EMCrit https://emcrit.org Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation Wed, 24 May 2017 01:23:36 +0000 en-US hourly 1 https://wordpress.org/?v=4.7.5 http://emcrit.org/feed/podcast/ Help me fill in the blanks of the practice of ED Critical Care. In this podcast, we discuss all things related to the crashing, critically ill patient in the Emergency Department. Find the show notes at emcrit.org. Scott D. Weingart, MD clean Scott D. Weingart, MD spambin55@gmail.com spambin55@gmail.com (Scott D. Weingart, MD) 2009- Online Medical Education on Emergency Department (ED) Critical Care, Trauma, & Resuscitation EMCrit http://emcrit.org/wp-content/uploads/powerpress/3000x3000-emcrit.jpg https://emcrit.org EM Nerd-The Case of the Tardy Delegate https://emcrit.org/emnerd/em-nerd-case-tardy-delegate/ https://emcrit.org/emnerd/em-nerd-case-tardy-delegate/#comments Wed, 24 May 2017 01:23:36 +0000 https://emcrit.org/?p=441104 We have discussed the dangers of surrogate outcomes at length, but none are more evident to an Emergency Physician than the time-based metrics we are subjected to on a daily basis. The latest of these temporal surrogates forced upon us is the 3-hour bundle of care in patients presenting to the Emergency Department with symptoms […]

EMCrit by Rory Spiegel.

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PulmCrit- Liberating the patient with no cuff leak https://emcrit.org/pulmcrit/cuff-leak/ https://emcrit.org/pulmcrit/cuff-leak/#comments Mon, 22 May 2017 11:01:54 +0000 https://emcrit.org/?p=440988 A new joint practice guideline by the ATS and ACCP addresses how to approach cuff leaks. This guideline recommends a clever compromise between these extremes, which is the basis of the algorithm below. This provides a streamlined, evidence-based pathway to extubate patients without a cuff leak.

EMCrit by Josh Farkas.

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CC Nerd-The Case of the Anatomic Inaccuracy https://emcrit.org/emnerd/cc-nerd-case-anatomic-inaccuracy/ https://emcrit.org/emnerd/cc-nerd-case-anatomic-inaccuracy/#comments Thu, 18 May 2017 19:46:15 +0000 https://emcrit.org/?p=441013 A recent publication in Chest by Semler et al examined the utility of the ramped position for the emergent intubation of patients in the ICU (1). The results not only call into question our use of this technique, but more importantly the outcomes we use to evaluate the efficacy of airway interventions outside the pristine […]

EMCrit by Rory Spiegel.

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EMCrit Podcast 199 – Management of Massive Hemoptysis with Oren Friedman https://emcrit.org/podcasts/massive-hemoptysis/ https://emcrit.org/podcasts/massive-hemoptysis/#comments Sun, 14 May 2017 19:13:04 +0000 http://emcrit.org/?p=5745 Management of Massive Hemoptysis

EMCrit by Scott Weingart.

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https://emcrit.org/podcasts/massive-hemoptysis/feed/ 13 Management of Massive Hemoptysis
Today, I am joined by my buddy and pulmonary-critical care stud, Oren Friedman, to discuss the management of Massive Hemoptysis
See More from Oren

* Clot Management of Massive and SubMassive PE
* Hemodynamic Management of PE

Some Basics on Massive Hemoptysis

* LitFL
* First10 EM
* Review by Sakkour on Massive Hemoptysis

Intubate Big
Localize
C-XR, chart review, and initial bronch. Remember Oren's tip: if you get in there and can't find any bleeding, temporarily disconnect the vent
Is it Amenable to Bronch Treatment?
If not, Block; preferably at the segmental level
Use a bronchial blocker, not a double lumen tube
Uni Blocker

EZ Blocker

A poor 2nd choice is mainstem intubation
Bougie for selective lung
Then Get a CTA of the Chest
Then go to IR for Bronchial Artery Embolization
95% of the lesions will arrise from the bronchial circulation. The ones that don't are PE, Pulmonary Art Catheter mishaps, and AVMs of the Pulmonary arterial circulation.
If that fails, Surgery or ECMO
Now, On to the Podcast...]]>
Scott D. Weingart, MD clean 24:32
EM Nerd-An Addendum to The Case of the Incidental Bystander https://emcrit.org/emnerd/em-nerd-addendum-case-incidental-bystander/ https://emcrit.org/emnerd/em-nerd-addendum-case-incidental-bystander/#comments Wed, 10 May 2017 18:50:45 +0000 https://emcrit.org/?p=440886 The October 2016 NEJM publication of the PESIT trial by Prandoni et al set the world of social media ablaze (1). There were the standard fear mongering headlines noting that 1 in 6 patients admitted to the hospital following syncope had a pulmonary embolism. This was followed by a reactionary flurry of commentary by the […]

EMCrit by Rory Spiegel.

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PulmCrit- Resuscitationist’s guide to status epilepticus https://emcrit.org/pulmcrit/status-epilepticus-2/ https://emcrit.org/pulmcrit/status-epilepticus-2/#comments Mon, 08 May 2017 11:02:27 +0000 https://emcrit.org/?p=440806 In 2014 I wrote a post suggesting an aggressive, streamlined approach to status epilepticus involving early intubation.  The fundamentals of that post remain valid.  However, much has changed over the last few years.  This post aims to refresh and extend the prior post.  It will also serve as a reference to explain my algorithm for […]

EMCrit by Josh Farkas.

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Podcast 198 – Insulin Pumps and Such with Josh Miller, MD https://emcrit.org/podcasts/insulin-pumps/ https://emcrit.org/podcasts/insulin-pumps/#comments Mon, 01 May 2017 16:26:22 +0000 http://emcrit.org/?p=18099 Scared of insulin pumps--not anymore

EMCrit by Scott Weingart.

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https://emcrit.org/podcasts/insulin-pumps/feed/ 9 Scared of insulin pumps--not anymore

Today, we discuss the topic of insulin pumps. Heralded as a huge advance in the management of insulin-dependent diabetes mellitus (IDDM), they also bring a bit more complexity to the mix. To sort through this confusion, I brought my friend Josh Miller (@glucosedoc) on to the show to discuss.
Josh Miller, MD
Dr. Joshua D. Miller is the Medical Director of Diabetes Care for Stony Brook Medicine and an Assistant Professor of Endocrinology & Metabolism in the Department of Medicine. He is dual board-certified in Internal Medicine and Endocrinology, Diabetes & Metabolism.  Dr. Miller has vast experience helping people with diabetes to conquer the challenges of living with the disease; he has been living with type 1 diabetes for over twenty years. He is an expert in insulin pump and glucose sensor management as well as the transition of care to adult endocrinology for young adults with diabetes.
What we Covered
Tell Us About Insulin Pumps

* Settings (Basal, Bolus)
* What can go wrong
* How do we know if it is functioning
* How to turn it Off
* Site Infection--is this even an issue?
* More on Insulin Pumps

What do We do If Pt with PUMP has DKA?

* Leave It on or
* Supplement or
* Adjust Settings or
* Turn it off--if so how to take pt settings into account

Basal Insulin in the Critically Ill

* How much and how
* Insulin Drip
* Is Lantus Safe-how much and when

Euglycemic DKA

* what agents (SGLT2)
* how to manage
* See also RebelEM

Hypoglycemia with a Pump
from Josh: Hypoglycemia in a patient with diabetes on pump is multifactorial. If the hypoglycemia is so severe as to warrant admission, I would suspend or remove the pump. The patient should undoubtedly be assessed for insulin pump competency and diabetes self management skills. Acutely, patients should know how to temp basal or suspend the pump. Rarely would we treat through the insulin with dextrose and continue 100% basal delivery. If the patient is altered in any way, the pump should be suspended (by someone knowledgeable about pump function) or removed and an alternative SQ insulin regimen should immediately be pursued. The risk of course is forgetting the depot regimen and, once hypoglycemia resolves, causing ketosis.

Take home point: hypoglycemia on pump = call endocrine immediately.

Now on to the Show...]]>
Scott D. Weingart, MD clean 23:03
A Letter to CMS from Paul Marik https://emcrit.org/isepsis/letter-cms-paul-marik/ https://emcrit.org/isepsis/letter-cms-paul-marik/#comments Sat, 29 Apr 2017 19:28:35 +0000 https://emcrit.org/?p=440650 Marik to CMS

EMCrit by Paul Marik.

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Ketamine ……. then Rocuronium, DSI & The Timing Principle https://emcrit.org/podcasts/ketamine-rocuronium-dsi-timing-principle/ https://emcrit.org/podcasts/ketamine-rocuronium-dsi-timing-principle/#comments Tue, 25 Apr 2017 14:47:21 +0000 https://emcrit.org/?p=440556 More on rocketamine...

EMCrit by Scott Weingart.

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https://emcrit.org/podcasts/ketamine-rocuronium-dsi-timing-principle/feed/ 9 More on rocketamine...

So Josh's post yesterday (Rocketamine vs. keturonium for rapid sequence intubation) sparked much controversy and comment. I wanted to wade into the conflict, hence this wee.
Rocuronium Administration-Prior to Sedative
Administering roc as first drug is a variation of the timing principle demonstrated in a bunch of studies RCTs, here are 4 of them:

* http://www.ncbi.nlm.nih.gov/pubmed/9195356
* http://www.ncbi.nlm.nih.gov/pubmed/9585312
* http://www.ncbi.nlm.nih.gov/pubmed/7923516
* https://www.ncbi.nlm.nih.gov/pubmed/21547177

The most effective way to administer the med is actually to administer the sedative 15 sec after the roc, but most do not go that far. An easier to justify method is:

* Roc
* Induction agent
* Flush

This is my method for etomidate or propofol. For ketamine, I prefer DSI-type administration.
Listen to the Wee to Hear my Thoughts...]]>
Scott D. Weingart, MD clean 10:49
PulmCrit- Rocketamine vs. keturonium for rapid sequence intubation https://emcrit.org/pulmcrit/pulmcrit-rocketamine-vs-keturonium-rapid-sequence-intubation/ https://emcrit.org/pulmcrit/pulmcrit-rocketamine-vs-keturonium-rapid-sequence-intubation/#comments Mon, 24 Apr 2017 11:01:35 +0000 https://emcrit.org/?p=440483 Background:  Devil in the details Airway management is a detail-oriented sport.  Minor nuances of patient positioning can be essential.  Or gentle laryngeal manipulation.  Apneic oxygenation can improve first-pass success.  Placing the pulse oximeter on the same arm as the blood pressure cuff can cause real headache.  Failure to recognize and remove dentures is an enormous […]

EMCrit by Josh Farkas.

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Podcast 197 – The Logistics of the Administration of Massive Transfusion https://emcrit.org/podcasts/logistics-administration-massive-transfusion/ https://emcrit.org/podcasts/logistics-administration-massive-transfusion/#comments Mon, 17 Apr 2017 16:51:34 +0000 https://emcrit.org/?p=440330 The hands-on of orchestrating a massive transfusion protocol

EMCrit by Scott Weingart.

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https://emcrit.org/podcasts/logistics-administration-massive-transfusion/feed/ 40 The hands-on of orchestrating a massive transfusion protocol

We've talked about the rationale of massive transfusion a bunch on the EMCrit show:

* EMCrit Podcast 13: Trauma Resus II: Massive Transfusion
* Podcast 71: Critical Questions on Massive Transfusion Protocols with Kenji Inaba
* Podcast 144: The PROPPR trial with John Holcomb
* Podcast 081 - An Interview on Severe Trauma with Karim Brohi
* Hemorrhagic Shock Resus with Rick Dutton

Let's talk about the logistics of the actual administration of a massive transfusion protocol in an exsanguinating patient.
Some of the Stuff Mentioned in the Show

* The Level-1 Rapid Infusion System
* The Belmont Rapid Infuser

Now on to the 'Cast:]]>
Scott D. Weingart, MD clean 25:36
PulmCrit- Submassive PE 2017: Getting ’em off the cliff https://emcrit.org/pulmcrit/submassive-pe-peitho/ https://emcrit.org/pulmcrit/submassive-pe-peitho/#comments Mon, 10 Apr 2017 11:01:57 +0000 https://emcrit.org/?p=440066 Follow-up data from the PEITHO trial shows that thrombolytics don't affect long-term morbidity.  This simplifies management substantially. PEITHO trial & long-term follow up The PEITHO trial was a multi-center RCT investigating the effect of thrombolysis in submassive PE.  Tenecteplase caused an increase in intracranial hemorrhage and a reduction in hemodynamic collapse.  Overall there was a […]

EMCrit by Josh Farkas.

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The Sick and the Dead: Evidence-Based Trauma Resuscitation in 2016 by Hicks & Petrosoniak https://emcrit.org/wee/the-sick-and-the-dead/ https://emcrit.org/wee/the-sick-and-the-dead/#comments Tue, 04 Apr 2017 18:46:16 +0000 https://emcrit.org/?p=439783 The sick and the dead from SMACCdub

EMCrit by Scott Weingart.

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https://emcrit.org/wee/the-sick-and-the-dead/feed/ 8 The sick and the dead from SMACCdub
Trauma Year in Review 2016 from SMACCdub
by Chris Hicks and Andrew Petrosoniak
The science of trauma resuscitation has undergone a fairly massive evolution in the past decade.  This talk was our attempt to summarize the best-of-the-best in trauma literature from the past several years, and package it into a series of clinically useful recommendations (i.e., our evidence-based opinions).  This talk was live peer reviewed by trauma surgery deity Karim Brohi, who gave us a thumb’s up (although you kind of had to be there).

 
Here’s a run-down of our take-home points:
Use the Clamshell
Unless you’re a thoracic surgeon, consider the bi-thoracotomy as your initial approach to resuscitative thoracotomy. Don't operate in a hole – give yourself the best exposure, and the best shot at fixing the problem.

* Ref: WJS 2013, 37: 1277-1285
* How-to guide: http://emj.bmj.com/content/22/1/22

Prognosticate with POCUS
Point-of-care ultrasound (POCUS) has an ever-expanding role in trauma resuscitation, including prognosticating in cardiac arrest. In this study, patients with no cardiac activity and no pericardial effusion had no survival.

* Ref: Ann Surgery 2015, 262(3): 512-518

Get with the Guidelines
The EAST thoracotomy guidelines might be the most useful and evidence-based set of recommendations for the management of traumatic cardiac arrest yet. Bottom line: VSA trauma patients with penetrating thoracic injuries and an arrest time of < 10 minutes deserve a resuscitative thoracotomy – these are salvageable patients, and deserve an aggressive approach.

* Ref: Critical Care 2013, 17:308, J Trauma 2015, 79(1): 159-173
* Compare and contrast – WEST guidelines (2012): http://bit.ly/2mFemtM

Skip the Films
Stable patients with a plan for CT imaging don’t need a chest x-ray or pelvis x-ray. Not all patients undergoing CT need the full “pan-scan”. In the middle are assessable patients with reassuring vital signs, POCUS +/- x-ray imaging: they can be admitted for observation, or discharged.

* Ref: http://bit.ly/292tAUm
* In the same spirit – local wound exploration for anterior abdo stab wounds can eliminate the need for CT imaging, admission: https://www.ncbi.nlm.nih.gov/pubmed/22182859

Crystalloids kill
The paradigm of 1-2L of crystalloid boluses in hypotensive trauma patients is harmful and should be abandoned. If PRBCs aren’t immediately available, give small boluses (250 cc at a time) for patients with sBP < 70, altered mental status or loss of peripheral pulses. NICE guidelines restrict crystalloids to pre-hospital only.

* Ref: BJM 2012; 345: 38-42, http://bit.ly/292tAUm

Be Propper PROPPR
PROPPR in a nutshell: A balanced ratio of blood products (approximating 1:1:1) is probably the optimal approach for patients who are bleeding to death; also, platelets are pretty important early in trauma resus.

* Ref: JAMA 2015, 313(5): 471-482

Who Needs Mass Trans?
Predicting the need for massive transfusion in trauma is tricky. Relying on gestalt alone is associated with under-resuscitation in about one third of patients, even when trauma experts are making the call. In tricky situations, use the ABC score or shock index to improve situation awareness.

* Ref: Injury 2015, 46: 807-813, J Trauma 2009, 66: 346-352

Drop the dose
Trauma patients in profound shock don’t need the Full Monty when it comes to induction agents for RSI. Even the all-mighty ketamine can have negative hemod...]]>
Scott D. Weingart, MD clean 29:43
Podcast 196 – Having a Vomit SALAD with Dr. Jim DuCanto – Airway Management Techniques during Massive Regurgitation, Emesis, or Bleeding https://emcrit.org/podcasts/having-a-vomit-salad-with-ducanto/ https://emcrit.org/podcasts/having-a-vomit-salad-with-ducanto/#comments Mon, 03 Apr 2017 14:58:23 +0000 http://emcrit.org/?p=16488 Friend to the show, Jim DuCanto has been obsessed with SALAD. Not the leafy greens delicately touched with a tart emulsion, but with Suction Assisted Laryngoscopy and Airway Decontamination (SALAD). Jim DuCanto, MD  is an anesthesiologist extraordinaire with a constant drive to perfect new airway techniques and document them on video along the way. COI […]

EMCrit by Scott Weingart.

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https://emcrit.org/podcasts/having-a-vomit-salad-with-ducanto/feed/ 7 Friend to the show, Jim DuCanto has been obsessed with SALAD. Not the leafy greens delicately touched with a tart emulsion, but with Suction Assisted Laryngoscopy and Airway Decontamination (SALAD). Jim DuCanto,

Friend to the show, Jim DuCanto has been obsessed with SALAD. Not the leafy greens delicately touched with a tart emulsion, but with Suction Assisted Laryngoscopy and Airway Decontamination (SALAD). Jim DuCanto, MD  is an anesthesiologist extraordinaire with a constant drive to perfect new airway techniques and document them on video along the way.
COI Statement
Dr. DuCanto invented and receives royalties on the DuCanto Catheter from SSCOR and the Nasco SALAD mannequin
Read More about SALAD from Taming the Sru

* TtS Post

Esophageal Diversion Maneuver (Intentional Esophageal Intubation)
deliberately insert the ETT down the esophagus and gently inflate the balloon

There is lit for this
SALAD Park Maneuver
Keep tip of suction catheter in the esophagus on the left side of the mouth
SALAD Techniques

Meconium Suction Set-Up
Here was our original letter (J Clin Anesth, 23 (2011), pp. 518–519) (fulltext)

It was recently validated (The Journal of Emergency Medicine Volume 52, Issue 4, April 2017, Pages 433–437)



 
More Stuff

* SALAD Facebook Page
* SSCOR Site
* Taming the SRU write-up of SALAD
* DuCanto Suction Catheter
* General Description of system and demonstration by Jeff Hill of the University of Cincinnati’s EM Program
* Product page of SALAD Mannequin
* University of Wisconsin HEMS Fellow with the “Static” Excercise
* University of Wisconsin HEMS Fellow with the “Dynamic” Excercise
* University of Wisconsin HEMS Attending takes on the SALAD Simulator
* Check out the next level of SALAD—SALAD 2.0
* Listen to the JellyBean with Jim

More from Jim DuCanto on EMCrit

* Podcast 73 – Airway Tips and Tricks
* A New Bougie for your Pocket by Jim DuCanto
* A Guide to Intubating through the Intubating Laryngeal Airway
* Two New Videos from Jim DuCanto
* The Oxylator
* More DuCanto and Pocket Bougie Videos
* Two OR Intubation Videos
* How to Custom Bend a Video Stylet for use with the Cookgas ...]]>
Scott D. Weingart, MD clean 19:20
EM Nerd-The Case of the Bridge to Nowhere https://emcrit.org/emnerd/em-nerd-case-bridge-nowhere/ https://emcrit.org/emnerd/em-nerd-case-bridge-nowhere/#comments Sat, 01 Apr 2017 21:19:09 +0000 https://emcrit.org/?p=439896 The use of mechanical cardiopulmonary resuscitation (mCPR) has been a polarizing topic almost from its inception. The idea, a simple one. Why not build a machine that is capable of doing perfect chest compressions? A simple, effective way to eliminate the inconsistencies common to manual chest compressions. And yet, despite building a number of devices […]

EMCrit by Rory Spiegel.

]]> https://emcrit.org/emnerd/em-nerd-case-bridge-nowhere/feed/ 8 Dr. Marik Responds to a Few Tough Questions on the Metabolic Resus of Sepsis Strategy https://emcrit.org/podcasts/dr-marik-responds-tough-questions-metabolic-resus-sepsis-strategy/ https://emcrit.org/podcasts/dr-marik-responds-tough-questions-metabolic-resus-sepsis-strategy/#comments Fri, 31 Mar 2017 15:00:04 +0000 https://emcrit.org/?p=439836 If you don't know what all of the kerfuffle is about, read the Pulmcrit Post (including the comments) then Listen to the interview with Paul Marik I sent Paul the questions below and he was kind enough to answer them: ———————————————— Hey Paul, As I imagined, the interview and post were galvanizing. We've had thousands […]

EMCrit by Scott Weingart.

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EMCrit Wee – Edited Version of Paul Marik on the Metabolic Resuscitation of Sepsis https://emcrit.org/wee/edited-marik-metabolic-sepsis/ https://emcrit.org/wee/edited-marik-metabolic-sepsis/#comments Tue, 28 Mar 2017 16:22:20 +0000 https://emcrit.org/?p=439749 Edited interview with Paul Marik

EMCrit by Scott Weingart.

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https://emcrit.org/wee/edited-marik-metabolic-sepsis/feed/ 2 Edited interview with Paul Marik
Read Josh's Post on the Metabolic Resuscitation of Sepsis first, then listen to this interview with Paul Marik:
Note to Listeners:
I took down the original version and put up this edited version. The only difference from the original is some additional comments added at 13:03 to give a more accurate perception of the current level of evidence of this therapy.

Please, please read the Pulmcrit post listed above before listening.
On to the Wee...]]>
Scott D. Weingart, MD clean 16:05
PulmCrit- Metabolic sepsis resuscitation: the evidence behind Vitamin C https://emcrit.org/pulmcrit/metabolic-sepsis-resuscitation/ https://emcrit.org/pulmcrit/metabolic-sepsis-resuscitation/#comments Mon, 27 Mar 2017 11:01:15 +0000 https://emcrit.org/?p=439192 The Metabolic Resus of Sepsis

EMCrit by Josh Farkas.

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EM Nerd-The Case of the Shadowy Spector https://emcrit.org/emnerd/em-nerd-case-shadowy-spector/ https://emcrit.org/emnerd/em-nerd-case-shadowy-spector/#comments Fri, 24 Mar 2017 22:16:44 +0000 https://emcrit.org/?p=439590 The shadow of the long-term sequelae of submassive pulmonary emboli has stalked the hearts and minds of Emergency Physicians. The use of thrombolytics to prevent these ramification has previously been supported primarily with surrogate data, physiological reasoning and communal anecdotal experience. Thrombolytics for submassive pulmonary emboli have failed to demonstrate an improvement in short-term mortality […]

EMCrit by Rory Spiegel.

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PulmCrit Wee: MDCalc for the perfect tape-measure intubation https://emcrit.org/pulmcrit/tape-measure-intubation/ https://emcrit.org/pulmcrit/tape-measure-intubation/#comments Wed, 22 Mar 2017 11:05:29 +0000 https://emcrit.org/?p=439545 Imagine you went to buy an expensive piece of clothing.  Rather than measuring your size, the store owner simply said “well, on average most folks require a medium, so let's try that on, we can always re-size it later.”  You would be irritated that they were wasting your time.  When you go clothes shopping, you […]

EMCrit by Josh Farkas.

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Podcast 195 – Management of Tracheostomy (Trach) and Laryngectomy Emergencies https://emcrit.org/podcasts/tracheostomy-emergencies/ https://emcrit.org/podcasts/tracheostomy-emergencies/#comments Mon, 20 Mar 2017 17:58:51 +0000 http://emcrit.org/?p=5742 Trach Emergencies

EMCrit by Scott Weingart.

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https://emcrit.org/podcasts/tracheostomy-emergencies/feed/ 11 Trach Emergencies
The Best Paper and the most amazing site
Guidelines for Tracheostomy and Laryngectomy Emergencies (Anaesthesia 2012;67:1025)

from the National Tracheostomy Safety Project (NTSP), the ultimate site for trach emergency management
Bedside Signs


Get the Tracheostomy Sign as double-sided sign for the bedside



Get the Laryngectomy Sign as double-sided sign for the bedside

Here is the version to edit your own signs
Now on to the Podcast...]]>
Scott D. Weingart, MD clean 30:18
EM Nerd-A Brief Addendum to the Adventure of the Red-Headed League https://emcrit.org/emnerd/em-nerd-brief-addendum-adventure-red-headed-league/ https://emcrit.org/emnerd/em-nerd-brief-addendum-adventure-red-headed-league/#comments Sun, 19 Mar 2017 14:49:59 +0000 https://emcrit.org/?p=439440 What is the clinical significance of a post traumatic seizure (PTS) in children presenting to the Emergency Department following minor head trauma? This is a question surrounded by myth and dogma. As with most questions regarding traumatic brain injury (TBI) in children, the PECARN authors have come to our aid. Badawy et al published a […]

EMCrit by Rory Spiegel.

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PulmCrit- Hypertriglyceridemic pancreatitis: Can we defuse the bomb? https://emcrit.org/pulmcrit/hypertriglyceridemic-pancreatitis/ https://emcrit.org/pulmcrit/hypertriglyceridemic-pancreatitis/#comments Mon, 13 Mar 2017 11:00:35 +0000 https://emcrit.org/?p=439196 Hypertriglyceridemia causes ~9% of pancreatitis, the third most common cause after alcohol and gallstones.  It is a risk factor for severe pancreatitis, making it more frequent among ICU patients with pancreatitis.  I see this a few times each year.  Nonetheless, it has low penetration into educational curricula or our collective awareness. The treatment of hypertriglyceridemic […]

EMCrit by Josh Farkas.

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EM Nerd-The Case of the Inconsequential Truth https://emcrit.org/emnerd/em-nerd-case-inconsequential-truth/ https://emcrit.org/emnerd/em-nerd-case-inconsequential-truth/#comments Fri, 10 Mar 2017 18:24:08 +0000 https://emcrit.org/?p=439123 There have been a number of publications recently maligning the use of morphine for the treatment of acute coronary syndrome (ACS). The hypothesis proposed is that morphine slows the absorption of the oral p2y12 inhibitors, such as ticagrelor, delaying the dual- platelet inhibition desired by cardiologists worldwide. The most recent data supporting this hypothesis was […]

EMCrit by Rory Spiegel.

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Podcast 194 – Definitive Emergent Awake Intubation with George Kovacs https://emcrit.org/podcasts/definitive-emergent-awake-intubation/ https://emcrit.org/podcasts/definitive-emergent-awake-intubation/#comments Mon, 06 Mar 2017 18:15:12 +0000 https://emcrit.org/?p=438582 Podcast 194 - The Definitive Emergent Awake Intubation Lecture by @kovacsgj

EMCrit by George Kovacs.

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Not enough people are doing awake intubation in the ED or doing it as quickly as possible in the ICU. I have spoken about the technique many times on EMCrit. This lecture was specifically crafted for the EMCrit audience by my friend and airway guru, George Kovacs. I consider it to be the definitive discussion on emergent awake intubation.

For the equipment links, go to the Rapid Sequence Awake Post
Previous Podcasts on Awake Intubation

* The original method (I've moved away from the teachings here with the availability of better equipment)
* The Rapid Sequence Awake Intubation

Awake in Halifax, Part I - An interview with Ian Morris, Anesthesiologist

More Great Stuff from George Kovacs

* Lights Camera Action: Redirecting Videolaryngoscopy (Guest Post)
* Antifragile in EM by George Kovacs
* George's Self-Intubation

Sign up for REANIMATE4


REANIMATE Site
Now on to the Vodcast...
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Scott D. Weingart, MD clean yes
PulmCrit- Killer resuscitation: Abdominal hypertension as an occult driver of multiorgan failure  https://emcrit.org/pulmcrit/abdominal-hypertension/ https://emcrit.org/pulmcrit/abdominal-hypertension/#comments Mon, 27 Feb 2017 11:14:56 +0000 https://emcrit.org/?p=438963 Introduction with a clinical conundrum A 66-year-old man is transferred from an outside hospital due to inability to be liberated from the ventilator.  He presented a week earlier with pneumonia and sepsis.  He received six liters of fluid initially, and has been running net positive 1-2 liters daily since then (for a total of about […]

EMCrit by Josh Farkas.

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EHPR Part 5: Using Mental Practice and Visualization Exercises by Mike Lauria https://emcrit.org/blogpost/ehpr-part-5-using-mental-practice-visualization-exercises-mike-lauria/ https://emcrit.org/blogpost/ehpr-part-5-using-mental-practice-visualization-exercises-mike-lauria/#comments Tue, 21 Feb 2017 10:50:55 +0000 https://emcrit.org/?p=438838 See: Employing visualization exercises, imagery, and mental practice Another psychological skill that can benefit emergency medical care providers is visualization, or mental practice. This skill allows a provider to walk through the steps of a procedure or skill in his or her mind before actually performing it. This process can act as blueprint or mental […]

EMCrit by Mike Lauria.

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Podcast 193 – Emergency Medicine is a Failed Paradigm https://emcrit.org/podcasts/podcast-193-emergency-medicine-failed-paradigm/ https://emcrit.org/podcasts/podcast-193-emergency-medicine-failed-paradigm/#comments Mon, 20 Feb 2017 16:26:12 +0000 http://emcrit.org/?p=336999 Yep, EM is indeed a failed paradigm

EMCrit by Scott Weingart.

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https://emcrit.org/podcasts/podcast-193-emergency-medicine-failed-paradigm/feed/ 24 Yep, EM is indeed a failed paradigm
At SmaccDUB, I got to debate my friend and head wizard of St. Emlyns, Simon Carley. Our topic was, Emergency Medicine (EM) is a Failed Paradigm. I took the pro side--it was a ton of fun. Take a watch and then tell me what you think in the comments section below.
The St. Emlyn's Post
Simon wrote a wonderful blogpost about the debate.
The Slides

Additional Links of Interest
Graham Walker on "Emergentology: Don't Worry; We'll Handle It"
The Video
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Scott D. Weingart, MD clean 27:55 yes
EM Nerd-The Case of the Aimless Company https://emcrit.org/emnerd/em-nerd-case-aimless-company/ https://emcrit.org/emnerd/em-nerd-case-aimless-company/#comments Sat, 18 Feb 2017 19:47:31 +0000 https://emcrit.org/?p=438685 No one can deny the severity of the opioid crisis in which we currently reside. But what is less clear is whether we are innocent bystanders, facing the consequences of someone else’s problem, or directly responsible for causing a portion of the addiction we are currently witnessing. In a recent publication in the NEJM, Barnett […]

EMCrit by Rory Spiegel.

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EMCrit Wee – The Golden Fleece, the Golden Hour, and the Golden Rule by Ashley Liebig https://emcrit.org/podcasts/golden-rule-by-ashley-liebig/ https://emcrit.org/podcasts/golden-rule-by-ashley-liebig/#comments Thu, 16 Feb 2017 00:40:32 +0000 https://emcrit.org/?p=438611 Ashley crushes stigma and leaves us acutely aware of how our words and actions affect our colleagues and those that we love

EMCrit by Scott Weingart.

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https://emcrit.org/podcasts/golden-rule-by-ashley-liebig/feed/ 17 Ashley crushes stigma and leaves us acutely aware of how our words and actions affect our colleagues and those that we love

I have a friend named, Ash. She is a nurse, a veteran, a prehospital/retrieval provider, and a... badass. She gave this talk at SmaccDUB. I loved it so much; I hope you do as well:
Blurb
Time tested rules and myths explored in a real life adventure, meant to honor and display the courage, commitment and sacrifice made by emergency medicine and critical care professionals around the globe. In a painfully honest reflection, Ashley crushes stigma and leaves us acutely aware of how our words and actions affect our colleagues and those that we love.
The Talk
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Scott D. Weingart, MD clean 24:48 yes
PulmCrit- Epinephrine vs. atropine for bradycardic periarrest https://emcrit.org/pulmcrit/epinephrine-atropine-bradycardia/ https://emcrit.org/pulmcrit/epinephrine-atropine-bradycardia/#comments Mon, 13 Feb 2017 12:35:55 +0000 https://emcrit.org/?p=438239 Introduction with a case An elderly woman is admitted with atrial fibrillation and fast ventricular rate.  She is asymptomatic, with a heart rate of 160 b/m.  She is treated with a 20 mg diltiazem bolus followed by an infusion at 15 mg/hour for several hours.  Her heart rate slows to 110 b/m. She is then […]

EMCrit by Josh Farkas.

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Choose the 2017 EEM Fellowship Winner https://emcrit.org/misc/choose-the-eem-fellowship-winner/ https://emcrit.org/misc/choose-the-eem-fellowship-winner/#comments Tue, 07 Feb 2017 15:00:36 +0000 http://emcrit.org/?p=18734 Who gets the EEM 2016 Fellowship

EMCrit by Scott Weingart.

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Podcast 192 – Powerpoint and Meth – Presentation Creation from #TTC https://emcrit.org/podcasts/powerpoints-meth/ https://emcrit.org/podcasts/powerpoints-meth/#comments Mon, 06 Feb 2017 20:02:55 +0000 https://emcrit.org/?p=438242 The slides are not the problem...

EMCrit by Scott Weingart.

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https://emcrit.org/podcasts/powerpoints-meth/feed/ 5 The slides are not the problem...
People have a tendency to blame powerpoint (or keynote) for the horrible presentations they are forced to sit through. But the slides are merely an external manifestation of a deeper problem, just like the teeth of a meth addict.

For the past two years, I have been speaking at The Teaching Course in NYC. Two years ago, I gave a 60-minute talk on presentation creation (you can see that original talk below). This year, the course directors reduced my time to 30-minutes...resulting in a tighter and much better talk. That is what I am posting today.
The Twelve Steps
1. Admit you have a problem
2. Choose your Topic and your Purpose
3. Create Brainstorming Spaces

* Template for folders
* Mindmap reference book

4. Choose a Structure
5. Add the flesh
6. Work the Transitions
7. Visualize the Visuals

* Where to get Images from First10EM

8. Edit to Time
9. Mark the Stage
10. Create a "Handout"
11. Give it for Real
12. Do it Again
Other Things mentioned in the Talk

* Beyond Bullet points template
* Recorder recommendations
* Rich Borden Reference
* How to Sequence a Talk
* Ira Glass Quote
* 10 ways to end your talk
* Cicero rules for good talk
* Lawrence Lessing talk
* Multimedia Learning book
* Slideument reference
* Feedback form (see slides)
* Brief Feedback form (see slides)
* Using space information
* Nancy Duarte Reference and this one
* Presentation Zen
* Scriptwriting: Story by McKee
* Ed Tufte on Data Presentation
* Posture Reference
* Up resolution to PPT link
* Screencast on how to save as jpg (pending)
* Iskysoft Imedia Converter for Mac or Windows
* Share your checklist (pending)
* Good remote
* Test slide

The Rehearsals as elaborated in the Public Words Blog
See the posts here: Rehearsals, Rehearsals

* Rehearsal 1 is for content (I would recommend doing this one twice, once before powerpoint and once after)
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Scott D. Weingart, MD clean 32:15 yes
Wee – Warning: Nothing Useful Here – Politics and Why I’m “Divorcing” Twitter https://emcrit.org/wee/wee-warning-nothing-useful-politics-im-divorcing-twitter/ https://emcrit.org/wee/wee-warning-nothing-useful-politics-im-divorcing-twitter/#comments Wed, 01 Feb 2017 22:17:23 +0000 http://emcrit.org/?p=437662 if you still want to listen after reading the title

EMCrit by Scott Weingart.

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https://emcrit.org/wee/wee-warning-nothing-useful-politics-im-divorcing-twitter/feed/ 35 if you still want to listen after reading the title
Politics
not even going to bother writing anything here, my country has gotten so ridiculous.
Why I'm Divorcing Twitter


* The Hey Girl Meme
* Feminist Ryan Gosling
* I was going to post he twitter threads from the EMCritConf discussing the meme here, but looking back at them today, I see a ton of them have been deleted. It prob. would have been poor form to call any particular person out by name anyway as I am sure there were innocents amongst the guilty.

The Intro to the EMCritConf 2017 - Full lectures will be posted on EMCrit soon

Now on to the Useless Wee...
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Scott D. Weingart, MD clean 13:21
PulmCrit- Six myths promoted by the new surviving sepsis guidelines https://emcrit.org/pulmcrit/sepsis-myths/ https://emcrit.org/pulmcrit/sepsis-myths/#comments Mon, 30 Jan 2017 13:09:14 +0000 http://emcrit.org/?p=438040 Early Goal-Directed Therapy:  A house collapsing in slow motion The original foundation of the Surviving Sepsis Campaign was the Rivers trial on early goal-directed therapy.  This is basically the NINDS trial of the critical care world:  a study with ~300 patients showing implausibly positive results, published in NEJM, and rapidly brainwashing an entire discipline.  The […]

EMCrit by Josh Farkas.

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CC Nerd-The Case of the Elusive Mirage https://emcrit.org/emnerd/cc-nerd-case-elusive-mirage/ https://emcrit.org/emnerd/cc-nerd-case-elusive-mirage/#comments Sat, 28 Jan 2017 21:06:53 +0000 http://emcrit.org/?p=438001 Tales are often told of an exhausted travel who has lost their way in the desert, and are drawn astray by the the sight of a lush oasis. But as they draw close, their salvation vanishes only to reappear on the distant horizon. This optical tormentor continues to lead the hapless travelers further and further […]

EMCrit by Rory Spiegel.

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Podcast 191 – Cardiac Arrest Update https://emcrit.org/podcasts/cardiac-arrest-update/ https://emcrit.org/podcasts/cardiac-arrest-update/#comments Mon, 23 Jan 2017 13:00:09 +0000 http://emcrit.org/?p=437743 Cardiac Arrest Update & the Syndromes of Arrest

EMCrit by Scott Weingart.

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https://emcrit.org/podcasts/cardiac-arrest-update/feed/ 37 Cardiac Arrest Update & the Syndromes of Arrest
The team has done a bunch of stuff on cardiac arrest here on the EMCrit site:

* Podcast 125 - The New Intra-Arrest (Cardiac Arrest Management)
* EMNerd: The Tell-Tale Heart
* Hemodynamic-Directed Dosing of Epinephrine for Arrest
* The Future of CPR

There has been a lot of interesting stuff that has come out since my SMACCgold talk. This podcast will bring you up to date on the crap running though my mind. Beware: very little evidence lies here.
The Syndromes of Cardiac Arrest
Refractory Vfib/Vtach (Electrical Storm)

* Anti-Dysrhythmics
See EMNERD's ALPS Post
* Dual-Sequential Defib

Amazing session on EMRAP by Zack Shinar (membership required)
* Esmolol
Driver et al. (Resuscitation. 2014 Oct;85(10):1337-41 PMID 25033747)
500 mcg/kg IVP, can add a drip starting at 50 mcg/kg/min
See this great EMPharmD Post
* Take them to the Lab
* ECMO anyone?

Vasoplegia

* High-Dose Epi
* Methylene Blue
What's the dose? Who knows? I give 2 mg/kg (but not in pts on SSRIs)
* REBOA
* Junctional Tourniquet

PREM/PRES
We did an episode on this topic on the EDECMO podcast (ignore the ECG stratification stuff--since been debunked).

 
Monitoring

* ETCO2
* Cerebral ox
* Ultrasound (preferably TEE)

Time Zero Prognostication

* What can we use??
* This retrospective study from France indicates that if the pt has the following 3: 1. OHCA not witnessed by emergency medical services personnel, 2. nonshockable initial cardiac rhythm, and 3. no return of spontaneous circulation before receipt of a third 1-mg dose of epinephrine then there was no RONF and the pts should be put on the donation path. (Ann Intern Med. 2016 Dec 6;165(11):770-778. doi: 10.7326/M16-0402. Epub 2016 Sep 13.  Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation)

Blood Gases during Cardiac Arrest

* From the book Cardiac Arrest
* Study on Blood Gases during Arrest

Nurse-Run Codes

* 30 seconds to rhythm check
* Rhythm Check
* Administer Epi
* Task-Handler

Peri-Shock Pause

* Pre
Look-Through Analysis
Precharge the Defib (blogpost), (Podcast)
* During
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Scott D. Weingart, MD clean 24:26
Practical Evidence Podcast 015 – Surviving Sepsis Campaign (SSC) Guidelines 2016 (in 2017) https://emcrit.org/practicalevidence/ssc-guidelines-2016/ https://emcrit.org/practicalevidence/ssc-guidelines-2016/#comments Sun, 22 Jan 2017 18:47:38 +0000 http://emcrit.org/?p=437733 SSC 2016 Guidelines

EMCrit by Scott Weingart.

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https://emcrit.org/practicalevidence/ssc-guidelines-2016/feed/ 18 SSC 2016 Guidelines
We've discussed SEPSIS a ton on EMCrit.

* Podcast 154 - Preemptive Sepsis Panel SmaccBack
* Wee - Cliff Deutschman with Additional Thoughts on Sepsis 3.0
* Renoresuscitation: Sepsis resuscitation designed to avoid long-term complications
* Podcast 112 - A Response to the Marik Sepsis Fluids Lecture
* Podcast 169 - Sepsis 3.0 with Merv Singer
* Podcast 89 - Lessons from the STOP Sepsis Collaborative

Recently, the Surviving Sepsis Campaign released their 2016 guideline update. Overall, I think this iteration moves the guidelines closer to the best evidence out there. Of course, when you travel that path it forces a divergence from the distinctly non-evidence-based CMS guidelines. In this Practical Evidence Podcast, we will discuss the SSC guidelines, the aforementioned divergence, and various alcohol recommendations. I brought on my buddy, Jeremy Faust, to discuss the changes. Jeremy is 1/2 of the FOAMcast podcast which just discussed the new guidelines in a recent episode.
Guideline Stuff

* The SSC 2016 Guidelines
* PDF Version of the SSC 2016
* Users' Guide to the Guidelines
* Our Emergency Medicine Clinics Article

The Guideline Recommendations
The Definition of Sepsis


They basically ratified SEPSIS 3.0

(Jeremy found where he saw the remnants of the old definition; it was in the Users' guide figure 2--super contradictory)
Fluids
30 ml/kg in the first 3 hours

Crystalloid first, then maybe albumin

Use dynamic markers and/or fluid challenges

Goal MAP>65

EGDT is no longer recommended
Lactate
attempt to normalize lactate
Blood Cultures
get them before antibiotics, if obtaining them will not delay the provision of antibiotics
Antibiotics
Within 1 hour of sepsis or septic shock
Vasopressors
Norepi is the first choice, add in epi or vaso

Do not use dopamine
Steroids
200 mg Hydrocortisone for patients who are still unstable after fluids and vasopressors
Blood
In most circumstances, use a trigger of <7.0 g/dL
Glucose
goal is < 180 mg/dL
Bicarb
Not recommended if pH is >7.15 (which in no way means it is recommended for pHs less than that)
What are we Drinking?

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Scott D. Weingart, MD clean 24:38
EM Nerd-The Case of the Cryptic Truth https://emcrit.org/emnerd/em-nerd-case-cryptic-truth/ https://emcrit.org/emnerd/em-nerd-case-cryptic-truth/#comments Sat, 21 Jan 2017 20:38:11 +0000 http://emcrit.org/?p=437773 On the morning of January 1st, 2017 a number of proud South Carolinians woke up to find themselves no longer living in their former state of residence. Without moving from the beds in which they slept, they were all magically transported into the neighboring the state of North Carolina. Due to a border dispute which […]

EMCrit by Rory Spiegel.

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PulmCrit- How to convert a VBG into an ABG https://emcrit.org/pulmcrit/vbg-abg/ https://emcrit.org/pulmcrit/vbg-abg/#comments Mon, 16 Jan 2017 11:49:22 +0000 http://emcrit.org/?p=437588 This post is about a research project I did as a pulmonary critical care fellow in 2011. To understand it, you need to know a bit of the story behind it.

EMCrit by Josh Farkas.

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