EMCrit https://emcrit.org Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation Mon, 20 Feb 2017 19:56:55 +0000 en-US hourly 1 https://wordpress.org/?v=4.7.2 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) 2009-2013 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 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/ 1 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/ 4 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/ 1 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)
* Rehearsal 2 is for Body Language
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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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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/ 30 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
* 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

Shock during compressions!!!


* Post

Mechanical CPR

* Check a rhythm on EMS' monitor
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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/ 16 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?

* EMCrit is drinking South Hill Cider‘s Packbasket Still and Dry Cid...]]>
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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PulmCrit- Sedation update: IV olanzapine & combo vs. monotherapy https://emcrit.org/pulmcrit/iv-olanzapine/ https://emcrit.org/pulmcrit/iv-olanzapine/#comments Wed, 11 Jan 2017 14:03:18 +0000 http://emcrit.org/?p=423754 The potential role for IV olanzapine was examined in a post last year.  The following conclusions were reached: IV olanzapine appears to be safe. IV olanzapine has equal potency compared to IV droperidol and about twice the potency of IV haloperidol. Olanzapine doesn't affect QT interval or cause torsade de pointes. Two articles were just […]

EMCrit by Josh Farkas.

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Podcast 190 – Emergencies with a Side of Hypertension https://emcrit.org/podcasts/hypertensive-emergencies/ https://emcrit.org/podcasts/hypertensive-emergencies/#comments Tue, 10 Jan 2017 02:47:17 +0000 http://emcrit.org/?p=3008 Hypertensive emergencies look like emergencies!

EMCrit by Scott Weingart.

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https://emcrit.org/podcasts/hypertensive-emergencies/feed/ 27 Hypertensive emergencies look like emergencies!
The first thing to understand about Hypertensive Emergencies is that they look like emergencies
The second thing is in the short term, the only way to really fuck up non-emergent hypertension is by acutely lowering it too much
Hypertensive emergencies, hypertensive urgencies, markedly elevated blood pressure–ugggh! Hypertension is a real annoyance in emergency medicine. Folks get scared of numbers and encourage dangerous behavior because of them. It's a bit better in the ICU, where there is a filter to keep out non-emergent hypertension cases. “Hypertensive Emergencies” are a whole different bag. In these conditions, the hypertension is usually secondary to the actual emergency. So I prefer to call these emergencies with a side of hypertension.
Treatment Priorities
25% in the first hour

* Pain
* Inotropy/Chronotropy
* Arterial Vasodilation

The Meds

* Labetalol
* Esmolol
* Nitroglycerin
* Nitroprusside
* Nicardipine
* Clevidipine
* Fenoldopam
* Hydralazine Sucks

The Emergencies
ACS
SCAPE

* SCAPE Podcast

Aortic Dissection/AAA

*  Treatment of Aortic Dissection

Ischemic Stroke

* Stroke Podcast

ICH or TBI
aSAH

* Management of SAH

PreEclampsia/Eclampsia
Hypertensive Encephalopathy/Malignant Hypertension
a headache is not a hypertensive emergency unless the patient looks so bad that you are rushing her to CT
Usually (but not always) will have papilledema
Visual Changes, AMS, Confusion, Severe Headache, Coma
Tox
Sympathomimetic OD
MAO Inhibitors
Pheo
Acute Glomerulonephritis
Thyroid Storm

* Thyroid Storm Podcast

Want More Info?

* Great Htn Review Article from Paul Marik
* Fantastic post from the Strayer

Now on to the Podcast…

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Scott D. Weingart, MD clean 25:01
PulmCrit- Dogmalysis of PCI for NSTEMI patients with a history of CABG https://emcrit.org/pulmcrit/pci-nstemi-cabg/ https://emcrit.org/pulmcrit/pci-nstemi-cabg/#comments Mon, 02 Jan 2017 11:50:45 +0000 http://emcrit.org/?p=387511 Many patients with prior CABG probably benefit from catheterization and repeat revascularization (PCI or a repeat CABG). However, this cannot be assumed to be universally true. In particular, patients with smaller infarcts and advanced renal failure could be harmed.

EMCrit by Josh Farkas.

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EMCrit 189 – End of Year Grab Bag https://emcrit.org/podcasts/end-year-grab-bag/ https://emcrit.org/podcasts/end-year-grab-bag/#comments Wed, 28 Dec 2016 16:38:49 +0000 http://emcrit.org/?p=387430 A brain dump at the end of 2016

EMCrit by Scott Weingart.

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https://emcrit.org/podcasts/end-year-grab-bag/feed/ 16 A brain dump at the end of 2016
Some topics that have been batting around my head over the past few months:
The Secret Sixth Cause of Arterial Hypoxemia
You should know the standard five:

* V/Q Mismatch (Deadspace)
* Low FiO2
* Hypoventilation
* Diffusion Abnormality
* Shunt (Usually Physiologic)

but the sixth cause can be particularly dangerous with cause #5, the physiologic shunt. The sixth cause is Low Mixed Venous Saturation (SvO2).
Pure Vasoactives
It ain't phenlephrine anymore
Dissociated Awake for Critical AS/Pulmonary Hypertension
just keep loving this more and more
Subscribe to the EMCrit Mailing Lists (and open the messages)
Name

Email






Support the Show and Keep it on the Air
Sign Up at cme.emcrit.org
Now on the the Podcast and Happy New Year…

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Scott D. Weingart, MD clean 22:05
EM Nerd-The Case of the Otalgic Squire https://emcrit.org/emnerd/em-nerd-case-otalgic-squire/ https://emcrit.org/emnerd/em-nerd-case-otalgic-squire/#comments Tue, 27 Dec 2016 03:52:08 +0000 http://emcrit.org/?p=387365 As the year draws to a close it is safe to say that it has not been a productive twelve months for antibiotic stewardship in the Emergency Department. A recent example is the latest NEJM publication by Hoberman et al examining the efficacy of antibiotics for children with acute otitis media (OM) (1). Using a […]

EMCrit by Rory Spiegel.

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CC Nerd-The Case of the Uncertain Surrogate https://emcrit.org/emnerd/387335/ https://emcrit.org/emnerd/387335/#comments Fri, 23 Dec 2016 22:21:43 +0000 http://emcrit.org/?p=387335 I’ve often wondered if the devastating outcomes observed in patients presenting in status epilepticus (SE), are far more influenced by the underlying etiology inciting this seizure activity than the time it takes us to control this neurological outburst. And while the HYBERNATUS study does not directly address this question, it does allow for some interesting […]

EMCrit by Rory Spiegel.

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PulmCrit- Triple therapy for influenza with naproxen, clarithromycin, and oseltamavir? https://emcrit.org/pulmcrit/influenza_naproxen_clarithromycin/ https://emcrit.org/pulmcrit/influenza_naproxen_clarithromycin/#comments Mon, 19 Dec 2016 13:20:15 +0000 http://emcrit.org/?p=387077 Flu seasons is upon us again. A recent paper in CHEST provides some tantalizing evidence about possible treatment. Will this pan out, or is it just another fairy tale?

EMCrit by Josh Farkas.

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EM Nerd-An Addendum to the Case of the Incidental Bystander Part II https://emcrit.org/emnerd/em-nerd-addendum-case-incidental-bystander-part-ii/ https://emcrit.org/emnerd/em-nerd-addendum-case-incidental-bystander-part-ii/#respond Tue, 13 Dec 2016 18:11:52 +0000 http://emcrit.org/?p=386781 Recently I wrote a post discussing overdiagnosis in the workup for pulmonary embolism (PE). In it we discussed a recently published paper, the RESPECT-ED trial. Shortly after posting I was contacted by the lead author, Dr. David Mountain, with a number of comments and concerns on how the trial was represented. I have included it […]

EMCrit by Rory Spiegel.

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Podcast 188 – Rudeness Part II (the Brindley Sessions) https://emcrit.org/podcasts/rudeness-ii/ https://emcrit.org/podcasts/rudeness-ii/#comments Mon, 12 Dec 2016 18:29:49 +0000 http://emcrit.org/?p=386776 Brindley Session 2 - continuing the rudeness discussion

EMCrit by Scott Weingart.

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https://emcrit.org/podcasts/rudeness-ii/feed/ 1 Brindley Session 2 - continuing the rudeness discussion
This is part II of the Brindley Sessions on Rudeness. If you haven't yet, you should listen to Part I:
Brindley Session I – On Rudeness
In this podcast, we discuss some more concrete approaches to dealing with rudeness. I also had a chat with Paul Jhun on these issues with the ALiEM wellness thinktank.
Some Things We Mentioned
Vic Brazil's Tribalism Talk
Timing, Tribes, and STEMI from SMACC Gold
and the book she mentions:
Very Rough Sketch of the EM Culture Requests for Folks Visiting our Department

* Be Polite
* Be Kind
* Be Open Minded
* Be Communicative
* Be Non-Accustory – errors should be looked at as an opportunity to discuss, learn, and make things better in the future

Links of Interest

* Seems these issues are going on in the UK as well

Buy a Ticket to the EMCrit Conference

* EMCritConference Site

Now on to the Podcast…

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Scott D. Weingart, MD clean 22:22
Lights Camera Action: Redirecting Videolaryngoscopy (Guest Post) https://emcrit.org/blogpost/redirecting-videolaryngoscopy/ https://emcrit.org/blogpost/redirecting-videolaryngoscopy/#comments Fri, 09 Dec 2016 17:15:28 +0000 http://emcrit.org/?p=386144 Bob Dylan, Leonard Cohen, & the Cochrane review of videolaryngoscopy

EMCrit by Guest Author.

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EM Nerd-The Case of the Incidental Bystander Part II https://emcrit.org/emnerd/em-nerd-case-incidental-bystander-part-ii/ https://emcrit.org/emnerd/em-nerd-case-incidental-bystander-part-ii/#comments Fri, 09 Dec 2016 01:36:26 +0000 http://emcrit.org/?p=386500 The existence of overdiagnosis in the pursuit of pulmonary embolism (PE) is undeniable. But the burden of clinically insignificant PEs diagnosed by our current hypersensitive, zero-miss culture is less apparent. The authors of a recent article ironically entitled RESPECT-ED, attempted to quantify the role in which overdiagnosis plays in the current incidence of PE. Recently […]

EMCrit by Rory Spiegel.

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PulmCrit- Coagulation balance in sepsis-associated DIC https://emcrit.org/pulmcrit/sepsis-dic/ https://emcrit.org/pulmcrit/sepsis-dic/#comments Mon, 05 Dec 2016 13:07:41 +0000 http://emcrit.org/?p=386158 An 80-year-old man was admitted with sepsis due to liver abscess. Over the first two hospital days his platelet count decreased from 122 to 39. Prophylactic heparin was held due to concerns about bleeding risk. Additional coagulation studies showed a D-dimer of 1221 ng/ml, a fibrinogen of 672 mg/dL, and the following thromboelastograph:

EMCrit by Josh Farkas.

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Podcast 187 – Hypernatremia (Uggggh!) https://emcrit.org/podcasts/hypernatremia/ https://emcrit.org/podcasts/hypernatremia/#comments Mon, 28 Nov 2016 17:24:56 +0000 http://emcrit.org/?p=10134 Hypernatremia -- not sexy, but we gotta get 'im done

EMCrit by Scott Weingart.

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https://emcrit.org/podcasts/hypernatremia/feed/ 3 Hypernatremia -- not sexy, but we gotta get 'im done  
So we've discussed hyponatremia a ton on the blog site. That's because hyponatremia has become a little bit sexy. Not so with sodium that is too high. But I've seen a bunch of less than ideal management of hypernatremia, so I figured it is time to put out a podcast about it. This is mostly so I have a place to go to look all of this up.
Join us at the EMCrit Conference Jan 11 2017
EMCrit Conference Site
Articles

* Androgue-Madias from NEJM
* Hypo and Hypernatremia in the Crit Ill
* Hypernatremia in the Critically Ill

Read this Book

* Joel Topf is of PBF is 2nd author of an excellent fluids and electrolyte text. He has released it for free on the Precious Body Fluids Blog

How do you become Hypernatremic
Loss of free water and/or
Loss of hypotonic fluid and/or
Increased Solute and
thirst or access to water must be thwarted
Hypernatremia Results in…

* Impaired glucose metabolism
* Rhabdo
* AMS
* Seizures

Avoid Iatrogenic Complications
Cerebral Shrinkage is Bad


Causes of  Hypernatremia



Extrarenal water loss

* Dehydration by exposure
* Burns
* Gastric losses
* Diarrhea (Lactulose)
* Fever

Salt gain

* Infusion of sodium-rich fluids of some sort (eg. hypertonic saline)
* Ingestion of sea water
* Salt pica


Nephrogenic DI

* Hypercalcemia
* hypokalemia
* Lithium
* Pyelonephritis
* Medullary sponge kidney
* Multiple myeloma
* Amyloid
* Sarcoid


Central DI

* Traumatic brain injury
* Pituitary tumour
* Meningitis
* Encephalitis
* Tuberculosis
* Sarcoidosis
* Idiopathic
* ICH


Renal losses

* Glucosuria
* Mannitol
* Urea therapy
* Loop diuretics
* Post obstructive diuresis
* Hyperaldosteronism
* Cushings





This table stolen directly from Deranged Physiology (primarily b/c I hate making html tables)
Chart of Figuring Out What the Hell is Going On
Treatment
Stop or Correct the Underlying Cause
Correct Quickly if Na got high superrapid-style (Idiots drinking a quart of soy sauce)
Correct < 10 meq/day (< 0.5 mmol/L/hr) if the Na went up gradually (2-3 mmol/L/hr if rapid rise in sodium)
Oral/Gastric Tube is the safest way to correct
Administer Hypotonic Fluids (D5W, 1/4 NS, 1/2 NS, sterile water (central line))
Do not administer NS unless pt is HYPOVOLEMIC (NS doesn't work!!!; see Androgue-Madias for mathematical demonstration of this)
Calculating Required Volume
remember to account for daily losses

Probably the best way to go is to calculate with the AM-formula, resend a sodium every 2 hours for the first few hours and then recalculate with each new sodi...]]>
Scott D. Weingart, MD clean 21:09
Pulmcrit Wee- Vasopressin vs. norepinephrine for vasoplegic shock after cardiac surgery https://emcrit.org/pulmcrit/vasopressin-vancs/ https://emcrit.org/pulmcrit/vasopressin-vancs/#comments Wed, 23 Nov 2016 13:05:10 +0000 http://emcrit.org/?p=383284 Patients in the VANISH trial treated with vasopressin had a lower incidence of renal failure requiring hemodialysis. However, this was a secondary endpoint which seemed to contradict the primary endpoint (defined as a milder degree of kidney injury). New data may clarify this controversy.

EMCrit by Josh Farkas.

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PulmCrit- Devil in the details: Endotracheal tube depth https://emcrit.org/pulmcrit/endotracheal-tube-depth/ https://emcrit.org/pulmcrit/endotracheal-tube-depth/#comments Mon, 21 Nov 2016 12:39:02 +0000 http://emcrit.org/?p=365709 According to Napoleon, “the moment of greatest vulnerability is the instant immediately after victory.”  In airway management, this instant occurs immediately after placement of the endotracheal tube.  There is a risk of relaxing and overlooking critical details.  Meanwhile, this is often the point when the patient's blood pressure and saturation nadir. Introduction with a rare but […]

EMCrit by Josh Farkas.

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Podcast 186 – Coma with Eelco Wijdicks https://emcrit.org/podcasts/coma/ https://emcrit.org/podcasts/coma/#comments Sun, 13 Nov 2016 16:33:29 +0000 http://emcrit.org/?p=347218 How to Diagnose and Manage Coma

EMCrit by Scott Weingart.

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https://emcrit.org/podcasts/coma/feed/ 3 How to Diagnose and Manage Coma
So you have an unresponsive patient. The CT is negative. What now? Coma is tough! The differential is long and filled with many life threats. Today, I talk to Eelco Wijdicks about some specific questions regarding the evaluation of the comatose patient in the first few hours in the ED or ICU.
Eelco Wijdicks MD PhD is Professor of Neurology and Chair of the Division of Critical Care Neurology and currently practicing in the Neurosciences Intensive Care Unit at Saint Marys Hospital (Mayo Clinic Rochester). He is the founding editor of the journal Neurocritical care, the official journal of the Neurocritical Care Society.He has over 650 research papers,book chapters,topic reviews and editorials to his credit.
Join the RLA

Resus Leadership Academy
Eelco's Book
Coma Differential
Legend: Initial thoughts on coma in the ICU. This algorithm is a simplification of clinical practice. Localization and withdrawal motor responses are most probably not associated with brainstem involvement, and therefore the dichotomy is made. Once abnormal brainstem reflexes are found, two options are likely—acute hemispheric mass or acute brainstem lesion. Bihemispheric injury is structural or physiological and further differentiated into specific locations and suggestions for tests. ABG arterial blood gas, CSF cerebrospinal fluid, CT computed tomography, CTA computed tomography angiography, EEG electroencephalogram, SAH Subarachnoid hemorrhage
The Coma Neuro Exam

* Carefully examine the eyes (Vertical Skew, Anisocoria, Eye Movements)
* Check Brainstem Reflexes
* Check Tone
* Assess the FOUR Score

Full Outline of UnResponsiveness (FOUR) Score
FOUR Score Handout from the Mayo
Coma Review Articles

* Eelco's Amazing Article on Coma Basics
* Traub-Diagnosis and Management of Coma
* Why you may need a Neurologist to see a Comatose Patient in the ICU

Now on to the Podcast…
 

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Scott D. Weingart, MD clean 21:31
PulmCrit- New guidelines simplify ICU nutrition https://emcrit.org/pulmcrit/enteral-nutrition-intubated/ https://emcrit.org/pulmcrit/enteral-nutrition-intubated/#comments Mon, 07 Nov 2016 11:09:31 +0000 http://emcrit.org/?p=361032 Introduction to nutritional dogma Everyone has strong opinions about food.  We all feel that we have some special, intuitive understanding of nutrition.  Nonsense.  Such intuitions have historically created a wide array of dogma regarding nutrition, complicating matters immensely. Fortunately, the 2016 SCCM/ASPEN guidelines have stripped away much of the nonsense involved in nutritional support.  This […]

EMCrit by Josh Farkas.

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CC Nerd-The Case of the Sussex Vampire Continues… https://emcrit.org/emnerd/cc-nerd-the-case-of-the-sussex-vampire-continues/ https://emcrit.org/emnerd/cc-nerd-the-case-of-the-sussex-vampire-continues/#comments Mon, 07 Nov 2016 00:52:29 +0000 http://emcrit.org/?p=360506 Catheters designed for superficial vessels that can be identified by palpation or direct visualization are not effective in accessing the deeper veins of the upper extremity. We have discussed the follies of ultrasound (US) guided peripheral venous catheters in a previous post, but in brief their length and intent hinder their reliability, so much so […]

EMCrit by Rory Spiegel.

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Situation Awareness in Resuscitation Part 2: A Force of Habit https://emcrit.org/blogpost/situation-awareness-resuscitation-part-2-force-habit/ https://emcrit.org/blogpost/situation-awareness-resuscitation-part-2-force-habit/#comments Fri, 04 Nov 2016 10:36:37 +0000 http://emcrit.org/?p=336804 Now the way of life that I preach is a habit to be acquired gradually by long and steady repetition. It is the practice of living for the day only, and for the day’s work… -Sir William Osler In Situation Awareness in Resuscitation (Part 1), I discussed the cognitive science behind situation awareness (SA) and […]

EMCrit by Mike Lauria.

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PulmCrit- Top 10 reasons pulse oximetry beats ABG for assessing oxygenation https://emcrit.org/pulmcrit/pulse-oximetry/ https://emcrit.org/pulmcrit/pulse-oximetry/#comments Wed, 02 Nov 2016 11:43:18 +0000 http://emcrit.org/?p=336882 What does it mean if PaO2 and oxygen saturation seem to disagree? Do we need to measure an ABG if the oxygen saturation waveform is adequate? What is the best way to measure oxygenation?

EMCrit by Josh Farkas.

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Podcast 185 – Disruption, Danger and Droperidol by Reub Strayer https://emcrit.org/podcasts/disruption-danger-droperidol/ https://emcrit.org/podcasts/disruption-danger-droperidol/#respond Mon, 31 Oct 2016 12:41:00 +0000 http://emcrit.org/?p=283072 Danger, Disruption, and Reub Strayer

EMCrit by Scott Weingart.

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Way back in episode 60, I discussed the chemical takedown. My buddy Reub Strayer blew that podcast away with his lecture at SmaccDUB. This lecture was note-perfect and enhanced by Reub's inimitable presentation style. I know you'll enjoy it.


For more Strayer goodness, head on over to the EMUpdates Site.
Slides
Now on to the Vodcast…

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Scott D. Weingart, MD clean 26:09 yes
The Brindley Sessions: Rudeness https://emcrit.org/wee/brindley-sessions-rudeness/ https://emcrit.org/wee/brindley-sessions-rudeness/#comments Wed, 26 Oct 2016 15:07:27 +0000 http://emcrit.org/?p=56151 The first Brindley Session is on Rudeness

EMCrit by Scott Weingart.

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https://emcrit.org/wee/brindley-sessions-rudeness/feed/ 7 The first Brindley Session is on Rudeness
The Brindley sessions brings the brilliance of Peter Brindley to the EMCrit Podcast. Our first topic of conversation is rudeness and its ill effects on the medical team. Peter gave a great lecture on this topic at SmaccDUB, but I wanted to hear more.
Part II on Rudness is now up as well
Dr. Peter Brindley

Peter Brindley MD, FRCPC, FRCP (Lond), FRCP (Edin), Full-time Critical Care Doc from the University of Alberta Hospital. To the surprise of many (himself included) he is a Professor of Critical Care Medicine, Anaesthesiology, and Medical Ethics. He has authored 90 peer-reviewed manuscripts, 25 book chapters, 50 lesser manuscripts, and has two textbooks pending. He has given over 300 invited presentations in 10 countries, and over 30 plenaries. He was a founding member of the Canadian Resuscitation Institute; and was perviously Medical-Lead for Simulation, Residency Program Director, and Education Lead at the UofA. He has advised the Canadian Patient Safety Institute, and the Royal Colleges of Canada and of Edinburgh. There are many better speakers, but none happier to be here. He welcomes questions; comments and especially disagreements: after all he doesn’t wish to be wrong a moment longer than absolutely necessary.

Some Studies & Papers

* RCT of the effects of rudeness on team performance (CoreEM discussion of this paper)
* Improving Verbal Communication in Critical Care
* Improving Teamwork
* Questionnaire Study on Rudeness
* More Rudeness
* McLuhan on the Medium is the Message

Verbal AiKiDo aka Dealing with Assholes
Psychologist Albert Bernstein recommends these three tips:

* Say, “Please speak more slowly, I’d like to help” or some variation thereof. Doesn't matter if they are already speaking slow as molasses.
* Ask, “What would you like me to do to make this better.” or ANY other question. Questions short circuit the anger cycle.
* Let them have the last word

See more from this post
Now on to the Session…

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Scott D. Weingart, MD clean 22:08
PulmCrit mythbusting- Anaphylaxis to penicillins isn’t a contraindication to meropenem https://emcrit.org/pulmcrit/pulmcrit-mythbusting-anaphylaxis-penicillins-isnt-contraindication-meropenem/ https://emcrit.org/pulmcrit/pulmcrit-mythbusting-anaphylaxis-penicillins-isnt-contraindication-meropenem/#comments Mon, 24 Oct 2016 11:16:24 +0000 http://emcrit.org/?p=316875 An unconscious septic patient rolls in wearing a “PCN anaphylaxis” medic-alert bracelet. What is the best broad-spectrum antibiotic for this patient? There is no agreement between allergy guidelines, infectious disease society guidelines, or individual infectious disease experts.

EMCrit by Josh Farkas.

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DasSMACC Tickets on Sale this Week https://emcrit.org/misc/dassmacc-tickets-sale-week/ https://emcrit.org/misc/dassmacc-tickets-sale-week/#respond Sun, 23 Oct 2016 21:55:45 +0000 http://emcrit.org/?p=324790 get them before they sell out

EMCrit by Scott Weingart.

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Response to Letters on my Mechanical Ventilation Article in the Ann Emerg Med https://emcrit.org/wee/response-mechanical-ventilation/ https://emcrit.org/wee/response-mechanical-ventilation/#comments Fri, 21 Oct 2016 17:18:25 +0000 http://emcrit.org/?p=234409 Response to letters to the editor on mechanical ventilation article

EMCrit by Scott Weingart.

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Recently, I wrote an article for the Annals of Emerg Med on initial mechanical ventilation settings in the ED. Two letters to the editor were sent regarding the article. As usual, the number of words I was given to respond to these letters was grossly inadequate. So the replies the letters deserve are posted in this wee.
The Original Annals Article

* mech-vent-article

The Letters to the Editor

* Letter One
* Letter Two

Some Articles of Interest

* Breath Stacking Dysynchrony (Beitler, J.R., Sands, S.A., Loring, S.H. et al. Intensive Care Med (2016) 42: 1427. doi:10.1007/s00134-016-4423-3)
* Lung-Protective Ventilation With Low Tidal Volumes and the Occurrence of Pulmonary Complications in Patients Without Acute Respiratory Distress Syndrome: A Systematic Review and Individual Patient Data Analysis. (Crit Care Med. 2015 Oct;43(10):2155-63. doi: 10.1097/CCM.0000000000001189.)
* Chatburn – A taxonomy for mechanical ventilation

Now on to the Wee…

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Scott D. Weingart, MD clean 30:36
Situation Awareness in Resuscitation by Mike Lauria https://emcrit.org/blogpost/situation-awareness-resuscitation-mike-lauria/ https://emcrit.org/blogpost/situation-awareness-resuscitation-mike-lauria/#comments Fri, 21 Oct 2016 09:49:37 +0000 http://emcrit.org/?p=297525 The more and more you are aware, the more and more you shed from day to day what you have learned so that your mind is always fresh, uncontaminated by previous conditioning. -Bruce Lee   Perhaps one of the most dangerous events in both military and civilian retrieval medicine is hoisting. Although relatively infrequent it is […]

EMCrit by Mike Lauria.

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EM Nerd-The Case of the Incidental Bystander https://emcrit.org/emnerd/the-case-of-the-incidental-bystander/ https://emcrit.org/emnerd/the-case-of-the-incidental-bystander/#comments Fri, 21 Oct 2016 00:53:35 +0000 http://emcrit.org/?p=304556 It is quite uncommon that while reading the results of a clinical trial one feels the universal gasp of sorrow released from the hearts and minds of Emergency Physicians worldwide. Maybe it was my own personal anguish at the realization of the disastrous consequences the results of a recent trial published in the NEJM will […]

EMCrit by Rory Spiegel.

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