EMCrit Project https://emcrit.org Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation Wed, 08 Apr 2020 19:49:01 +0000 en-US hourly 1 https://wordpress.org/?v=5.4 https://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 FCCM clean episodic Scott D. Weingart, MD FCCM spambin55@gmail.com spambin55@gmail.com (Scott D. Weingart, MD FCCM) 2009- Online Medical Education on Emergency Department (ED) Critical Care, Trauma, & Resuscitation EMCrit Project http://emcrit.org/wp-content/uploads/powerpress/3000x3000-emcrit.jpg https://emcrit.org IBCC chapter: Guide to APRV for COVID-19 https://emcrit.org/pulmcrit/aprv-covid/ https://emcrit.org/pulmcrit/aprv-covid/#comments Wed, 08 Apr 2020 19:49:01 +0000 https://emcrit.org/?p=473780 COVID appears to cause a form of pseudoARDS (rather than true ARDS).  This responds especially well to APRV, often avoiding many forms of iatrogenesis (e.g., proning, paralysis, myopathy, deep sedation, and delirium).  Embracing APRV requires a zentensivist perspective on tidal volumes and minute ventilation (they will vary a bit!  you won't have total control of […]

EMCrit Project by Josh Farkas.

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COVID19 – Awake Pronation (aka the Pig Roast) A guest write-up by David Gordon, MD https://emcrit.org/emcrit/awake-pronation/ https://emcrit.org/emcrit/awake-pronation/#comments Mon, 06 Apr 2020 17:39:49 +0000 https://emcrit.org/?p=473552 Awake Proning for COVID19

EMCrit Project by Scott Weingart.

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EMCrit Wee – Webinar I Gave to Pulm/Crit Care Fellows on Avoiding Intubation and Initial Ventilation of COVID19 Patients https://emcrit.org/emcrit/avoiding-intubation-and-initial-ventilation-of-covid19-patients/ https://emcrit.org/emcrit/avoiding-intubation-and-initial-ventilation-of-covid19-patients/#comments Sat, 04 Apr 2020 16:38:50 +0000 https://emcrit.org/?p=473485 as of 3 APR 2020

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/avoiding-intubation-and-initial-ventilation-of-covid19-patients/feed/ 21 as of 3 APR 2020 ESICM Webinar Mentioned

* ESICM Seminar on COVID Ventilation

Read this to See the Thoughts of Actual Smart People

* in ICM

M. Ramzy's Infographic on the Article

Subtypes of COVID
Mild

Silent Hypoxemia (can cause iatrogenic injury when patients are intubated in this phase)

Indolent- Fine then Not (Intubated or Not-Inflammatory Markers)

Hyperacute

 
Cytokine Storm
Hemophagocytic Lymphohistiocytosis (HLH) Overlap / DIC

 
PathoPhys
Loss of hypoxic vasoconstriction

Micro-thrombotic disease

 
Avoidance of Intubation
Tachypnea, hypoxemia, do not seem to be indication

Mental status, Increased Dyspnea, PaCO2 rising

 
Progression of Therapies
NC

Venti

NRB+NC

Hi Flo with Surg Mask

CPAP—must monitor for excessive WOB

 
Non-Intubated Proning
ask them to move

 
Run them Dry
but not too dry--must replace external and insensible losses or else badness ensues

 
How to not kill patients with Intubation
EMCrit Airway Page

 
How to Ventilate
High FiO2 Strategy—Normal Compliance Patients
8 ml/kg, high fiO2

keep checking Driving Press and Plat

Avoid the PEEP Tables

Driving Pressure <=15

Proning

 

Prost/NO

 
Low Compliance Patients
6 ml/kg

Conventional Low Vt PEEP Table

Driving Pressure > 15
APRV
works for either subtype

if experienced, should be dominant mode of ventilation

 
Other Meds

* Heparin
* Steroids

 
Here is the Video Version

Audio Version Here:


 

 

 

 

 

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Scott D. Weingart, MD FCCM 47:12
PulmCrit Theoretical Post – The COVID Severity Index (CSI 1.0) https://emcrit.org/pulmcrit/csi/ https://emcrit.org/pulmcrit/csi/#comments Thu, 02 Apr 2020 09:54:14 +0000 https://emcrit.org/?p=473361 Prognostication is tough.  The challenge is often not that we have too little data, but rather that we have too much data.  There are now about two dozen risk factors for poor outcomes with COVID-19.  How are we supposed to integrate all these bits of information at the bedside?  Which pieces of information are redundant […]

EMCrit Project by Josh Farkas.

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EMCrit 269 – Rationing of Critical Care and Ventilators in COVID19 with Reub Strayer https://emcrit.org/emcrit/rationing-of-critical-care-and-ventilators-in-covid19/ https://emcrit.org/emcrit/rationing-of-critical-care-and-ventilators-in-covid19/#comments Tue, 31 Mar 2020 19:20:14 +0000 https://emcrit.org/?p=473152 You need a plan right now for the allocation of scarce resources

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/rationing-of-critical-care-and-ventilators-in-covid19/feed/ 14 You need a plan right now for the allocation of scarce resources

In many hospitals ventilators have become a scarce or non-existent resource in the face of the COVID19 pandemic. We need a ethical structure to allocate ventilators and other scarce resources:
Exclusion Criteria before Entry into Ventilator Allocation Strategies

* Swiss Intensive Care Society Guidelines

 
Reub's Adaptation of the NYC Vent Allocation Guideline

* Strayer Ventilator-Allocation-Protocol
* Original EMUpdates Post
* ECOG Calculator


Original NYC Vent Allocation Guidelines

* 2015 Update

 
Publications

* NEJM Allocating Vent Discussion
* NEJM Fair Allocation of Scarce Medical Resources in the Time of Covid-19
* JAMA White & Lo
* Requests for Potentially Inappropriate Treatments in Intensive Care Units

Forming a Rationing Team

* LitFL Post

Now on to the Podcast...]]>
Scott D. Weingart, MD FCCM 24:11
EMCrit Wee – Stop Kneejerk Intubation with the EMCrit Crew https://emcrit.org/emcrit/stop-kneejerk-intubation/ https://emcrit.org/emcrit/stop-kneejerk-intubation/#comments Mon, 30 Mar 2020 16:59:57 +0000 https://emcrit.org/?p=473212 not NC at 6lpm then tube

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/stop-kneejerk-intubation/feed/ 69 not NC at 6lpm then tube Additional Stuff

* Cameron Kyle-Sidell, MD Video
* Chest PT
* Incentive Spirometry
* Gattinoni Article in the Blue Journal

Now on to the wee...]]>
Scott D. Weingart, MD FCCM 14:16
PulmCrit wee – Why the SCCM/AARC/ASA/APSF/AACN/CHEST joint statement on split ventilators is wrong. https://emcrit.org/pulmcrit/pulmcrit-wee-why-the-sccm-aarc-asa-apsf-aacn-chest-joint-statement-on-split-ventilators-is-wrong/ https://emcrit.org/pulmcrit/pulmcrit-wee-why-the-sccm-aarc-asa-apsf-aacn-chest-joint-statement-on-split-ventilators-is-wrong/#comments Sun, 29 Mar 2020 13:45:57 +0000 https://emcrit.org/?p=473149 The story began in early March.  With COVID-19 bearing down upon us, it became clear that we could run out of ventilators.  This sparked interest in the concept of splitting ventilators between several patients.  Some articles and videos were circulated on twitter describing how this could be done.  These mostly described splitting a ventilator set […]

EMCrit Project by Josh Farkas.

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EMCrit Wee – Alternatives to Vent Splitting and the Safest Vent Splitting Methods in COVID19 https://emcrit.org/emcrit/alternatives-to-vent-splitting-and-the-safest-vent-splitting-methods-in-covid19/ https://emcrit.org/emcrit/alternatives-to-vent-splitting-and-the-safest-vent-splitting-methods-in-covid19/#comments Sat, 28 Mar 2020 21:32:24 +0000 https://emcrit.org/?p=473084 Will be updated as new info comes in...

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/alternatives-to-vent-splitting-and-the-safest-vent-splitting-methods-in-covid19/feed/ 4 Will be updated as new info comes in...  
Hospital Non-Invasive Machines can be Adapted for Invasive Ventilation
Issues:

Most machines are single tube circuits that allow exhalation from a vented mask. If hooked up to an ETT, you need an exhalation port and it must be proximal to a viral filter. Many of the companies sell circuits purpose-built for this, for example:

Respironic's Version

If not, items can be adapted to this use by Respiratory Therapy. Key is anything venting to the environment is filtered
Home BiPAP/CPAP Machines
Same deal as above

Adapting the V60
Back-Up Ventilators
Many chronically vented patients have their primary ventilator and a back-up in their homes. If they want to help, their community, a loan of these back-up ventilators would be helpful.
Oxygen Powered Commercial CPAP Devices
Like the Boussignac device, Pulmodyne Go-PAP,

and similar devices
Intensive Blog's take on NHS Guidance on CPAP
Anesthesia Machines

* APSFASA Anesthesia Machines as ICU Ventilators

Oxylator
See the EMCrit Post

With a PEEP cap in place, these will replace a ventilator
EMCrit CPAP Set-Up
can be used for invasive CPAP through an ETT for patients who are awake and spontaneously breathing freeing up the ICU ventilators for patients requiring mandatory breaths.



see video describing set-up on EMCrit COVID Airway Post

This will not be as comfortable as a legit machine, but it should get the job done
Vortran Garbage Disaster Vents

* Instructional Video

 
Splitting Non-Invasive CPAP




Listen to the Wee below for more on this...

Should work on invasive CPAP as well
Helmet CPAP

* Helmet-Based Ventilation

Splitting Ventilators
This seems absolutely a last resort situation. SCCM has released a guidance document saying the same:

* SCCM Statement on Vent Splitting
* PULMCrit Retort to the SCCM Statement
* Read Jack Iwashyna take on the issue

If it has to be done, there are a number of sources for info on the FOAMverse. Josh released his thoughts in his PULMcrit Post.
Additional Vent Splitting Resources

* Strategic Clamping
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Scott D. Weingart, MD FCCM 9:34
COVID Airway Management Thoughts https://emcrit.org/emcrit/covid-airway-management/ https://emcrit.org/emcrit/covid-airway-management/#comments Fri, 27 Mar 2020 16:30:25 +0000 https://emcrit.org/?p=472076 additional COVID airway management thoughts

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/covid-airway-management/feed/ 96 additional COVID airway management thoughts For the Most Comprehensive Info on COVID19, go to Josh's IBCC Chapter
 

PPE - What to Wear

* N95 (add a PAPR if available to the N95)
* Surgical Mask over N95
* Goggles that surround eyes with facial contact, face shield, or full joint-replacement-hood with visor (full face coverage desperately preferred)
* Bunny suit, preferably with hood or disposable fluid-proof gown
* Something to cover your neck if not in hood
* If no hooded suit available, disposable cap
* 2 pairs gloves, 1 under sleeves of bunny suit or gown and 1 over, under-layer gloves would ideally be long cuffed
* Booties are a big doffing risk, so wear shoes you can disinfect

Preoxygenation
All of this is based on no evidence (there are no evidence-based strategies out there)
Non-Rebreather
This has been the most recommended strategy in articles/write-ups, but in my mind, it may be the worst of the viable options. To get a decent fiO2, you will need to crank it up to flush rate and I am not sure what effect that will have on the patient’s exhalations becoming aerosolized.
NIPPV
This has been panned for potential to increase risk to providers—however, that is predicated on passive exhalation systems (i.e. vents exhalation goes to the environment and has only 1 tube). However, a 2-tube system is a closed circuit. With the addition of 2 viral filters, this may be acceptable in a negative pressure room. It can also be left on during the apneic period with a jaw thrust. Place on CPAP/PSV, leave the PSV at 0, dial up PEEP only if patient’s saturations do not come up with 100% fiO2.

Critical Note: If you use the vent for preox, you MUST disconnect the vent circuit proximal to the viral filter before removing the mask. Otherwise, COVID will be sprayed all around the room!!!!! See Triple C below.
 
BVM with Viral Filter

* If you don’t have a vent available
* Turn BVM flow up to flush rate, higher flows do not translate to patient end of the bvm
* Place viral filter between BVM stem and mask
* Ideally, a NIPPV mask should still be placed to allow good seal with you away from the patient or just hold two hands on the mask in a thumbs-forward grip

from Safer Airways
* Addition of nasal cannula underneath will allow CPAP with PEEP valve if needed. I would only turn NC up to 4-6 lpm if this used. Often NC fits with no mask leak. More preferable is porting the oxygen through a luer or pressure connection port.

 
Optimal Preoxygenation
The first video uses a nasal cannula, the second avoids the NC leading to even less mask leak:
The Nasal Cannula Video (Next Video avoids using Nasal Cannula)

EMCrit CPAP Set-Up without the NC

Here is a Pict

Here is a Pict with the 22mm OD Male-to-Male Connector and Corrugated Tubing

Better way to use the 3-way Stopcock
I showed in the video that you can use O2 tubing with 3-way stopcock but there is a clean oxygen leak. Bill Murphy, medic extraordinaire, wrote me with a better way. Cut off the fat part of the O2 line.]]>
Scott D. Weingart, MD FCCM 1 15:10
EMCrit – Critical Care for Non-Intensivists during COVID19 Pandemic https://emcrit.org/emcrit/critical-care-for-non-intensivists/ https://emcrit.org/emcrit/critical-care-for-non-intensivists/#comments Wed, 25 Mar 2020 17:09:40 +0000 https://emcrit.org/?p=472804 Crit Care during COVID19

EMCrit Project by Scott Weingart.

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PulmCrit- Is Lopinavir/Ritonavir down and out? https://emcrit.org/pulmcrit/lopinavir-ritonavir/ https://emcrit.org/pulmcrit/lopinavir-ritonavir/#comments Thu, 19 Mar 2020 13:16:11 +0000 https://emcrit.org/?p=472535 A lot has happened since the last post on Lopinavir/Ritonavir (it was only March 4, but it seems like a year ago).  Here is a quick reminder of where we left off:  Lopinavir/ritonavir (tradename KALETRA) is a combination of protease inhibitors used in HIV, which might also be effective in COVID-19. Prior studies on SARS […]

EMCrit Project by Josh Farkas.

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PulmCrit Wee- Could the best mode of noninvasive support for COVID-19 be… CPAP ?? https://emcrit.org/pulmcrit/cpap-covid/ https://emcrit.org/pulmcrit/cpap-covid/#comments Tue, 17 Mar 2020 18:32:13 +0000 https://emcrit.org/?p=472429 COVID-19 patients seem to behave in a somewhat unique fashion, compared to other patients with ARDS.  This isn’t based on high-level data, but it seems to be a theme emerging from a variety of centers (including my experience with one patient).  Some salient points are: Low driving pressures are seen among ventilated patients.  Thus, it […]

EMCrit Project by Josh Farkas.

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PulmCrit – Splitting ventilators to provide titrated support to a large group of patients https://emcrit.org/pulmcrit/split-ventilators/ https://emcrit.org/pulmcrit/split-ventilators/#comments Sun, 15 Mar 2020 20:30:52 +0000 https://emcrit.org/?p=472287 COVID-19 might out-strip the number of mechanical ventilators available to us.  This has led to interest in using a single ventilator to support multiple patients.  This post will review the theory and evidence regarding this (with the admission that I don’t have experience with this). basic principles Bedrock principle:  Patient-Ventilator Independence Normally, we adjust the […]

EMCrit Project by Josh Farkas.

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EMCrit 267 – They are not All Right!! An interview on Hemodynamic Assessment with Mike Patterson https://emcrit.org/emcrit/hemodynamic-lows/ https://emcrit.org/emcrit/hemodynamic-lows/#comments Fri, 06 Mar 2020 21:41:27 +0000 https://emcrit.org/?p=471195 Patients can become neurologically injured or code with no overt signs

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/hemodynamic-lows/feed/ 10 Patients can become neurologically injured or code with no overt signs Michael Patterson FCICM FANZCA
Mike is an intensivist anaesthetist in Melbourne. He has spent years thinking about disasters seen in anaesthetics and ICU--most of them are hemodynamic ones. His original interest in this problem stemmed from the death of a young lady having elective gynae surgery, in the setting of anaphylaxis. She had an easily palpable central pulse and reassuring EtCO2 throughout. He was involved late due to issues with arterial access. She died of a hypoxic brain injury solely because her pressure was too low for too long. He has been reflecting on this over the last few years and building up a picture of the problems and the solutions. Subsequently, he had been involved in one patient that died in the setting of a POCUS pulse but inadequate pressure and another young lady who lived despite nearly the same problem occurring as the lady that died.
Central pulses are almost meaningless
- We are mostly just feeling a change in pressure

- Hence 50/10 might feel similar to 120/80

Central pulses are particularly dangerous in distributive shock where the pulse will be felt strongly below 50/-. This has been my repeated experience. It is easily palpable even in hypovolaemic shock with BP < 60 on occasion - You can’t measure pressure from a central pulse until you place an arterial line
POCUS Pulse as a Representation of Adequate Pulse
The use of POCUS to confirm flow in the femoral artery or palpation of a femoral artery pulse is problematic, as you discussed. In your hands (and proper resuscitationists), there will be an arterial line in place very quickly so it is a non-issue. Obviously, those involved in resuscitation should fix their system to achieve this but for lots of reasons that is a problem in many parts of the world (including most Melbourne ED’s/ICU’s).

The problems with ROSC in the setting of PEA or profound hypotension in general are:

POCUS pulse has the same problems as a central pulse unless applied to the brachial artery where you can place a manual cuff and visualize the occlusion pressure
Normal EtCO2
A normal EtCO2 is not reassuring that the pressure is adequate, as you mention - It is useful to suggest ROSC when it kicks up - It is dangerous as any reassurance in distributive shock where pulmonary perfusion is maintained and EtCO2 often doesn’t drop at all despite BP’s < 50/- - In the cardiac arrest setting, PaCO2 has often risen significantly so an EtCO2 in the 30’s may still represent inadequate perfusion let alone pressure I like your step-wise summary of the progression to ROSC. It is brilliant.

 



The yellow zone is where all the badness is happening in the anaesthetic world and I wonder if that is true in ED and ICU but we just don’t recognize it (as the patients are sick beforehand so any bad outcome isn’t attributed to the haemodynamic management).

You explained the problems with this zone excellently but I wonder if people will appreciate the dangers of a POCUS pulse or a palpable central pulse for that matter. I am concerned they will be misused and prolong periods of hypotension. I know you were only talking PEA but the issues are the same in profound hypotension.

My approach is as follows in the setting of profound hypotension = POCUS pulse:
Radial Pulse?
Identify that the radial pulse is rapidly and easily felt before you have a problem - This is obviously irrelevant for those presenting in cardiac arrest - In most other circumstances, if you knew it was strong and easily palpable prior, you can’t end up with confirmation bias - convincing yourself there is no problem. Occasionally it is difficult to locate prior,]]>
Scott D. Weingart, MD FCCM 1 22:35
PulmCrit – Preview of Lopinavir/Ritonavir efficacy in COVID-19? https://emcrit.org/pulmcrit/lopinavir/ https://emcrit.org/pulmcrit/lopinavir/#comments Wed, 04 Mar 2020 12:01:28 +0000 https://emcrit.org/?p=471914 background Lopinavir/Ritonavir (tradename KALETRA) is a combination of protease inhibitors typically used in HIV, including post-exposure prophylaxis (lopinavir is the actual antiviral agent, with ritonavir functioning to inhibit metabolism of lopinavir, thereby boosting levels of lopinavir).  In vitro, Lopinavir/Ritonavir has activity against SARS-CoV-1 and functions synergistically with ribavirin (the addition of ribavirin increases Lopinavir's potency […]

EMCrit Project by Josh Farkas.

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IBCC: COVID-19 https://emcrit.org/pulmcrit/covid19/ https://emcrit.org/pulmcrit/covid19/#comments Mon, 02 Mar 2020 15:35:31 +0000 https://emcrit.org/?p=471848 Friends, As COVID-19 has exploded, so has the amount of information about COVID-19.  There are currently over 700 publications regarding coronavirus listed in PubMed within the past few months.  More are being released daily.  Many haven’t been catalogued on PubMed yet. This chapter will attempt to synthesize the latest and most important information on COVID-19.  […]

EMCrit Project by Josh Farkas.

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Tox and Hound – Love and Half-Life* https://emcrit.org/toxhound/half-life/ https://emcrit.org/toxhound/half-life/#comments Wed, 26 Feb 2020 13:35:03 +0000 https://emcrit.org/?p=471673 by Sarah Shafer *Not the video game I’ve gotten some version of this call many times in my budding career as a medical toxicologist: “Hello, we have a something-year-old patient in the ER who overdosed on ______ (fill in the blank) medication. How long do we need to watch them before we can medically clear […]

EMCrit Project by Tox & Hound.

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PulmCrit- Nonsedation in ventilated patients: Two dueling RCTs https://emcrit.org/pulmcrit/nonseda/ https://emcrit.org/pulmcrit/nonseda/#comments Wed, 26 Feb 2020 12:42:22 +0000 https://emcrit.org/?p=471688 A new study in NEJM compared nonsedation with light sedation in ventilated ICU patients.  This is a follow-up study, aimed at clarifying the results of a prior trial at the same center.  To best understand the current study, we need to start with the first trial… Strom et al. 2010:  A protocol of no sedation […]

EMCrit Project by Josh Farkas.

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PulmCrit- My favorite 20 abstracts from SCCM https://emcrit.org/pulmcrit/sccm-abstracts-2020/ https://emcrit.org/pulmcrit/sccm-abstracts-2020/#comments Tue, 25 Feb 2020 12:11:59 +0000 https://emcrit.org/?p=471424 The Society of Critical Care Medicine published over 1,800 abstracts to go along with their latest conference. I sifted through them to come up with my favorite 20. Kudos to all the authors on creating diverse and thoughtful work – the future of critical care is indeed bright! The abstracts are divided into six groups: […]

EMCrit Project by Josh Farkas.

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EMCrit 266 – High Sensitivity Troponins with Louise Cullen https://emcrit.org/emcrit/high-sensitivity-troponins/ https://emcrit.org/emcrit/high-sensitivity-troponins/#comments Thu, 20 Feb 2020 19:04:52 +0000 http://emcrit.org/?p=10672 High Sensitivity Troponins are coming

EMCrit Project by Scott Weingart.

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https://emcrit.org/emcrit/high-sensitivity-troponins/feed/ 1 High Sensitivity Troponins are coming Professor Louise Cullen
Louise Cullen is a Senior Staff Specialist in the Department of Emergency Medicine, Royal Brisbane and Women’s Hospital, and an active clinician-researcher with particular interests in acute cardiac diseases, syncope, and cardiac biomarkers. She is widely published in numerous peer-reviewed journal including the Lancet. Her mantra is that “You do not do research for research sake” and as such, clinical redesign and translational research is a key part of her endeavours.
 COI
Dr. Cullen reports receiving grants from Roche; grants, consultancy fees, and personal fees from Abbott Diagnostics; personal fees from AstraZeneca; and personal fees from Novartis outside of the submitted work.

We have resolved these conflicts by:

1. Not speaking of any individual manufacturer's assays

2. In the US, the manufacturers are eliminating prior assays, thereby obviating the conflict of discussing hsTN (i.e. there will be no purchasing decision on your part--you're getting 'em whether you like it or not)
High Sensitivity Troponins
IFCC has released a lab spec sheet on troponins

Troponin values must be individualized based on your hospital's assay
ACS Decision Aides

* IMPACT Trial
* Comparison of four decision aids for the early diagnosis of acute coronary syndromes in the emergency department
* MDCalc TMACs
* MDCALC EDAC
* HsTNi with decision rules

Other FOAM

* EM Topics

Now on to the Podcast...
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Scott D. Weingart, MD FCCM 1 26:04
IBCC chapter & cast – Vasopressors https://emcrit.org/pulmcrit/pressors/ https://emcrit.org/pulmcrit/pressors/#comments Thu, 20 Feb 2020 13:40:18 +0000 https://emcrit.org/?p=471535 Vasopressor use is an everyday exercise in critical care.  Unfortunately, high-level evidence regarding these agents is often lacking.  Furthermore, patients may react in unique ways.  This chapter attempts to clarify some vasopressor basics, but beware – all of your patients will not read the book. The IBCC chapter is located here. The podcast & comments […]

EMCrit Project by Josh Farkas.

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PulmCrit – It’s insane to keep using mortality as a primary endpoint in critical care trials https://emcrit.org/pulmcrit/mortality-2/ https://emcrit.org/pulmcrit/mortality-2/#comments Wed, 19 Feb 2020 13:11:20 +0000 https://emcrit.org/?p=471504 There, I’ve said it.  That’s a bit of a bold statement, but it seems to be supported by the evidence. failure to prove mortality benefit A post in 2018 explored the difficulty of proving mortality benefit from any intervention.  To summarize, there are many barriers to proving all-cause mortality benefit: Mortality is decreasing over time […]

EMCrit Project by Josh Farkas.

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Tox and Hound – One Therapy To Rule Them All? Sugar vs Squeeze in Cardiotoxic Poisoning https://emcrit.org/toxhound/hdi-vs-pressor/ https://emcrit.org/toxhound/hdi-vs-pressor/#comments Tue, 18 Feb 2020 21:02:09 +0000 https://emcrit.org/?p=471416 by Jon Cole and Meghan Spyres Jon: Meghan, thank you for joining me on this post. I’ve wanted to write about the logistics of high dose insulin (HDI) for some time now, but I have a lot of my own biases about where insulin belongs in the ordering of our therapies for sick cardiotoxic overdoses […]

EMCrit Project by Tox & Hound.

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PulmCrit – The 65 trial: Is 60 the new 65? https://emcrit.org/pulmcrit/65trial/ https://emcrit.org/pulmcrit/65trial/#comments Sat, 15 Feb 2020 13:01:33 +0000 https://emcrit.org/?p=471254 The 65 trial compares MAP targets of >65 mm to >60 mm in treating vasodilatory hypotension.  This trial challenges decades of protocols which have targeted a MAP >65 mm.  As such, it is a courageous and practice-changing study.  However, we need to be realistic about the study’s limitations.     trial overview This multi-center RCT was […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Anaphylaxis https://emcrit.org/pulmcrit/anaphylaxis/ https://emcrit.org/pulmcrit/anaphylaxis/#respond Thu, 13 Feb 2020 13:47:37 +0000 https://emcrit.org/?p=471222 Anaphylaxis is a somewhat unique emergency, as one of the few conditions which can kill an otherwise healthy person within a matter of minutes.  This is very treatable, so immediate and definitive management is paramount.  To make matters worse, different patients will manifest with a variety of diverse presentations, so a high index of suspicion […]

EMCrit Project by Josh Farkas.

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PulmCrit – Steroid for ARDS? The DEXA-ARDS trial https://emcrit.org/pulmcrit/dexa-ards/ https://emcrit.org/pulmcrit/dexa-ards/#comments Wed, 12 Feb 2020 13:06:22 +0000 https://emcrit.org/?p=471159 A fresh trial shows considerable efficacy of dexamethasone in ARDS.  This may come as a bit of a surprise, but it’s actually entirely consistent with prior evidence.  To understand the study, we need to start with previous data… Part I:  Background:  The Rabbit hole of ARDS, pneumonia, and septic shock We often think about ARDS, […]

EMCrit Project by Josh Farkas.

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PulmCrit Wee: The Yale experience with hyperdiuresis https://emcrit.org/pulmcrit/hyperdiuresis-yale/ https://emcrit.org/pulmcrit/hyperdiuresis-yale/#comments Tue, 11 Feb 2020 12:28:19 +0000 https://emcrit.org/?p=471140 Hyperdiuresis involves combining hypertonic saline with a loop diuretic for management of diuretic-resistant volume overload.  This may seem a bit counter-intuitive, but there are several reasons why it might work:  Hypochloremia promotes sodium retention; this could be reversed with hypertonic saline.  Hypertonic saline could osmotically pull fluid into the intravascular space, thereby promoting diuresis without […]

EMCrit Project by Josh Farkas.

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IBCC chapter & cast – Status epilepticus https://emcrit.org/pulmcrit/status-epilepticus-3/ https://emcrit.org/pulmcrit/status-epilepticus-3/#comments Sat, 08 Feb 2020 13:46:52 +0000 https://emcrit.org/?p=471058 Status epilepticus is one of the true neurologic emergencies, where minutes may actually count.  Prompt and definitive treatment often yields excellent outcomes, whereas sluggish or inappropriate treatment can have severe consequences.  Management has changed substantially over the past decade including a new definition of convulsive status epilepticus (>5 minutes of seizing, rather than >30 minutes) […]

EMCrit Project by Josh Farkas.

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EMCrit 265 – ECPR 2.0 (ECMO CPR) https://emcrit.org/emcrit/ecpr-2-0/ https://emcrit.org/emcrit/ecpr-2-0/#comments Wed, 05 Feb 2020 19:46:55 +0000 https://emcrit.org/?p=471005 Our ECPR is different...

EMCrit Project by Scott Weingart.

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This ECPR interview was origianlly published on edecmo.org. The interview was conducted by my buddy, Zack Shinar. I wanted to expose a broader audience to the episode, so I am reposting it here:
ECPR 2.0
The Patient
1. OOH Cardiac Arrest Patients are Different

Cannulation
2. Ultrasound-Guided Percutaneous Placement
3. Wire choices
4. Wire Location Verification
5. Small arterial cannulae
6. Simpler Circuits

Post-Pump Critical Care
7. Find the Injuries
8. Mandatory leg perfusion
9. Lower Anticoagulation Goals
10. Lower Flow Goals
11. Try to avoid venting – Truby et al. PMID:28422817, less is more
12. Understanding Cardiac Prognostication / Stunning
13. Understanding Neuro Prognostication
14. Protection/Ownership
15. In it for the Long Haul
16. Lower Anticoagulation and Hb targets
17. Parade your Successes to every person in the chain
Now on to the Podcast...]]>
Scott D. Weingart, MD FCCM clean 38:34
Tox & Hound – A Toxicological Brain Teaser. The Complexities of Valproic Acid Metabolism. https://emcrit.org/toxhound/vpa/ https://emcrit.org/toxhound/vpa/#comments Wed, 05 Feb 2020 00:51:34 +0000 https://emcrit.org/?p=470932 by Christine Murphy What do you think about when you hear the words “drug toxicity”? Do you think about a patient who overdosed or someone who is experiencing a toxic side effect from a medication? A lot of times, the answer might depend on what we remember about a drug when we hear the name. […]

EMCrit Project by Tox & Hound.

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PulmCrit- WHO guidelines regarding fluid administration for coronarvirus are dangerously misguided https://emcrit.org/pulmcrit/coronavirus/ https://emcrit.org/pulmcrit/coronavirus/#comments Tue, 04 Feb 2020 12:45:14 +0000 https://emcrit.org/?p=470909 The Surviving Sepsis Campaign is a blight on modern, evidence-based medicine.​1​  It’s been clear for some years that its fundamentals were flawed (centering around rapid, large-volume fluid resuscitation).  Rather than adapt guidelines to modern evidence, the campaign recently doubled down on immediate administration of fluid and antibiotics within one hour.  This provoked widespread protest, including […]

EMCrit Project by Josh Farkas.

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EMCrit – Midlines Part 2-Explosion with Rory Spiegel https://emcrit.org/emcrit/midlines-part-2/ Sat, 01 Feb 2020 18:26:48 +0000 https://emcrit.org/?p=470885 Midlines part 2 with @emnerd

EMCrit Project by Scott Weingart.

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Midlines part 2 with @emnerd
Here is part 2 on midlines.

See Part 1 for the shownotes and introduction. Also, go to part 1 to comment on midline stuff.
Part 1-Primer on Midlines
Now on to the Podcast...
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Scott D. Weingart, MD FCCM clean 25:43
IBCC chapter & cast – Hypocalcemia https://emcrit.org/pulmcrit/hypocalcemia/ https://emcrit.org/pulmcrit/hypocalcemia/#comments Thu, 30 Jan 2020 13:34:04 +0000 https://emcrit.org/?p=470783 Hypocalcemia in the ICU is one of the more confusing electrolyte abnormalities, because it's frankly unclear exactly what to do with it.  Most patients in ICU are hypocalcemic, but there is little evidence that trying to “replete” hypocalcemia back to euboxia is beneficial (or even feasible).  Of course, there are some patients who have severe […]

EMCrit Project by Josh Farkas.

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EMCrit 264 – Case Discussion of Combined CCB and BB Overdose https://emcrit.org/emcrit/combined-ccb-and-bb-overdose/ https://emcrit.org/emcrit/combined-ccb-and-bb-overdose/#comments Sun, 26 Jan 2020 20:16:52 +0000 http://emcrit.org/?p=443214 A case as a means of discussing severe CCB and BB OD

EMCrit Project by Scott Weingart.

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Today, we discuss a case of a patient who 45 mintues prior to arrival took took 150 Labetalol 100mg and 70 Amlodipine 10mg.
Hemodynamically Neutral Intubation

* See this EMCrit Podcast

3 Presentations for CCB or BB OD

* Vasodilatory
* Negative-Inotropy (& Chronotropy)
* Combined Picture

Vasopressor-Only Management
For me this is only appropriate for primarily vasodilatory shock (PMID 23642908, Skoog et al., Levine et al.)
Tum-E-Vac Commercial Device for Gastric Lavage
If you believe in lavage...

from manufacturer site
Prior Post on Calcium Channel Blocker OD

* EMCrit Podcast 27

Tox & Hound on Mechanism of Insulin

* Insulin for CCB/BB OD

Now on to the Podcast...
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Scott D. Weingart, MD FCCM clean 34:53
PulmCrit- The Rothman Index: Artificial intelligence or merely a symptom of a broken healthcare system? https://emcrit.org/pulmcrit/rothman-index/ https://emcrit.org/pulmcrit/rothman-index/#comments Sat, 25 Jan 2020 12:16:27 +0000 https://emcrit.org/?p=470621 We are constantly hunting for newer and better sources of information.  This leads to a perpetual generation of newer lab tests, different hemodynamic gizmos, and fresh decision tools.  Some of these pan out.  Most don’t. Why are these new sources of information generally disappointing?  The answer is simple:  we’re already doing pretty well.  In order […]

EMCrit Project by Josh Farkas.

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“B-Sides” in Analgesia https://emcrit.org/toxhound/b-sides/ https://emcrit.org/toxhound/b-sides/#comments Thu, 23 Jan 2020 18:58:04 +0000 https://emcrit.org/?p=470608 by Meghan Spyres Ketamine was gifted to the world as a result of investigations into its evil older brother: phencyclidine (PCP). PCP, commonly known as ‘angel dust’ (quite the misnomer, Urban Dictionary suggests the use of the more fitting ‘devil dust’. . .) was initially used as a pharmaceutical in the 1950s under trade name […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast – Toxic Alcohols https://emcrit.org/pulmcrit/alcohols/ https://emcrit.org/pulmcrit/alcohols/#comments Thu, 23 Jan 2020 13:14:53 +0000 https://emcrit.org/?p=470596 The diagnosis of toxic alcohols is a particularly controversial topic, based on recent evidence that the osmolal gap has a fairly awful sensitivity and specificity.  This chapter describes an approach to toxic alcohol diagnosis which doesn't depend on the osmolal gap.  Although this may seem radical, this strategy has been previously recommended by other authors […]

EMCrit Project by Josh Farkas.

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PulmCrit – An alternative view of the PEPTIC trial https://emcrit.org/pulmcrit/peptic/ https://emcrit.org/pulmcrit/peptic/#comments Wed, 22 Jan 2020 12:39:42 +0000 https://emcrit.org/?p=470539 The PEPTIC multi-center RCT compared histamine-2 receptor blockers (H2RBs) versus proton pump inhibitors (PPIs) for stress ulcer prophylaxis among ventilated ICU patients.​1​  It’s a landmark trial of unprecedented size and statistical power.  PEPTIC was presented at the Critical Care Reviews meeting in Ireland and live-cast around the world (available here).  This presentation and the editorials […]

EMCrit Project by Josh Farkas.

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EM Nerd: The Case of the Sour Remedy Continues https://emcrit.org/emnerd/em-nerd-the-case-of-the-sour-remedy-continues/ https://emcrit.org/emnerd/em-nerd-the-case-of-the-sour-remedy-continues/#comments Mon, 20 Jan 2020 19:14:48 +0000 https://emcrit.org/?p=470507 The use of IV vitamin C as a therapeutic agent in sepsis has caught the hearts and minds of emergency medicine and critical care clinicians. Since the publication of a small single center before and after study by Marik et al in 2017 (1), we have spent countless hours screaming into the void that is […]

EMCrit Project by Rory Spiegel.

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PulmCrit- Metabolic Resuscitation: Was the answer inside us all along? https://emcrit.org/pulmcrit/vitamins/ https://emcrit.org/pulmcrit/vitamins/#comments Fri, 17 Jan 2020 12:33:15 +0000 https://emcrit.org/?p=470415 Now that VITAMINS is published, it’s worth trying to look at the big picture of sepsis treatment with hydrocortisone, ascorbate, and thiamine (HAT).  Marik et al. 2017:  The beginning HAT therapy began with a single-center, before/after study.​1​ There was a stark mortality reduction following the routine adoption of HAT therapy in septic shock (figure below, […]

EMCrit Project by Josh Farkas.

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