, nimodipine, nisoldipine) will cause profound hypotension without bradycardia, due to poor affinity for myocardial calcium channels.  This selectivity is not lost in overdose.  They may actually present with reflex tachycardia

How to tell CCB OD from B-Blocker

CCBs do not cause AMS

CCBs block receptor in B-Islet cells, preventing insulin release, so can see hyperglycemia as opposed to the normal-low sugar in B-Blockers

Presentation

Weak/Dizzy, mild confusion, bradycardia progressing to severe hypotension and shock

Selectivity is lost in overdose (except dihydropyridines)

Treatment

·        Activated Charcoal x 1

·        Whole bowel-Irrigation is not recommended by Leon’s group

·        Frequent glucose and k checks

·        Atropine (can try it once, but it will limit gastric motility and probably won’t work)

·        Calcium, 1 g of CaCl or 3 g of CaGluc.  Give slowly over 3 minutes for CaCl and 10 min for CaGluc.

·        Glucagon 5 mg bolus, probably won’t do much, unlike in beta blocker OD

·        IVF

·       High Dose Insulin. Start with 1 unit/kg push followed by 0.5-1 unit/kg/hr. Fingersticks q30 minutes and adequate glucose replacement if needed. Check potassium; supplement if < 2.5. (Crit Care 2006;10:212) You can see our protocol on High-Dose Insulin Euglycemic Therapy (for informational purposes only, don’t use clinically until approved by your P&T committee).

·        May need to use norepinephrine or dopamine (alternatively Epi). May need much higher doses of epi or norepi. Dopamine must be stopped at 20 mcg/kg/min, which is kind of a joke in this OD. Switch to one of the others if you get this high.

·        Levosimendan may have a role, but not available in the US.

·        IABP, CP Bypass

<photo by ilovespoons>
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EMCrit Lecture – Top Ten Hypothermia Tips

At this stage of the game, if your hospital is not offering hypothermia to out-of-hospital cardiac arrests, you are probably lagging behind optimal care. For shockable rhythms, you essentially double your patient’s chances of leaving the hospital with good neurological outcome. However hypothermia can be tough, unless you have done a bunch. Learn from my mistakes in this lecture.

NCS 2010 Hypothermia Talk

I’d love to hear your comments and what you are doing at your hospital.

for more hypothermia resources, see my NYC Hypothermia Section

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EMCrit Lecture – Dominating the Vent: Part II

When I was a resident, every vent lecture either put me to sleep or left me dazed and bewildered. I gave a lecture of that ilk when I started working after fellowship. I had become part of the problem. I decided there must be a way to make vent management more understandable and if not interesting, at least bearable.

This lecture was up on the soon to be defunct EMCrit Lecture site. It offers a path to managing any patient on the ventilator in the ED. I have tried to simplify as much as possible while still maintaining an evidence-based approach.

This is Part II, it deals with the obstructive strategy. Last week, we spoke about the strategy for patients with  lung injury.

Your goal with these patients is to let them have adequate time to breathe out.

There are only 4 things you need to remember for an obstructive patient

Vt (Tidal Volume) = 8 ml/kg, don’t mess with it

Flow Rate = shorter insp times, 80-100 lpm

Resp Rate = Lung protection, start at 10 work your way down if necessary

FiO2/PEEP = Oxygenation, should need much O2 (40%)m I recommend PEEP of 0, but certainly keep it less than 5

First Print out this Handout

If you need just the audio [right or cntrl click here]

 

EMCrit Lecture – Dominating the Vent: Part I

When I was a resident, every vent lecture either put me to sleep or left me dazed and bewildered. I gave a lecture of that ilk when I started working after fellowship. I had become part of the problem. I decided there must be a way to make vent management more understandable and if not interesting, at least bearable.

This lecture was up on the soon to be defunct EMCrit Lecture site. It offers a path to managing any patient on the ventilator in the ED. I have tried to simplify as much as possible while still maintaining an evidence-based approach.

This is Part I, it deals with the lung injury strategy. Next week, we’ll talk about the strategy for patients with obstructive lung disease.

There are only 4 things you need to remember for a lung injury patient:

Vt (Tidal Volume) = Lung Protection

Flow Rate = Patient Comfort

Resp Rate = Ventilation

FiO2/PEEP = Oxygenation

First Print out this Handout

If you need just the audio [right or cntrl click here]