EMCrit Podcast - Critical Care and Resuscitation https://emcrit.org Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation Wed, 12 Dec 2018 20:00:24 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.9 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 episodic 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 Podcast - Critical Care and Resuscitation http://emcrit.org/wp-content/uploads/powerpress/3000x3000-emcrit.jpg https://emcrit.org EMCrit 238 – Medical Error Epidemic Craziness with G. Gianoli https://emcrit.org/emcrit/medical-error-epidemic-craziness/ Wed, 12 Dec 2018 16:43:58 +0000 http://emcrit.org/?p=452087 EMCrit 238 - Medical Error Epidemic Craziness with G. Gianoli. Medical Error is the 3rd leading cause of death in the US--or is it? EMCrit 238 - Medical Error Epidemic Craziness with G. Gianoli. Medical Error is the 3rd leading cause of death in the US--or is it?
You and your brethren are the 3rd leading cause of death in the United States. Medical error is rampant, why are you not doing anything about this problem?
How many times have you heard these statistics and others like them? How many times have you been berated by patient safety experts using these very statistics as their foundation and their whip. Have you ever wondered how these statistics could possibly be true when it doesn't jibe at all with your day-to-day experience.

I know I have wondered...

Today, we get to the bottom of this craziness.
Gerard Gianoli, MD
He did an internship in General Surgery and an internship in Pediatrics. Following a residency in Otolaryngology- Head and Neck Surgery, he completed a fellowship in Otology, Neurotology and Skull Base Surgery at the Michigan Ear Institute. He was a full-time Associate Professor at Tulane Medical School until July 2000 when he joined Ear and Balance Institute. He still maintains a Clinical Associate Professor appointment at Tulane in both the Department of Otolaryngology-Head and Neck Surgery and the Department of Pediatrics. He has published and lectured extensively in the field of Neurotology and serves on multiple Editorial Review Boards for the fields of Neurotology and Otolaryngology.
Dr. Gianoli's Two Pieces on the Medical Error Studies

* Medical Error Hysteria1
* Unreliable Research on Error-Related Hospital Deaths in America - Gianoli and Dunn2

The Makary and Daniel article

* From the BMJ

More...

* Additional reanalysis from Shojania

Now on to the Podcast...





1.
Gianoli G. Medical Error Epidemic Hysteria. Am J Med. 2016;129(12):1239-1240. [PubMed]




2.
Gianoli G. Unreliable Research on Error-Related Hospital Deaths in America. JPANDS. 2016;21(4):104-108. http://jpands.org/vol21no4/gianoli.pdf.



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Scott D. Weingart, MD clean 17:09
EMCrit Podcast 237 – Vent & PreVENT – An Update https://emcrit.org/emcrit/vent-prevent/ Wed, 28 Nov 2018 19:39:36 +0000 http://emcrit.org/?p=455055 More on Vents More on Vents PreVENT Trial

* PreVENT Trial
* The Bottom Line on the PreVENT Study

Dominating the Vent Series

* EMCrit Lecture – Dominating the Vent: Part I
* EMCrit Lecture – Dominating the Vent: Part II
* Response to Letters on my Mechanical Ventilation Article in the Ann Emerg Med

PRVC Refs

* A rabbit study1
* PC vs. PRVC in Brain Injury Patients2
* Work of Breathing Analysis
* Small Study demonstrating that you are not getting the Vt you think you are3
* Small Crossover Trial4

Now on to the Podcast

References




1.
Porra L, Bayat S, Malaspinas I, et al. Pressure-regulated volume control vs. volume control ventilation in healthy and injured rabbit lung: An experimental study. Eur J Anaesthesiol. 2016;33(10):767-775. [PubMed]




2.
Schirmer-Mikalsen K, Vik A, Skogvoll E, Moen K, Solheim O, Klepstad P. Intracranial Pressure During Pressure Control and Pressure-Regulated Volume Control Ventilation in Patients with Traumatic Brain Injury: A Randomized Crossover trial. Neurocrit Care. 2016;24(3):332-341. [PubMed]




3.
Kallet R, Campbell A, Dicker R, Katz J, Mackersie R. Work of breathing during lung-protective ventilation in patients with acute lung injury and acute respiratory distress syndrome: a comparison between volume and pressure-regulated breathing modes. Respir Care. 2005;50(12):1623-1631. [PubMed]




4.
Guldager H, Nielsen S, Carl P, Soerensen M. A comparison of volume control and pressure-regulated volume control ventilation in acute respiratory failure. Crit Care. 1997;1(2):75-77. [PubMed]



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Scott D. Weingart, MD clean 24:31
EMCrit Wee – The Brindley Sessions – Followership https://emcrit.org/emcrit/followership/ Sun, 11 Nov 2018 22:14:31 +0000 http://emcrit.org/?p=451181 on followership on followership

Another iteration of the Brindley Sessions:
The Article
Followership by Leung, Lucas, Brindley et al.
The Table

Figure 1: Robert Kelley’s Followership dimensions and styles, adapted from Kellerman (2008)1



in the podcast, the passive followers are described as yes-people
from: https://www.medicalprotection.org

More Sparks for Ideas

* Kelley's followership model with discussion
* A related discussion we published in BMJ
* A discussion on culture (including nations) by Geert Hofstede
* And a darn good book about cultivating "eulogy virtues" rather than "resume virtues"
* NOLS 4 leadership roles

Listen to the Rest of the Brindley Sessions
More from Peter
Now on to the Session...
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Scott D. Weingart, MD clean 26:48
EMCrit 236 – George Kovacs on EVLI Airway Incrementalization https://emcrit.org/emcrit/evli/ Wed, 31 Oct 2018 17:45:25 +0000 http://emcrit.org/?p=455075 Approach to steps of laryngoscopy/intubation Approach to steps of laryngoscopy/intubation
A video lecture from my friend and airway guru,  Prof. George Kovacs. He has been obsessed with airway for decades. This lecture discusses breaking down the steps of airway management into chunks.
George's Site

* AIME Airway

More from George on EMCrit

* The Psychologically Difficult Airway by George Kovacs
* Definitive Emergent Awake Intubation with George Kovacs
* Airway Things I Learned from George Kovacs at the NYC Airway Course
* Antifragile in EM by George Kovacs

Now on to the Vodcast...


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Scott D. Weingart, MD clean 22:07 yes
EMCrit #235 – Cardiac Arrest Science with Zack Shinar https://emcrit.org/emcrit/cardiac-arrest-science/ Wed, 17 Oct 2018 16:17:05 +0000 http://emcrit.org/?p=451613 Cardiac Arrest Science Cardiac Arrest Science


Today, I get to speak with my buddy Zack Shinar about soem cardiac arrest science.

Questions Discussed

Is there a no-flow time past which there is no hope for survival?
If there is, how do we know the pt was actually fully no-flow--are we are conflating no-cpr for no flow?
What is the survival limit on low flow time?
VF survival is not linear across time. What happens to that number if you strip out all the 1-2 shock v-fib (real comparator for ecmo right?
Who are the few (5%) of non-ecpr patients who survive after 30 minutes of CC?
Effect of Transient ROSC on outcome data






Current Cardiac Arrest Assumptions – mantras needs changing

* Cardiac arrest rhythms have overlap but are very different disease
* Termination of Resuscitation (TOR) is outdated
* Pre-hospital prognostication needs an increase in sophistication

Some Literature on the Stuff Spoken About



* Asystole in patients with wearable ICDs are much better than historical1
* Shockable rhythm patients can have neurologically intact survival with CPR out to 47 minutes (mRS 0-3)2
* When Should EMS Transfer-Transport for ECPR should be considered between 8 to 24 minutes of professional on-scene resuscitation, with 16 minutes balancing the risks and benefits of early and later transport. Earlier transport within this window may be preferred if high quality CPR can be maintained during transport and for those with initial non-shockable rhythms.3 50%of ROSC would be captured at 8 minutes and 90% by 16 minutes.
* Reynolds et al. found similar data with 21 minutes being the 90% capture mark.4
* PEA should prob. not be an exclusion for ECMO, they can have a 23% neuro intact survival in this paper.5
* Wake County Data Packet
* Rate of Brain Death and organ donation, possibly another reason field termination in the field is a bad strategy in viable cohorts
* Adnet et al. on No-Flow and Low-Flow Durations

Other EMCrit Links of Interest

* Cardiac Arrest Update
* EMS Field Decisions in Cardiac Arrest with Howie Mell

Sign up for REANIMATE6 before tickets sell out
REANIMATEconference.com
Now on to the Podcast...

References




1.
Liang J, Bianco N, Muser D, Enriquez A, Santangeli P, D’Souza B. Outcomes after asystole events occurring during wearable defibrillator-cardioverter use. World J Cardiol. 2018;10(4):21-25. [PubMed]




2.
Reynolds J, Grunau B, Rittenberger J, Sawyer K, Kurz M, Callaway C. Association Between Duration of Resuscitation and Favorable Outcome After Out-of-Hospital Cardiac Arrest: Implications for Prolonging or Terminating Resuscitation. Circulation. 2016;134(25):2084-2094. [PubMed]




3.
Grunau B, Reynolds J, Scheuermeyer F, et al. Relationship between Time-to-ROSC and Survival in Out-of-hospit...]]>
Scott D. Weingart, MD clean 33:06
EMCrit 234 – Pardon Me, I Couldn’t Help but Overhear or How to go from being an Ass-hole to an AYS-hole on Twitter https://emcrit.org/emcrit/ays-holes/ Wed, 03 Oct 2018 19:21:07 +0000 http://emcrit.org/?p=454458 Are you saying?... Are you saying?...
* Jenny Rudolph on WTF



* Pew Center Article
* Types of People to Hate on Facebook


Now on to the Podcast...
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Scott D. Weingart, MD clean 25:43
EMCrit 233 – EMCrit Failed Airway Algorithm 2018 from ResusTO https://emcrit.org/emcrit/failed-airway-algorithm-2018/ Wed, 19 Sep 2018 16:11:24 +0000 http://emcrit.org/?p=453905 Remixed and Better for 2018 Remixed and Better for 2018 Why First Pass Success?
Best review article - first-shot-is-the-best-shot

Each Attempt Makes Things Worse

Hasegawa et al. showed at 3 attempts, things got bad (Ann Emerg Med 2012;60:749)

Sackles JC et al. showed that >1 attempt radically increased complications (ACADEMIC EMERGENCY MEDICINE 2013; 20:71–78)

Mort demonstrated this in the ICU, after two attempts risk of crit desat (70%) is huge and assoc. with cardiopulm arrest (Anesth Analg 2004;99:607)

Mort has further elaboration re: the dangers of intubation in the critically ill (J Inten Care Med 2007;22(4):208)

Heffner et al. showed a 4% cardiac arrest rate in ED intubations (Incidence and factors associated with cardiac arrest complicating emergency airway management. Resus 2013)

Duggan showed >1 attempt = badness
Learning Curve for Laryngoscopy
Best review of lit is at Openairway
EMCrit Failed Airway Algo V2.0

Bug the ResusTO Folks to Do the Course Again
ResusTO
Blade Views by Nick Chrimes

Now on to the Vodcast...


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Scott D. Weingart, MD clean 37:14 yes
EMCrit 232 – SteelMan Debate – EMS Field Decisions in Cardiac Arrest with Howie Mell https://emcrit.org/emcrit/ems-field-decisions-in-cardiac-arrest-with-howie-mell/ Wed, 05 Sep 2018 16:11:42 +0000 http://emcrit.org/?p=453318 Stay or Go with Cardiac Arrest in the Field? Stay or Go with Cardiac Arrest in the Field? A few tweets sparked a debate (big surprise there) and suddenly there was a storm of opinions on whether OOH cardiac arrests should be transported or terminated in the field. Well, since I do not debate on twitter anymore, I needed a person to speak with on the topic--and there is no better than Howie Mell.

Howie Mell, MD, MPH, FACEP
Chair - ACEP Subcommittee on EMS Education
Reservist Emergency Physician - Vituity
Host of the So What 2.0 podcast
SMACCforcer
(@DrHowieMell)


Steel-Man Rules for this Debate

* Any time you want to contradict the other discussant, you must first restate the views they have just stated and confirm with them that you are understanding correctly. If you can bolster their point even more strongly before contradicting, this is even better.
* No ad-hominem attacks (i.e. attacks on the person, not their views. Feel free to politely destroy the views)
* Logical fallacies should be pointed out
* Try to state whether a viewpoint is based on evidence, and what quality or based on your clinical practice

Accepted as Given?

* We are dealing with Adults
* Asytole without signs of life should be run and terminated in the field
* There are EMS services and EDs where EMS does a better job running the arrest than the ED, in those venues EMS should run almost all codes to field termination
* There are some venues where nothing (nothing!) additional gets done in the ED beyond what EMS can do, in those venues EMS should run almost all codes to field termination

The Questions

* What is a public health view of EMS vs. a medical view?
* What is the best approach to <75 y/o vfib/vtach/PEA patient without end-stage comorbidity?
* Can we safely get these patients to the ED?

Cardiocerebral Resuscitation (CCR)

* Watch Ben Bobrow's vid
* Search for Pit Crew CPR to see amazing coordination and perfect, continuous hand cpr

Beam Me Up Scotty?
if we had teleporters…
Can We Safely Transport?
Take Out 1-2 Shocks from the Field Success Rates
and everything changes!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
why is this cheaper?
Things I Can Do in the ED

* Ultrasound
* TEE
* Arterial Lines
* Esmolol
* DSD
* Multiple Antidysrhythmics for Electrical Storm
* Cath Lab
* ECMO
* Blood
* Pericardial Drainage
* Thrombolytics

 
3 Scenarios for when a Resus Center can make a difference
Vfib shocks to Sinus and then Regresses
these patients almost always have a coronary lesion and there is NOTHING the field management can offer these patients. Even if they don’t you don’t have the monitoring to keep these patients in sinus. multiple pressors/varied pressors
Electrical Storm
there is nothing the field is going to accomplish in these patients
PEA

* what you can fix—hypoxemia
* what you can’t accurately diagnose

* tension pneumo


* what you can’t

* bleeding
* pericardial tamponade
* PE
* SAH


* what you sort of can

* hyperk
* toxicology in most protocols



Please tell us what you think in the comments section below
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Scott D. Weingart, MD clean 44:27
EMCrit 231 – How to Practice Cricothyroidotomy (Cric) https://emcrit.org/emcrit/how-practice-cricothyroidotomy-cric/ Sat, 25 Aug 2018 15:32:29 +0000 http://emcrit.org/?p=453216 How to use the cric models and optimal surgical airway technique. How to use the cric models and optimal surgical airway technique.
Call it cric, call it surgical airway, call it FONA. Whatever you call it, you need to have the skills and mindset to make it happen at the ready every time you intubate. Every month make an appointment for yourself to practice cric (just like my buddy Sara Gray does).
First, you Need the Model
Head over here and print out a 3D model to have for the rest of your career
Next, Buy Some Gaffer Tape




One roll will last a LONG time. And trust me, buy the gaffer power brand, some of the knockoff brands really suck.
Then Acquire Some 4x4s and Plastic Bags
I think you know where to find some...
Then, Watch the Video

For More on All Things Cric
Come on over to the EMCrit Cric Page

They made a bleeding model using Laura's Model



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Scott D. Weingart, MD clean yes
EMCrit #230 – Resuscitation Communication https://emcrit.org/emcrit/resuscitation-communication/ Wed, 08 Aug 2018 18:00:42 +0000 http://emcrit.org/?p=452074 Precise Resuscitation Communication is crucial for patient safety Precise Resuscitation Communication is crucial for patient safety
What we have here is a failure to Resus Communicate...

Inspired by Reid, Brindley, Hicks, & Novak
My Favorite Paper on Resus Communication

* by the Brindley

Lecture You Must Watch

* Novak on Combat Aviation Lessons

Resus By Voice

* from flying by voice
* Shared Mental Model
* Resuscitate - Differentiate - Communicate

Tactical Pause (Hick's term)

* Step-Back or SitRep
* aka The Cross-Check- Keep coming back to the global patient picture before diving into any minutiae
* "What am I missing" - team realignment
* Ten-for-Ten1


Close the Loop


* Set a notification -"Put in an art line and tell me when it is done"

Podium Nurse

* 360 awareness
* Assignment of Tasks (3 Cs: Clear Instructions, Cite Names, Close the Loop)

Sterile Cockpit

* 10,000 feet
* Train the team to acknowledge that phrase
* Central Line Kits / Shock Trauma Hallways

Resuscitese

* from Cliff
* Combat Mitigating Language-Efficient and Unambiguous Communication - Directive, Descriptive, Informative
* Belay that
* Acknowledge or Close-the-Loop
* Say Again
* Read Back
* Tally Ho
* Nato Phonetic and

Briefings
PreBrief

* Planning: Mission, Defined Roles, and Set the tone
* Zero Point Survey Self-Team-Environment


Debrief

* Learning happens in the debrief
* Hot Debrief - INFO Model

Additional Info

* Communication Under Pressure
* More Critical Strategies
* LitFL Article

Sai De Silva

What are your thoughts on resuscitation communication? Tell me in the comments section below.
Now on to the Podcast...





1.
Rall M. Human Performance and Patient Safety. In: Miller’s Anesthesia. Saunders; 2015:3271.



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Scott D. Weingart, MD clean 20:05
EMCrit Podcast 229 – No-Shitters, Boldface, and the Resus QRH https://emcrit.org/emcrit/no-shitters-boldface-rqrh/ Wed, 25 Jul 2018 14:53:40 +0000 http://emcrit.org/?p=452373 drum roll please... drum roll please...
In an amazing lecture; Joe Novak, ED doc and former combat aviator; spoke about the need for memorized boldface actions and then the availability of a quick reference handbook (QRH) for the next steps. But where are either of those things for resuscitation? That lack was the inspiration for the past 4 years of my life and the life of my guest this week, Dave Borshoff. Dave is an anesthesiologist in Perth, AU and a former pilot. He is author of the Anesthesia Crisis Manual and co-editor of the just-released Resus Crisis Manual.
A QRH from a Cockpit

The Bold Face for Emergency Ejection

The Rest of the QRH for Controlled Ejection

Combat Aviation with Joe Novak
EMcrit # 99
Ready to Check Out the RCM?


See the Resus Crisis Manual
Now on to the Podcast...


Music by Caged Dreams (CC)]]>
Scott D. Weingart, MD clean 18:22
EMCrit Wee – The Mock Trial Verdict and a Discussion with Mike Weinstock https://emcrit.org/emcrit/mock-trial-verdict/ Mon, 23 Jul 2018 20:45:04 +0000 http://emcrit.org/?p=452399 The verdict is in... The verdict is in...
We recently put up an amazing mock trial of an anaphylaxis case put together by my friend Mike Weinstock. If you have not watched that, then this wee is pretty much useless to you. In this discussion, we reveal the verdict and talk a little bit of the philosophy of malpractice and how to stay safe in the ED. I think you'll like it!]]>
Scott D. Weingart, MD clean 21:30
EMCrit Wee – The Great Beta-Blocker for Cocaine Toxicity Slugfest https://emcrit.org/emcrit/beta-blocker-for-cocaine-toxicity/ Sun, 22 Jul 2018 17:49:38 +0000 http://emcrit.org/?p=451615 Is it safe to use beta-blockers in cocaine toxicity and is that even the questions... Is it safe to use beta-blockers in cocaine toxicity and is that even the questions... The Participants (alphabetically)
Jeff Lapoint (@lapizity)
Emergency Physician and Medical Toxicologist
Director, Division of Medical Toxicology
Kaiser San Diego
California, USA

John Richards (@JR_Code3)
Emergency Physician
Professor of EM
UC Davis Emergency Medicine
California, USA
The Posts that Got us Here

* John on LitFL
* Jeff on the Tox and the Hound

Steel-Man Rules for this Debate

* Any time you want to contradict the other discussant, you must first restate the views they have just stated and confirm with them that you are understanding correctly. If you can bolster their point even more strongly before contradicting, this is even better. The moderator may prompt you if you forget.
* No ad-hominem attacks (i.e. attacks on the person, not their views. Feel free to politely destroy the views)
* Logical fallacies will be pointed out by the moderator if they have not been by the other discussant
* Try to state whether a viewpoint is based on evidence, and what quality or based on your clinical practice

The Questions

* Should beta-blockers be used in patients with cocaine toxicity?

* How are we defining cocaine toxicity?
* Does Unopposed Alpha phenomena actually exist?
* Are beta-blockers safe in cocaine toxicity?
* Even if they are safe, is there any compelling reason we should use them over other treatments?


* What about the non-floridly toxic patient, for instance: a case of hypertensive, tachycardic, sweaty patient with chest pain. Already received 2 rounds of Ativan and nitro with continuing symptoms, see how each manage
* Do your thoughts on beta-blockers in cocaine toxicity apply to the other stimulants?
* What about patients who admit to taking cocaine in the recent past, but show no signs of toxicity--Is it safe to use beta-blockers in these patients?

* A case: 48 y/o with type I DM, HTN, High Chol. Presents with substernal CP, first trop negative. For some reason nurses obtained a urine drug screen positive for cocaine. When asked, pt states he is an occ. User and last use was 2 days ago. Denies any use today. Pt has been totally forthcoming about all of his drug use and you believe him. Your hospital uses CTCA for this risk category of chest pain to allow immediate discharge for f/u if negative. You order the test, but radiology refuses to do the scan b/c of the requirement for beta-blockers and a drug screen positive for cocaine. Is this justified or not?



Additional Info

* John's extensive publications on cocaine and beta-blockers
* If you don't trust my editing and want an unabridged version, it is here.

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Scott D. Weingart, MD clean 34:21
EMCrit RACC 228 – Physiology-Guided Cardiac Arrest Management in 2018 with Dr. Robert Sutton https://emcrit.org/emcrit/emcrit-racc-228-physiology-guided-cardiac-arrest-management-in-2018-with-dr-robert-sutton/ Wed, 11 Jul 2018 16:27:04 +0000 http://emcrit.org/?p=451898 Physiology-Guided Cardiac Arrest Management in 2018 with Dr. Robert Sutton Physiology-Guided Cardiac Arrest Management in 2018 with Dr. Robert Sutton
The slide above is from an SCCM talk by Robert Sutton. Dr. Sutton is a pediatric intensivist at CHOP in Philadelphia. His research interests include pediatric CPR quality research with a focus on evaluating novel interventions, both educational and technological, with the overall goal to improve care delivered to children during resuscitation attempts.
What We Spoke About...
We went box by box through the algorithm above. Note, very little of this is supported by high level evidence. However, neither is anything we are doing now--so be wary of staus quo bias.
Additional Info

* An article by Dr. Sutton on Hemodynamic Guided CPR
* Physio-Guided CPR1
* Article: Ahn, S et al. Sodium bicarbonate on severe metabolic acidosis during prolonged cardiopulmonary resuscitation: a double-blind, randomized, placebo-controlled pilot study. J Thorac Dis 2018; 104(4): 2295-2302
from rebelem
* Comp. of DBP and ETCO2 for CT quality (hint DBP is better)
* Brain Ox

Prior Posts on EMCrit

* Podcast 125 - The New Intra-Arrest (Cardiac Arrest Management)
* Podcast 191 - Cardiac Arrest Update

Now on to the Podcast...





1.
Morgan RW, Sutton RM, Berg RA. The Future of Resuscitation. P. 2017;18(11):1084-1086. doi:10.1097/pcc.0000000000001316



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Scott D. Weingart, MD clean 33:53
EMCrit RACC – A Refractory Anaphylaxis Mock Trial by Mike Weinstock https://emcrit.org/emcrit/refractory-anaphylaxis-mock-trial/ Thu, 05 Jul 2018 14:45:43 +0000 http://emcrit.org/?p=452054 A refractory anaphylaxis case presented as a mock trial A refractory anaphylaxis case presented as a mock trial
The Case (Refractory Anaphylaxis and Difficult Airway)

* Mock Trial - The Case

 
Please place your vote on the verdict below!
Photo by Melinda Gimpel
Video Version

Audio Version
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Scott D. Weingart, MD clean 1:26:20
EMCrit Podcast – Acid Base Ep. 7 – Bicarb Updates, Quantitative Approach, and Prof. David Story https://emcrit.org/emcrit/bicar-icu-lactate-debate/ Thu, 28 Jun 2018 17:25:18 +0000 http://emcrit.org/?p=451770 Bicar-ICU changes my practice with bicarb infusions and let's end the great lactate debate on EMCrit 227: Bicar-ICU changes my practice with bicarb infusions and let's end the great lactate debate on EMCrit 227:
The Acid Base Series


Time for more discussion of acid-base, a subject you know i obsess about.
Bicar-ICU Trial

* Read the amazing trial by Jaber et al.
* PulmCrit's take
* The Bottom Line
* CCNerd

Keith Corl's Email
Hi Scott,

By now I'm sure you've seen the work from Jaber's group on using bicarb in critically ill academic patients. Obviously there are limitations to the trial, not the least of them a negative primary outcome. And while the study wasn't powered to look a 28 day mortality or 7 day organ failure in those with a AKIN score of 2-3 I am sure many will take this positive secondary finding and run with it.

My biggest criticism was that they didn't break the study down into patients with anion gap metabolic acidosis (AGMA) vs. non-anion gap metabolic acidosis (NAGMA). I'm a big fan of your acid base pods and tend to agree with your take and the Forsythe paper and don't give bicarb to patients with an AGMA. So I went ahead and emailed Jaber and he got back to me. He told me that "90% of the patients enrolled were hyperlactatemic." Moreover, most GI and renal patients with base loss were excluded b.c. bicarb was considered standard care, therefore the "large majority" had an AGMA. Interesting, now I'm second guessing myself and wondering if I should consider bicarb in AKIN patients with a AGMA.

I'm interested to hear your thoughts. I think it would make a great pod or a topic for Josh or Rory.

I hope all is well,

Keith
 

then I bring on Dr. David Story to discuss acid base and a set of posts by Jon-Emile Kenny.

Professor David Story

Head of Anaesthesia, Perioperative and Pain Medicine Unit (APPMU), Melbourne Medical School, University of Melbourne; Director, Melbourne Clinical and Translational Sciences (MCATS) research platform
Jon-Emile Kenny Lactate Debate Posts

* Part 1
* Part 2

Gamblegram


go to acidbase.org and use their analyzer to truly understand the quantitative approach
More Stuff to Read

* Hemodynamic Consequences of Severe Lactic Acidosis

Intracellular pH always decreases with sodium bicarb (See Table I)
Bicarb administration causes ICal
If you control CO2 and Calcium, then it works (Animal Study-Anesthesiology 2014;120:926)

Now on to the Podcast...


 

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Scott D. Weingart, MD clean 25:42
EMCrit Podcast 226 – Airway Update – Bougie and Positioning https://emcrit.org/emcrit/bougie-and-positioning/ Wed, 13 Jun 2018 14:26:54 +0000 http://emcrit.org/?p=451435 A discussion of bougie-first, bougie best and hopefully a summary of proper positioning A discussion of bougie-first, bougie best and hopefully a summary of proper positioning
Bougie First?
A recent RCT from Hennepin1 by Driver et al. evaluated the effect of bougie use on first pass success. This adds to a prior retrospective study by the same group.2 These studies lend support to a practice that many of us have already adapted--bougie first intubation.
Few things on the bougie stuff

Some bougies are too short & this leads to A LOT of their downsides (RCT used a 70 cm bougie, as opposed to the 60cm bougie that I have)
Most bougies don't retain their shape, which is a shame b/c the airways where you most need the bend to stay are the ones that are least likely to tolerate multiple removals to reshape. Levitan bougie should solve this
We cannot conflate the Hennepin article with preloading the bougie

Technique

* A discussion is in the episode and 2-person vs. 1 person

Can You Advance an ETT over a bougie without having someone grab the proximal end first?​

* Listen to the episode and let me know what you think

How to know the bougie is in when used in a C/L 3 view

* Clicks - I find this unreliable
* Hold-Up - as long as this is done gently, it is fantastic
* Laura Duggan recommends: A trained assistant with gentle thumb on one side, two fingers on the other of trachea at the sternal notch is priceless to confirm placement without the need for the 'hang up test'



What about the Pre-Load Techniques?
See this poster for one bench eval



VBM S-Guide

* Video for S-Guide

I'd also like to see their METTS stylet. Go to VBM Medical to see these.
Snail Trail for Bougie Bending


from3 though I actually put the circle closer to the tip
Also See

* Bougie Vids
* EMNerd on the Bougie RCT
* Kovacs on why he doesn't like the D-Grip
* ETT vs. Railroad Bougie vs. Preload Bougie
* Sal on Driver's first study

Update

* This is the highest FPS I have seen using CMAC and Frova on all intubations4

Positioning

stand behind the patient
lift their head
and push their head towards their feet (causing base of neck flexion)
until their ear holes (ext auditory meatus) are at or higher than the level of their sternal line (sternal notch to xiphoid process)
while constraining the face plane to stay parallel to the ceiling
then padding under head & shoulders until this position is maintained


Semler et al.5 showed Ramping is worse, however you'll need to listen to the podcast to understand what that means.





 



 

 

 



1st step: head lift or flex lower Cx spine to flatten secondary curve (red curve):

A. obese patient: ~7cm head elevation - poor positioning (at least C&L Gr 3)

B. obese adult: 1x pillow under shoulders & 2x pillows (or equiv) under head = "ramped" or

C. head of bed elevated so ext meatus level with sternal notch
...]]>
Scott D. Weingart, MD clean 25:26
EMCrit Podcast 225 – Tox(&Hound)idromes with Howard & Dan https://emcrit.org/emcrit/tox-hound-idromes/ Mon, 28 May 2018 15:07:13 +0000 http://emcrit.org/?p=451224 The real scoop on toxidromes The real scoop on toxidromes
I brought the DantasticTox guys back to discuss how toxidrome really present, you know in real life.
If you missed their first EMCrit episode, go listen:

* EMCrit Podcast 215 - A Disagreement of Toxicologists

and then check out the Dantastic Tox Podcast


Anticholinergic
Altered, but will give you 3 seconds of attention

Big, non-reactive pupils (constrictors knocked out); Pupils may not even be enormous until you stimulate and then they get wide

Dry-everywhere. Put a gloved hand in the axilla if you are brave like Howard

Voice--Worst cottonmouth ever


Picking behaviors (this is the big one) - they will be plucking at EVERYTHING. Taking off gown.

Stimulus evoked tachycardia

Bowel Sounds-screw bowel sounds, because DEMONS

 
Cholinergic
Like Spongebob when you squeeze-water comes from everywhere

“SLUDGE”: Salivation, Lacrimation, Urination, Defecation, GI cramping, Emesis + “Killer B’s”: Bronchorrhea, Bradycardia, Bronchospasm

Pinpoint pupils

Pooping on themselves

Lacrimation

So remember cardiogenic shock with crying and diarrhea and pinpoint pupils.


 
Sympathomimetic
Mydriasis, but briskly reactive (i.e. they will constrict when you shine light)

Sweaty

Psychomotor agitation, Paranoia, Psychotic, but they will respond to questions (but you won't like the answers)

Tachycardia, htn,

BODY TEMPERATURE

Blunts fatigue, pain response, and exhaustion

Sedative/ETOH Withdrawal can only really be differentiated by history

 
Opioid
bradypnea first then look at the pupils


 
Sedative/Hypnotics
Sleepy

Ventilations preserved

Benzo plus is where the problem comes
Now on to the Podcast...]]>
Scott D. Weingart, MD clean 26:56
EMCrit Podcast 224 – TTP & DIC with Tom DeLoughery – Part II – Treatment https://emcrit.org/emcrit/ttp-dic-part-ii/ Mon, 14 May 2018 16:29:18 +0000 http://emcrit.org/?p=437979 Part 2 of DIC vs TTP - Treatment Part 2 of DIC vs TTP - Treatment

This is Part II of a 2-part lecture on TTP, DIC, and thrombocytopenia in the critically ill patient. It was given by Tom Deloughery at the EEMCrit Conference. The Essentials folks have a video package of the whole day at their site.
See Part I for Diagnosis
TTP
Never Give Platelets Never Give Platelets Never Give Platelets

Plasma Exchange is the treatment of Choice

Temporize with 2 units of Plasma, then 1 unit q6 hrs until plasma exchange

These patients will not bleed regardless of PLTs when you place the HD Cath--just do it (but not the intern)

Give Steroids (i.e. 125 mg solumedrol or similar)

 

Send ADAMSTS13 find out how long it takes and make sure it is sent before plasma exchange

 
Goals

* PLT target >150,000 on 2 draws
* normalizing LDH
* neuro sx fixed

after this, 2 more days; then cold turkey or wean

 
DIC
Treat underlying cause (duh_

Transfuse to

* Fibrinogen > 150 (200 in OB disasters) -- Give 10-pack of cryo and recheck (even in places that have fibrinogen conc.)
* PLT > 50
* HCT > 21
* PTT < 1.5 x control
* INR < 2-3

Heparin and AT III have not panned out. Only use heparin if there is macro-thrombosis (i.e. PE)
Now on to the Vodcast...
]]>
Scott D. Weingart, MD clean 20:03
EMCrit – Retract SSC 2018 – You Only Have Yourself to Blame if You Do Not Take Action https://emcrit.org/emcrit/retract-ssc-2018/ Tue, 08 May 2018 18:04:43 +0000 http://emcrit.org/?p=450782 please read this post--if you care about your practice and your patients please read this post--if you care about your practice and your patients

Please, please read the guidelines, listen to the wee, and then if you agree--sign the petition below
Literature Mentioned

* 2018 SSC Guidelines 1-hour Bundle
* Prehospital Antibiotics didn't result in benefit
* Kumar Editorial

Additional Resources

* Merv Singer on Early Antibiotics for Sepsis
* PulmCrit Take
* EMNerd Take
* PulmCCM Take
* Must Read: Evidence Underpinning the US Government-Mandated Hemodynamic Interventions for Sepsis
* IDSA's rationale for not endorsing

The Petition

*
Please sign here if you agree with this wee

]]>
Scott D. Weingart, MD clean 17:46
EMCrit Podcast 223 – TTP & DIC with Tom DeLoughery – Part I – Diagnosis https://emcrit.org/emcrit/ttp-dic-1/ Mon, 30 Apr 2018 16:10:24 +0000 http://emcrit.org/?p=449617 Low platelets in the Critically Ill Patient--TTP, DIC, MAHA Low platelets in the Critically Ill Patient--TTP, DIC, MAHA

This is Part I of a 2-part lecture on TTP, DIC, and thrombocytopenia in the critically ill patient. It was given by Tom Deloughery at the EEMCrit Conference. The Essentials folks have a video package of the whole day at their site.
See Part II for Diagnosis
Tom DeLoughery MD, MACP, FAWM
Professor of Medicine, Pathology and Pediatrics, Divisions of Hematology/Oncology and Laboratory Medicine at Oregon Health & Science University

Tom DeLoughery is a native Hoosier who graduated from Indiana State University in 1981 (one year after Larry Bird) and the Indiana University School of Medicine in 1985. He did his internship at the University of California, Irvine before traveling to Oregon where he finished his internal medicine residency and hematology/oncology fellowship.

His clinical interests are in blood diseases, hemostasis, and thrombosis, subjects on which he has written extensively. He has won numerous teaching awards and has given education sessions to national meetings of many professional societies. He is a master at the American College of Physicians and Fellows of the Academy of Wilderness Medicine. Recently the 3rd edition of his popular handbook Hemostasis and Thrombosis was published. His one odd fact is that he has been to 40 Bob Dylan concerts in 5 countries.
Thrombotic Thrombocytopenic Purpura (TTP)

* Primary Disease
* Decreased ADAM-TS-13
* A Disease of Excess Platelet Aggregation
* Terrible Triad



* No schistocytes = no TTP
* Symptoms wax and wane

Disseminated Intravascular Coagulation (DIC)

* aka Disease-Induced Coagulopathy
* Secondary Disease
* Too much thrombin
* Thrombosis and Bleeding
* Platelet Activation
* Markedly increased D-Dimer
* Decreased Fibrinogen
* Normal Coags = No DIC

Amazing Image Above by Dr. Hanson
Now On to the Vodcast...


 ]]>
Scott D. Weingart, MD clean 19:25
EMCrit RACC Podcast 222 / EDECMO Podcast – Demetris Yannopoulos on ECPR-the Minneapolis Way https://emcrit.org/emcrit/yannopoulos-ecpr/ Sun, 08 Apr 2018 18:49:22 +0000 http://emcrit.org/?p=450007 Yannopoulos on ECPR Yannopoulos on ECPR

You are getting this podcast 1 week early.

We do an EDECMO ECPR course each year called REANIMATE. REANIMATE5 blew away all previous iterations. One of the main reasons was our guest of honor, Demetris Yannopoulos from the University of Minnesota. Demetris has organized Minneapolis into arguably the most impressive ECPR city in the world. We were lucky enough to be able to film his Sharp Hospital Grand Rounds. This lecture was mind-blowing and made me so jealous. We think you will love it.
Tickets are on Sale for REANIMATE6

* REANIMATEconference.com

Slides from the Talk

* Dr. Yannopoulos' Slides (Minus In Review Data)

Additional Info/Resources

* EDECMO 36 - Zack interviews Demetris
* EDECMO Crash Episode - Microdissection of Demetris' ECPR Techniques
* JAHA Publication on ECPR Results

Now on to the Vodcast...
]]>
Scott D. Weingart, MD clean 1:18:47
EMCrit RACC Wee – Debate re: Idarucizumab with @First10em https://emcrit.org/emcrit/debate-re-idarucizimab/ Thu, 05 Apr 2018 12:00:40 +0000 http://emcrit.org/?p=449033 So my friend, Justin Morgenstern recently put up a post on Idarucizumab, aka Praxbind. He seemed pretty fired up on the issue, so I got him on the line to talk about it. What follows is a conversation on evidence and what to do when there is not a good amount of it. Schtuff The EM Cases Podcast that partially sparked the debate Justin Wrote an Additional Post after our Discussion On Parachutes and Such On to the Wee... So my friend, Justin Morgenstern recently put up a post on Idarucizumab, aka Praxbind. He seemed pretty fired up on the issue, so I got him on the line to talk about it. What follows is a conversation on evidence and what to do when there is not a good...

So my friend, Justin Morgenstern recently put up a post on Idarucizumab, aka Praxbind. He seemed pretty fired up on the issue, so I got him on the line to talk about it. What follows is a conversation on evidence and what to do when there is not a good amount of it.
Schtuff

* The EM Cases Podcast that partially sparked the debate

Justin Wrote an Additional Post after our Discussion

* On Parachutes and Such

On to the Wee...]]>
Scott D. Weingart, MD clean 25:33
EMCrit RACC Podcast 221 – Burns Part II with Dennis Djogovic – Airway, Lungs, Tubes and Stuff https://emcrit.org/emcrit/burns-ii-airway-lungs/ Mon, 02 Apr 2018 12:58:23 +0000 http://emcrit.org/?p=449497 Part II on Airway and Breathing in Burns Part II on Airway and Breathing in Burns



Today we are joined by Dennis Djogovic to do Part II on severe burns.

* See Part I on Fluid Therapy

Dennis Djogovic
Dr. Djogovic completed training in Emergency Medicine and Critical Care Medicine from 1999-2005, and is currently employed at the University of Alberta Hospital as an Emergency Physician, and as an Intensivist in the General Systems Intensive Care Unit and in the Firefighters Burn Treatment Unit.
Inhalation Injuries and Airway Management
Read These

* Tracheal intubation difficulties in the setting of face and neck burns: myth or reality? (Am J Emerg Med. 2014 Oct;32(10):1174-8)
* Diagnosis and Management of Inhalation Injury



Securing Tubes and Catheters
 
More Info

* PulmCrit on Flash Cigarette Burns
* Maryland CC Project Severe Burns Episode
* EM Practice Smoke Inhalation Issue

Now on to the Podcast...]]>
Scott D. Weingart, MD clean 30:04
EMCrit RACC Podcast 220 – Beat the Stress Fool (BtSF) with Mike Lauria — Just In Time Performance-Enhancing Psychological Skills https://emcrit.org/emcrit/emcrit-racc-podcast-220-beat-stress-fool-mike-lauria-just-time-performance-enhancing-psychological-skills/ Mon, 19 Mar 2018 15:10:44 +0000 http://emcrit.org/?p=440717 Beat The Stress Fool! Beat The Stress Fool!
The Article
PEP under Stress
Breathe
Conscious control of the autonomic system




Xhaler

https://twitter.com/nathanwpyle/status/1071860695371825155
Talk
Positive self-talk
See
Mental Rehearsal/Visualization
Focus
Development and Use of a focus/trigger word


Additional Resources

* Brindley's CRM for Team Performance Guide
* Hicks and Petrosoniak on Human Factors in Trauma Resus (Show on this Soon)
* Anything by Jason Brooks

Now on to the Podcast...]]>
Scott D. Weingart, MD clean 20:12
EMCrit RACC Podcast 219 – Critical Burn Patients in the ED/ICU – Part I with Dennis Djogovic https://emcrit.org/emcrit/critical-burn-patients-in-the-ed/ Mon, 05 Mar 2018 16:33:49 +0000 http://emcrit.org/?p=3932 Burns Part I - Fluid Management Burns Part I - Fluid Management

Today we are joined by Dennis Djogovic to do Part I on severe burns.
Dennis Djogovic
Dr. Djogovic completed training in Emergency Medicine and Critical Care Medicine from 1999-2005, and is currently employed at the University of Alberta Hospital as an Emergency Physician, and as an Intensivist in the General Systems Intensive Care Unit and in the Firefighters Burn Treatment Unit.
Fluid Management in Burn Patients
 
Additional Resources

* Victorian Burn Unit Resources

Now on to the Podcast...]]>
Scott D. Weingart, MD clean 28:47
EMCrit RACC Podcast 218 – Physostigmine with Bryan Hayes https://emcrit.org/emcrit/physostigmine/ Tue, 20 Feb 2018 04:02:33 +0000 http://emcrit.org/?p=444318 Physostigmine for Anticholinergic toxicity Physostigmine for Anticholinergic toxicity
That diphenhydramine OD that is driving you up a wall, the seroquel OD that can't give you any history and is sucking up all of your benzos--there is a solution! Physostigmine used to be standard care, but then after a scare with TCA ODS, its use by non-tox folks markedly diminished.
Bryan Hayes
Today I am lucky to have Bryan Hayes, the Pharm ER Tox Guy, back on the show to discuss Physostigmine for anti-cholinergic toxicity. Bryan is a ED pharmacist with a fellowship in toxicology. He tweets as PharmERToxGuy and blogs at Academic Life in EM and on his own site, pharmertoxguy.com.
Use in Anticholinergic Poisoning
Physostigmine controlled agitation and reversed delirium in in 96% and 87% of patients, respectively (Ann Emerg Med 2000;35(4):374-81.). Benzodiazepines controlled agitation in only 24% of patients but were ineffective in reversing delirium.

Indications
Presence of peripheral or central antimuscarinic effects without significant QRS or QT prolongation

* Peripheral: dry mucosa, dry skin, flushed face, mydriasis, hyperthermia, decreased bowel sounds, urinary retention, and tachycardia
* Central: agitation, delirium, hallucinations, seizures, and coma


Hayes' Algorithm

* Physostigmine 1 mg IV over 5 minutes (mixed in 50 mL NS), can be repeated x 1, ~10-15 minutes after the 1st dose. Continuous cardiac monitoring and atropine at the bedside.

Contraindications (from package insert)

* Reactive airway disease, peripheral vascular disease, intestinal or bladder obstruction, intraventricular conduction defects, and AV block and in patients receiving therapeutic doses of choline esters and succinycholine.
* Known or suspected TCA OD

The Post on Bryan's Site

* Don’t be Afraid of Physostigmine

Nice Review Article

* Dawson et al.

Some Literature


* 1980's cases of asystole in TCA poisoning: https://www.ncbi.nlm.nih.gov/pubmed/7001962
* 1998 case of 15 year old with asystole in TCA poisoning: https://www.ncbi.nlm.nih.gov/pubmed/9655671
* Physo clearly beneficial over benzos: https://www.ncbi.nlm.nih.gov/pubmed/10736125
* Physo associated with less ICU admissions:  clean 16:48
EMCrit RACC Wee – State of the Crit https://emcrit.org/emcrit/emcrit-racc-wee-state-crit/ Sat, 17 Feb 2018 16:53:52 +0000 http://emcrit.org/?p=448600 what's going on with the EMCrit Project what's going on with the EMCrit Project
Want to be a Section-Editor for EMCrit?
You need to be a current 2nd year EM Resident or a 1st year Crit Care Fellow

Express interest here:

Interest Form

and we'll be in touch
Now on to the State of the Crit...]]> Scott D. Weingart, MD clean 10:40 EMCrit RACC Podcast 217 – The Ultimate “Ultimate” BVM https://emcrit.org/emcrit/ultimate-bvm/ Mon, 05 Feb 2018 18:04:23 +0000 http://emcrit.org/?p=448190 So in prior posts, I have discussed the jerry-rigged "ultimate" BVM. But there is a better way--the creation of a manufactured BVM that helps us not kill patients. It would have the following characteristics: Facets of the Ultimate BVM     Now on to the Vodcast... So in prior posts, I have discussed the jerry-rigged "ultimate" BVM. But there is a better way--the creation of a manufactured BVM that helps us not kill patients. - It would have the following characteristics: Facets of the Ultimate BVM   -

So in prior posts, I have discussed the jerry-rigged "ultimate" BVM. But there is a better way--the creation of a manufactured BVM that helps us not kill patients.

It would have the following characteristics:
Facets of the Ultimate BVM


 

 
Now on to the Vodcast...
]]>
Scott D. Weingart, MD clean 16:30
EMCrit RACC Podcast 216 – The Hemodynamically Neutral Intubation https://emcrit.org/emcrit/hemodynamically-neutral-intubation/ Mon, 22 Jan 2018 09:00:51 +0000 http://emcrit.org/?p=447563 Even better than Hemodynamic Kills Even better than Hemodynamic Kills



 

 

 

 

In Podcast 104, we discussed how to avoid killing hemodynamically unstable patients while intubating. Today's podcast takes that concept a step further to allow you achieve a hemodynamically neutral intubation.
The Pieces
Rapid Sequence Awake

Discussed in this podcast

or

Dissociated "Awake" Intubation

or

A Combination

then

you can consider a DSI for Hemodynamics, but only in non-tenuous patients

then

place the patients on CPAP/PSV mode with both set to zero

if the patient requires mechanical ventilatory support because they continue to decline, consider

Higher Vt/Lower Rate as per Davis et al.

and

Sedate with small hits of ketamine or fentanyl
Further Reading

* Pulmonary Hypertension Awake Intubation from CCM

Now on to the Podcast...]]>
Scott D. Weingart, MD clean 23:13
EMCrit Wee – Steroids for Septic Shock — PRE-ADRENAL https://emcrit.org/emcrit/steroids-for-septic-shock-preadrenal/ Mon, 08 Jan 2018 15:37:35 +0000 http://emcrit.org/?p=447281 Get ready for ADRENAL Get ready for ADRENAL
Bottom Line

* Fantastic look at the history of this issue

Farkas on Steroids in Septic Shock

* PulmCrit

European & SCCM CIRCI Guidelines

* Guidelines

Crit Care Reviews Meeting

* A Few Tickets are Left

Find the Livestream and then the Edited Version of the Session at this Link:
emcrit.org/adrenal
Now on to the Wee...]]>
Scott D. Weingart, MD clean 14:08
EMCrit Podcast 215 – A Disagreement of Toxicologists with Dantastic Mr. Tox/&Howard https://emcrit.org/emcrit/disagreement-of-toxicologists/ Mon, 25 Dec 2017 16:44:17 +0000 http://emcrit.org/?p=446707 Dantastic Mr. Tox/&Howard discuss some Tox stuff and Santa Beards Dantastic Mr. Tox/&Howard discuss some Tox stuff and Santa Beards

Happy Solstice!

A delightful and hilarious toxicology podcast started up a few months ago, the Dantastic Mr. Tox & Howard Show. I managed to get the hosts on the line to talk some tox.
Howard Greller (@heshiegreshie)
Dr. Greller is EM and toxicology out of St. Barnabas in NYC


Dan Rusyniak (@drusyniak)
Dr. Rusyniak  is EM and toxicology at Indiana University


Opioids

* New York State Opioid Statistics
* DantasticTox Opioid Show

Intralipids

* The DantasticTox Lipids Show
* LipidRescue Site

Calcium Channel Blocker Overdose

* EMCrit CCB Episode

The Santa Beard

EEMCrit Conference
REANIMATE ECMO Conference
Now on to the Podcast...]]>
Scott D. Weingart, MD clean 30:09
EMCrit Wee – Advanced Ultrasound Assessment of Volume Status https://emcrit.org/emcrit/emcrit-wee-advanced-ultrasound-assessment-volume-status/ Fri, 15 Dec 2017 16:11:23 +0000 http://emcrit.org/?p=446609 Advanced uses of ultrasound to assess volume status Advanced uses of ultrasound to assess volume status

My buddies, Rory Spiegel and Phillipe Rola taped an amazing conversation about the advanced uses of ultrasound to assess volume/fluid status. I think you will find it as interesting as I did.
Links of Interest

* Portal Veins & Pocus
* A physiologist/intensivist responds
* And more from Phillipe
* Marik has a whole bunch of recent posts on the evils of fluid overload

Now on to the Wee...]]>
Scott D. Weingart, MD clean 25:22
EMCrit Podcast 214 – When they Stay https://emcrit.org/emcrit/emcrit-podcast-214-stay/ Mon, 11 Dec 2017 18:42:19 +0000 http://emcrit.org/?p=446506 Issues with pts in the ED without an inpatient team yet Issues with pts in the ED without an inpatient team yet
You Need to Round on Them
Pulm Toilet
Cuff Pressure
Vent Adjustments
Analgesia and Sedation
Eye Care
 
FEN
Urine Output
Maintenance Fluids
Repeat Labs
Repletions
 
Meds
The 2nd Dose of Antibiotics

* Crit Care Med 2017;45:956

Insulin for IDDM
Medication Reconciliation
anti-coagulants, anti-platelets, rejection meds, endocrine meds, statins,
Update--Venous Thromboembolism Prophylaxis
Glaring omission in the audio. Thanks for reminding me, Maarten!
Alarms
Ventilator Alarms
Pump Alarms
 

 ]]>
Scott D. Weingart, MD clean 25:06
EMCrit Podcast 213 – Controlled Burn for Hypercapneic Encephalopathy in COPD https://emcrit.org/emcrit/controlled-burn-hypercapneic-encephalopathy/ Mon, 27 Nov 2017 15:44:19 +0000 http://emcrit.org/?p=446215 Intubation is failure! Intubation is failure!

This post is part of the bleeding edge series--you have been warned!


What you'll hear....
Two Phenotypes of Critical COPDers

* Severe Bronchospastic Crisis
* Hypercapneic Encephalopathy

This episode primarily talks about #2
The New Reflex Actions for Coma/AMS

* Check Fingerstick
* Look at the Pupils/Resp Rate
* Look for Stigmata of Seizure/Recently Completed Seizure
* Get a VBG

The Controlled Burn for Hypercapneic Encephalopathy in COPD
This is the bleeding edge part. I am super-curious to hear what you think. Place your comments below.
Articles to Read

* Resp Med 2011;105:1109

Now on to the Podcast...]]>
Scott D. Weingart, MD clean 19:10
EMCrit Podcast 212 – Thoughts on Deliberate Practice and Expertise https://emcrit.org/emcrit/thoughts-on-deliberate-practice-expertise/ Sun, 12 Nov 2017 20:56:01 +0000 http://emcrit.org/?p=445581 My thoughts on the recent interview with Anders Ericcson My thoughts on the recent interview with Anders Ericcson

After Podcast 211 with Anders Ericsson, I promised my thoughts on deliberate practice and expertise...

But first, something sad:
Bob Wears has died
Read a wonderful obituary
Reality behind 10,000
let's think about that... Innate non-physical talent doesn't really matter that much.  Can't alter your height, but can alter your brain

Driving a car for 10000 hours doesn't make you an expert driver. We do exactly zero hours of deliberate practice. We have no coach.
Procedures
My fellows filming themselves

Microskill breakdown
Why Purposeful much less deliberate practice is tough in Emergency Medicine
Experts vs. Experts @ Teaching

EM & Crit Care Lacks Feedback
Mental Representations/Mental Models
OODA Loops

experts have very good memory of what has happened

verbalize thinking

sob low sat tachypenic

pt looks bad, start thinking airway

SCAPE, mental status good, pt will respond to BIPAP

CHF

Surgical Scripts Book Abernathy & Hamm

Mental Models Article from Michael Simmons
Shadowboxing
watch stimuli

commit to a course

listen to the expert
Thought Experiment on Computer Based Ratings
Are Experts Actually Experts?

Name Badge Believers
How to Create Purposeful/Deliberate
right time of day

plenty of sleep

deliberate practice is deep work

patience 15-20 minutes, not 4-5 hours at least at first

need a coach or if you can't find an expert performer and ask them how they got good

good teacher builds representations
Mental practice
cric training

given videos

smacc airway workshop

no place your hands here
The Diamond Age


a

We need a primer
Now on to the Podcast...]]>
Scott D. Weingart, MD clean 21:27
EMCrit – Some Weeish Elaboration on my Interview with the Curbsiders https://emcrit.org/emcrit/curbsiders/ Tue, 31 Oct 2017 16:50:59 +0000 http://emcrit.org/?p=445448 Why can't we all just get along Why can't we all just get along The Curbsiders with Guest, EMCrit
 
Find Out What this Diagram Means


EEMCrit Conference Resident Competition
Speak at the EEMCrit Conference and win a spot at the EEM Conference in May

EEMCrit Blast Competition
Now on to the Wee...]]>
Scott D. Weingart, MD clean 8:05
EMCrit Podcast 211 – Expertise with Anders Ericsson https://emcrit.org/emcrit/expertise-ericsson/ Sun, 29 Oct 2017 18:15:52 +0000 http://emcrit.org/?p=439164 Expertise & Deliberate Practice with Anders Ericsson and @resuspadawan Expertise & Deliberate Practice with Anders Ericsson and @resuspadawan

Mike Lauria set up an interview with Dr. K. Anders Ericsson, first author of . Dr. Ericsson is a brilliant cognitive psychologist, currently at the Florida State. He has dedicated his career to studying the science of expertise and performance. He was incredibly generous with his time, to the tune of a 2-hour interview. In the podcast below, I excerpted some of the most interesting pieces, but it was all great. If you want to listen to the unedited, full interview I have placed a link below.


10,000 Hour Rule Debunked

* from Salon

How to Deliberately Practice in Diagnostic Medicine

* Get recordings of patient presentations, get people to commit, listen to what an expert would do, and then show what happened.

Full Unedited Interview

* ~ 2 hours of Dr. Ericsson

Want More?

* Art of Charm Interview with Dr. Ericsson was Amazing!
* Brian Johnson's Summary
* The Seductive Path of Good Enough
* Deliberate Practice from Farnam Street
* The Academic Paper on Deliberate_Practice_and_the Acquisition of Expertise by Dr. Ericsson
* Pondering EM did a Two-Parter on Deliberate Practice (Part 1 & Part 2)
* The Path to Insanity

Now on to the Interview...]]>
Scott D. Weingart, MD clean 50:51
EMCrit Podcast 210(2) – Arterial Lines – Part 2 https://emcrit.org/emcrit/arterial-lines-part-2/ Fri, 20 Oct 2017 16:06:10 +0000 http://emcrit.org/?p=445338 Part 2 on Art Lines Part 2 on Art Lines
For Show Notes and To Leave Comments, Got to EMCrit.org/210
Now here is Part 2]]>
Scott D. Weingart, MD clean 19:37
EMCrit Podcast 210 – Arterial Lines (Part 1) https://emcrit.org/emcrit/arterial-lines/ Mon, 16 Oct 2017 15:57:33 +0000 http://emcrit.org/?p=10106 All things Arterial Lines-Part 1 All things Arterial Lines-Part 1

Today, we talk about arterial lines. I love arterial lines: monitoring, true MAPs, easy blood draw, easy blood gases, fluid status--what's not to love.

This turned into a 2-parter. Part 1 covers radial art lines
Here is Arterial Lines - Part 2
covers everything else below
The (Essentials of EM)Crit Conference


go to EMCritConference.com

use the promo code "emcrit" when you sign up
Part 1 Covers:
Radial Arterial Lines
Peripheral vs. Central Arterial Lines
Sterility
Here is a systematic review of most of the literature

[cite]24413576[/cite]

My take on it is, use sterile gloves, mask, chlorhexidine prep, and if you can grab a fenestrated drape or some OR towels.
Technique

* Kit (The one I use is Arrow RA-04020)
* Ultrasound
* Threading
* How to Save it
* Allen Test

Securing
Tegaderm alone is not enough. I suture, but I really wish we had arterial line stat-locks

I always loop around the thumb and secure with tape outside of the tegaderm--I hate replacing pulled out art lines
Central vs. Peripheral Arterial Pressures
[cite]28523028[/cite]
Part 2 Covers:
Femoral
Sterility-Full Sterile

unless you are going for speed or the Dirty Double

Technique

Use Ultrasound

Find the Common Femoral Artery



 



Use of a central line kit?--No!

Back of wire? Check, but yes!
Axillary
Need Ultrasound
Brachial
Is it safe?
Dorsalis Pedis
https://www.ncbi.nlm.nih.gov/pubmed/28523028
The Arterial Line Set-Up
How to set up an art line pressure transducer

You do not need to wait for crash arterial lines

Heparin Flush
Pimping Ammunition - Where is that Catheter
sent by Intensivist, Mark Dunn


Now on to the podcast (and Remember: Here is Part 2)...]]>
Scott D. Weingart, MD clean 24:25
EMCrit Wee – Dissemination and Information Transfer (Questions not Answers) https://emcrit.org/emcrit/dissemination-information-transfer/ Wed, 11 Oct 2017 20:42:24 +0000 http://emcrit.org/?p=445252 I need help... I need help...

Please Send me your ideas on how to...
Artificiality of Dissemination

* Is email the best forum?
* Get people to actually read the emails you send re: departmental protocols, changes, ideas, etc.
* Do you track?

Referencing Reference

* How do you create a reference site?
* What nitty-gritty details?
* Is it password protected? Does everyone have a unique login?
* How do you sort/create search--what pages, tags, categories, long tables of contents, etc.
* How do you handle orientation into your new unit/department

Old Dogs, New Skills
How do you teach new skills

* Meetings
* Videos
* Screencasts

Post thoughts on Reddit here:
REDDIT Post for this Wee
Now on to the Wee...]]>
Scott D. Weingart, MD clean 10:49
EMCrit Podcast 209 – GTD Redux – Opportunities, Time, & Future Selves https://emcrit.org/emcrit/emcrit-podcast-209-gtd-redux-opportunities-time-future-selves/ Mon, 02 Oct 2017 18:39:30 +0000 http://emcrit.org/?p=445010 More on GTD More on GTD

A few years ago, I put out a podcast on Getting Things Done--people seemed to really like discussing this topic. I am giving a lecture on this subject this week. It has gotten me thinking about some of the higher level aspects of GTD and I thought I would share some of them with you.
Deciding on Opportunities
Present you vs. future you
Petrie Triangle

Time Tracking/Forecasting
Opportunity Cost

Deciding on Goals





Deep Work

Time Blocking
Pomodoro technique

creator's website
Getting Tactical re: Email

* Put the call to action up top
* Preempt the back-and-forths
* doodle.com
* Close the loop beforehand
* Ask one ?, make it easy, and make sure it is not web-searchable/already answered

Resus Fellowship
Click Here for More Info on the Stony Brook Resus Fellowship
Now on to the Podcast...]]>
Scott D. Weingart, MD clean 32:11
EMCrit Podcast 208 – Felipe Teran on Why We are Doing CPR Wrong https://emcrit.org/emcrit/why-we-are-doing-cpr-wrong/ Mon, 18 Sep 2017 15:08:38 +0000 http://emcrit.org/?p=443658 You are doing CPR wrong You are doing CPR wrong

You are doing CPR wrong, or so says Felipe Teran, an ED resuscitation sonographer. Felipe has just started as a Resus/ED attending at University of Pennsylvania.
The Vodcast



Let us know what you think in the comments section below
 

 ]]>
Scott D. Weingart, MD clean 19:21
EMCrit 207 – A Case to Acid Test your Resus Logistics https://emcrit.org/emcrit/acid-test-resus-logistics/ Tue, 05 Sep 2017 20:04:48 +0000 http://emcrit.org/?p=444379 Acid Test your Resus Acid Test your Resus

This week a case to test your Resus chops. The care is not hard, the logistics definitely are.
Items of Interest

* Dirty Double
* Push-Dose Pressor Update
* RUSH Exam
* Hyperkalemia
* HOP Killers
* Peripheral Vasopressors
* SLED

Now on to the Podcast...
 ]]>
Scott D. Weingart, MD clean 27:28
EMCrit Wee – Central Line MicroSkills – Dilation https://emcrit.org/emcrit/microskills-dilation/ Tue, 29 Aug 2017 18:06:57 +0000 http://emcrit.org/?p=444118 The next in the microskill series The next in the microskill series

This is the next installation in the central line (and really any Seldinger procedure) microskills. You should have already watched the videos with the following microskills:

* Syringe Suction while Manipulating
* Needle Stabilization during Syringe Removal & Wire Insertion
* Wire Manipulation
* Dilation (this video)
* Bonus Skills (Wire Straightening without Cheater)

This microskill video discusses dilation. I see this being done improperly with incredible frequency, but people get away with their bad technique because they are using small dilators for small catheters. When you go big, you will do damage unless you know what you are doing.
Dilation Mantras

* Push & Rack
* Twist & Rip
* Pinch & Pull

Additional Tips

* Keep wire and dilator wet with saline (thanks for the reminder, Matt)
* Clots are your nemesis--if there are clots on the wire, clear them off before continuing to upsize your dilators

]]>
Scott D. Weingart, MD clean 9:13
EMCrit Podcast 206 – ApOx, ENDAO, & PreOx Update https://emcrit.org/emcrit/apox-preox-update/ Mon, 21 Aug 2017 15:15:46 +0000 http://emcrit.org/?p=444046 ApOx & PreOx Update ApOx & PreOx Update

We've spoken a ton on EMCrit on Apneic Oxygenation and Preoxygenation, well here is some more. Nick Caputo and his Lincoln Airway Group did an amazing trial of ApOx in the ED. Rory recently wrote about it and there have been some amazing posts around the FOAM world as well (see Rory's post). Now I weigh in with my take and a discussion of my new thoughts on PreOx.
Three Items to Read

* The ENDAO Trial
* Sakles' Editorial
* The EMNerd Post

Also See

* Fellow Trial Post
* EMCrit Preox

Should we use Nasal Cannula?
I think yes, because:

* ApOx will still probably benefit some patients (probably those without sig. physiological shunt or those whom you have recruited)
* Makes BVM mask leaks better
* Allows apneic CPAP with the devices below

Why Doesn't It Work in this RCT?

* Great Preox
* Not Enough Potential for Sig. Desat due to rapidity and ease of intubation
* THRIVE NC is Different than Standard
* Physiologic Shunt-Shunt Fraction would be a great thing to know to interpret these studies

What Should be on the Patient's Face just prior to Induction
choose one:

* Vent as Bag with BVM Mask
* Oxylator with BVM Mask
* BiPAP Machine with BVM Mask
* Ultimate BVM with PEEP Valve, Pressure Gauge

All of the above should have a NC @ >15 lpm and ETCO2 capnography

Why not the Mapleson C (or similar)? I'd like a pressure gauge on that badboy to track each breath
Update
Ivan Pavlov updated the tables from our MA (Am J Emerg Med. 2017 Aug;35(8):1184-1189) to include the Caputo trial:






Additional Articles of Interest

* Narrative review of ApOx in Anesthesia realm (PMID 28050802)

Update
Peter Young Sent me this interesting poster on THRIVE and Pressure
Now on to the Podcast...]]>
Scott D. Weingart, MD clean
EMCrit Podcast 205 – Push-Dose Pressors Update https://emcrit.org/emcrit/push-dose-pressor-update/ Mon, 07 Aug 2017 16:00:49 +0000 http://emcrit.org/?p=443672 An update on push-dose pressors An update on push-dose pressors

Today, an update on Push-Dose Pressors. I coined the name Push-Dose Pressors (PDPs) way back on episode 6. The idea was not new, anesthesiologists and resus docs have been using bolus-dose vasopressors for decades. I just thought the name was dumb, these are not boluses in the way I have always thought of them (a brief iv drip). I also thought it was crazy that the concept had not really penetrated very far into emergency medicine and the ICU--at least in the States. My prehospital doc friends told me it was common in their world. Since the podcast, I have received 100s of emails describing the use of PDPs to lifesaving effect (or at least code-preventing), but there has been scant published literature on this technique in EM. Recently that has all changed.
Can We Wait for the Drip?
Resus-Ready EDs should be able to get a vasopressor drip up within 8 minutes (completely made-up number, just like most hospital certification standards)

Dead Space in the Lines

What should you do when you can't wait that long?

How do you treat critically low perfusion to the heart & brain?
Push-Dose Pressors Fill the Gap
Especially in the Peri-Intubation, when patients have an annoying habit of popping into cardiac arrest
ED Pharmacists Discussion of Medication Safety for Push-Dose Pressors
Safety Guidelines for Push Dose Pressors

While there seems to be a slightly negative bias against docs' capability to mix drugs and a pro-pharmD bias (understandable), the messages from this article as a whole were fantastic. Here are some alterations/things to be aware of that I discuss in the podcast:

* The Prohibition against Pre-Filled Saline Syringes
* The Phenylephrine Chart

An Editorial on the Above Article
Cole Editorial on Push-Dose Pressors
Why EPI has won my Heart
Sorry Phenyl you were but a brief fling
Push-Dose Epi Labels
Inspired by the Danny the Medic


Cardiac Arrest EPI Syringe
0.5 mls of the cardiac arrest epi is an ok stopgap
Dirty Epi Drip
I do not recommend the dirty epi drip. Please, please understand how this makes our specialty look

For the love of all this is Resus, Label the frackin bag!

This is not the time to have something going on in the background that you are paying no attention to
Push-Dose Norepi if you Just Never Want to Deal with Mixing
Check your premixed concentration: If you have the 4mg in 250 ml (16 mcg/ml) you can give 0.5 to 1 ml per minute
Pick One Way to Go in your ED
Otherwise errors are more likely
ED Pharmacists in General
Love having ED PharmDs as part of the team! Are there downsides?
Premixed Push-Dose Epi

Other Lit Mentioned

* The impact of push-dose phenylephrine use on subsequent preload expansion in the ED setting. The American Journal of Emergency Medicine Volume 34, Issue 12, December 2016, Pages 2419–2422
* This study compares push-dose phenylephrine to continuous infusion–no difference between the two (Anesthesia Analgesia 21012;115(6):1343)
First article in the ED demonstrates efficacy on blood pressure ( clean
A Wee Bit More on Massive Hemoptysis https://emcrit.org/emcrit/wee-massive-hemoptysis/ Mon, 31 Jul 2017 17:06:08 +0000 http://emcrit.org/?p=443548 Hemoptysis redux Hemoptysis redux

George Kovacs left a great comment on the hemoptysis post:

Great discussion.  Unfortunately with these cases getting the tube is THE major problem before we consider any bronchoscopic intervention. Here are my pearls based on experience and cadaveric simulations:

* Call for help: Patients with massive pulmonary hemorrhage die. Respect hemoptysis especially related to tumors or scenarios where there is an erosion into a vessel. They're ok until they're not and then its often too late,
* Send someone to the chart/x-ray to get info as to which side the pathology is on
* Raising the bed will help allow you to lift the epiglottis out of the pool of blood and see it more easily.
* Do the Ducanto thing... SALAD
* Hope that the disease is on the left. If you know this use a bougie and 1/4 turn to the right once (if) you feel clicks and place gently until holdup then go ahead with a BFT. As per the study quoted in this piece we have been able to consistently cannulate the bronchus of choice using a bougie in cadavers.
* If you are not sure of the side they are bleeding from then we would suggest a poor man's isolation technique using a 7.0 ETT and intubating the RM bronchus either with or without a bougie. The left side can then be accessed with a bougie again by a 1/4 turn to the left once in the trachea and advancing until gentle hold up at ~30 cm and placing a second 7.0 ETT. Yes I know that a bronch won't like these tubes but otherwise there is no opportunity for subsequent therapy as the patient drowns. It's an awful death. You can block the offending side with a foley.
* If bleeding is too much and SALAD etc approach fails... these patients die. One device that will be returning to the market developed here in Halifax is the lightwand and its the only device out there that will consistently be successful in a soiled airway.... IF YOU HAVE IT AND IF YOU HAVE EXPERIENCE WITH IT which most don't. It has saved my ass numerous times.
* If you can't see from above then FONA is indicated use a small ETT 5.0 and push it too hilt will usually go to RM bronchus. You will either be able to oxygenate or divert blood so now you can put a second tube in if necessary from above. Used a 5.0 ETT because takes up less real estate for second tube to pass from above.
* When your consultant comes down and complains about the size of tubes that are in place resist telling them to fuck off.

Now on to the Wee...]]> Scott D. Weingart, MD clean 8:21 EMCrit Wee – An Amazing (Wearable) Cric Trainer from Laura Duggan and the AirwayCollaboration Folks https://emcrit.org/emcrit/wearable-cric-trainer/ Tue, 25 Jul 2017 00:10:58 +0000 http://emcrit.org/?p=443306 The new amazing cric trainer The new amazing cric trainer
So my friend Laura Duggan has been engaged in a multi-prong project to save lives through the dissemination of surgical airway information. We've previously discussed the airway app to collect data on front-of-neck-access. Now she is releasing a cric model that blows the old ones I used to recommend out of the water. You want one of these models... You want one to practice the moves of surgical airway at least once a month. Laura is not charging for this model, she is releasing it into the wild as FOAM. You'll have to get it 3d printed yourself--we'll tell you how

Instructions for Printing
3D Cric Trainer Instructions
Where to Print
3Dsmith in Canada
3Dsmith.ca
Chris and Steve are brothers who own their small company
They are awesome
info@3Dsmith.ca

get  formlabs standard resin as the material and it will resist scalpels beautifully!
Shapeways for the USA
shapeways.com

Got my model

Went with the strong & flexible plastic for $21.78

feel is rough but function is great
Buy Kevlar if you plan on wearing this cric trainer



The Model (Send this to your 3D Printer)

* Full Resolution Plans
* Slightly Lower Resolution for Places with Upload Limits

Go to Airway Collaboration Site

* www.airwaycollaboration.org/

Matt Mac Partlin Has a Cardboard Model
See the ETM/Vortex Version by Andy Buck (with a cool printable neck)
Disclaimer
If you decide to wear or have colleagues wear this, it is at your own risk. It is inherently dangerous to come at anyone with a scalpel
Now on to the Wee...]]>
Scott D. Weingart, MD clean 8:29
Podcast 204 – The Nurse-Led Code with Joe Bellezzo https://emcrit.org/emcrit/nurse-led-code/ Mon, 24 Jul 2017 14:26:38 +0000 http://emcrit.org/?p=443317 Nurses should be leading cardiac arrest management Nurses should be leading cardiac arrest management

I am joined again by my good friend, Joe Bellezzo, to discuss the nurse-led code. I've been doing this at my two shops for about a decade. Joe, along with his partners-in-crime Zack Shinar & Chris Ho, have set up a beautiful process for nurse led code management at their hospital, Sharp Memorial in San Diego.
Stuff Mentioned in the Podcast

* Here is the tactical-approach podcast from EDECMO.org
* EMCrit Intra-Arrest Management Lecture
* Podcast 191 - Cardiac Arrest Update

The SBM Nurse Leader Responsibilities

* Call forEpi q 5 minutes. Once a-line is in, decide on epi based on art line DBP<40
* Pre-announce the rhythm check 30 seconds beforehand
* Call for the rhythm check
* Act as the receiver for all requests from the team and assign people to get these tasks done
* Spur doc-leader based on timing of code and any thoughts that occur while having a non-task focused view of the code

Now on to the Podcast...]]>
Scott D. Weingart, MD clean 19:54
Podcast 203 – New Reversals for New Anticoagulants with Nadia Awad https://emcrit.org/emcrit/new-reversals-agents-for-new-anticoagulants/ Mon, 10 Jul 2017 14:29:04 +0000 http://emcrit.org/?p=439399 New agents for Reversal of NOACS New agents for Reversal of NOACS

This stuff is not sexy and frankly, it hurts my head. That is all the more reason to do a show on the new landscape of NOAC reversal. We must pursue rather than avoid the subjects we are weak on. But I needed someone far smarter than myself--I needed a EM PharmD. Nobody better to speak about this topic than Nadia Awad. Nadia is associate editor of the Emergency Medicine PharmD Blog. She is an Emergency Medicine Pharmacist at the Robert Wood Johnson University Hospital in New Jersey.
Laboratory Parameters for Monitoring Target-Specific Oral Anticoagulants

* Hawes EM et al. J Thromb Haemost 2013; 11:1493-1502.
* Cuker A et al. J Am Coll Cardiol 2014; 64:1128-1139.
* Favaloro EJ et al. Semin Thromb Hemost 2015; 41:208-227.
* Samuelson BT et al. Blood Reviews 2017; 31:77-84.

Interim Analysis of Idarucizumab: REVERSE-AD

* Pollack CV et al. N Engl J Med 2015; 373:511-20.

Clinical Experiences Reported in Literature with Idarucizumab Following Approval by FDA

* Reviewed on Emergency Medicine PharmD

Fantastic Review on Idarucizumab

* Miller et al.

Use of Extracorporeal Measures to Expedite Elimination of Dabigatran in the Setting of Life-Threatening Bleeding

* Awad NI et al. J Med Toxicol 2015; 11:85-95.

Andexanet Alfa

* Siegal DM et al. N Engl J Med 2015; 373:2413-2424.
* Connolly SJ et al. N Engl J Med 2016; 375:1131-1141.

Low-Dose FEIBA for ICH Induced by Factor Xa Inhibitors
Mao G et al. JEM 2016 [Epub ahead of print].
Aripazine (PER977) AKA Ciraparantag

* Ansell JE et al. N Engl J Med 2014; 22:2141-2142.
* Ansell JE et al. Thromb Haemost 2017; 117:238-245.

Recommendations for Reversal of ICH Induced by Antithrombotics from Neurocritical Care Society

* Frontera JA et al. Neurocrit Care 2016; 24:6-46.

Excellent reviews on Idarucizumab

* Ann Emerg Med 2017;69(5):554
* EM Lit of Note

Dosing
Monoclonal antibody
works within minutes
Thrombin time and ECT are best monitoring, aPTT if stone-cold normal prob. rules out Dabi
Package comes with 2 vials
2.5 gm each
5 gms is the initial dose
Give each over 5 minutes
Spike and hang vial
give 2nd vial with 15 minutes of first (no reason not to give immediately)
$4200 for both vials at Janus General
Dabi lasts 12 hours in normal patients, and antidote lasts same ostensibly
Kcentra Studies

* RCT of Kcentra (Circulation 2013;128:1234)

]]>
Scott D. Weingart, MD clean 27:44
EMCrit 202 – Blood Bank Essentials with Joe Chaffin https://emcrit.org/emcrit/blood-bank-essentials/ Sun, 25 Jun 2017 18:11:03 +0000 http://emcrit.org/?p=437626 blood bank stuff: The basics of crit care transfusion medicine blood bank stuff: The basics of crit care transfusion medicine
I wanted to do a show on the basics of the blood bank and there was no better guest than Joe Chaffin, MD. He is the CMO of the Lifestream Blood Center and a pathologist with expertise in transfusion medicine. I first came across Dr. Chaffin due to his extraordinary blog and podcast at bbguy.org. He started BBGuy.org in 1998 primarily to teach pathology residents. Today, the site exists to help anyone who wants to learn the essentials of blood banking and transfusion medicine. His teaching includes humor, occasional irreverence, and clear communication to highlight your path to understanding complex topics. I've been an avid listener since its inception, so it was a great honor to get him on the show.

At the same time we recorded this episode, I was interviewed for an episode of Joe's show. If you like what you heard here, check out that one as well:
Ep. 33 of the Blood Bank Guy Essentials Podcast
Topics of Discussion

* What actually is a type + screen
* What are you actually accomplishing with a crossmatch
* What type of FFP is acceptable for massive/emergent transfusion (PMID:28452877)
* Do we need to be type-specific with platelets
* What INR is acceptable for procedures

Episodes to Listen to Immediately on the BBGE Podcast

* When to Transfuse Plasma
* Intro to Apheresis
* Treatment of TTP

EMCrit Episodes Mentioned

* Podcast 197 - The Logistics of the Administration of Massive Transfusion
* Podcast 144 - The PROPPR trial with John Holcomb
* Podcast 71 - Critical Questions on Massive Transfusion Protocols with Kenji Inaba

Now on to the Podcast...]]>
Scott D. Weingart, MD clean 30:42
EMCrit 201 – Deeper on Vasopressors and Athos 3 with Mink Chawla https://emcrit.org/emcrit/deeper-vasopressors-athos-3/ Mon, 12 Jun 2017 14:42:09 +0000 http://emcrit.org/?p=441950 A new vasopressor is out there--angio II A new vasopressor is out there--angio II

In Ep. 138, we discussed the basics of vasopressor and inotrope use. During that podcast, I promised we would go more in-depth in subsequent episodes--this is one of those that will fulfill that promise. Angiotensin II is a new (old) player on the field. To discuss this topic and more on vasopressors, I asked Dr. Mink Chawla to join me on the podcast.
Conflict of Interest Disclaimer
Dr. Chawla is the CMO of La Jolla Pharmaceuticals, the manufacturer of Angiotensin II
Bio for Dr. Chawla
Dr. Chawla is Chief Medical Officer of La Jolla Pharmaceuticals. Dr. Chawla was an Professor of Medicine at the George Washington University, where he had dual appointments in the Department of Anesthesiology and Critical Care Medicine and in the Department of Medicine, Division of Renal Diseases and Hypertension. Dr. Chawla was also the Chief of the Division of Intensive Care Medicine at the Washington D.C. Veterans Affairs Medical Center. During his tenure at George Washington, Dr. Chawla was the designer and lead investigator of a pilot study called the ATHOS (Angiotensin II for the Treatment of High Output Shock) trial.  Dr. Chawla was an active investigator in shock, inflammation and extracorporeal therapies, including: continuous renal replacement therapy, dialysis and albumin dialysis. Dr. Chawla is also the author of over 100 peer-reviewed publications and an Associate Editor for the Clinical Journal of the American Society of Nephrology.
Dr. Chawla's Maryland CC Project Lecture

* Link to the Maryland CC Project Video
* Link to the Maryland CC Project Shownotes

Article Mentioned Regarding IntraOp Hypotension

* Walsh & Sessler et al.
* Also Check out: (Intens Care Med 2018;44:811)

Now on to the Podcast...
Angio II Papers

* The use of angiotensin II in distributive shock-
* Angiotensin II for the Treatment of Vasodilatory Shock - NEJM - 2017-(Athos 3)
* Angiotensin-II- More Than Just Another Vasoconstrictor to Treat Septic Shock–Induced Hypotension
* ATHOS-3 protocol & editorial, CCR_Mar_17_text[1]
* ATHOS-3_appendix
* Chawla-ATHOS-Crit Care-2014-(Athos 1)
* Clinical_Experience_With_Angiotensin_II

Links of Interest

* Vasopressor Basics Show
* PulmCrit's Voodoo
* clean 28:45
EMCrit Podcast 200 – Orman Grills EMCrit – No Clinical Medicine Here https://emcrit.org/emcrit/orman-grills-emcrit/ Mon, 29 May 2017 15:12:00 +0000 http://emcrit.org/?p=441207 My friend Rob Orman Interviews Me for Ep. 200 My friend Rob Orman Interviews Me for Ep. 200

Hey Folks

For episode 200 of EMCrit, my friend Rob Orman of ERCast interviews me on some non-clinical topics--you've been warned.]]> Scott D. Weingart, MD clean 25:44 EMCrit Podcast 199 – Management of Massive Hemoptysis with Oren Friedman https://emcrit.org/emcrit/massive-hemoptysis/ Sun, 14 May 2017 19:13:04 +0000 http://emcrit.org/?p=5745 Management of Massive Hemoptysis 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
Updates

* Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018 Oct 12. pii: S0012-3692(18)32572-8. doi: 10.1016/j.chest.2018.09.026.

Now, On to the Podcast...]]>
Scott D. Weingart, MD clean 24:32
Podcast 198 – Insulin Pumps and Such with Josh Miller, MD https://emcrit.org/emcrit/insulin-pumps/ Mon, 01 May 2017 16:26:22 +0000 http://emcrit.org/?p=18099 Scared of insulin pumps--not anymore 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.

Additional Info
Br. J. Anaesth.-2016-Partridge-18-26

Now on to the Show...]]>
Scott D. Weingart, MD clean 23:03
Ketamine ……. then Rocuronium, DSI & The Timing Principle https://emcrit.org/emcrit/ketamine-rocuronium-dsi-timing-principle/ Tue, 25 Apr 2017 14:47:21 +0000 http://emcrit.org/?p=440556 More on rocketamine... 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
Podcast 197 – The Logistics of the Administration of Massive Transfusion https://emcrit.org/emcrit/logistics-administration-massive-transfusion/ Mon, 17 Apr 2017 16:51:34 +0000 http://emcrit.org/?p=440330 The hands-on of orchestrating a massive transfusion protocol 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

Update
Removal of needle free valves had dramatic effect on flow rates1
Now on to the 'Cast:




1.
Khoyratty S, Gajendragadkar P, Polisetty K, Ward S, Skinner T, Gajendragadkar P. Flow rates through intravenous access devices: an in vitro study. J Clin Anesth. 2016;31:101-105. [PubMed]



]]>
Scott D. Weingart, MD clean 25:36
The Sick and the Dead: Evidence-Based Trauma Resuscitation in 2016 by Hicks & Petrosoniak https://emcrit.org/emcrit/the-sick-and-the-dead/ Tue, 04 Apr 2017 18:46:16 +0000 http://emcrit.org/?p=439783 The sick and the dead from SMACCdub 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 hemody...]]>
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/emcrit/having-a-vomit-salad-with-ducanto/ 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 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 [cite source='pubmed']25943615[/cite] 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 AirQ ILA image at the top from J Downham Now on to the Podcast... 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 [cite source='pubmed']25943615[/cite]
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 AirQ ILA

]]>
Scott D. Weingart, MD clean 19:20
EMCrit Wee – Edited Version of Paul Marik on the Metabolic Resuscitation of Sepsis https://emcrit.org/emcrit/edited-marik-metabolic-sepsis/ Tue, 28 Mar 2017 16:22:20 +0000 http://emcrit.org/?p=439749 Edited interview with Paul Marik 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
Podcast 195 – Management of Tracheostomy (Trach) and Laryngectomy Emergencies https://emcrit.org/emcrit/tracheostomy-emergencies/ Mon, 20 Mar 2017 17:58:51 +0000 http://emcrit.org/?p=5742 Trach Emergencies 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
Podcast 194 – Definitive Emergent Awake Intubation with George Kovacs https://emcrit.org/emcrit/definitive-emergent-awake-intubation/ Mon, 06 Mar 2017 18:15:12 +0000 http://emcrit.org/?p=438582 Podcast 194 - The Definitive Emergent Awake Intubation Lecture by @kovacsgj Podcast 194 - The Definitive Emergent Awake Intubation Lecture by @kovacsgj

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...
]]>
Scott D. Weingart, MD clean
Podcast 193 – Emergency Medicine is a Failed Paradigm https://emcrit.org/emcrit/podcast-193-emergency-medicine-failed-paradigm/ Mon, 20 Feb 2017 16:26:12 +0000 http://emcrit.org/?p=336999 Yep, EM is indeed a failed paradigm 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"
Transcript
(note-it is computer generated so many errors)

EM_is_a_Failed_Paradigm
The Video


 ]]>
Scott D. Weingart, MD clean 27:55
EMCrit Wee – The Golden Fleece, the Golden Hour, and the Golden Rule by Ashley Liebig https://emcrit.org/emcrit/golden-rule-by-ashley-liebig/ Thu, 16 Feb 2017 00:40:32 +0000 http://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 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
]]>
Scott D. Weingart, MD clean 24:48
Podcast 192 – Powerpoint and Meth – Presentation Creation from #TTC https://emcrit.org/emcrit/powerpoints-meth/ Mon, 06 Feb 2017 20:02:55 +0000 http://emcrit.org/?p=438242 The slides are not the problem... 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)
* clean 32:15
Wee – Warning: Nothing Useful Here – Politics and Why I’m “Divorcing” Twitter https://emcrit.org/emcrit/wee-warning-nothing-useful-politics-im-divorcing-twitter/ Wed, 01 Feb 2017 22:17:23 +0000 http://emcrit.org/?p=437662 if you still want to listen after reading the title 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...
 ]]> Scott D. Weingart, MD clean 13:21 Podcast 191 – Cardiac Arrest Update https://emcrit.org/emcrit/cardiac-arrest-update/ Mon, 23 Jan 2017 13:00:09 +0000 http://emcrit.org/?p=437743 Cardiac Arrest Update & the Syndromes of Arrest 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)
]]>
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/ Sun, 22 Jan 2017 18:47:38 +0000 http://emcrit.org/?p=437733 SSC 2016 Guidelines 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?

]]>
Scott D. Weingart, MD clean 24:38
Podcast 190 – Emergencies with a Side of Hypertension https://emcrit.org/emcrit/hypertensive-emergencies/ Tue, 10 Jan 2017 02:47:17 +0000 http://emcrit.org/?p=3008 Hypertensive emergencies look like emergencies! 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...]]>
Scott D. Weingart, MD clean 25:01
EMCrit 189 – Secret Sixth Cause of Arterial Hypoxemia and Vasoactive Purity https://emcrit.org/emcrit/end-year-grab-bag/ Wed, 28 Dec 2016 16:38:49 +0000 http://emcrit.org/?p=387430 A brain dump at the end of 2016 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. See the hemodynamically neutral intubation podcast for the final version of this idea.
Now on the the Podcast and Happy New Year...]]>
Scott D. Weingart, MD clean 22:05
Podcast 188 – Rudeness Part II (the Brindley Sessions) https://emcrit.org/emcrit/rudeness-ii/ Mon, 12 Dec 2016 18:29:49 +0000 http://emcrit.org/?p=386776 Brindley Session 2 - continuing the rudeness discussion 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...]]>
Scott D. Weingart, MD clean 22:22
Podcast 187 – Hypernatremia (Uggggh!) https://emcrit.org/emcrit/hypernatremia/ Mon, 28 Nov 2016 17:24:56 +0000 http://emcrit.org/?p=10134 Hypernatremia -- not sexy, but we gotta get 'im done 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

clean 21:09
Podcast 186 – Coma with Eelco Wijdicks https://emcrit.org/emcrit/coma/ Sun, 13 Nov 2016 16:33:29 +0000 http://emcrit.org/?p=347218 How to Diagnose and Manage Coma 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...
 ]]> Scott D. Weingart, MD clean 21:31 Podcast 185 – Disruption, Danger and Droperidol by Reub Strayer https://emcrit.org/emcrit/disruption-danger-droperidol/ Mon, 31 Oct 2016 12:41:00 +0000 http://emcrit.org/?p=283072 Danger, Disruption, and Reub Strayer Danger, Disruption, and Reub Strayer

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...
]]>
Scott D. Weingart, MD clean 26:09
The Brindley Sessions: Rudeness https://emcrit.org/emcrit/brindley-sessions-rudeness/ Wed, 26 Oct 2016 15:07:27 +0000 http://emcrit.org/?p=56151 The first Brindley Session is on Rudeness 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
Rudeness Affects Team Performance as well
Pediatrics. 2017 Jan 10. pii: e20162305. doi: 10.1542/peds.2016-2305.

Rudeness and Medical Team Performance.
Now on to the Session...]]>
Scott D. Weingart, MD clean 22:08
Response to Letters on my Mechanical Ventilation Article in the Ann Emerg Med https://emcrit.org/emcrit/response-mechanical-ventilation/ Fri, 21 Oct 2016 17:18:25 +0000 http://emcrit.org/?p=234409 Response to letters to the editor on mechanical ventilation article Response to letters to the editor on mechanical ventilation article

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...]]>
Scott D. Weingart, MD clean 30:36
Podcast 184 – Needle Cric (Again) and Transtracheal Jet Ventilation with Laura Duggan https://emcrit.org/emcrit/needle-cric-again/ Sun, 16 Oct 2016 16:22:18 +0000 http://emcrit.org/?p=190532 The needle vs. knife debate rages on, but it looks like the knife may be winning The needle vs. knife debate rages on, but it looks like the knife may be winning

So we have discussed my preference for surgical over needle-based techniques for front-of-neck-access (FONA) many times on the podcast. You can see the needle vs. knife discussions in some of the earlier posts as well. Cut to air just works better in my opinion. If you'd like to see how I advocate you perform this procedure, come to the EMCrit Cric Page. This debate has heated up as the airway society of the UK has recently recommended scalpel-bougie cricothyrotomy as the first technique for FONA. Editorials explain why this decision was made. Currently, the Australians are still recommending needle-based techniques. So, to add gasoline to the debate, today I interview Laura Duggan, MD.

Laura completed residencies in both paediatrics and anesthesiology, as well as a cardiothoracic anesthesiology fellowship. She practiced for a time as a paediatric emergency physician in Canada. She now practices cardiac and general anesthesia at a level 1 trauma centre. In short, she is the perfect person to discuss these issues with. I got to chat with Laura at SmaccDUB about a paper she had just written on the high failure rate of transtracheal jet ventilation in can't intubate, can't oxygenate situations.
Laura's TTJV Failure Paper

* TTJV by Duggan et al.

Recent EM Paper regarding Needle Cricothyrotomy

* Marshall et al in academic_emergency_medicine

The Airway App
Download it on the Airway Collaboration Site
The Ventrain Device


I tested this device on the bench (no COI) and the reason I think it is the best of the crop is its active exhalation and the ability to monitor ETCO2. They sell it in kits with a proper cannula as well.



* [cite]24980421[/cite]
* [cite]:21177698[/cite]
* [cite]20100697[/cite]

Other Jury-Rigged Techniques (None are Recommended)
3-Way Stopcocks are Probably Inadequate
Catheter or cath with 3-way stopcock is prob. inadequate for exhalation unless 13 seconds between breaths (Anaesthesia 2009;64:1353 and Pediatric Anesth 2009;19:452)
Use a Ventilator
Br J Anaesth 2013;110(3):456
Additional
[cite]22436319[/cite]
Also See
The original needle vs. knife for Andy Heard's Method
If you had to use one, here is the one Ric Solis and I Conceptualized




You can read more about it in EM News
Now on to the Podcast...
]]>
Scott D. Weingart, MD clean 21:46
Podcast 183 – Driving Pressure with Dr. Roy Brower https://emcrit.org/emcrit/driving-pressure/ Mon, 03 Oct 2016 18:10:28 +0000 http://emcrit.org/?p=62998 Driving Pressure with Dr. Roy Brower Driving Pressure with Dr. Roy Brower

So, last year Amato et al published a paper on Driving Pressure:
Driving Pressure and Survival in the Acute Respiratory Distress Syndrome
It contained an incredibly interesting theory--driving pressure may be a much better measure of lung protection than Plateau Pressure. Driving pressure is Vt/Crs (Vt being tidal volume based on ideal body weight and Crs is the compliance of the respiratory system. In patients who are not spontaneously breathing, driving pressure could also be calculated by Plateau Pressure minus PEEP. These graphs explain how it can be both:





Based on the study, a driving pressure < 15 seems associated with lower mortality, even in patients with elevated plateau pressures. Conversely, patients with Plats < 30, but driving pressures >=15 still seem to be at risk. The study also offers a possible explanation for why the ARDSnet higher PEEP trials did not show benefit--higher PEEP only seems to help if it leads to reductions rather than elevations of the driving pressure (due to lung recruitment).

In this episode, I dicuss the logistics of Driving Pressure with Dr. Roy Brower, senior author of the study. Dr. Brower is a professor of Medicine and Medical Director of the MICU at the Johns Hopkins Hospital. He has over 150 publications, numerous national teaching awards and is the most recent recipient of the ATS Life Time Achievement Award (intro cribbed from MCCP).

After listening to the show, if you want to hear more of the underpinnings of driving pressure, listen to Dr. Browers lecture on the amazing Maryland CC Project:

Brower on Driving Pressure
Additional Reading

* From LitFL CCC Project
* ICU Physiology by JE Kenny
* Gattinoni on PEEP Selection

Now on to the Podcast...]]>
Scott D. Weingart, MD clean 19:25
Podcast 181 – Pulmonary Hypertension and Right Ventricular Failure with Susan Wilcox https://emcrit.org/emcrit/pulmonary-hypertension-right-ventricular-failure/ Mon, 05 Sep 2016 17:46:41 +0000 http://emcrit.org/?p=11368 Pulmonary Hypertension and Acute on Chronic RV Failure Pulmonary Hypertension and Acute on Chronic RV Failure


The Right Ventricle gets no respect, but it is an easy source of clean kills in the ED. We haven't covered pulmonary hypertension and acute on chronic RV failure on the show yet--we need to fix that ASAP. So, let's hear from Susan Wilcox, MD on this critical topic. She just wrote an amazing review on the subject for Ann Emerg Med and as an EM Intensivist, she is the perfect person to talk on this topic.
Best Current Review for EM

* Ann Emerg Med 2015;66(6):619 by Susan R. Wilcox, MD

Other Articles to Check Out

* Inten Care Med 2014;40:1930
* 21700906
* Crit Care Clin 2014;30:475
* CCR-4-49
* DOI 10.1111/anae.12831

Note: A good portion of these shownotes were contributed by Gregg Chesney, MD; ED Intensivist
Some Info

RV function determined by 3 P’s: preload, pump (RV contractility), and pipes (afterload)

RV is different than LV

* Thin walled, less muscular, more compliant, working against less afterload (PVR 1/10 of SVR)
* More dependent on volume loading than pressure to accomplish work of ventricle
* LV contracts in a wringing motion, RV contracts in a longitudinal up-and-down motion and compresses medially against septum
* RV doesn’t adapt well to acute changes in pressure/volume à dilates and becomes stiffer (takes 96 hrs to adapt)

Ventricular interdependence = LV and RV function are dependent on one another.

* LV preload = RV stroke volume, failing RV = decreased LV preload
* LV and RV share a muscular septum - contributes 20-40% of the work of RV contraction when LV contracts
* Dilated failing RV pushes IV septum into LV impairing LV filling/contractility and also impairing role of RV septum on RV contractility

RV Spiral Of Death


 

RV ischemia is the common final pathway that contributes to progressively worsening acute RV failure
Types of Pulmonary Hypertension

Causes of RV Failure can be broken into 4 Categories

ECHO: How to evaluate for RV failure at bedside

* Apical 4 chamber to evaluate relative size of RV to LV and to evaluate how RV “looks”
* If you are skilled, focus on lateral tricuspid annulus movement (TAPSE) 1.6
* McConnell’s sign may be indicative of acute RV failure with RV ischemia, not just seen in acute PE
* Parasternal short at level of mid-papillary to eval relationship between volumes and size of LV and RV and intraventricular septum – look for septal shift and the "D" Sign
* Plethoric IVC regardless of volume Status
* As RV dilates in chronic failure, there will be disruption of the tricuspid annulus leading to tricuspid regurg

 
Six step approach to management of acute RV failure
Step 1: Optimize volume status

* Lasix vs. fluids, use PSAX echo view to decide
* Err on the side of volume constriction, they are often overloaded unless the patient has a known source of volume loss
* Passive Leg Raising is probably a clever move before each small fluid bolus
]]>
Scott D. Weingart, MD clean 25:26
Podcast 180 – On Argumentation, Fallacies, and Twitter Misery https://emcrit.org/emcrit/argumentation/ Mon, 22 Aug 2016 23:11:21 +0000 http://emcrit.org/?p=96429 A slight diversion to discuss how to argue better A slight diversion to discuss how to argue better
Anatol Rapoport’s Rules: How to compose a successful critical commentary by Daniel Dennett

* You should attempt to re-express your target’s position so clearly, vividly, and fairly that your target says, “Thanks, I wish I’d thought of putting it that way.
* You should list any points of agreement (especially if they are not matters of general or widespread agreement).
* You should mention anything you have learned from your target.
* Only then are you permitted to say so much as a word of rebuttal or criticism.

Step 1 is analagous to steel-manning, aka the principle of charity. This is to avoid the act of straw-manning.

from the amazing book,
Paul Graham's Hierarchy of Disagreement


for more on this
What would it take to Change Your Mind?
Ask your subject, what would need to change for them to change their belief?

More questions to ask yourself
Grice's Maxims


* 4 Maxims that can serve as a guide-map to conversation and argument

Anti-Good Argumentation

* Some tips for evil debate

Logical Fallacies

* Avoiding Logical Fallacies
* More on logical fallacies
* How to craft a good argument

The Book to Buy



Ten Commandments of Rational Debate


by trolling2day1
The ones I see infecting FOAM debate again and again
Three logical fallacies, two seen universally and the other unique to medicine. The former two are the status quo bias and the bad-bayesian bias and the latter is Benefit/Harm Evidence Equalization.
Status Quo Bias
Thinking b/c we do things a certain way, there is evidence behind this way
Bad-Bayesian Bias
See Rich Carden's discussion of Baye
Benefit/Harm Evidence Equalization
Harm requires markedly less evidence of lower quality than benefit
An Example
responses to the Wee on the modification of scalper-finger-bougie technique


Hey Scott, I'm sorry for calling you out on Twitter like that, but the stance you have taken in regards to hold up conflation in bougie cric is a kind of a load of crap. I mean no disrespect when I say that because I trust you a ton, I do my own fact finding as well, but to me that seems way out of character for you to watch a video of someone else, not you, performing a skill very incorrectly,]]>
Scott D. Weingart, MD clean 24:43
Podcast 179 – An Interview with Gary Klein https://emcrit.org/emcrit/decision-making-gary-klein/ Sun, 07 Aug 2016 19:10:58 +0000 http://emcrit.org/?p=19054 Today, I am joined by my friend, Mike Lauria, to interview Gary Klein, PhD. Dr. Klein is a masterful cognitive psychologist. He is known for many groundbreaking works, including: the Recognition-Primed Decision (RPD) model to describe how people actually make decisions in natural settings; a Data/Frame model of sensemaking; a Management by Discovery model of planning to handle wicked problems; and a Triple-Path model of insight. He has also developed several research and application methods: The Critical Decision method and Knowledge Audit for doing cognitive task analysis; the PreMortem method of risk assessment; the ShadowBox method for training cognitive skills. He was instrumental in founding the field of Naturalistic Decision Making. The Books This is the one that got Mike and I started as Klein Fanboys The absolute best compilation of Dr. Klein's decision-making concepts that are directly applicable to medicine Next up on my reading list Recognition Primed Decisionmaking Wikipedia Link for RPD Sites and Links Dr. Klein's Company Shadowbox Training Articles Mentioned in the Show Kahneman D, Klein G. Conditions for intuitive expertise: a failure to disagree. Am Psychol. 2009 Sep;64(6):515-26. Can We Trust Best Practices? Six Cognitive Challenges of Evidence-Based Approaches. Journal of Cognitive Engineering and Decision Making Additional Related Stuff Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. Effects of reflective practice on the accuracy of medical diagnoses.  Going fast might not induce more error, it's about experience and if you have the patterns to recognize: Disrupting diagnostic reasoning: do interruptions, instructions, and experience affect the diagnostic accuracy and response time of residents and emergency physicians? Slowing down doesn't help.  Slow is just slow. Smooth is FAST, and smooth is about economy of cognitive resources and movements The relationship between response time and diagnostic accuracy. The etiology of diagnostic errors: a controlled trial of system 1 versus system 2 reasoning. Now on to the Podcast: Today, I am joined by my friend, Mike Lauria, to interview Gary Klein, PhD. Dr. Klein is a masterful cognitive psychologist. He is known for many groundbreaking works, including: the Recognition-Primed Decision (RPD) model to describe how people actual...

Today, I am joined by my friend, Mike Lauria, to interview Gary Klein, PhD. Dr. Klein is a masterful cognitive psychologist. He is known for many groundbreaking works, including: the Recognition-Primed Decision (RPD) model to describe how people actually make decisions in natural settings; a Data/Frame model of sensemaking; a Management by Discovery model of planning to handle wicked problems; and a Triple-Path model of insight. He has also developed several research and application methods: The Critical Decision method and Knowledge Audit for doing cognitive task analysis; the PreMortem method of risk assessment; the ShadowBox method for training cognitive skills. He was instrumental in founding the field of Naturalistic Decision Making.
The Books



This is the one that got Mike and I started as Klein Fanboys



The absolute best compilation of Dr. Klein's decision-making concepts that are directly applicable to medicine



Next up on my reading list
Recognition Primed Decisionmaking


Wikipedia Link for RPD
Sites and Links

* Dr. Klein's Company
* Shadowbox Training

Articles Mentioned in the Show

* Kahneman D, Klein G. Conditions for intuitive expertise: a failure to disagree. Am Psychol. 2009 Sep;64(6):515-26.
* Can We Trust Best Practices? Six Cognitive Challenges of Evidence-Based Approaches. Journal of Cognitive Engineering and Decision Making

Additional Related Stuff

* Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents.
* Effects of reflective practice on the accuracy of medical diagnoses.  Going fast might not induce more error, it's about experience and if you have the patterns to recognize:
* Disrupting diagnostic reasoning: do interruptions, instructions, and experience affect the diagnostic accuracy and response time of residents and emergency physicians? Slowing down doesn't help.  Slow is just slow. Smooth is FAST, and smooth is about economy of cognitive resources and movements
* The relationship between response time and diagnostic accuracy.
* The etiology of diagnostic errors: a controlled trial of system 1 versus system 2 reasoning.
*
*

Now on to the Podcast:]]>
Scott D. Weingart, MD clean 53:19
Modification of Scalpel Finger Bougie Technique https://emcrit.org/emcrit/modification-scalpel-finger-bougie-technique/ Mon, 01 Aug 2016 03:52:20 +0000 http://emcrit.org/?p=73030 No more bougie hold-up for scalpel-finger-bougie cric No more bougie hold-up for scalpel-finger-bougie cric

So I've been teaching my version of the scalpel-finger-bougie cric method for a few years now. I've used it on actual patient cricothyrotomies with great success. If you are not familiar with the way I teach, you can see a ton of the EMCrit cric resources here. One component of the technique that I'd been teaching is a secondary confirmation of intratracheal placement via obtaining hold-up with the bougie somewhere in the right bronchial tree. A set of comments brought up the possibility that with enough effort, a false hold-up could be obtained:

@ketaminh @emcrit @the_TOTAL_EM @cliffreid it is possible to unintentionally intubate the right atria when trying to cric, with min effort
— Jason Bowman (@texprehospital) July 4, 2016


Well, that sounds less than good. So first I wrote to EM anatomy guru, Andy Neill.

From the most recent Gray’s anatomy Textbook (the big bible at the mo)

"The pretracheal layer of the deep cervical fascia is very thin. It provides fascial sheaths for the thyroid gland, larynx, pharynx, trachea, oesophagus and the infrahyoid strap muscles. Superiorly, it is attached to the hyoid bone; inferiorly, it continues into the superior mediastinum along the great vessels and merges with the fibrous pericardium;”

and

"The retrovisceral space [this would be if you got your bougie between post trachea and oesophagus] is continuous superiorly with the retropharyngeal space. It is situated between the posterior wall of the oesophagus and the prevertebral fascia. Inferiorly, the retrovisceral space extends into the superior mediastinum. Should the prevertebral fascia merge with the connective tissue on the posterior surface of the oesophagus – usually at the level of the fourth thoracic vertebra – the retrovisceral space then has a distinct inferior boundary."

The suggestion here is that there’s a fascial plane from the pretacheal fascial space to the sup mediastinum but closed at that point and you would have to penetrate the fibrous pericardium with bougie to access the pericardial space (which i suppose you could do if you were really enthusiastic with your bougie!). You’d have to push even harder to actually penetrate the heart itself. The retrovisceal space has a clear boundary at T4 posteriorly which is still above the heart and more importantly much more posterior.

Bottom line the communicating fascial planes won’t get you further than the superior mediastinum as far as i can work out.

Though if you sharpened your bougie to a fine a point or used a chest drain trocar then i’m sure you could make it to the heart ;-)
Well, that sounds less than good because it still means if you are willing (unaware) and dissect through some tissue planes, you can definitely get holdup on the pericardium. But could this really be done easily? To find out, I reached out to my friend, George Kovacs. George tested this theory with the help of his amazing EM residents. You can see the results below.

TLDW: It is possible, in the hands of adrenalized novices, to get a false hold-up sign with the bougie during cricothyrotomy. I no longer recommend this secondary confirmation.
Minh, before you comment, this has nothing to do with the hold-up sign during orotracheal intubation.
Now on to the Wee...
]]>
Scott D. Weingart, MD clean 9:03
Emergency Awake Topicalized (EAT) Intubation – An Awake Intubation Update https://emcrit.org/emcrit/awake-intubation-update/ Fri, 29 Jul 2016 16:11:03 +0000 http://emcrit.org/?p=5480 Rapid Sequencing of Awake Intubation Rapid Sequencing of Awake Intubation
So I love awake intubation. I've done a ton of previous stuff on the topic of Awake Intubation. My friend, George Kovacs, introduced me to some new gear at one of the AirwayCam course. This changed the way I performed awake intubation--it also made it MUCH faster. So here is how I currently perform awake intubation.

* If you want to see a full lecture by George, go to Podcast 194

Dissociated Awake is what I used to do when I had a time crunch (Pt needs to be tubed now)

EAT Awake is what I do now

* Suck & Pad
* Topicalize
* Analgese
* Intubate
* Sedate

EZ-Atomizer


use the EZ Atomizer to topicalize everything but through-the-cords

You must use 4% lidocaine. Give 10-14 mls (may want to dilute to 3% in patients with low body weight or liver failure)

Flow Rate is 8 lpm on oxygen or air
Topical Lidocaine Lollipop
As high a concentration as you can get
MADgic Device

Plus/Minus Sedation/Analgesia
 

You can never see too many demonstrations of the technique, so here is another video:
George Kovacs on Airway Topicalization

Now on to the Wee...]]>
Scott D. Weingart, MD clean 7:59
Podcast 178 – A Better Management Strategy for Symptomatic Hyponatremia (dDAVP Clamp) https://emcrit.org/emcrit/better-management-hyponatremia/ Mon, 25 Jul 2016 20:47:45 +0000 http://emcrit.org/?p=16722 What to actually do (besides nothing) for severe hyponatremia What to actually do (besides nothing) for severe hyponatremia

I laid out my thoughts on the management of hyponatremia way back in Podcast 39. Josh has weighed in here on the dDAVP clamp as well. I'd been continuing my readings on this matter, especially with some great posts from the renal fellow network (below). Then, fortuitously, I was approached by Nand Wadhwa, one of our amazing nephrologists at Stony Brook. He wanted to partner with my unit to create a euvolemic hyponatremia protocol. So in this episode, we'll discuss the use and basis of the new Euvolemic Hyponatremia Guideline.
The Protocol

Included Patients

* Euvolemic or Hypovolemic
* Na <=125 (we changed this to <=120)

Evidence for dDAVP Clamp with 3%

* Am J Kidney Dis. 2013;61(4):571-578
* Clin J Am Soc Nephrol 9: 229–237, 2014

from this post

http://renalfellow.blogspot.com/2014/10/severe-chronic-hyponatremia_20.html

Clin J Am Soc Nephrol 2007;2:1110
Modified Edelman Equation

Video on Why Androgue Madias Equation doesn't work and how to use the Edelman Equation from Hashim Mohmod

Causes of Hyponatremia
See this Deranged Physiology Page and the LitFL Page
The Renal Fellow Network Hyponatremia Series by Hashim Mohmand

* Part 1
* Part 2
* Part 3
* Part 4
* Part 5

Key Points from the Series


Severe hyponatremia is multifactorial


Three issues that will screw your plans up:

* Subclinical Volume Depletion: Because we suck at assessing this
* Solute Depletion Hyponatremia: For instance,  "Tea and Toast Diet " hyponatremia and "Beer Potomania."
* Hypokalemia Repletion [case report]
* Read a Review Article by Dr. Mohmand on these issues

Review Articles

* Crit Care Hyponatremia Review 2013
* Androgue Madias Review

Peripheral 3% Hypertonic Saline is Safe

* Here is just some of the evidence

Things to think About

* Oral K repletion math-am I on the right track?
* Why doesn't SIADH lead to edema

Update

]]>
Scott D. Weingart, MD clean 20:30
EMCrit Wee – Should a Nasal Cannula be Part of Denitrogenation / Preoxygenation https://emcrit.org/emcrit/nasal-cannula-denitrogenation-preoxygenation/ Tue, 19 Jul 2016 21:56:37 +0000 http://emcrit.org/?p=18398 NC: yea or nay NC: yea or nay

In the LaMW: Ox Kills podcast, I discussed preoxygenation strategies. Sam Ghali had some questions; this wee has the answers.
Groombridge et al.
NRB @ 15 lpm  = 52.6%
NRB @ 15 lpm + NC @ 5 lpm = 57.1%

Max with anesthesia circuit
Hayes-Bradley et al.
http://www.annemergmed.com/article/S0196-0644(15)01500-0/abstract

Here are their numbers (they also simulated air leaks in this study)

NRB @ 15 lpm alone = 52% ETO2

NRB @ 15 lpm + NC @ 10 lpm = 67%

BVM = 79%

BVM with Mask Leak: BVM markedly improved with NC
Russell_et_al.
Nasal cannula improved ETO2 when mask leak was created]]>
Scott D. Weingart, MD clean 11:56
Podcast 177 – Chris Hicks on the Fog of War: Training the Resuscitationist Mindset https://emcrit.org/emcrit/chris-hicks-fog-of-war/ Mon, 11 Jul 2016 17:18:46 +0000 http://emcrit.org/?p=61116 Team Performance from Chris Hicks Team Performance from Chris Hicks

My friend, Chris Hicks, is an emergency physician and trauma team leader in Toronto, Canada. His niche and research work revolves around human factors, team performance, and stress management for individuals and teams. We brought him down to give a grand rounds lecture; this is a recording of that lecture.
The Slides

* Hicks-Stony Brook GR 2016

Videos from the Talk
Scene from the amazing movie, The Hurt Locker

Rhee performing Surgical Airway
https://vimeo.com/174238414
Trauma Sim

Trauma Sim Movement Tracking

Now on to the Lecture...]]>
Scott D. Weingart, MD clean 49:06
How Not to be a #ResusWANKER https://emcrit.org/emcrit/how-not-to-be-a-resuswanker/ Fri, 01 Jul 2016 14:15:15 +0000 http://emcrit.org/?p=17745 The seven folks that ruin your day... The seven folks that ruin your day...

John Hinds coined the term #resusWANKER at his amazing SMACC lecture on thoracotomy. I created this lecture on resusWANKERS in dedication to John and gave it at the Teaching Course in NYC with Rob Rogers. I gave it a second time at the Royal College of Emergency Medicine meeting in Manchester. This recording came from the third and final iteration in Glasgow, Scotland. I'd love to hear what you think--please comment below:
the seven resusWANKERS:

1. Wrong-but-Strongers (Dunning Kruger Effects)

* J Pers Soc Psychol 1999;77(6):1121
* Are We All Less Risky and More Skillful than our Fellow Drivers? (DOI: 10.1016/0001-6918(81)90005-6)
* Dunning When Knowledge Knows No Bounds- Self-Perceived Expertise Predicts Claims of Impossible Knowledge

2. Name Badge Believers (Specialty Name Bias)
3. Water Torturers (Decision Fatigue)

* PNAS 108(17):6889

4. EKG Thrusters (Slips/Sterile Cockpit)

* Intraoperative Noise Increases Perceived Task Load and Fatigue in Anesthesiology Residents: A Simulation-Based Study (Anesthesia and Analgesia 2016, 122 (2): 512-25)
* Noise Levels in Surgical ICUs Are Consistently Above Recommended Standards. (DOI: 10.1097/CCM.0000000000001378)

5. Leadership Encroachers
6. Slothful and Avoidant
7. Just Plain Dicks
Now watch the lecture...
]]>
Scott D. Weingart, MD clean 34:43
Podcast 176 – Updated EMCrit Rapid Sequence Intubation Checklist https://emcrit.org/emcrit/intubation-checklist-2-0/ Mon, 27 Jun 2016 17:06:09 +0000 http://emcrit.org/?p=57608 The new improved version of the EMCrit RSI checklist The new improved version of the EMCrit RSI checklist Podcast (92). Vahe Ender (@calldaburd) inspired me to reduce it to a business card/ID card sized version. I also simplified, clarified, and improved every aspect of the checklist. So here is the 2.0 version. The original is still great, it may just take a few seconds longer to use the old one. This is a no bullshit, less than 60 second version that has been field-tested 100's of times.
The EMCrit RSI Checklist v 2.0


Printable Version of EMCrit RSI Checklist
CricCon2

EMCrit Remix of the STC Failed Airway Algorithm


Printable Version of the STC Failed Airway Algo 2.0
Here is the Failed Airway Algo I see many centers use in lieu of the STC Algo


Attribution: Doktor Schnabel from the GomerBlog
Syringe Labels

* RACC Syringe Labels as of 2015-10-21 (Right Click and Choose Save-as)

Airway Bag (Sydney HEMS DumpKit)
Go to the Resus.cc site to see our version
Want to hear an actual use of the checklist with nurse calling and doc responding?
I'll be putting it up as a wee this week; sorry : (
Some Literature on Checklists for Crit Care Airway

* Resuscitationists Airway Checklists

Additional Stuff

* Article on IVC to predict hemo decompensation after intubation
* Evidence for Intubation Checklists (Ann Emerg Med. 2016 Mar;67(3):389-95)

Here is the checklist sheet and debrief form we will actually be using in the RACC

* Airway Debrief 20160508

Now on to the Vodcast...
]]>
Scott D. Weingart, MD clean 20:30
EMCrit Wee – Vipassana Meditation https://emcrit.org/emcrit/vipassana-meditation/ Sun, 19 Jun 2016 21:42:12 +0000 http://emcrit.org/?p=55387 My opening talk at SMACCdub was on meditation: vipassana and stoic negative contemplation. It will be available in the next few months. Hopefully this wee will tide you over. My opening talk at SMACCdub was on meditation: vipassana and stoic negative contemplation. It will be available in the next few months. Hopefully this wee will tide you over.
My opening talk at SMACCdub was on meditation: vipassana and stoic negative contemplation.

This wee will make more sense if you watch that lecture first

* Kettlebells for the Brain

It will be available in the next few months. Hopefully this wee will tide you over.
Read

* Book: The Mindful Geek: Secular Meditation for Smart Skeptics
* Book: Waking Up: A Guide to Spirituality Without Religion

Watch

* Michael Taft at Google

Science
Scientific American Article on the Mind of a Meditator
Muse Headband


* Muse: The Brain Sensing Headband - Black

Headspace App
Online or for Phones
Now on to the Wee...]]>
Scott D. Weingart, MD clean 20:26
EMCrit Podcast 175 – A Follow-Up on the Fluids in Sepsis Panel with Phillipe Rola https://emcrit.org/emcrit/fluids-sepsis-rola/ Tue, 31 May 2016 21:07:53 +0000 http://emcrit.org/?p=22004 Fluids in Sepsis Fluids in Sepsis
 

So I got to moderate a panel on Fluids in Sepsis with such luminaries as Manny Rivers, Dave Gaieski, Phillipe Rola, and Terry Clemmer. The panel was incredibly interesting, but in some ways exemplified treatment pathways that I don't quite agree with. If you'd like to listen for yourself, the link is here:
Fluids in Sepsis Panel
Since I felt some of the key messages were slightly askew, I wanted to debrief with my friend Phillipe Rola. Phillipe is a self-described Internist-Intensivist, mad sonographer, ducatista and Brazilian Jujitsu aficionado. He blogs at the site: Thinking Critical Care.
Topics we Discussed

* Fantastic Post on Fluid Tolerance/Responsiveness
* Cerebral and Somatic NIRS
* Hepatic Vein Doppler
* Portal Vein Flow

Now on to the Podcast...]]>
Scott D. Weingart, MD clean 29:31
SMACC-Back – On Marik and Lactate https://emcrit.org/emcrit/smacc-back-marik-lactate/ Sat, 21 May 2016 20:06:17 +0000 http://emcrit.org/?p=20667 Banging -- My -- Head -- Against -- Wall -- Repeatedly... Banging -- My -- Head -- Against -- Wall -- Repeatedly...

My friend, Paul Marik, is a mythbuster. He has been vindicated in so many viewpoints that were initially branded as crazy. But... sometimes the weapon he chooses, in his war against perceived pseudo-axioms, is hyperbole. This was the case in a few instances in his talk from SMACC-Chicago on Lactate:

http://intensivecarenetwork.com/understanding-lactate-paul-marik/

 
The Paper Paul Cited

* Roberg Article [cite source='pubmed']15308499[/cite]

The Many Retorts Explaining Its Flaws

* If you only read one retort
* [cite source='pubmed']16105825[/cite]
* [cite source='pubmed']16760335[/cite]
* [cite source='pubmed']16105824[/cite]
* [cite source='pubmed']16105823[/cite]


Post-Publication Peer Review
I wanted to be extra sure about this one before sending it to Paul, so I reached out to the brilliant Dr. David Story:
I agree with your thoughts, I’ll try not to be too random in my response as a Stewartite.

From a Stewart perspective Dr Marik’s comments about lactate seem incorrect.

One of the many attractions of the Stewart quantitative approach to acid-base (Stewart 2009) is that one does not have to do hydrogen ion accounting. What determines hydrogen ion concentration (and pH) in body fluids (plasma, interstitial AND intracellular) is the partial pressure of carbon dioxide, the strong-ion-difference, and the total weak acids (Stewart 2009). Water is the hydrogen ion source.

Lactate has a pKa of 3.9 (pH of 50% dissociation), and is therefore almost completely dissociated in plasma at pH 7.40. In plasma, lactate is a strong anion and acts like chloride in quantitative acid-base assessment. This effect can be easily quantified in clinical chemistry (Story 2016).

The same applies to the intracellular environment (Magder 2009) including skeletal muscle at maximal exercise or any lactate producing cell in sepsis. If lactate increases without a change in other ions the strong-ion-difference will decrease and acidity will increase. At extreme exercise the pH in skeletal muscle will be above 6.2. Even if one were to argue that lactate is no longer acting like a strong anion in pockets of extreme acidity such as lysozymes, it would be acting like a weak acid and increases in total lactate will increase acidity. Therefore if lactate goes up, acidity goes up. The paper referred to Dr Marik by Robergs (2004) demonstrates how confusing acid-base can be if trying to account for hydrogen ions, particularly when considering complex metabolism. Ignore the attempts to account for hydrogen ions in assorted cellular events and stick with the strong-ion-difference and total weak acids: increased lactate causes acidosis in any body fluid.

References

* Stewart PA, Whole-body acid-base balance. IN: Kellum JA, Elbers PWG (Eds) Stewart’s Textbook of Acid-Base. 2nd Ed. www.AcidBase.org, 2009
* Magder S, Intracellular [H+]. IN: Kellum JA, Elbers PWG (Eds) Stewart’s Textbook of Acid-Base. 2nd Ed. www.AcidBase.org, 2009
* Story D. (Open Mind) Stewart Acid-Base: A Simplified Bedside Approach. Anesthesia and Analgesia, 2016 (ePub ahead of print).
* Robergs RA, Ghiasvand F, Parker D. Biochemistry of exercise-induced metabolic acidosis. Am J PhysiolRegulIntegr Comp Physiol. 2004 Sep;287(3):R502-16


Professor David Story, MBBS,]]>
Scott D. Weingart, MD clean 9:52
Podcast 174 – LaMW – Oxygenation Kills Part II https://emcrit.org/emcrit/lamw-oxygenation-kills-ii/ Sun, 15 May 2016 21:17:58 +0000 http://emcrit.org/?p=20333 Laryngoscope as a Murder Weapon - Oxygenation Kills Part II Laryngoscope as a Murder Weapon - Oxygenation Kills Part II

This is Part II, you need to Watch Part I First!

So I've been giving this talk for Grand Rounds for a decade now. I've kept it off the podcast so I would have something unheard to discuss when I come to visit a program. I don't do many grand rounds any more--so the time has come, here is:
Laryngoscope as a Murder Weapon: Oxygenation Kills
There are two other LaMW talks:

* LaMW: Ventilatory Kills
* LaMW: Hemodynamic Kills

Most of the things discussed are elaborated upon on the EMCrit Preox Page.

This will be a two-parter. The things we will cover over the course of these two segments are:

* PreOx (Including VaPoX)
* Preventing Deox with ApOx and Apenic CPAP

* ReOx

Need an Audio-Only Version?
Right Click and Choose Save-As
Now on to the Vodcast...
]]>
Scott D. Weingart, MD clean 18:13
Podcast 173 – LaMW – Oxygenation Kills Part I https://emcrit.org/emcrit/lamw-oxygenation-kills/ Tue, 03 May 2016 00:29:43 +0000 http://emcrit.org/?p=19962 Laryngoscope as a Murder Weapon - Oxygenation Kills, Part I Laryngoscope as a Murder Weapon - Oxygenation Kills, Part I

So I've been giving this talk for Grand Rounds for a decade now. I've kept it off the podcast so I would have something unheard to discuss when I come to visit a program. I don't do many grand rounds any more--so the time has come, here is:
Laryngoscope as a Murder Weapon: Oxygenation Kills
There are two other LaMW talks:

* LaMW: Ventilatory Kills
* LaMW: Hemodynamic Kills

Most of the things discussed are elaborated upon on the EMCrit Preox Page.

This will be a two-parter. The things we will cover over the course of these two segments are:

* PreOx (Including VaPoX)
* Preventing Deox with ApOx and Apenic CPAP

* ReOx

See Part II
Part II of LaMW Ox Kills
Need an Audio Only Version
Right-Click here and Choose Save-as
Now on to Part I...
]]>
Scott D. Weingart, MD clean 30:16
Reddit and A Free Sepsis Webinar https://emcrit.org/emcrit/reddit/ Thu, 21 Apr 2016 19:28:05 +0000 http://emcrit.org/?p=19421 G+ is dead, long live reddit G+ is dead, long live reddit
Reddit
Google Plus is surely on its last legs. Let's ditch this dying corpse, my fellow fleas. On to the next corpus: reddit.
CGP Grey on What is Reddit?


so come to emcrit.org/reddit and subscribe to the emcrit subreddit
Subscribe to EMCrit Subreddit

Leave Questions for the Fluid Webinar Here
Questions for Fluids in Sepsis Webinar

 
New York State Partnership for Patients: Fluids in Sepsis Webinar
4/27/2016 at 1400 Eastern Time

Panel Moderator:
• Scott Weingart, M.D., Chief of the Division of Emergency Critical Care at Stony Brook University Medical Center

Panelists:
• Terry P. Clemmer, M.D., Director of Critical Care Medicine, LDS Hospital, Intermountain Healthcare
• David Gaieski, M.D. Co-Director, Early Goal-directed Therapy, Co-Director Clinical Resuscitation, Thomas Jefferson University
• Emanuel Rivers, M.D, M.P.H., Vice Chairman and Research Director, Henry Ford Health System, Department of Emergency Medicine
• Phillippe Rola, M.D., ICU Chief of Service, Santa Cabrini Hospital, Montreal Canada

Register at this Link

 ]]>
Scott D. Weingart, MD clean 7:53
EMCrit Podcast 172d – Enough with the Can you Trust Podcasts/Blogs/New Media https://emcrit.org/emcrit/emcrit-podcast-172d-enough-can-trust-podcastsblogsnew-media/ Sun, 17 Apr 2016 17:52:51 +0000 http://emcrit.org/?p=19329 Yes, you can trust medical podcasters Yes, you can trust medical podcasters

This is in response to a bunch of comments from this Wildcast EM episode.

Please let me know what you think!
Update
Response and my comments just posted on the new Wildcast EM Site
Now on to the Podcast...
 ]]>
Scott D. Weingart, MD clean 10:41
EMCrit Podcast 172c – Vent as Bag & VAPOX https://emcrit.org/emcrit/emcrit-wee-vapox/ Sun, 17 Apr 2016 17:52:32 +0000 http://emcrit.org/?p=19234 the BVM is the most dangerous device in medicine--let's do better the BVM is the most dangerous device in medicine--let's do better
VAPOX and Vent-as-Bag
In a concept piece called Preoxygenation. Reoxygenation and Delayed Sequence Intubation in the Emergency Department, I outlined a concept which I called: the vent as a bag. Why would we use the unpredictable and unmeasured BVM, when instead we could use a purpose-built, strictly internally regulated machine like a ventilator. I had stopped talking about the idea when numerous people told me it was unfeasible in their environment--however, I continued this practice for my own patients throughout my practice.

Recently, Grant et al. published a case series using the same concept--they have dubbed their vision of it VAPOX.


Ventilator-assisted preoxygenation: Protocol for combining non-invasive ventilation and apnoeic oxygenation using a portable ventilator (DOI: 10.1111/1742-6723.12524)[cite source='doi']10.1111/1742-6723.12524[/cite]


their protocol is very similar to the one I have used:

Non-Invasive SIMV

* Respiratory rate of 6–8 breaths per minute
* Pressure support 0 cm water (I never bothered unless pt had severe acidosis--the authors used PS of 10)
* Positive end expiratory pressure starting at 5 cm water (titrate up to 15 if not getting sats > 95% in preox)
* Fraction inspired oxygen 1.0
* Vt 550 ml
* Inspiratory Flow (30 lpm)



See Grant et al.'s paper for their protocol

Also consider getting some mask straps

And Remember the Nasal Cannula at 15 lpm
For More
See the EMCrit Preoxygenation Page
Now on to the Podcast...
 

]]>
Scott D. Weingart, MD clean 7:09
EMCrit Podcast 172b – MoTR – Get Faster! https://emcrit.org/emcrit/faster/ Sun, 17 Apr 2016 17:52:05 +0000 http://emcrit.org/?p=17669 Slow is Smooth, Smooth is Fast. Now, get faster Slow is Smooth, Smooth is Fast. Now, get faster
Mind of the Resuscitationist
In a previous wees and lectures, we discussed Chapman's Dictum: smoothness=speed; slow is smooth, smooth is fast

So go slow!
Update
Love this quote brought to my attention by G. Harrison:
When I say that I learned to take my time in a gunfight, I do not wish to be misunderstood, for the time to be taken was only that split fraction of a second that means the difference between deadly accuracy with a sixgun and a miss. It is hard to make this clear to a man who has never been in a gunfight. Perhaps I can best describe such time taking as going into action with the greatest speed of which a man’s muscles are capable, but mentally unflustered by an urge to hurry or the need for complicated nervous and muscular actions which trick-shooting involves. Mentally deliberate, but muscularly faster than thought, is what I mean

--Wyatt Earp
Now I will extol the virtues of getting faster...
 ]]>
Scott D. Weingart, MD clean 4:03
EMCrit Podcast 172a – The Mind Palace? https://emcrit.org/emcrit/mind-palace/ Sun, 17 Apr 2016 17:51:47 +0000 http://emcrit.org/?p=18360 I want the perfect external mind palace... I want the perfect external mind palace...


The mind palace, also known as the memory palace or the memory theatre, is something I want badly! Ever since I read the incredible book, the , I have dreamed of building a mind palace. But in medicine, we should be able to externalize the palace--in fact, we must! The method of loci will not suffice.



Technology should surely have advanced to the point where this is simple--the programming requirements are trivial.

My current mind palace is at CrashingPatient.com. It is quite good, but not perfect.
Factors
Storage
We need a place to store all of the literature, books, and internet posts/media we feel will be valuable. The storage must be durable (if an internet site goes down, the work remains). If we lose our paid access, we retain the full text of the literature.
Readability



The medium should allow comfortable reading of the literature, viewing of the media, etc.
Accessibility
Should be immediately accessible offline or online. Should be firewall resistant.
Ease of Commenting/Summarizing
Need to put the take-home message somewhere. Additional thoughts, new findings. Really two separate things:

* We need the ability to comment on, by which I mean literally on the paper (i.e. scribblings, marginalia, highlighting)
* But also the ability to summarize a Topic and add those papers as citations in a way that would link to the scribbled on paper

Ease of the Edit
Front end editing
Open Source
Or at the very least, immediately exportable to open source
Search
All information should be easily retrievable with logic, operator,  and fuzzy logic based searches
Option to Publish
Should you want to share your memory palace
The Mind Palace Cycle

* Discovery
* Storage for to-be-read/to-be-viewed
* Process=Read/Comment/Summarize
* Storage
* Retrieval/Search
* Publish or Protect as Desired

Possibilities

* Wordpress
* Evernote
* Zotero
* Papers
* Mendeley

image from memorise.org
Want to read more about memory?
The Art of Memory, mentioned above, is amazing--but oh so dense. For a lighter, contemporary read:


Update
Some additional requirements/desires:

* Self-Updating TOC as frontpage (see crashingpatient.com)
* Search must be browsable by either google or a plug-in and updates in real time
* Need to be able to do edits/additions on firewalled computers in any computer in the hospital.
* Want, but not essential--evernote's real time search of the contents of embedded pdfs would be pretty swell

Now on to the Podcast...
]]>
Scott D. Weingart, MD clean 12:51
Podcast 171 – OODA Loops https://emcrit.org/emcrit/ooda-loops/ Sat, 02 Apr 2016 21:08:12 +0000 http://emcrit.org/?p=14229 Resuscitation is a System I Game... Resuscitation is a System I Game...

My keynote lecture at SMACC-Chicago was on OODA loops and the supremacy of System I for resuscitation. The lecture was plagued by AV-wankers to the point that I thought the talk was a shambles. I am rerecording the lecture here for EMCrit and the SMACC site. I hope you enjoy--SDW.
The OODA Loop

OODA Loops and John Boyd

* I'm loathe to link to this, but this probably the most accessible description of OODA loops and Boyd Philosophy

Protocols May Cause Harm

* Protocols for the OODA Loop Trilogy

Why I Hate ATLS

* Archaic Trauma Life Support

Guidelines are not for experts
https://twitter.com/Drmanoj_s/status/614443279971520512
Articles

* Conditions for Intuitive Expertise by Gary Klein
* ED Cognition by Croskerry

Croskerry's Loop

More to Read and Watch

* Physiology Inside the Loop
* More on OODA
* Klein Ted Talk
* Klein Strategies of Decision Making
* Croskerry Lecture Thinking Straight Lecture from SMACC
* System 1 vs. System 2
* All things John Boyd

The Book to Buy



Update
Ugggggghhhh. I couldn't see my notes while rerecording and I said Boyd was a Navy Pilot, when of course he was air force. And it was the air force that has reportedly not embraced his work. Sorry Navy. Thanks, Jim!
The Slides

* From SMACC Chicago

Audio Only Version

* Audio-Only OODA

Updates:
ED Docs seem to perform as well as trauma teams
Now On to the Vodcast...
]]>
Scott D. Weingart, MD clean 38:56
Wee – Cliff Deutschman with Additional Thoughts on Sepsis 3.0 https://emcrit.org/emcrit/wee-cliff-deutschman-additional-thoughts-sepsis-3-0/ Fri, 11 Mar 2016 17:56:00 +0000 http://emcrit.org/?p=18846 More on Sepsis 3.0 More on Sepsis 3.0
Cliff Deutschman, coauthor of the Sepsis 3.0 overview paper, reached out to me because he had additional thoughts he wanted to add to Merv Singer on Podcast 169. He also did not want Merv's mustache getting all of the sepsis attention.
Here is Cliff's Outline

* Additional thoughts on Sepsis 3.0

Now on to the Wee...
 ]]>
Scott D. Weingart, MD clean 27:00
Podcast 169 – Sepsis 3.0 with Merv Singer https://emcrit.org/emcrit/sepsis-3/ Mon, 07 Mar 2016 22:19:46 +0000 http://emcrit.org/?p=18796 Hear from the lead author of the new Sepsis 3.0 definitions Hear from the lead author of the new Sepsis 3.0 definitions

Sepsis-3.0 has been released!

Please read the paper!

Then read some of the amazing discussions from the FOAM community:

* Jeremy Faust and Lauren Westafer reveal the new sepsis definitions.
* Great links to pro/con discussion too by Natalie May and Richard Carden at St Elmyn’s.
* Justin Mandeville also summarises Sepsis 3.0 and uses the “rule of 2s” in his post from ICMWK.

Then read Josh's PulmCrit Post

And only then, listen to this discussion with Mervyn Singer, lead author of the new definitions.

Here from Cliff Deutschman as well

* On this EMCrit Sepsis Wee

Flowchart from the Paper

Links and Stuff

* SOFA Calculator
* NY STOP SEPSIS Collaborative Triage Screening
* SCCM Sepsis Redefined Resource Page
* More on Timing of Antibiotics from Salim
* Meta-Analysis that Salim Mentions (Crit Care Med 2015;43:1907)

Please let me know what you think in the comments section below.
Update

* Great post on the ICN

Now on to the Podcast...]]>
Scott D. Weingart, MD clean 32:33
Podcast 168 – Kyle Gunnerson and the EC3 https://emcrit.org/emcrit/ec3/ Tue, 23 Feb 2016 16:23:32 +0000 http://emcrit.org/?p=18706 The USA's first stand-alone EDICU, the EC3 The USA's first stand-alone EDICU, the EC3

A few years ago, I wrote an article about ED Intensivists and EDICUs. In the article, I discussed the hypothetical stand-alone EDICU. It is hypothetical no more. Kyle Gunnerson, with the support of his chair Bob Neumar, has created the EC3 at University of Michigan. Last week, I visited the unit--it was absolutely incredible! I invited Kyle to our RESUSCITATE NYC conference to discuss the great work he and his team have done.

Come to the Last Castlefest
This is the last one. Sign Up Now!
EC3 Tour

* Tour of the U Michigan EC3

ED Critical Care Ask Us Anything

* Read the description by Rob Huang
* See the Video


Now on to the Vodcast...
]]>
Scott D. Weingart, MD clean 32:26
Podcast 167- Emergency Critical Care with Sara Gray https://emcrit.org/emcrit/emergency-critical-care-sara-gray/ Tue, 09 Feb 2016 02:07:12 +0000 http://emcrit.org/?p=18630 Sara Gray is amazing--hear her talk about ED Critical Care from @smaccteam: Sara Gray is amazing--hear her talk about ED Critical Care from @smaccteam:

Sara Gray practices Emergency Medicine and Critical Care in Canada.  She works in both areas at St. Michael’s Hospital and is an Associate Professor at the University of Toronto.  Her academic interests include patient safety and knowledge translation, specifically how to optimize the care of critically ill patients in the ED.  Her most important achievements are her kids, who don’t care what she does at work all day, but who appreciate her chauffeuring skills and her sense of humor.She was a speaker at SMACCchicago; I thought her talk on ED Critical Care was just perfect for EMCrit.
Abstract
Is the care you deliver to critically ill patients in your ED the same as the care delivered in your ICU? And if not, why not?

Consider the challenges facing the delivery of excellent care in the ED, and be inspired to make changes at your hospital to improve your system. Learn ten strategies for optimizing the care of critically ill patients in your ED.

References:

1. Learn more about ED-ICU’s here at EMCrit

2. Consider a resuscitation fellowship like this one

3. There are zillions of articles about the benefits of simulation and training, here is a link to just one, if you only want to dip your toe in the water:

4. Audit and feedback around quality outcomes are a potential strategy. Read more about the pros and cons from the World Health Organization
Slides
http://www.slideshare.net/oliflower/optimising-critical-care-in-the-emerency-department-by-sara-gray?ref=http://www.smacc.net.au/2015/12/optimising-critical-care-in-the-emerency-department-by-sara-gray/
Now on to the Podcast...]]>
Scott D. Weingart, MD clean 18:06
Podcast 166 – Endocarditis with David Carr https://emcrit.org/emcrit/endocarditis/ Tue, 26 Jan 2016 01:06:40 +0000 http://emcrit.org/?p=16808 Endocarditis in Acutely Ill Patients Endocarditis in Acutely Ill Patients
Some Points on Acute Endocarditis from the Talk

* Keep Endocarditis on the radar for all febrile patients without a source
* Examine your febrile-listen for murmur and look at teeth
* Ask about teeth cleaning in past 2 weeks
* Even though we were taught about Janeway lesions and Osler’s nodes in medical school, the reality is that these peripheral manifestations of endocarditis occur in only about 10% of patients.  Listening for heart murmurs which are present in about 90% of patients with endocarditis is one of the most important physical exam maneuvers in patients who present with fever
* Various Ways to Categorize

* Native Valve | Prosthetic Valve | IV Drug User
* Right vs. Left-sided
* Acute vs. Subacute


* Acute Endocarditis may present so acutely that a murmur has not yet developed despite the patient being quite ill
* Oh so fastidious, the HACEK organisms are Haemophilus species, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae
* Endocarditis should be on your radar for any patient with valvular heart disease who presents to the ED whether they are febrile or not, especially if they are vaguely unwell
* Ideal cultures: 3 sets at 3 sites with an hour between first and last, each with a bunch of blood
* Coag-Negative Staph Aureus positive blood culture in a patient with valvular disease is endocarditis until proven otherwise, even though the majority of Coag Negative Staph Aureus positive blood cultures are contaminants. A blood culture positive for a particular type of Coag-Negative Staph Aureus called SLUG (Staphylococus lugdunensis) should raise the possibility of endocarditis even in patients without valvular heart disease
* Get nervous when the bacteria doesn't fit the crime
* No ED/ICU procedure requires prophylaxis
* 2/3 of L-sided emboli will be CNS. Brain emboli will be in the MCA territory
* Be scared of new-onset of CHF and CHF in young patients
* Look at the ECG for new heart blocks in patients with fever (Even 1st Degree HB) - Consider Valvular Abscess
* Antibiotic coverage-your empiric sepsis antibiotics + sepsis-dose Vanco will cover everything you need to worry about. Vanco alone will get the job done in almost every case

More Information

* Dave Carr on Anton Helman's Show
* The AHA Guidelines (but highly recommend placing toothpicks under your eyelids before reading)

Now on to the Podcast....]]>
Scott D. Weingart, MD clean 33:32
Podcast 165 – The Semantics of End of Life Discussions with Ashley Shreves https://emcrit.org/emcrit/semantics-end-of-life-discussions/ Sun, 10 Jan 2016 20:29:18 +0000 http://emcrit.org/?p=18356 How to have an end of life conversation in the ED How to have an end of life conversation in the ED
End of Life Conversations are Hard
We stumble, we stutter, we say things that derail the discussion when we have a patient at the end of life. But how do we learn to do better? We model good behavior. But in order to do that we need to hear good discussions. I listened to Ashley Shreve's amazing SMACC Chicago talk:

SMACC Talk: What is a Good Death?

After listening, I wanted to bring Ashley back on to really get into the nitty-gritty of the semantics of End of Life discussions. Ashley has been on the EMCrit podcast before discussing Critical Care Palliation. Now lets hear from here again...
Tidbits I pulled out of the Podcast

* The three patients that will spur Ashley to try to have these discussions:

* 1. Advanced Cancer or Terminal Disease with Instability
* 2. Advanced Frailty/Dementia with Instability
* 3. Advanced Physiological Age (>85 y/o) with Instability


* Start with, "I'm so worried about your family member," and see the response
* Then, "Tell me how things have been going with your family member"
* Technique: Ask, Tell, Ask, Tell
* Know the trajectories of care for the diseases we deal with
* Does that mean you will do nothing? No, we actually want to intensify the treatment, with a focus on peace and dignity
* We don't want to artificially prolong the dying process
* Vitalists comprise 5-10% of the population, you are unlikely to convince these folks in the ED
* What if things don't get better?


Additional Resources

* Vital Talks Web Site
* Book:
* Six ways to have End of Life Conversations with Compassion by Ashley
* Palliative Care FastFacts from Wisconsin

Now on to the Podcast...]]>
Scott D. Weingart, MD clean 42:47
Podcast 164 – The Day I Didn’t Use Ultrasound by Mike Mallin https://emcrit.org/emcrit/day-i-didnt-use-ultrasound/ Sat, 26 Dec 2015 23:40:55 +0000 http://emcrit.org/?p=18168 An amazing story from Mike Mallin An amazing story from Mike Mallin

So I was at the Blood & Sand conference a few weeks ago in the Bahamas. The highlight of the course was a lecture by Mike Mallin. The lecture is now on EMCrit--I'm sure you'll enjoy it.
Thoughts I had during the Talk & Meta Stuff

* Sympathetics lead to/augment: fight, flight, freeze, or shout
* We need to get Mike on to do a book club on

* Since I've started speaking about crics, I've received more than 50 emails from people who heard a lecture or a podcast and it gave them a boost to get the job done. That's why I keep putting up lectures like this one.

More on Surgical Airway
Well we have a wee bit on the EMCrit Surgical Airway Page
Now on to the Vodcast...
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Scott D. Weingart, MD clean 33:55
Resuscitation Program and FEMinEM discussion on Women as Conference Speakers and Unconscious Bias https://emcrit.org/emcrit/women-conference-speakers/ Sun, 20 Dec 2015 22:52:00 +0000 http://emcrit.org/?p=17690 ART Program and FEMinEM Hangout ART Program and FEMinEM Hangout If you are interested in the ART Program, please go to the program page
Advanced Resuscitation Training (ART) Program

FEMinEM Discussion
So we have our RESUSCITATE NYC conference coming up soon. On the day we listed the program, we got this tweet from @First_do_noharm



Well, needless to say, I was a bit upset by the tone of this tweet--but the issues raised were incredibly important. Hence, instead of touching off a tweet-war, I instead reached out to the FEMinEM folks to see if they would host a discussion. Dara Kass (@darakass) and Jenny Beck-Esmay (@jbeckesmay) were kind enough to set up a google hangout to discuss the issues. Simon Carley (@EMManchester) has been doing research on this topic and was kind enough to join us as well.



I thoroughly enjoyed the conversation and felt it was balanced and hopefully raises some things to think about. Especially in the setting of this kind of ridiculous sexist trolling:


Update
Ashley Liebig wrote with this message:
What are you waiting for?

In 7th grade, I was at a school dance. Everyone was dressed in their best; boys and girls stood, clustered together, on opposite sides of a vacant dance floor.

I loved to dance, and at the age of 12, this wasted opportunity was a tragedy. “Why isn't anyone dancing?”

“None of the boys have asked us.”

I recall this conversation like it was yesterday. I remember the look on my friend’s face as the words came out of her mouth. Even as a young girl, she nearly choked on them as she realized what she was saying. Almost as quickly as they passed her lips, she grabbed my hand, and marched across the gymnasium floor to the boys and commanded, “Let’s go! We are dancing!”

I couldn’t help but recall this story as I listened to the #feminEM forum addressing the need for more female conference speakers.

From this, and the conversations I have had in person and viewed in the Twittersphere, it seems that women are waiting for an invitation to be heard. Women: smart, powerful, articulate professionals are WAITING for someone to invite them to the stage and then become frustrated when no one does! Wouldn’t that energy be better spent in active pursuit of that opportunity?

Public speaking can be terrifying and becoming a great public speaker doesn’t just happen organically. It takes work, a massive amounts of time and practice. Ask women like Natalie May, Liz Crowe and Victoria Brazil. All brilliant speakers, whose craft has been honed over countless hours of commitment to the design and choreography of great lectures. This is not said to deter anyone, but rather to provide an appreciation of the effort involved. Submitting ideas, preparing for and giving lectures is a job in and of itself. Great speakers don’t just appear, they build a name for themselves, they work “the circuit”. They give lectures on a small scale, at grand rounds, and at regional conferences until they establish a reputation that propels them to the national level.

With this in mind, have you submitted proposals to speak? Granted not all conferences call for speakers, but most do. When is the last time you submitted a lecture idea or topic? If you have not, the better question to ask is why not?

]]>
Scott D. Weingart, MD clean 2:09
Response to a Letter to the Editor on DSI Study https://emcrit.org/emcrit/response-to-a-letter-dsi/ Sat, 19 Dec 2015 00:41:22 +0000 http://emcrit.org/?p=17995 A response to some DSI questions in the Annals A response to some DSI questions in the Annals

Recently, a letter to the editor was published in the Annals of Emergency Medicine. We were asked to respond in print, which we did. However, due to space limitations and the limitations of the Letter to the Editor System, we did not feel that the response was complete. Here is the complete response:

These opinions are those of the lead author and have been corroborated by the other authors of our DSI paper.

Written Response
More Information
A comprehensive collection of Delayed Sequence Intubation information can be found at this page

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Scott D. Weingart, MD clean 20:26
Podcast 163 – MotR – The Post-Resuscitation https://emcrit.org/emcrit/post-resuscitation/ Tue, 15 Dec 2015 19:30:40 +0000 http://emcrit.org/?p=16636 You saved a life or blew an airway--Now What? Handling the post-resuscitation on EMCrit # 163: You saved a life or blew an airway--Now What? Handling the post-resuscitation on EMCrit # 163:
What to do in the Post-Resuscitation
Inspired by my friend Mike Mallin, today I discuss the post-resuscitation. This squarely fits into the Mind of the Resuscitationist (MotR) series.
Parasympathetic Backlash
Follows the adrenaline dump. You are basically performing at a much lower level than normal.
The moment of greatest vulnerability is the instant immediately after victory.
~ Napoleon Bonaparte
We briefly touched on this concept in the On Combat bookclub.
...It doesn’t take a rocket scientist to guess that a soldier must pay a heavy physiological price for an enervating process this intense. The price that the body pays is an equally powerful backlash when the neglected demands of the parasympathetic system become ascendant. This parasympathetic backlash occurs as soon as the danger and the excitement are over, and it takes the form of an incredibly powerful weariness and sleepiness on the part of the soldier.
~ Grossman, On Combat
What to Do?

* Scene Check/360 degree sweep/Stabilization steps
* Eat
* Drink
* Change Clothes
* Nap?

Debrief

* Organized Debrief
* Need your input here
* Guilt Release

Process and Avoid Post-Traumatic Negatives
Go on the Couch
Cliff Reid's Couch
Visualization
Use the highest fidelity simulator, your brain, to replay, re-act, and improve
Meditation
Will discuss on an upcoming podcast
Gaming Processing and Recreation


Play Tetris or Mindcraft

[cite source='doi']10.1371/journal.pone.0004153[/cite], [cite source='doi']10.1177/0956797615583071[/cite]

Jane McGonigal's Ted Talk & her interview on Tim Ferriss' podcast. Read her book: SuperBetter.
What if you actually screwed up?
Jason Brooks-Come Help me...
Post-Traumatic Growth
Resilience may lead people to go down the path of Post Traumatic Growth rather than PTSD

 

 ]]>
Scott D. Weingart, MD clean 23:06
Podcast 162 – Assessing Fluid Responsiveness https://emcrit.org/emcrit/assessing-fluid-responsiveness/ Sun, 29 Nov 2015 18:51:06 +0000 http://emcrit.org/?p=5410 yep, more on fluid responsiveness yep, more on fluid responsiveness

In Podcast 64, Paul Marik and I discussed the concept of Fluid Responsiveness, and then we had the amazing Jean-Francois Lanctot discussing his four-part assessment with ultrasound to determine fluid use in sepsis. After that talk, I definitely felt I needed to discuss some of these issues further. If you have not listened to those two podcasts, it may be beneficial to go back before listening to this one.

and what has come to me is that perhaps we have been conflating two concepts:

*
Can the RV take it?

*
Can the LV use it?


Perhaps the problem we have been having is that we are trying to blend these two questions into 1. Let's use that as our path to discuss this morass of volume-responsiveness
Fluid Challenge or PLR with CO measurements
Stress the System with PLR or Fluid Challenge
Passive Leg Raise

Worth mentioning, though it should be obvious, PLR demonstrates how ridiculous the practice of Trendelenberg Position for resuscitation
Fluid Challenge
500 ml crystalloid or colloid
10-Second Mini-Fluid Challenge
50 ml bolus over 10 seconds through a central line (Critical Care 2014;18:R108) change in VTI measured immediately afterwards
Then Measure the Response
Can Changes in MAP Predict Fluid Responsiveness?
[cite source='pubmed']22278593[/cite], [cite]20111858[/cite], [cite]22464162[/cite]

Most recent analysis states changes in MAP don't predict CI increase from fluid load in septic shock (Intensive Care Med (2012) 38:422–428)

The Cardiac Output Monitors
Marik's Comprehensive Review Article

and my buddy Seth Manoach wrote a nice review as well [cite source='pubmed']22537573[/cite]


NICOM - Bioreactance

* Marik studied 34 patients in the ICU with PLR, NICOM, SVV, and Carotid Flow (The use of NICOM (Bioreactance) and Carotid Doppler to determine volume responsiveness and blood flow redistribution following passive leg raising in hemodynamically unstable patients (Chest 2012 Marik et al.)
* Big validation study showed good accuracy (Intensive Care Med (2007) 33:1191–1194)
* There were a couple of small studies indicating inaccuracy, but when I looked into these--the authors may have had some conflicts

USCOM - Aorta Ultrasound

* Anaesthesia. 2012 Nov;67(11):1266-71.

PiCCO

* PCA + thermodilution

Pulse Contour Analysis Alone

* Bunch of studies keep going back and forth in the lit. I'm not sure if these track changes in afterload. They don't accurately track pressors/inopressors (Anesth Analg. 2011 Oct;113(4):751-7.)

ETCO2

* A PLR-induced increase in EtCO2 >5 % predicted a fluid induced increase in CI >15 % with sensitivity of 71 % (95 % confidence interval: 48–89 %) and specificity of 100 (82–100) %. (Intensive Care Med (2013) 39:93–100)
* Passive leg raise to etco2 (CCM 2014;42:1585)

Carotid and Brachial Artery Analyses
Search for the evidence on pubmed, it is emerging now
LVOT velocity time integral (VTI)

* Accurate in the hands of experts--kind of annoying to obtain

]]>
Scott D. Weingart, MD clean 26:57
Podcast 161 – The New Fluid Assessment in Sepsis with Jean-Francois Lanctot https://emcrit.org/emcrit/new-fluid-assessment-sepsis/ Fri, 20 Nov 2015 16:41:09 +0000 http://emcrit.org/?p=17258 Fluids, Sepsis, Ultrasound, French-Canadian: what more do you want? Fluids, Sepsis, Ultrasound, French-Canadian: what more do you want?

Jean-Francois Lanctot along with his partner in crime, Maxime Valois, has markedly advanced the field of resuscitative ultrasound. The two of the them also created Echo-Guided Life Support (EGLS) and the Shock Echo app.

Today, Jean-Francois and I discuss the current state of fluid assessment and treatment.
TLDR Take-Home Points

* Rule out obstruction to Venous Return (Can the Right Ventricle Take Volume Loading)
* Look for Left Ventricular Failure (Can the Left Ventricle Take Volume Loading)
* Correct Vascular Tone
* Only then, Decide if the Patient may be Fluid Responsive


Marik and Bellomo on the Fluid Management of Severe Sepsis
from Br J Anaesth
See this amazing fluid physiology lecture from the Ultrasound Podcast Site
An Integrated Approach to Ultrasound-Guided Fluid Management

 ]]>
Scott D. Weingart, MD clean 25:52
Podcast 160 – Sepsis smaccDOWN https://emcrit.org/emcrit/sepsis-smaccdown/ Wed, 04 Nov 2015 03:19:09 +0000 http://emcrit.org/?p=16675 An all-star panel of world sepsis experts discuss the controversial areas An all-star panel of world sepsis experts discuss the controversial areas
At smaccChicago, I had the honor to host an incredible panel of Sepsis Experts. I think most everyone who heard it was left with more questions than answers. I have already posted a preemptive response to the panel here:

EMCrit Podcast Episode 154
In a few days, I will post a wee with some additional thoughts. I want to hear what you think--post your comments below.
The Blurb from the SMACC Folks
An all-star panel discuss the burning issues in sepsis right now. Hosted by Chris Nickson and I, the conversation on the controversial aspects of sepsis was lubricated with on-stage alcohol (my idea!)
Mervyn Singer (research guru, sepsis expert and self-proclaimed Sex-God) and Paul Marik (iconoclast and dogma-basher) reveal just how hard it is to describe what sepsis is. Flavia Machado (intensivist and researcher) brings common sense and the perspective from South America, representing middle-income countries. Kath Maitland (author of FEAST, African-based paediatrician and clinical trialist) talks about sepsis management issues in Africa, where sepsis strikes its biggest global impact. Heavyweight researcher and clinician John Myburgh, argues that the word “sepsis” should be removed from our language and turns the paradigm on its head, arguing for a more pragmatic approach to sepsis management. Simon Finfer (crit care clinician, clinical trialist, voice of reason) describes the history, the good, the bad and the ugly about the Surviving Sepsis Guidelines, and some of the controversy surrounding them.
There’s a fascinating, very high level discussion on antibiotics which is not as clear cut as you might imagine. You couldn’t discuss fluids without talking about fluids and this panel features several world experts on this topic. Kath Maitland’s insights from FEAST, combined with the opinions of the rest of the panel will hopefully leave you an informed agnostic.
 
We’d highly recommend watching this discussion with your colleagues at work and use it to spark more discussion on this incredibly important topic that still kills so many of our patients.
 
Additional Resources

Mortality after Fluid Bolus in Children with Shock Due to Sepsis or Severe Infection: A Systematic Review and Meta-Analysis
Exploring mechanisms of excess mortality with early fluid resuscitation: insights from the FEAST trial
John Myburgh on Fluids
Surviving Sepsis Guidelines
Simon Finfer on Sepsis in 2014
NEJM article on Sepsis by Angus et al

Now On to the Vodcast...
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Scott D. Weingart, MD clean 1:18:08
Huge Announcement for EMCrit.org https://emcrit.org/pulmcrit/huge-announcement-for-emcrit-org/ Mon, 02 Nov 2015 20:14:31 +0000 http://emcrit.org/?p=16736 Big news... Big news...

I am a podcaster. I like audio! But I also love reading well-crafted, incisive blog posts. One of my favorite blogs has been PulmCrit.org by Josh Farkas.

Well now, PulmCrit and EMCrit are merging. This will be a boon for the audiences of both products. You'll be hearing more in the coming weeks.
What do you think?]]>
Scott D. Weingart, MD clean 2:05
Podcast 159 – Rounding in the RACC https://emcrit.org/emcrit/rounding-racc/ Fri, 30 Oct 2015 01:26:07 +0000 http://emcrit.org/?p=16690 Rounding on critically ill patients in the ED Rounding on critically ill patients in the ED

 
Rounding Sheet

* RACC Rounding Form

The Literature

* Systemic Review of ICU Rounds Practices (Crit Care Med 2013;41:2015)

#HollywoodWeingart
from EDECMO.org
Now on to the Podcast...
 ]]>
Scott D. Weingart, MD clean 20:01
Podcast 158 – The FELLOW Trial on Apneic Oxygenation in ICU Patients https://emcrit.org/emcrit/fellow-trial/ Tue, 06 Oct 2015 18:07:18 +0000 http://emcrit.org/?p=16581 Matt Semler, MD and colleagues performed an RCT on Apneic Oxygenation in Medical ICU patients Matt Semler, MD and colleagues performed an RCT on Apneic Oxygenation in Medical ICU patients

Matt Semler, MD and colleagues performed an RCT on Apneic Oxygenation in Medical ICU patients. I got a chance to sit down and interview him on the trial.
The Trial
The Fellow Trial (Published ahead of Print)
Bottom Line Review
Trial Summary
Additional Written Comments from Matt Semler
as provided by Matt Anderson (@ccinquisivist)
From: Anderson, Matthew J

Dr Semler
I'm a CCM fellow at the University of Wisconsin, interested in airway mgmt in the ICU.

Just saw your article published in ATS. I had a question about the airway mgmt protocol (or if there was one?). Did the airway team leader/intubator maintain a patent airway (ie were they instructed to do this just prior to the intubation attempt when getting sedation/analgesia and/or NMB)? I am unable to find/get to the supplement which this information may be listed but I didn't see any mention in the main manuscript, which I think is a extremely important discussion point. Previous, studies in the OR w/ or w/o maintenance of airway patency resulted in 'no difference in the non-airway patency (ie jaw thrust/head tilt chin lift) group vs 'stat significant difference in the airway patency group' during apneic oxygenation. If airway patency was maintained in your study this would be one of the first 'negative' results I have seen with apneic oxygenation. If airway patency was not required, this may explain the 'no difference' that was found in your study, which in my opinion, makes the use of apOX still an important part of endotracheal intubation. Until a randomized control trial to evaluate apOx with airway patency versus no apOx with airway patency confirms that previous. Further trials may need 30 degree ramp/optimal positioning, as well?

Thanks for taking the time to answer my questions and publish/perform important ICU airway research.

Matt Anderson
Critical Care Medicine Fellow, PGY5
________________________________________

From: Semler, Matthew

Matt,

Thanks for your interest in the trial.  You ask two really important questions -- actually two of the same points Rich Levitan emphasized when he visited during the conduct of the trial.

(1) When discussing the effect of airway patency on outcomes of apneic oxygenation, the time-period in question is between administration of RSI medications (with anything prior to induction technically a part of pre-oxygenation) and the onset of laryngoscopy (when patency of the airway is directly established by the laryngoscope better by external maneuvers).  Objectively assessing whether the airway is patent during this period is challenging.  For the 30% or so in the trial who were on BIPAP between induction and laryngoscopy, the airway was known to be patent through monitoring of the returned tidal volumes.  In cases where NIV was not present, the operator was charged with maintaining patency of the airway between induction and laryngoscopy.  In 60% of cases this required an oral airway and a head-tilt-chin-lift maneuver.  In around 40 patients, the operator felt the airway was patent without such a maneuver.  Whether these maneuvers were effective in maintaining patency or whether patency was truly present in those patients who were not felt to require a maneuver is difficult to know.  We did analyze the subgroup of those who were on BIPAP and we were certain the airway was patent and there was not a significant effect of apneic oxygenation on lowest oxygen saturation in this group -- though obviously this is a not a large population.
An important thing to consider when thinking about the period between induction and laryngoscopy is that high flows of oxygen...]]>
Scott D. Weingart, MD clean 24:18
Podcast 157 – Central Lines II – Placement Tips https://emcrit.org/emcrit/central-lines-placement-tips/ Sun, 13 Sep 2015 22:43:22 +0000 http://emcrit.org/?p=16270 Part II of the Central Line Series discusses placement tips Part II of the Central Line Series discusses placement tips
Listen to Part I - Avoiding Complications

* Confirmation of Proper Placement

Micro-Skills and Deliberate Practice


* You definitely need to watch the central line micro-skills video

Steps Of Central Line Insertion

* Go to the Central Line Page

Subclavian Insertion

* Go to the Central Line Page

Dilation

* The wire CAN'T BE ALLOWED TO ADVANCE
* I need to record dilator use as a microskill
* Move wire in out sequentially during dilation (racking the wire)

Internal Jugular

* Keep head in neutral not rotated for IJ (Journal of Emergency Medicine Volume 31, Issue 3 , October 2006, Pages 283-286)

Subclavian

* Subclavian is safe in mech vent pts (Anesthesiology:2009 – Volume 111 – Issue 2 – pp 334-339)
* Use lower shoulder position puncture site just lateral to mid-clavicular line [cite source='pubmed']15564937[/cite]
* Shoulder retraction (padding behind the back) was not helpful (Br. J. Anaesth. (2013) 111 (2): 191-196.)
* If you miss twice, consider abandoning the site (3 on a match)

Ambesh Maneuvers

* Finger in fossa technique to prevent guidewire malposition in subclavians (Ambesh SP, Anesthesiology.  2002; 97(2): 528-529.)

Checking Subclavian Placement after Catheter is In

* After subclav line placement, if you push on IJ and CVP increases 3-5 mmHg then the lumen is in the IJ instead of the SVC (Anesthesiology 2002;97(2):528), IJ occlusion test (Anesthesiology 2001;95(6):1377) and (Anesthesiology 2006;105(5):1062-1063)

Can We Place Central Lines in Anti-Coagulated Patients?

* Central line insertion while anti-coagulated seems safe and complications probably correlate with skill of physician (emerg med j 2011;28(6):536)
* Micropuncture Sets seem to be a very clever way to go

Guidewire Exchange
Guidewire exchange seems safe [cite source='pubmed']24004883[/cite] GWX-CVC’s and NI-CVC’s had similar rates of tip colonization at removal, CA-BSI and mortality. If the CVC removed by GWX is colonized, a new CVC must then be inserted at another site. In selected ICU patients at higher central vein puncture risk, guide-wire exchange may be an acceptable initial approach to line insertion.
Tips for Flushes
Drop a sterile 50 ml bag on to field; slash that bad boy with a scalpel. (Thanks Haney)
Update:
Chris Bond does an interview on hand motion analysis as a means of demonstrating expertise on the procedure

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Scott D. Weingart, MD clean 30:12
EMCrit Wee – Central Line MicroSkills (Deliberate Practice) https://emcrit.org/emcrit/central-line-micro-skills-deliberate-practice/ Sat, 12 Sep 2015 17:08:21 +0000 http://emcrit.org/?p=16417 A break down of the skills needed for Seldinger technique A break down of the skills needed for Seldinger technique

On Monday, I'll be doing the 2nd part of the central line series--this one on placement tips. In anticipation, I had to release this video on central line micro-skills (microskills). These are the steps of the Seldinger technique to which you need to devote deliberate practice time. Thanks to Jeremy Faust for the filming help.



 ]]>
Scott D. Weingart, MD clean 11:37
Podcast 156 – The Central Line Show – Part I: Avoiding Complications and Confirmation https://emcrit.org/emcrit/central-line-show/ Sat, 29 Aug 2015 19:39:02 +0000 http://emcrit.org/?p=13722 Stop Effing Up Your Central Lines Stop Effing Up Your Central Lines
Read this Review of Vascular Complications of CVC Placement
(J Cardiothoracic and Vascular Anesthesia 2014;28(2):358)
When to Confirm
I prefer to confirm all non-crash introducers and especially HD caths prior to dilation. There are times I will place a triple lumen and then confirm the line after insertion (do the latter at your own risk)
Confirming Venous Placement (Choose at least 1)

* Observation of the intravascular pressure waveform using an electronic transducer and pressure tubing
* Determination of the of the intravascular pressure using sterile tubing as a venous manometer
* Analysis of the PO2 of a blood specimen drawn from the needle/catheter compared to simultaneously drawn arterial blood (this is stupid!)
* Bubble Test-when saline is rapidly injected through the catheter, there is opacification of the echocardiographic view of the right heart structures.
* Using real-time fluoroscopic or echocardiographic confirmation of venous catheterization (e.g., visualizing the guide wire or catheter within the superior vena cava)
* Using a contrast study to opacify the venous structures.

Less Desirable

* Guidewire Visualization in the Vein

The Methods in Depth
Pressure Transduction
Easiest way to do this is use the casing of the wire was packaged in--this tip thanks to my friend Taku Taira, MD.
How to Use Wire Casing to Transduce Pressure


[cite source='pubmed']19377052[/cite]
[cite source='pubmed']9412883[/cite]
Numerous other studies cited here: (J Cardiothoracic and Vascular Anesthesia 2014;28(2):358)

Study specifically on using tube transduction (Anesth Analg 2009;109:130)
Or if doing IJ, Just use the Catheter-Over-Needle from the Get-go (but I will lose all respect for you)


thankfully Reub provided the study showing the needle technique is superior [cite source='doi']10.1097/CCM.0000000000001167[/cite]
Or Using a Commercial Device
Compass Single Use Manometers with or without guidewire slot
Bubble Test, Flush Test, Rapid Atrial Swirl Sign (RASS)
Inject 10 ml of saline and observe Right Atrium/Right Ventricle

* [cite source='doi']doi:10.1016/j.ajem.2014.10.010[/cite]
* [cite source='pubmed']24552526[/cite]
* [cite source='pubmed']25624649[/cite]
* [cite source='pubmed']17006130[/cite]
* [cite source='pubmed']19829102[/cite]
* [cite source='pubmed']23242559[/cite]
* Should appear in <2 seconds for properly placed neck line [cite source='pubmed']25550065[/cite]
* Saline Flush and Pneumo Exclusion obviates immediate chest radiography [cite source='pubmed']26112633[/cite]
* For Hemodialysis Caths (Kidney International Reports 2017;2:952
* Crit Care Med 2017;45(7):1192
* SR DOI 10.1097/CCM.0000000000002188

bubble confirm of central lines



Video from Sinai EM Ultrasound

and


from Prekker et al. Rapid Confirmation of Central Venous Catheter Placement Using an Ultrasonographic “Bubble Test” DOI: 10.1111/j.1553-2712.2010.00785.x

Guidewire Visualization
[cite source='pubmed']20006207[/cite]

but...

This series should scare the hell out of you [cite source='pubmed']19531950[/cite]

so,]]>
Scott D. Weingart, MD clean 31:50
Wee – Avoiding Disaster – Endotracheal Tube Cuff Leaks and Tube Exchanges https://emcrit.org/emcrit/tube-exchanges/ Sat, 29 Aug 2015 00:15:13 +0000 http://emcrit.org/?p=116699 It seems simple, but not treating this situation with respect can lead to disaster. It seems simple, but not treating this situation with respect can lead to disaster.

 
Equipment to have Bedside

* VL
* Suction
* New Same-Sized Empty ETT
* Additional ETTs
* Syringe
* Tube Exchanger (Cook CAE19 for ETT 7 or larger; CAE15 for ETT 5-6.5)
* BronchPort
* Tons of lube
* Bougie or Glidescope Stylet depending on your VL choice
* SGA and Scalpel
* ETCO2 with Waveform
* BVM
* If you have one available, a Bronchoscope is a wonderful bonus esp. if it can fit an Aintree catheter

A Video from AirwayOnDemand

Literature

* [cite source='pubmed']19299792[/cite]
* [cite source='pubmed']26111264[/cite]

Now on to the Wee...]]>
Scott D. Weingart, MD clean 18:33
Podcast 155 – Status Epilepticus with Tom Bleck https://emcrit.org/emcrit/status-epilepticus/ Fri, 14 Aug 2015 00:43:03 +0000 http://emcrit.org/?p=11067 Tom Bleck on Status Epilepticus Tom Bleck on Status Epilepticus

Today I get to talk Status Epilepticus with Tom Bleck.

Tom Bleck is a neurointensivist from Rush Medical College in Chicago, where he is a professor of neurological sciences, neurosurgery, medicine, and anesthesiology. Dr. Bleck is board certified in internal medicine, with subspecialty certification in critical care medicine; neurology, with subspecialty certification in vascular neurology; clinical neurophysiology; and neurocritical care. He was the founding president of the Neurocritical Care Society.

Here are the questions we discussed:
Initial Treatment
RAMPART [cite source='pubmed']21967361[/cite] showed us that 10 mg IM Midazolam was at least as good as 4 mg IV Lorazepam

If we have an IV, why are we not using IV midazolam over IV Lorazepam?
When is Status Refractory?

* "Status should be considered refractory after the failure of the first agent that should have worked"
* "If you fail lorazepam, you should move to general anesthesia"
* "The longer you seize, the tougher it will be to break"

When should you say that the seizure is unlikely to end? At 5 minutes, you have an 80% or greater chance that you will continue seizing

See Josh Farkas' view on the rapid sequence termination

So if they fail lorazepam (midazolam?), we should consider intubation and general anesthesia.
Which Paralytic?
Sux vs. Roc
Which agent is best for General Anesthesia?
High Dose Midazolam (Neurology 2014;82:359)
– loading dose: 0.2 mg/kg
– maintenance: 0.1 -­ 2.0 mg/kg/hr

Propofol

may be bad (Prasad A et al Epilepsia 2001;?42:380-­386)
Conventional AEDs
Which one and when?

* Fosphenytoin
* Valproic Acid
* Levetiracetam (Keppra)
* Lacosamide

Dr. Bleck recommends one of the latter two. Levetiracetam at a dose of 1 gm, may repeat 1-2 times or Lacosamide 200-300 mg.
Still Refractory

* Ketamine for Status [cite source='pubmed']23758557[/cite] and this article. Reasonable Starting Dose 3-5 mg/kg.
* Hypothermia
* Inhaled General Anesthesia-AnaConDa with Iso or Desflurane
* This Review Article Discusses Super-Refractory Status Management

EEGs
When should a patient get continuous EEGs?

What if you don't have access

EEG Interpretation for Dummies

* EEG should be the opposite of your EKG (Vfib is good)
* Reactive is better than non-reactive

What if we can't get one?

NitWitticism: Being in burst suppression will prevent you from seizing. Pts can seize through burst. May need to be made flatline EEG.
Etiology
Consider Autoimmune Encephalitis, especially Anti-NMDA Encephalitis (Neurology 2015 vol. 85 no. 18 1604-1613)
Consider Tox

* INH
* Tricyclics
* Theophylline
* Cocaine
* Alcohol/Benzo withdrawal
* Organophosphates

More from Tom on Status

* Rossetti and Bleck in ICM
* Tom Bleck's Slides from SMACC on SE
* clean 24:11
Podcast 154 – Preemptive Sepsis Panel SmaccBack https://emcrit.org/emcrit/sepsis-panel-smaccback/ Wed, 29 Jul 2015 01:17:11 +0000 http://emcrit.org/?p=15810 A preemptive smaccback on the SMACC Chicago Sepsis Panel A preemptive smaccback on the SMACC Chicago Sepsis Panel
Update:

* Listen to Podcast 160 for the Actual Panel Discussion

Consider Joining the RLA if you want to commit to Resuscitation

* Resuscitation Leadership Academy

Does SIRS Suck?

* Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis (DOI: 10.1056/NEJMoa1415236)
* The Falsely Reported Death of SIRS [cite source='doi']10.1056/NEJMoa1415236[/cite]

We are Complicit

* Please read my post, We are Complicit, to understand why this Table 2 from SSC will make life miserable for all ED docs:


Sepsis Collaborative Triage Screen

* Here you go

More Recent Evidence on the Benefit of Lactate for Prognosis

* doi:10.1136/emermed-2013-203541
* doi:10.1136/emermed-2014-204305

Peripheral Pressors

* A discussion on peripheral pressors on EMCrit
* Paul Mayo's Article from LIJ

Additional Posts of Interest

* 2012 SSC Guideline Post
* Lessons from the NYC STOP Sepsis Collaborative
* ARISE has Arisen

 Now on to the Podcast...
]]> Scott D. Weingart, MD clean 38:34 Podcast 153 – In Memory – John Hinds, On How He Ran His Unit https://emcrit.org/emcrit/john-hinds-on-how-he-ran-his-unit/ Sun, 05 Jul 2015 16:01:39 +0000 http://emcrit.org/?p=15365 In Memory of Our Friend, John Hinds In Memory of Our Friend, John Hinds

John was one of the most wonderful people I knew in medicine. He was kind. He was an amazing doc; strong and confident in what he believed was right, but the consistent trait noticed by all who met him in the FOAM world was his rare humility. John was just lovely, with an acerbic wit that kept me in tears whenever I was around him. He was trying to better the trauma care of Northern Ireland, hopefully his work will be continued and his amazing contributions remembered. My thoughts are with John's family. He left us far too soon, and I miss him so.

If you want to send condolences to John's Family, please contact Rob Mac Sweeney--Tweet (@CritCareReviews)

Please see these words from John's friends in the FOAM World:

* The St. Emlyn's folks
* Michelle from the LitFL Crew
* Cliff from resus.me





A few months ago, John came and visited us at Stony Brook to give EM Critical Care Grand Rounds. He was easily the speaker of the year. He gave an amazing lecture on how he ran his unit (along with his 5 amazing colleagues). The audio quality of the recording was crap (my fault, not John's). We had plans to rerecord it as a podcast, but that can't happen now, so I hope you love listening to John in any form possible, as I know I do:
How John Ran His Unit
When not in the field as a road-racing doc, John was an Anesthesia-Intensivist at Craigavon Area Hospital. He worked in a ten bed unit, only eight of which could have mechanically ventilated patients and yet...

The unit has

* CO2 Dialysis with Novalung
* One of the first centers in the UK to offer REBOA (done by the intensivists)
* Tele-Critical Care
* TEE

Central Lines

* Remove all peripheral ivs
* Remove all resus placed lines
* Place all resus lines 5x ports in left sub clav sunk to 20cm. 10% of them sit in the right atrium; they've had no problem with cardiac erosion. John felt this is a relic of the past.
* Place all CRRT lines r subclav sunk to 20 cm (intra-arial)
* They get CVP off prox port
* Most dangerous drug in the distal
* Subclav is the Line of Champions
* 800-1000 lines per year, no infections in the past year. Pneumothorax rate 0.8% in the last 300 lines tracked

Sepsis

* All get arterial line
* Serial Lactates
* All get a central line
* Fresh PIVs
* Norepi or epi
* Max fluid load of ~2 liters and then need a good reason to give anymore
* No etomidate; They use ketamine, it is open shelf
* No Inodilator (b/c they run their patients extremely dry)
* Phenylephrine and Metaraminol are banned to prevent lazy resuscitation
* No cardiac output monitors until they are not random number generators--they use TTE and TEE
* They don't see ARDS (You need to listen to the Podcast)
* No standing maintenance fluids

InoPressors
Not in the lecture, but here is John's correction of my algorithm


Aggressive De-Resuscitation
-Start with Diuretics
Lasix

* 50 mg IV, they infuse over 30 minutes
* Double dose if it doesn't work
* 500 mg/dose max
* Max dose 2g/day
* Back off if they become hemodynamically unstable, BUN/Cr start to rise,]]>
Scott D. Weingart, MD clean 41:33
Podcast 152 – High Flow Nasal Cannulae – Just Blowin’ Hot Air? https://emcrit.org/emcrit/hfnc/ Mon, 29 Jun 2015 19:50:20 +0000 http://emcrit.org/?p=14930 HFNC--the new hot thing or just blowin' hot air? HFNC--the new hot thing or just blowin' hot air?
Today we have a brief discussion on the new hottie in the respiratory care world, High-Flow Nasal Cannulae

Check Out Critical Care Horizons
Critical Care Horizons published its first articles this week, with a further article due out in the next few days.
How do these Bad Boys Work?

* Best Review by Ward et al.
* Review from an RT Journal
* LitFL CCC Entry
* Josh Farkas has a great post on sole use of high-flow NC
Gastric rupture following nasopharyngeal catheter oxygen delivery-a report of two cases
Some of the Devices: Optiflow, Vapotherm

THRIVE

The THRIVE Study

Miguel-Montanes Study

* The Study in CCM

PREOXYFLOW

* The PREOXYFLOW Study

and the response from the FOAM World

PulmCrit
The Bottom Line Review

FLORALI


The FLORALI Study
The FLORALI Editorial

and the response from the FOAM World


The Bottom Line Review
ICMWK
PulmCCM
ESICM
PulmCrit
EMNerd

Update:
This trial demonstrates that in poor mental status, Nasal Facemask rather than Full Facemask led to better outcomes (Crit Care. 2013; 17(6): R300)

John Greenwood, editor of the CCProject, adds this great comment:
Hey Scott,

Great summary and review as always. I've seen a worrisome trend of people citing FLORALI to justify HFNC as a reasonable strategy for pts with hypoxic RF rather than (in my opinion) what should probably be a tool used as bridge during intubation planning. Consider adding this study (http://www.ncbi.nlm.nih.gov/pubmed/25691263) to your pack.

Just out of curiosity, are there any specific patients you are maintaining on HFNC?

]]>
Scott D. Weingart, MD clean 21:49
EMCrit Podcast 151 – Procedural Sedation Part 3 with Jim Miner https://emcrit.org/emcrit/procedural-sedation-3/ Sun, 14 Jun 2015 20:12:56 +0000 http://emcrit.org/?p=15143 Jim Miner discusses the fine points of ED/ICU procedural sedation Jim Miner discusses the fine points of ED/ICU procedural sedation
Today I am joined by James Miner, MD; chief of emergency medicine at Hennepin and an amazing, prolific researcher on procedural sedation.

 
Some of Jim's Procedural Sedation Studies

* [cite source='pubmed']25441247[/cite]
* [cite source='pubmed']23701339[/cite]
* [cite source='pubmed']20624140[/cite]
* [cite source='pubmed']19845550[/cite]
* [cite source='pubmed']16997421[/cite]
* [cite source='pubmed']15692132[/cite]

Some of the Points on Jim's Method for Short Procedures in Stable Patients

* Pre-procedural analgesia rather than peri-procedural
* He uses preoxygenation and ETCO2
* In stable patietnts, he gives 1-1.5 mg/kg of propofol up front
* 30-90 sec retrograde amnesia
* Can do painful things as propofol is coming on, but not coming off

Are there patients who will need different dosing?

* The elderly may need less, especially if they have opioids on board
* Volume depleted patients will need less
* Thin patients will need more, obese patients will need less (if we dose by actual weight)
* (IBW + 1/3 of remaining weight) may be the better way to dose with the 1.5 mg/kg

The biggest mistakes

* People ignore how long it takes for the propofol to kick in, need to wait 60 sec before a 2nd dose

Cardioversion

* Jim (and I) uses Etomidate

Nasal CPAP for Procedural Sedation

* [cite source='pubmed']25455053[/cite]

Alfentanil for Procedural Sedation
Stay Tuned
Update
An article demonstrating that supplemental oxygen impairs pulse ox detection of hypoventilation (Chest 2004;126:552)

And an article on Fasting (Ann Emerg Med. 2014;63(2):247-58. PMID: 24438649)
Now on to the podcast...
 ]]>
Scott D. Weingart, MD clean 23:34
Podcast 150 – A Look Back https://emcrit.org/emcrit/a-look-back/ Mon, 01 Jun 2015 17:59:51 +0000 http://emcrit.org/?p=14967 Can't believe we made it this far...and it's all thanks to the emcritters! Can't believe we made it this far...and it's all thanks to the emcritters!
Can't believe we made it this far...and it's all thanks to the emcritters!
Rob Orman's ERCast for Episode 150
http://traffic.libsyn.com/ercast/Weingart_on_the_state_of_things.output.mp3

or listen at ERCast

note: this is not EMCrit Podcast 150, scroll down to play episode 150
Evolution of Sepsis Care
From EGDT to GNYHA to the Triumvirate of Good Care
Fluids in Sepsis
IVC Ultrasound for Non-Invasive Sepsis Protocol

hear the definitive word from Jean-Francois Lanctôt in an upcoming episode
Asthma Rx
Severe Asthma

Check out the 3MG Trial there
SCAPE
Sympathetic-surge Crashing Acute Pulmonary Edema

Standard nitro mix is 200 mcg/ml, so draw up 4 ml and give 2 ml the first minute and 2 ml the second minute.
VERIFY YOUR HOSPITAL’S MIX BEFORE USING THESE RECS
ECMO
EMCrit EDECMO Podcast

Check out the REANIMATE Conference to learn ECPR

See the EDECMO Site
PROPPR Trial Episode
So Good
Intubation Checklist
Soon to be updated, the EMCrit Intubation Checklist Page is a compilation of so many things that go into good airway management
Combat Aviation
The airline industry helps anesthesia, the Combat Aviation World should guide EM/CCM

Come here to put your hat in the ring for the Resus Crisis Manual
Do the Current CT Contrast Agents Really Cause Serious Kidney Issues
See those 2 blog posts here
Severe Accidental Hypothermia
Here is the accidental hypothermia episode, but use the...

Use the Xmas Tree to Luer Adapter (Made by Cook)


Cric Page
This EMCrit Cric Page has EVERYTHING!
Preox Page
All things EMCrit Preoxygenation

Videos from George Kovacs and Nick Sowers





What did I miss? Comment below:
Now on to the Podcast...]]>
Scott D. Weingart, MD clean 24:32
Podcast 149 – Thyroid Storm https://emcrit.org/emcrit/thyroid-storm/ Sat, 16 May 2015 22:17:01 +0000 http://emcrit.org/?p=13728 When hyperthyroidism goes really wrong... When hyperthyroidism goes really wrong...
Not a topic of specific expertise for me, but I wanted to get all of the info in one place for future use--Thyroid Storm
Most of the Below Information is from:

* [cite source='pubmed']23920160[/cite]
* EMRAP June 2010 Stuart Swadron Interviews Jonathan LoPresti

Diagnosing Thyroid Storm
From Jonathan LoPresti

* Hyperthyroid
* Fever
* AMS-trouble concentrating all the way to coma
* Sympathetic Surge
* Precipitating Event

Elderly-internalized beta receptors may have more subtle presentations of storm


Storm Score


* >45 is almost surely storm,
* 25-44 is suggestive,
* <25 is unlikely

(Endocrinol Metab Clin North Am. 1993 Jun;22(2):263-77)
Labs
TSH, Free T3, Free T4

Blood Cultures

May see low Cr and High Ca

Won't mount normal WBC increase in hyperthyroidism

May also have thrombocytopenia
Treatment
Block New Production
The thionamides: Methimazole and PTU; the latter may be preferred as it also blocks peripheral T4 to T3 conversion

PTU 500-1000 mg load then 250 mg Q4 hours (Guidelines from AACE (endo group))

Methimazole 60-80 mg qday, divided into doses q4-6 hrs (20 mg Q6)
Block Thyroid Hormone Release
Wolf-Chaikoff effect blocks iodide binding to thyroglobulin once critical levels of iodide are reached

SSKI 5 drops PO q6

or

Lugol's Solution 8 drops PO q 6

or Sodium Iodide 0.5 mg IV Q 12 hours

Don't give until 60 minutes after thionamides

Lithium can be substituted in patients who will undergo radioactive iodide treatment or patients allergic to Iodides, use 300 mg q 6-8 but personally, I would consult a endocrinologist before going this road. (J Inten Care Med 2015;30(3):131)
Treat Volume Loss
These patients have large insensible losses and diuresis. Even in the setting of seeming heart failure, they may need fluids as the heart failure is high-output.
Treat Sympathetic Surge
 

* Propanolol 1 mg IV (test dose) then Propranolol 1-2 mg q 15 minutes until HR of 100 bpm
* then start Propanolol drip at whatever dose it took to get IV load control (Max 3-­5 mg/hr)

 

Propranolol also blocks T4 to T3 conversion

or titrate esmolol for HR of 100 bpm, but selective B1 means may be less effective

Update: A listener, @Rx_Ed, sent this article on the pharmacokinetics of propanolol in thyroid storm (

Increased Clearance of Propranolol in Thyrotoxicosis (Ann Intern Med. 1981;94(4_Part_1):472-474. doi:10.7326/0003-4819-94-4-472)
Block Peripheral Conversion and Shield from Adrenal Insufficiency
Dexamethasone 4 mg IV Q 6 hours

or

Hydrocortisone 300 mg IV and then 100 mg q 8 hours
Not Available in the US?
Oral cholecystographic agents (HIDA Scan Contrast) 2g loading dose followed by 1g q day
Temperature regulation

* Do not aggressively cool these patients; this is contraindicated because it can lead to further vasoconstriction

Fix Precipitating Event/Treat Infection
Look carefully, treat aggressively
Sim Case
EMSimCases
Now on to the Podcast...
]]>
Scott D. Weingart, MD clean 20:16
Stuff Update https://emcrit.org/emcrit/stuff-may-2015/ Tue, 12 May 2015 17:52:30 +0000 http://emcrit.org/?p=14527 A whole bunch of stuff A whole bunch of stuff
2 Opportunities for Residents:
Essentials of Emergency Medicine Fellowship for US Residents
Get all of the info on the EEM fellowship page
Knowledge to Action Fellowship (KTAF)
An amazing opportunity for EM Residents. Here is the info on the KTAF.
4 Conferences to Check Out:
1. Reanimate San Diego - Learn ECMO for ECPR in Two Days
February 2016

Click here to see all of the information on the most concentrated and enjoyable ECMO Conference designed for Resuscitation Doctors
2. Blood and Sand - Resuscitation, Airway and Ultrasound in the Most Beautiful Climes in the World


December 6-10, 2015

Here is the Blood and Sand Conference Info
3. Shock Symposium
June 2015

Mike Donino's Shock Symposium in Boston
4. SMACC
June 2015

A little over a month left until the best Resuscitaiton and Critical Care Conference in the world. Sign up for SMACC today!
Now Listen to the Audio...]]>
Scott D. Weingart, MD clean 6:07
Podcast 148 – Airway Decisions and Online Etiquette https://emcrit.org/emcrit/airway-decisions/ Mon, 27 Apr 2015 01:52:54 +0000 http://emcrit.org/?p=14481 More on the recent cric case from the perspective of airway decision making More on the recent cric case from the perspective of airway decision making If you want to have any idea what I am talking about...

The Cric Wee
Here is the comment that sparked this podcast

How to Plan Your Airway

* Take Account of the Whole Situation, both Immediate and Delayed Issues
* Pick the Plan the Fails Best

What is a Bad Option IMrHO?

* Anything through the nose without cutting the wires

What are the Good Options

* Cut the Jaw Wires, Prep for Cric, Perform Awake Fiberoptic Nasal Intubation, then sedate/analgese
* Cut the Jaw Wires, Prep for Cric, Perform RSI, then sedate/analgese
* Perform an Awake Cric
* Perform an Awake Trach

How to Cut Jaw Wires (Arch Bars/Wired Jaw)
There will be 2-5 wires connecting the lugs of the arch bars--you need to cut all of them and retrieve the wires. There may also be elastic that needs to be cut. Medical wire-cutters are best, diagonal cutters also work. In a pinch, any heavy scissors will get through these wires. Then grab them with hemostats and pull them out.



Not many articles in the literature on this topic, but here is one Jones RT et al.

I think it is essential to understand the hardware and how long it takes to cut the wires. So watch this wiring video and then this cutting the wires video.
Do Crics Need to Come Out Right Away?
Probably not

* American Journal of Otolaryngology 2000;121(3):195
* British Journal of Oral and Maxillofacial Surgery 2013;51:779

NAP4
In appropriate circumstances (prophylactic cricothyroidotomy) has numerous advantages, not least the potential to secure and check the ‘rescue airway’ in a calm and unhurried manner, without hypoxia, before an emergency arises      — NAP4 Study

* See this Prior Episode for a Discussion of NAP4

Online Etiquette when Discussing Cases

* Just be nice
* Assume that there were factors you might not understand because you were not there
* Phrase as, "I think if I was in this situation, I would have..."
* If you are going to go nasty, make sure you have the knowledge base to comment (this last one does not pertain to the comment above)

Consent for Filming

* discussed in the podcast

Other Discussions of the Case (For Better or Worse)

* Student Doctor Net
* Reddit

Now on to the Podcast...]]>
Scott D. Weingart, MD clean 26:28
EMCrit Wee – Mind Blowing Cricothyrotomy Video https://emcrit.org/emcrit/real-surgical-airway/ Sat, 18 Apr 2015 19:26:26 +0000 http://emcrit.org/?p=14366 An amazing surgical airway case An amazing surgical airway case
Filmed by Reuben Strayer, MD and used with patient consent.

For more on Surgical Airway, come to the EMCrit Cricothyrotomy Page

Article on Arch-Bar Separation



 ]]>
Scott D. Weingart, MD clean 13:19
EMCrit Podcast 147 – Who Needs an Acute PCI with Steve Smith (Part II) https://emcrit.org/emcrit/who-needs-an-acute-pci-ii/ Sun, 12 Apr 2015 17:09:23 +0000 http://emcrit.org/?p=14193 Finally in one place, all of the STEMI equivalents with Steve Smith--Part II Finally in one place, all of the STEMI equivalents with Steve Smith--Part II
See Part I First; you'll find the shownotes there as well
Part I of Who Needs an Acute PCI?
Now on to the Podcast...
]]>
Scott D. Weingart, MD clean 23:27
EMCrit Podcast 146 – Who Needs an Acute PCI with Steve Smith (Part I) https://emcrit.org/emcrit/who-needs-acute-pci/ Sun, 29 Mar 2015 13:00:57 +0000 http://emcrit.org/?p=10568 Finally in one place, all of the STEMI equivalents with Steve Smith Finally in one place, all of the STEMI equivalents with Steve Smith
A Guideline from the Steve Smith’s ECG Blog and the EMCrit Podcast
Today, I am joined by Steve Smith, creator of one of the best ECG blogs out there. We discuss who needs an emergent cath. Who should get a transfer to a PCI center? Wouldn't it be great if all of the possibilities were gathered in one place? Here you go...
The Printable Versions:

* The Complete Document
* The Cheat Sheet

The Video Version from theEMC

Who needs an emergency PCI?
Activate the Lab for unambiguous STEMI (only clear STEMIs have a 90 minute CMS mandate). Get Cardiology or Interventional Consultation for more complicated cases: difficult ECGs, subtle ST elevation, ST depression with ongoing symptoms, STEMI “Equivalents”. This requires a systematic approach, with buy-in from Cardiology that they will respond immediately to such requests for help. What do they get out of it? Fewer false positive activations and more activations for the subtle cases that need it.

Know that the ACC/AHA guidelines for NonSTEMI recommend < 2 hour cath for:





* Refractory ischemia
* Ischemia with hemodynamic or electrical instability





Proviso: Many non-interventional cardiologists do not understand these subtle ECG findings or pseudo-STEMI patterns. You must be a strong advocate! If you are worried, get serial ECGs, compare with an old ECG, and get a high quality contrast echocardiogram exam. Persistent occlusion of a significant epicardial coronary artery will nearly always have a wall motion abnormality if the echo quality is good, is done with contrast, and is read by an expert.
I. ACC/AHA Criteria
ST-elevation at the J point in 2 contiguous leads that reaches the following thresholds: [cite source='doi']10.1161/CIR.0b013e3182742c84[/cite]





* Men < 40 years of age: 2.5 mm in V2-V3 and 1 mm in all other leads
* Men > 40 years of age: 2 mm in V2-V3 and 1 mm in all other leads
* Women: 1.5 mm in V2-V3 and 1 mm in all other leads





These criteria are only 45% sensitive for MI as measured by CK-MB, and about 70% sensitive for acute coronary occlusion, with perhaps 85% specificity. Beware of early repolarization, LVH, and LV aneurysm as false positives. Beware of subtle ST elevation as false negatives. Other less specific but more sensitive criteria require “new” ST elevation.
II. New Left Bundle Branch Block
New LBBB alone is not an indication for cath lab activation. MI may also present in the context of old LBBB. Therefore, in stable patients, determine if there is a concordant ST segment, or an excessively discordant ST segment (see figure) and then use the algorithm below:

Activate if any of these three: [cite source='pubmed']24016487[/cite]





* In an unstable patient (hypotensive, Acute Pulmonary Edema, electrical instability, or looks sick) [cite source='pubmed']22766335[/cite]
* Sgarbossa Criteria (1 of the following) [cite source='pubmed']8559200[/cite] & [cite source='pubmed']22939607[/cite]

* Concordant ST-segment elevation of 1 mm in at least 1 lead
* Concordant ST-segment depression of at least 1 mm in leads V1 to V3
* Note: I reduce these two to simply: Concordant ST-Segment Deviation


* They have Smith-Modified Sgarbossa criteria [cite source='pubmed']22939607[/cite] Any single lead with at least 1 mm of discordant ST elevat...]]>
Scott D. Weingart, MD clean 23:49
EMCrit Conference BLAST Winner – Ice Water Baths for Rapid Cooling of Hyperthermia https://emcrit.org/emcrit/ice-bath-hyperthermia/ Wed, 25 Mar 2015 03:52:40 +0000 http://emcrit.org/?p=14136 How to cool the too hot tox patient How to cool the too hot tox patient

Adaira Landry's excellent presentation that won the 2015 EMCrit Conference Blast Competition

Ice water submersion for rapid cooling in severe drug-induced hyperthermia.

* Laskowski LK et al. Clin Toxicol 2015 Mar;53:181-184.
* The Poison Review's Review

]]>
Scott D. Weingart, MD clean 7:06
Podcast 145 – Awake Intubation Lecture from SMACC https://emcrit.org/emcrit/awakeintubation/ Mon, 16 Mar 2015 18:14:12 +0000 http://emcrit.org/?p=14059 Awake Intubation from SMACC 2015 Awake Intubation from SMACC 2015

I gave this lecture at SMACC 2014. It combines many former podcasts so they are now directed here (Podcast 4 & 18)
Awake Intubation can save your butt!
It requires forethought and humility–you must be able to say to yourself, “I am not sure I will be able to successfully intubate this patient.” However, the payoff for this thought process is enormous. You can attempt an intubation on a difficult airway with very few downsides. If you get it, you look like a star, if you don’t you have not made the situation worse.

Two of my critical care resident specialists, Raghu Seethala and Xun Zhong, volunteered to intubate each other awake. The purpose of this was to let them gain experience, understand what their patients would feel during the procedure, and to prove that awake intubation can be done without complicated nerve block injections or fragile equipment, such as a bronchoscope.

Here is the procedure for ED Awake Intubation–EMCrit Style:
DRY THEM OUT & PRETREAT GAG
If you can give it early 10-15 min before topicalizing, it will be most effective.

* Glycopyrolate: 0.2 mg IVP (No central effects – does not cross BBB. You can use atropine, but more side effects are possible)
* Suction and then pad mouth dry with gauze – you want the mouth very dry!
* Adminster Odansetron 4mg IV to blunt the gag-reflex

TOPICALIZE

* 5 cc of 4% lidocaine nebulized @ 5 liters per min
* Gargle with viscous lidocaine (4% best, 2% ok). Place a blob (~3 cc) on a tongue depressor, put it in the back of the throat and have the patient gargle and then spit. In Canada, they have 5% paste
* Spray the epiglottis and the top of the cords with a Mucosal Atomizer Device (MAD). The patient will cough during this spraying, wear eye/face protection. I usually spray between 3-6 mls above the cords
* Alternatively, use the EZ Atomizer to topicalize everything but through the cords
* Spray into the trachea (through the cords) with 4% lidocaine (3 cc). 10% lidocaine would be wonderful to spray down the cords (not available in USA)
* Have another syringe loaded with 4% lidocaine to spray with during the procedure

Note: the systemic and pulmonary absorption from this method is quite low. The only place to watch out is spraying the trachea. I would not spray more than 2-3 cc down the ol’ windpipe.
SEDATE (Choose one!)

* Ketamine and propofol in the same syringe makes Ketofol. The classic mix is 50 mg of ketamine to make 5 cc and 50 mg of propofol to make 5 cc. Put these both in a 10 cc syringe and shake. Depending on the patient’s hemodynamics, I sometimes will use more ketamine (75% instead of 50%). Give 1-2 cc every minute until you have the patient relaxed, but still breathing and arousable.
* Ketamine alone also works just fine. Start with 20 mg and give 10 mg every minute or so. Push slowly.
* Remifentanil is supposedly wonderful, I've never had it to play with
* If you have neither of these 2 mg of midazolam will do just fine.

The Rest

* Preoxygenate with NRB and Nasal Cannula or CPAP + NC
* Optimally position (ear to sternal notch) with the head tilted all the way back
* Restrain both arms with soft restraints to prevent the “grabbies”. Explain why, don't do this in the UK.
* Switch to just nasal cannula @ 15lpm. You may need to place back the CPAP mask between attempts
* INTUBATE with Fiberoptic laryngoscope and bougie
]]>
Scott D. Weingart, MD clean 26:46
EMCrit Wee – The RLA and the Slope of Resuscitation https://emcrit.org/emcrit/slope-of-resuscitation/ Mon, 02 Mar 2015 17:46:52 +0000 http://emcrit.org/?p=13897 The RLA and Resus Graphs The RLA and Resus Graphs
Resuscitation Leadership Academy
Haney Mallemat, Matt Dawson, Mike Mallin, Mike Stone, and I are starting a new project called the RLA. It is an online resuscitation fellowship--I think it is going to be fairly grand.

If you want more info, click on over to the Resus Leadership Academy site.
Resuscitation Stuff We Do Graphs


this idea was first introduced to me by my vent hero, Nader Habashi, MD

Here is the Phases of Fluid Therapy Article
Now on to the Wee...


 ]]>
Scott D. Weingart, MD clean 14:08
Podcast 144 – The PROPPR trial with John Holcomb https://emcrit.org/emcrit/proppr/ Sun, 22 Feb 2015 18:01:36 +0000 http://emcrit.org/?p=13784 The biggest news in the management of traumatic hemorrhage is the PROPPR Trial. Want to hear from the lead author? The biggest news in the management of traumatic hemorrhage is the PROPPR Trial. Want to hear from the lead author?
Today, we discuss the PROPPR Trial with its lead author, John Holcomb, MD. This was an RCT of trauma patients with severe hemorrhage. It pitted 1:1:1 matched product transfusion with a 1:1:2 control group. Dr. Holcomb is a Trauma Surgeon at University of Texas, Houston. He spent decades in the military as a surgeon before continuing his career in Houston.

This podcast is coming out a week early, but it is too good to wait!
The Study
PROPPR Trial from JAMA
Study Summary
As per their routine, the Bottom Line Review summarized the study beautifully:

Sorry, you do not have iframe working. Click here to go to the article.
Questions I discussed with Dr. Holcomb

* If you had to give the elevator pitch for the take-home message of the trial, what would it be?
* The doubters may say that the control group in the study should have been 1:3 (plasma:rbc) or even no fixed ratio, but solely an INR/Plt lab based approach. They may say that PROPPR shows 1:1:1 is as good as or better than 1:1:2, but may not be better than a much lower rate of plasma and PLT transfusion. What do you say to this line of commentary?
* The trigger for massive transfusion in the PROPPR trial was ABC>=2 or clinician judgment. Do you bother with scores in your personal practice? Should we be using them?
* In the 1:1:1 group, platelets were given up front (0 unit mark). In the 1:1:2 group, they were only given after 9 units of product. What was the rationale for this? Do you think it might have made a difference?
* It seems the 1:1:2 group played catch up for plasma over the next 24 hours. Do you think this supports the contention that early 1:1:1 may spare the need for products down the road, especially in light of the fact that exsanguination deaths were an early phenomenon.
* Median RBCs were 9 units over 24 hours, which means over half of the patients did not receive the 10 units of RBC that traditionally define Massive Transfusion. Should we redefine MT? What is the point at which it was beneficial to have matched plasma/plt to RBCs.
* This trial was not designed to look at this question, but I want to know what you think. In 2015, should we be using the empiric ratios of the PROPPR trial or should we be switching to a visco-elastic (TEG/TEM) based strategy?
* Let’s do some rapid fire… Aside from the randomized intervention, the trial was pragmatic, so I would love to hear your personal feelings and practice on:
*BP goal
*TXA
*Cryoprecipitate
*Crystalloids
* Most studies have a back story—something all of the researchers know, but is not reflected in the word-trimmed, published version. What are we not seeing in the published form of the PROPPR study?

Some key points from the discussion

* Our current definitions of massive transfusion are outdated. Better may be the Critical Administration Threshold--if you give 3 units of blood in any 1 hour period, it is a massive transfusion. But...
* Dr. Holcomb doesn't wait for the 3 unit threshold. At his shop, they try to make the 1st unit transfused plasma or platelets and start matched transfusion from that point forward.
* In the PROPPR trial, only about 2/3 of the patients received TXA, but CRASH2 indications would have had all of them receive it. Dr. Holcomb uses TEG to decide, and wants to see more RCTS (they are being done) to better clarify the role of TXA. For more on that though,]]>
Scott D. Weingart, MD clean 20:35
Podcast 143 – Hemodynamic Management of Massive Pulmonary Embolism (PE) https://emcrit.org/emcrit/hemodynamic-management-massive-pulmonary-embolism-pe/ Mon, 16 Feb 2015 00:56:32 +0000 http://emcrit.org/?p=13261 Hemodynamic Management of Massive PE Hemodynamic Management of Massive PE

This is a lecture by Oren Friedman from the 2015 EMCrit Conference. See Oren's previous lecture on Clot Management in Pulmonary Embolism for the complete picture.
Watch the Video

See the Slides


Click here for Mobile Version
Additional Information

* Does epoprostenol work for these patients? Not according to this small RCT  [cite source='pubmed']20353588[/cite]
* If the patient codes, definitely give lytics if there are no contraindications, or so says the PEAPETT study (10.1016/j.ajem.2016.06.094)

For More, See this Excellent Post:

* PulmCrit on Crashing PE

Now on to the Podcast...
]]>
Scott D. Weingart, MD clean 32:33
Podcast 142 – Airway Things I Learned from George Kovacs at the NYC Airway Course https://emcrit.org/emcrit/airway-kovacs/ Sun, 25 Jan 2015 17:18:04 +0000 http://emcrit.org/?p=11222 In this 3rd post for JanuAirway, I am joined by airway educator extraordinaire: George Kovacs. In this 3rd post for JanuAirway, I am joined by airway educator extraordinaire: George Kovacs.
Post Three of Janu-Airway
I just finished teaching at one of the best airway courses I have ever participated in (well actually, it's been a few months now). The highlight of the course was meeting Prof. George Kovacs. He has been obsessed with airway for decades. I picked up a number of great tips from him and I'm sharing those tips with you today.
Anesthesia for Awake Intubation
See this lecture to understand the intricacies of Awake Intubation

* EZ Atomizer

* George uses 15 ml of Lidocaine 4% in the EZ atomizer


* 5% Paste on a Tongue Depressor
* 10% lidocaine would be wonderful to spray down the cords (not available in USA)


Not Seating Fully in the Vallecula

The Move: Lift the Head

Bagging Grip
Underhand grip, like you are holding a football


How to Build Direct Laryngoscopy Muscles
Residents don't lift enough

Two-Hand Lift

Lock and Load and Potato Sacks

the following video demonstrates all of the best-look laryngoscopy techniques we have discussed thus far:


VL/Long Scope Combo and the Triple Set-Up

* Video Laryngoscope
* Fiberoptic Scope
* Surgical Airway Supplies

How to ask for In-Line Stabilization

* Take Off the Collar!
* Ear-Muffs Approach to prevent obstruction of jaw mobility


Automation Addiction
The FAA Report and its ramifications for Crit Care Airway Management
Want More from George?

* Procedural Skills in Medicine (pdf)
* George's Talk on Human and Psychological Factors in Airway Management From EM London
* Airway in a Minute Videos on George Kovacs Youtube Channel
* AIME Airway Site
* Airway Management in Emergencies Monograph
* George's EMCrit Guest Post on Antifragility


Now on to the Podcast...


 ]]>
Scott D. Weingart, MD clean 26:21
EMCrit Wee – Preoxygenation Update 2015 https://emcrit.org/emcrit/preoxygenation-update/ Thu, 22 Jan 2015 21:00:30 +0000 http://emcrit.org/?p=11337 It's Janu-Airway: Here's a little update on preox (you know the topic I think about 20 hours a day) It's Janu-Airway: Here's a little update on preox (you know the topic I think about 20 hours a day)
For all of the shownotes, come to the EMCrit Preox Page
Now on to the Wee...
]]>
Scott D. Weingart, MD clean 19:08
Podcast 141 – A Janu-Airway Case Presented Live https://emcrit.org/emcrit/emcrit-live-2015/ Sat, 10 Jan 2015 20:36:44 +0000 http://emcrit.org/?p=13334 A case of anatomically and physiologically difficult airway presented live at #EMCritConf 2015. A case of anatomically and physiologically difficult airway presented live at #EMCritConf 2015. Janus General.
HOp Killers

Low SvO2 as a Source of Hypoxemia



Use an Intubation Checklist

Have a Failed Airway Plan

A Better BVM



* Pressure Gauge
* One-Way Exhalation Port
* PEEP Valve
* ETCO2

Dump Kit
Directly stolen from Sydney HEMS



The kit is the Aeromedic RSI Kit D953 from DHS of the Byron Group in Sydney


Here is a video on how Sydney HEMS sets up their kits
Hemodynamically Unstable Intubations
Laryngoscope as a Murder Weapon: Hemodynamic Kills Podcast from SMACC
Updated Cormac-Lehane Grading
Cook TM. Anaesthesia. 2000 Mar;55(3):274-9.  A new practical classification of laryngeal view.
NAP4 Study
Podcast with Cliff Reid
Scalpel Finger Bougie Logo

Lecture from SMACC on Crics
Cut to Air from SMACC Gold
Now on to the Podcast...
 ]]>
Scott D. Weingart, MD clean 22:04
Podcast 140 – Top Picks for 2014 https://emcrit.org/emcrit/top-picks-2014/ Wed, 31 Dec 2014 20:33:59 +0000 http://emcrit.org/?p=6429 Welcome to our annual rehash of the goodness of the past year. Welcome to our annual rehash of the goodness of the past year.

Welcome to our annual rehash of the goodness of the past year. Here is just a sampling of the great FOAM that I've discovered throughout the year:





Chris Nickson, Cliff Reid, Haney Mallemat, Michaela Cartner and Karel Habig

* The RAGE Website
* Subscribe to the RAGE Podcast on Itunes






Rob Mac Sweeny

* Critical Care Reviews
* Here's a wee
* Register for the Weekly Email






Leon Gussow, Theresa Kim, Steve Axe, Jenny Liu

* The Poison Review Podcast
* Subscribe in Itunes






Duncan Chambler, Dave Slessor, Steve Mathieu, Adrian Wong

* The Bottom Line Review






Jeff Hill & Bill Hinckley

* Taming the SRU Site
* Subscribe on Itunes






Alex Yartsev

* Deranged Physiology Site






Simon Carley, Rick Body, Natalie May, Iain Beardsell, Alan Grayson

* St. Emlyn's Podcast
* Subscribe on Itunes




Non-Medical Stuff
Books

* The Name of the Wind
* The Golem and the Jinni

Podcasts

* You are not So Smart

Want more Best of?

* clean 9:35
Podcast 139 – Opioid-Free ED with Sergey Motov https://emcrit.org/emcrit/opioid-free-ed/ Sun, 14 Dec 2014 18:56:25 +0000 http://emcrit.org/?p=12200 Can we manage pain more effectively without Opioids? Can we manage pain more effectively without Opioids?
Today I am joined by a good friend Sergey Motov, MD. Sergey is an EM doc with a particular interest in pain management in the ED. Sergey recently, as part of a approved study, ran an entire ED shift without a single administration of an opioid for pain. Can it be done?
The Pain-Free ED
Sergey has an amazing site, with resources and lectures: The Pain-Free ED
The Concept and Rationale of an Opioid-Free ED: Why do we need alternative to opioids in the ED?
No consensus on optimum opioid doses (weight-based, fixed, nurse initiated?)

* http://www.ncbi.nlm.nih.gov/pubmed/24210367
* http://www.ncbi.nlm.nih.gov/pubmed/23264318
* http://www.ncbi.nlm.nih.gov/pubmed/20825766
* http://www.ncbi.nlm.nih.gov/pubmed/16898939

Poor titration practices

* http://www.ncbi.nlm.nih.gov/pubmed/21908134
* http://www.ncbi.nlm.nih.gov/pubmed/20825766

Overdosing hydromorphone/ under-dosing morphine

* http://www.ncbi.nlm.nih.gov/pubmed/16898939
* http://www.ncbi.nlm.nih.gov/pubmed/19426295

Severe side effects ( especially geriatric patients)

* http://www.ncbi.nlm.nih.gov/pubmed/24033733
* http://www.ncbi.nlm.nih.gov/pubmed/24629443

Begetting Addiction

Regulatory concerns of prescribing opioids.
Concept of Multimodal Receptor/Channel Targeted Analgesia (RCTA)
Cox Inhibition


COX 1-2 - NSAIDS ( renal colic, back pain; by honoring “Analgesic Ceiling” concept)

COX 2 -Cox 3 - Acetaminophen (as well as TRPV1( capsaicin receprots) , cannabis, endogenous opioids)

* http://shortcoatsinem.blogspot.com/2012/03/iv-acetaminophen-all-rage.html
* http://www.anesthesiologynews.com/download/SR122_WM.pdf
* http://emj.bmj.com/content/early/2011/02/28/emj.2010.104687
* http://www.beat-journal.com/BEATJournal/index.php/BEAT/article/view/45
* http://www.ncbi.nlm.nih.gov/pubmed/25197573
* http://www.ncbi.nlm.nih.gov/pubmed/24381620
* http://www.ncbi.nlm.nih.gov/pubmed/22186009

NMDA antagonism- ketamine ( IV push, drip, continuous infusion as adjunct to opioids or single agents)

* http://www.ncbi.nlm.nih.gov/pubmed/25197290
* http://www.ncbi.nlm.nih.gov/pubmed/23602757
* http://www.ncbi.nlm.nih.gov/pubmed/23159425
]]> Scott D. Weingart, MD clean 28:35 Podcast 138 – Vasopressor Basics https://emcrit.org/emcrit/vasopressor-basics/ Mon, 01 Dec 2014 17:25:23 +0000 http://emcrit.org/?p=4215 There is a ton to speak about regarding vasopressors, but before we get to the edge cases, we need to set-up a foundation. There is a ton to speak about regarding vasopressors, but before we get to the edge cases, we need to set-up a foundation.
The Basics of Vasopressors
There is a ton to speak about regarding vasopressors, but before we get to the edge cases, we need to set-up a foundation.
Types of Shock

* Obstructive
* Hypovolemic
* Cardiogenic
* Distributive

It's all about flow!

* Should we get rid of blood pressure?

Critical Perfusion Pressures

* CV Collapse 35 mm HG (51 mm Hg in critical AS pts) in one study (Crit Care 2014;18:719)
* MAP of 50 in non-vasculopath dogs for the brain? [cite source='pubmed']9692450[/cite]
* MAP of 65 for the heart? (Dunser et al. think it is 45-50 for the heart)
* MAP 65-75 for the Kidneys? [cite source='pubmed']18382191[/cite]

When we put someone on a vasopressor, what are we hoping to accomplish?

* Critical Perfusion Pressures (Heart will get better, but may look worse)
* Increase Venous Return
* Avoid Gut Ischemia and Flow Reduction

Norepi Increases Venous Return as well as Constricting Afterload

* Crit Care Med. 2012;40(12):3146-3153
* Crit Care Med. 2011 Apr;39(4):689-94
* Crit Care Med. 2013 Jan;41(1):143-50
* Critical Care 2007, 11(Suppl 2):P37
* Critical Care 2010, 14:R142
* Anesthesiology 2014; 120:365–77
* Want to understand the physiology of venous return?

MAP of 65 or Higher?
No benefit to 80-85 group [cite source='pubmed']24635770[/cite]
Vasopressor Flow Chart

Update: The Hinds Perspective

Various Vasopressors
Terminology

* 'pressors/catecholamines/inotropes are not so helpful
* Pure Pressors
* Inopressors
* Inodilators (another show)

Why Norepi?
[cite source='pubmed']10966247[/cite]

Should become weight based

Should tolerate tiny doses
Why Not Dopamine?
'cause it is crappy
Vasopressin
Phenylephrine
Epinephrine
Effects on Mortality
Early norepi was better than later norepi [cite source='pubmed']25277635[/cite], [cite source='pubmed']25072761[/cite]
Up and Coming Vasopressors to be Discussed in Future Episodes
Methylene Blue

Angiotensin II

ATHOS Trial
Peripheral Vasopressors
EMCrit Episode 107
Very Good Review Article on the Effects of Vasoactive Agents on Microcirculation
Great Review [cite source='pubmed']20811874[/cite]
Review Articles
[cite source='pubmed']12386503[/cite]

[cite source='pubmed']21097695[/cite]

Moving beyond BP cosmetics by Dunser
Understanding Venous Return
[cite source='pubmed']24966066[/cite]
Must Read Posts By Josh Farkas

* Early MAP Stabilization
*
Scott D. Weingart, MD clean 30:33
EMCrit Podcast 136 – Getting Shit Done https://emcrit.org/emcrit/getting-shit-done/ Mon, 03 Nov 2014 18:44:20 +0000 http://emcrit.org/?p=11900 Not quite ED Critical Care, but I hope this discussion of EM/Resus Productivity may be helpful to some of you out there. Not quite ED Critical Care, but I hope this discussion of EM/Resus Productivity may be helpful to some of you out there.

So my friend Michelle Lin was kind enough to solicit a "How I Work Smarter" piece on her excellent ALIEM blog. One of the things I mentioned in that piece was a book called Getting Things Done. I've since gotten a bunch of questions and comments about the book. I'd like to take a brief diversion from the main topic of EMCrit and discuss a bit about the book and productivity for docs and resuscitationists.
The Books

* Getting Things Done by David Allen (A new edition, the first in years will be out in 3-4 months)
* The Organized Mind

The Philosophy
A clear mind eliminates stress and allows creativity, so...

Capture all the things that need to get done into a logical and trusted system outside of your head and off your mind, and...

Discipline yourself to make decisions about all the inputs you let into your life, so that you will always have a plan for next actions that you can implement or renegotiate at any moment

(altered from Mindzone Wiki)
Problems with the Book

* Mindset of the Author
* Based on an erstwhile paper-based world
* Can be read as Dogma

The Steps of GTD
Collect/Process/Organize/Review/Do
1. Collection/Universal Capture

* Index Cards
* Drafts for IOS

Inbox(es)

* Email
* Paper Landing Station (The Traditional/Actual Inbox)
* Pocket for Web and IOS

2. Process
What is it?
Is it an action, spam, or something non-actionable you want to keep?
Action Processing

* Decide if you want to Do it, Don't do it, Delegate it, or Put it in your system
* Is it a project?
* What is the physical next action that must occur to bring you 1 step closer to completion

Next Actions & Projects

Reference Processing
Things you just want to keep or references for actions

Eliminate Paper!

* Evernote
* Scansnap Scanner (this item will change your life)



 
3. Organize-If you are not doing it right now, put it in the system

* NirvanaHQ or Omnifocus
* GCal with Fantastical
* Add all reference material as links in your system

Calendar
Only things that absolutely must happen at this date/time
Lists on Task Management System


Especially important to have a someday/maybe list, a waiting list, and have a thorough understanding of scheduled events.
4. Review
Daily

* Try to process all email
* Kill all paper
* Clean off Desktop
* Look at Calendar
* Look at Focus and Inbox
* Make a To-Do Card
* Pack for next day


Weekly
(this list is from Mindzone wiki)

* Loose Papers

* business cards, receipts, etc.]]> Scott D. Weingart, MD clean 47:34 EMCrit Podcast 135 – Trauma Thoughts with John Hinds https://emcrit.org/emcrit/trauma-thoughts-john-hinds/ Mon, 20 Oct 2014 01:23:38 +0000 http://emcrit.org/?p=11422 John Hinds on Blunt Traumatic Arrest John Hinds on Blunt Traumatic Arrest

@docjohnhinds is the man behind Cricolol

I recently brought him to our EM Critical Care Grand Rounds at @stonybrookem

He gave two fantastic lectures! I then brought him back to EMCrit Studios to record a few of the take-home lessons from his talks.

See Cases from the Races on the RagePodcast site to see the inspiration for this 'cast.
Blunt Traumatic Arrest: a Road Racing Doc's Approach
If the patient is in blunt traumatic arrest, John and his team immediately perform the following before any further assessment:

* Intubation using a bougie and confirmed by waveform CO2
* Perform Bilateral Finger Thoracostomy
* Place Pelvic Compression Device
* Straighten Long Bone Fractures to Length
* Administer Fluid Bolus (Administer Blood if In-Hospital)

Only then reassess and decide what to do
Impact Apnea
Airway positioning and rescue ventilation can save a life

More on this soon when the Wilson, Hinds, Davies study is published. Until then, see the LiTFL CCC Entry
Central Line Placement
In John's unit, they use infraclavicular left subclavian for all ICU CVC placements]]>
Scott D. Weingart, MD clean 25:55
EMCrit Wee – I Thought This Would be the One, but Nope…. https://emcrit.org/emcrit/more-on-arise/ Mon, 13 Oct 2014 00:10:38 +0000 http://emcrit.org/?p=11458 Smells like some confirmation bias here Smells like some confirmation bias here EMCrit specializes in Type 2 Translation and Implementation. That crap wouldn't exist without the researchers. Go find a Critical Care Researcher today and give them a hug.
But they Weren't Sick Enough...
SSC Reverses their Stance on EGDT (Sort of...)

What do folks thing EGDT still brings to the table?
Cognitive DeBiasing
Please ask yourself, before you air your viewpoints in public, are you displaying Confirmation Bias



 ]]>
Scott D. Weingart, MD clean 10:14
Podcast 134 – ARISE has arisen; now where do we stand on Severe Sepsis in 2014 https://emcrit.org/emcrit/arise-trial-sepsis-2014/ Fri, 03 Oct 2014 22:55:35 +0000 http://emcrit.org/?p=11289 the Arise Study (Australasian Resuscitation In Sepsis Evaluation) and Severe Sepsis Care in 2014 the Arise Study (Australasian Resuscitation In Sepsis Evaluation) and Severe Sepsis Care in 2014
So the Arise Study (Australasian Resuscitation In Sepsis Evaluation) just dropped. The amazing guys at the Bottom Line did a summary (saving me a bunch of work)
Sorry, you do not have iframe working. Click here to go to the article.
Baseline Characteristics

Table S5-Therapies in the first 6 hours and 3 days

Videos from a Prime Author
Hear from Sandra Peake
Recognition-Find em' Early
SIRS+

Lactate or Persistent Hypotension (Arise used 1 liter)

I would use STOP Sepsis Campaign Modification of SIRS Critieria, so you don't need to wait for cbc


Treatment-Treat the Source/Perfuse the Tissues

Antibiotics
Another trial showing early abx are associated with goodness

If a patient is sick and you don't know what is going on, just give them appropriate spectrum abx. If a patient is persistently hypotensive and you don't know why--give them abx.

A very cute antibiotic summary
Source Control
Early, early, early
Don't box 'em with the tube
See the Hemodynamic Kills Lecture
The Right Amount of Fluid
Use whatever method you want, but you should probably give between 3-4 liters
Early Vasopressors
Give them peripherally to get them in fast and then you should probably put in a line

If you have given 3-4 liters, the patient probably deserves pressors for venous squeeze before giving more fluid
Check Your Work
Serial lactates?
Put them in a Monitored Setting
b/c of the way septic patients die
Other Stuff
Blood
No role for blood, except in niche cases, until Hb < 7 from the recent TRISS Trial (PMID 25270275)

Fewer pts got blood in EGDT group of either ProCESS or ARISE than the original EGDT study
Dobutamine
who the hell knows
Want to Hear from the Primary Investigator?
Oli Flower did a podcast in which Anthony Delaney addresses many comments from this post. Here's Oli:

Thanks Scott for your insights on ARISE and the state of play of sepsis management in 2014.

These open discussions that your podcast stimulates are incredibly important and essential for translating research findings into practice, and getting the important messages and critical interpretation of the data to as many people as possible!

Yesterday I interviewed the ARISE PI Anthony Delaney to hear his take, now he’s allowed to finally talk about the results, and I went through a lot of your listener’s comments to get an answer from the horse’s mouth.

The interview is here:
http://intensivecarenetwork.com/delaney-arise-study-emcrit-dogmalysis/

Cheers,
Oli

What do you think?]]>
Scott D. Weingart, MD clean 21:53
EMCrit Podcast 133 – The First Prehospital REBOA https://emcrit.org/emcrit/emcrit-podcast-133-first-prehospital-reboa/ Wed, 24 Sep 2014 14:58:07 +0000 http://emcrit.org/?p=11128 London HEMS docs peform REBOA and save a life London HEMS docs peform REBOA and save a life

A few months ago, we spoke about REBOA-resuscitative endovascular balloon occlusion of the aorta. You might have thought to yourself, "Interesting, but I'll never be doing that." Well, not so fast, on today's podcast we speak to the retrieval doctor that performed the first REBOA in the field.
REBOA in the Field and the ED


In London, the idea of bringing REBOA to the field and the ED was made reality by Gareth Davies. Dr. Davies is Chair and Medical Director of the London Air Ambulance (London HEMS), one of the best HEMS services in the world. In the first part of the podcast, we hear how he conceptualized and enacted the plan to bring REBOA to the field.


The First Prehospital REBOA
Then we speak with Jonny Price, Anesthesia and Intensive Care registrar doing a secondment in HEMS. At the time of the events of the podcast, he was flying with London HEMS. His story of the first prehospital REBOA is fascinating.

Special thanks to Cliff Reid for making these interviews possible.
Update
Here is the hot-off-the-press article on the technique: Resuscitation 2016 Jul 1; Resuscitative endovascular balloon occlusion of the aorta (REBOA) in the pre-hospital setting: An additional resuscitation option for uncontrolled catastrophic haemorrhage.S Sadek, D J Lockey, R Lendrum, Z Perkins, J Price, G E Davies PMID: 27377669
Now on to the podcast...]]>
Scott D. Weingart, MD clean 25:54
EMCrit Wee – Aggressiveness and the New Cutdown with Leon Boudourakis, MD https://emcrit.org/emcrit/aggressiveness-and-the-new-cutdown/ Wed, 17 Sep 2014 22:13:55 +0000 http://emcrit.org/?p=11035 Need access--this may be a way Need access--this may be a way ATACC Trauma Textbook
A free trauma textbook that is simply amazing and the best example of FOAM brought to traditional media that I have ever seen--want it? I bet you do. I could have written an entire post on this book, but luckily someone did it for me:

Tim Leeuwenburg on the ATACC Textbook

Just want to download it?

* The Ibooks Version can be found at this link
* or go to the ATACC site for the PDF versions

POCUS Ultrasound Book
My friend and ultrasound maven, Rob Arntfield is one of the editors of an amazing new Ultrasound Book



Here are some of the reasons why it is so good

* -44 chapters
* -60+ authors
* -285 videos
* -geared to be first ever book to support all specialties at different providers levels.
* -Inkling reading experience (laptop/phone/tablet) is amazing, with embedded videos in the chapters and high quality cases
* -The references are in the online version and have hyperlinks for the PMID allowing immediate access to the root literature

Buy the book

Get the POCUS book on Amazon

Win the book

Simply "like" the EMCrit Facebook Page and I'll choose a winner from there
Stony Brook Department of EM
We want the best medical students, faculty, and ED Intensivists

Check us out at the Stony Brook EM Page and contact me if you are interested or have questions
Aggressiveness and the New Cutdown with Leon


Here is an instructional video on the procedure
Now on to the Wee...]]>
Scott D. Weingart, MD clean 9:40
Podcast 132 – MoTR – Toughness Part I with Michael Lauria https://emcrit.org/emcrit/toughness-michael-lauria-i/ Sat, 06 Sep 2014 18:46:02 +0000 http://emcrit.org/?p=10379 Today, I interview Mike Lauria on the concepts of toughness and resilience. Today, I interview Mike Lauria on the concepts of toughness and resilience.

Today, I interview Mike Lauria on the concepts of toughness and resilience.
The Rationale of Selection Courses/Indoc
80-90% Attrition for the PJs Indoc
One of the things that people, I think, find distasteful about selection programs in the civilian word is that it uncovers fundamental weaknesses and shortfalls.  This is no commentary on the intrinsic worth of the individual.  It doesn't necessarily mean that they are smart or dumb.  But it is indicative of some inability or failure to meet a standard.  While it is hard for many civilians (and military members for that matter) to swallow, perhaps not everyone is cut out for a particular discipline.  Maybe we shouldn't be forcing training, pushing people along, coddling individuals to maintain the outward appearance that a program is "successful" if an individual can't make it through some sort of initial pipeline.  Perhaps a benefit of selection is making sure that the right people are there to begin with and the individuals that were simply not made for it are directed elsewhere.
I lost the source for the above quote, but I think it describes the process well. If anyone has it, please send me the attribution.

Builds an innate Espirit de Corps and a common thread of self and team-reliance
Residency as the Pipeline
Should we have culmination tests and exercises at the end of residency?
Stress Inoculation/Cognitive Tempering
Mike discusses four stages to do this right:

* Conceptualization-give a background of stress responses, why they happen, and what to expect.
* Train and educate on the skills and tasks we want to see performed under stress. Then give the tools to deal with the expected stress. The latter is where we may be failing our learners
* Do a dry run to train in simulation without added stressors
* Run the same training with stress inoculation

How can we make #4 work in EM/CCM?
Sound, distractions, equipment failures, and deliberate poor communications
So what tools can we offer for #2?
Mike offers an acronym: Beat The Stress, Fool

* B is for Breathe. Breathe tactically. See the On Combat Podcast for a description (and there is an app for that too: Tactical Breather App)
* T is for Talk. Self Talk. Positive self-talk is used by athletes and any elite performance group.
* S is for See. Visualization. Visualize yourself performing the task exactly how you want to see it done.
* F is for Focus. A key word to activate the state you want. Mike has chosen "focus" as his word. We then had a brief discussion of the book, the Art of Learning by Josh Waitzkin. The author creates an entire relaxation and mindset ritual that eventually gets boiled down to a key word or short set of actions. You'll be hearing more about this book on the podcast.

When Mike asked if I had anything to add to this excellent set of tools, I discussed this TED Video by Dr. Amy Cuddy:



 

So maybe...Beat the Stress, Foolish Padawan with a P for posture??
Too Much Macho Militarization?
Mike posted a Youtube Video Addressing this question
Cliff Reid's Resus.me Post on Self-Defense
During the intro, I discussed the contentious self-defense post on resus.me
First10EM Magnum Opus on Performance Under Pressure...]]>
Scott D. Weingart, MD clean 31:56
EMCrit Wee – A Case to Threaten Current ECMO Evidence from Sam Ghali https://emcrit.org/emcrit/prolonged-cpr-case/ Fri, 15 Aug 2014 14:35:53 +0000 http://emcrit.org/?p=7951 Should we be extending ACLS in patients we really want to save? Should we be extending ACLS in patients we really want to save?
Mirroring Cliff Reid's amazing talk: When Should We Stop Resuscitation?, I present Sam Ghali's (@EM_ResUS) case.
From Sam Ghali:

I just experienced probably the most amazing case I’ve ever been a part of this past Monday.     This case has become the talk of the place, as it was very controversial within the world emergency medicine, critical care and cardiology here @ Janus General.  It was discussed in M&M and there is gonna be a joint multidisciplinary thing, etc.  But otherwise there is no one else’s opinion I would be more interested to hear than yours, so I wanna share it with you:

I was working shift in Major Treatment Area here at Janus General, and we hear we’re getting a med resusc… rolls in a guy looks to be in about his 60’s (turns out he was 59).  Story was :

Witnessed Arrest with bystander CPR… shockable for EMS, but shocked 6-7 times… meds given were for some reason only bicarb and Lidocaine (not sure why?)

I will share with you my documentation, only b/c it will save me tons of typing and I trust sending it to you..

This patient was seen in the resuscitation bay along side Dr. XXXXX concurrently.  This patient presents status-post witnessed cardiac arrest after return of spontaneous circulation.  His rhythm was always shockable per EMS.  He arrived with a King airway in place.  There was a large air leak noted.  CPR was in progress shortly after arrival as he was noted to not have pulses.  Chest compressions were resumed immediately and multiple rounds of CPR with multiple rounds of epinephrine, and medications including amiodarone, bicarbonate, calcium, magnesium were administered.  Please see nursing medications charting.

Multiple echocardiographic images were obtained by myself.  Please see computer for images.  The patient was noted to be in and out of ventricular fib.  CPR was continued in line with ACLS protocol.  The King Airway was removed and endotracheal intubation was performed by myself using a MAC 4 blade and an 8.0 endotracheal tube without difficulty.  There was good condensation on the tube, good chest rise, and end tidal CO2 was detected immediately with excellent wave-form.  Intra-code bedside echo was performed and revealed no evidence of right ventricular enlargement or strain on echo, or any other signs of massive pulmonary embolism.  There was also no pericardial effusion.  Echo did show akinesis/hypokinesis inferiorly and somewhat laterally as well.  The inferior wall was essentially akinetic.   Anterior wall motion was clearly preserved.  This was best seen on the parasternal long and short axes.

There was very high suspicion for acute coronary event.  Furthermore there was no evidence of hypoglycemia, hyperglycemia, hypokalemia, hyperkalemia.  The patient’s pH was noted to be significantly acidotic, and 2 additional ampules of sodium bicarbonate were administered at that time.  There was good sliding bilaterally on ultrasound.  There was no evidence of massive pulmonary embolism on echo, and there was no evidence of pneumothorax.  Intravenous fluids were pressure bagged in.  There was no significant hypothermia.   End tidal was difficult to interpret due to multiple ampules of sodium bicarbonate.  After nearly 45 minutes of aggressive CPR the decision was made to use thrombolytics because we felt strongly that this was an acute myocardial event, it was also strongly felt that without thrombolytics stabilization and termination of electrical storm could otherwise not be accomplished,]]>
Scott D. Weingart, MD clean 5:44
EMCrit Podcast 130 – Hemodynamic-Directed Dosing of Epinephrine for Cardiac Arrest https://emcrit.org/emcrit/hemodynamic-directed-dosing-epinephrine/ Sun, 10 Aug 2014 19:22:21 +0000 http://emcrit.org/?p=9761 Today on the podcast, I address the last little bit from my SMACC lecture on the new management of the intra-arrest: hemodynamic, individualized dosing of epinephrine. Today on the podcast, I address the last little bit from my SMACC lecture on the new management of the intra-arrest: hemodynamic, individualized dosing of epinephrine.

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

The podcast is interspersed with clips from Professor Norman Paradis
Articles/Posts on Epinephrine by ACLS Guidelines

* [cite source='pubmed']15306666[/cite],
* http://www.emdocs.net/epinephrine-cardiac-arrest/
* http://www.jems.com/article/patient-care/new-resuscitative-protocol
* [cite source='pubmed']24846323[/cite]
* [cite source='pubmed']19934423[/cite]

Epinephrine Dosing Based on DBP
Three Swine Study

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

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

[cite source='pubmed']25321490[/cite]

[cite source='pubmed']24945902[/cite]

Here is the abstract from the latter study:


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

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

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

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

Perhaps we can extrapolate from these pig studies to--shoot for SBP of >=100 with compression efficacy and CPP>20 (DBP>40) with vasoconstriction. REBOA or SAAP may solve both



Human Study by Dr. Paradis


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

[cite source='doi']10.1001/jama.1990.03440080084029[/cite]

Coronary perfusion pressure (CPP), the aortic-to-right atrial pressure gradient during the relaxation phase of cardiopulmonary resuscitation, was measured in 100 patients with cardiac arrest. Coronary perfusion pressure and other variables were compared in patients with and with...]]>
Scott D. Weingart, MD clean 18:24
MotR – Mike Lauria on “Making the Call” https://emcrit.org/emcrit/motr-mike-lauria/ Thu, 31 Jul 2014 13:26:47 +0000 http://emcrit.org/?p=10394 You'll be hearing more from Mike You'll be hearing more from Mike Mike Lauria is the @resuspadawan. You'll be hearing a lot more about Mike when he comes on the show for an interview. For now, know that he was Air Force Pararescue, now a medic on the Dartmouth-Hitchcock Advanced Response Team (DART), and will be starting medical school in the Fall. He has a special interest in cognitive decision making under stress, aka the Mind of the Resuscitationist.
Recognition Primed Decision Making (RPD)
Sources of Power by Gary Klein
OODA Loop
From 40-second Boyd. Read a summary on wikipedia


Cognitive Unloading

* Standardization & Preparation
* Checklists
* Premade Decision Points and Triggers

Cognitive Rally Points (Stop Points)

* Hard and Soft Rally Points
* Take a Deep Breath

Build Decision Making Power

* Deliberate Practice
* Review Experiences
* Timely Expert Feedback
* Socratic Method-Suck it Up!
* Simulation

Stress Inoculation

* Cognitive Tempering
* The Rule of 130%-do the basics better than anyone else
* Limbic Learning-emotional reaction burns it in
* Train until you can't get it wrong
* You fall to the level of your training

Stay Flexible

* Cognitive Flexibility
* Acknowledge BIases
* Ask disconfirming questions

The Slides

Articles

* Resilience Training for Nurses

Update
See this amazing comment on Mike's Lecture
Now on to the Lecture...]]>
Scott D. Weingart, MD clean 42:52
Podcast 129 – LAMW: The Neurocritical Care Intubation https://emcrit.org/emcrit/neurocritical-care-intubation/ Sat, 26 Jul 2014 16:36:12 +0000 http://emcrit.org/?p=4458 This is the another of the Laryngoscope as a Murder Weapon lectures; though in this case it is really more of an aggravated assault. This is the another of the Laryngoscope as a Murder Weapon lectures; though in this case it is really more of an aggravated assault.

This is the another of the Laryngoscope as a Murder Weapon lectures; though in this case it is really more of an aggravated assault.
Who is this For?
Semi-elective intubations for patients with presumed or known elevated ICP

In TBI severity of brain injury doesn’t predict the lack of need for pharmacological blunting of increase in MAP or ICP [cite source='pubmed']23511147[/cite]

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

This is the same way we would intubate an aortic dissection patient
Preoxygenation
Ap Ox and high-flow fiO2 for the full 3 minutes or longer
ETCO2
Put it on the BVM
Non-Pharmacologic Methods to Blunt Reflex Response
Limit time of laryngoscopy and atraumatic laryngoscopy

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

No-touch intubation with video laryngoscopy by the best intubator
Pretreatment
Control the BP BEFORE the intubation
Lidocaine
While there is evidence that it blunts ICP rise and cough response, there is no good evidence that this has clinical results.[cite source='pubmed']11696494[/cite] Literature is pretty good on endotracheal suctioning, but nothing on patient-important outcomes during intubation. Not hemodynamically active in this one study, but I have experienced radical drops in BP. [cite source='pubmed']22633717[/cite] This one shows the hypotension potential. [cite source='pubmed']25237632[/cite]

Local is more effective than IV. [cite source='pubmed']10861151[/cite]

Lidocaine References [cite source='pubmed']11696494[/cite], [cite source='pubmed']17358099[/cite], [cite source='pubmed']23683444[/cite], [cite source='pubmed']7772359[/cite],
Fentanyl
Dose 5 mcg/kg [cite source='pubmed']6318605[/cite], [cite source='pubmed']7032347[/cite]

All equipment meds must be prepared before administration. Someone must be watching the pt. You need to have push-dose epinephrine drawn up at the bedside if you are going to use fentanyl in these doses.
Remifentanil
Remifentanil can also be used, but I don't have so I can't speak about it
Esmolol
Dose 1.5-2 mg/kg ~ 3min beforehand

Combo of Esmolol and Fentanyl [cite source='pubmed']1363221[/cite]

[cite source='pubmed']7788827[/cite]

[cite source='pubmed']9084524[/cite],[cite source='pubmed']1672488[/cite]
Nicardipine
Dose 20 mcg/kg (average 1.4 mg)

[cite source='pubmed']21696933[/cite] and [cite source='pubmed']10553821[/cite] and Review Article (16978041)
Other Group's Recs
At this stage, Emergency Airway Course only recommends Lidocaine and Fentanyl: they state prefasiculation is dead
Osmotic Therapy
Probably a good time to give a dose of hypertonic saline
Induction Agents
Etomidate, Propofol, or Propofol/Ketamine (75%/25%). If Thiopental was still available, it would be on the list as well.
Muscle Relaxants
Rocuronium or Succinylcholine at full dose
Post-Intubation Sedation
Propofol and Fentanyl
Post-Intubation Ventilation
Shoot for 95% saturation, use PEEP only if necessary; but if it is necessary it is safe to use

Increase Respiratory Rate until ETCO2 of 35 mm Hg; then send a blood gas
Other Situations
Basilar Stroke and Stuttering Stroke-lower bp=screwed
Review Article
Has anyone found a good one for ICP

Here is a great article for the clean 31:00
Podcast 128 – Pulmonary Embolism Treatment Options and the PEAC Team with Oren Friedman https://emcrit.org/emcrit/pulmonary-embolism-treatment-team/ Mon, 14 Jul 2014 14:24:33 +0000 http://emcrit.org/?p=9513 We now have way too many treatment options for sub-massive and massive pulmonary embolism (PE) patients who aren't coding in front of you. How do you decide which one is right for your patient? To help answer this question, I am joined today by Oren Friedman, pulmonary critical care doc and one of the members of the Cornell PEAC team. Cornell Pulmonary Embolism (PE) Advanced Care Team (PEAC), aka the CLOT Team Oren Friedman MD, Pulm Crit Care; James Horowitz MD, Cardiology; Arash Salemi MD, Cardiac Surgery; Akhilesh Sista MD, Interventional Radiology You can shoot the team an email: peadvancedcare at gmail dot com Who Should We Treat? 30% normotensive patients have RVD; 10% progressed to shock; 5% in hospital mortality[cite]10859287[/cite] The Better Risk Categories for Pulmonary Embolism Well and Stable Sub-Massive High-Risk Sub-Massive Massive PEITHO Trial NEJM 2014;370(15):1402 Full dose tenecteplase with concurrent heparin Death or hemodynamic decompensation occurred in 2.6% of the tenecteplase group as compared with 5.6% of the placebo group Extracranial bleeding occurred in 32 patients (6.3%) in the tenecteplase group and 6 patients (1.2%) in the placebo group (P<0.001) Intracranial Bleed 10 patients (2%) in the tenecteplase group and 1 patient (0.2%) in the placebo group (P=0.003) Also see my bud, Salim Rezaie's post on PEITHO and Konstantinides' prior study [cite]12374874[/cite] Ryan Radecki made some great observations in his post on PEITHO The criteria for myocardial injury was a troponin I >0.06 ?g/L or troponin T >0.01 ?g/L.  These may be relatively inclusive thresholds. Not all placebo patients developing hemodynamic collapse received subsequent thrombolysis; likewise, almost half of those who received open-label thrombolysis had no hemodynamic collapse. Half the deaths in the placebo arm were “sudden unexplained” or “other”, compared with bleeding or stroke complications in the thromboysis arm. TOPCOAT Trial Jeff Kline's trial was stopped midway through due to an institution change. Complicated primary endpoint with promising, but unusable results [cite]24484241[/cite] For the scoop on this one see the Bottom Line Review post on TOPCOAT MOPETT Trial Half-dose alteplase led to a marked reduction in pulmonary hypertension without sig. complications Sharifi M et al. Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT trial). (J Cardiol 2013; 111: 273) See this prior EMCrit Wee as well on MOPPETT Update: This meta-analysis states that the half-dose may be appropriate, effective, and safe [cite source='pubmed']24412030[/cite] Meta-Analysis Chatterjee et al. have the most current meta-analysis on this topic (JAMA. 2014;311(23):2414-2421) See the Bottom Line Review post on this study Nakamura just published another MA this week; see Rory Spiegel's take on the two here Is it just in the Oldies? Markedly lower risk in <75 y/o in PEITHO and <65 in the Meta-Analysis The Treatment Options Heparin Alone tried and true. but even if some degree of resolution of presenting severe symptoms, there is the question of long-term consequences of leaving a large clot burden--namely, loss of exercise tolerance due to chronic pulmonary hypertension Systemic Thrombolysis With either full or half-dose alteplase or full-dose tenecteplase Catheter-Based Intra-Arterial Thombolytic Infusion Angiography guided placement of pulmonary artery catheters allowing a 24-hour infusion of low dose tPA. [cite]19875060[/cite] A newer therapy is the EKOS catheter. This uses ultrasound to continuously break up the clot during the IA Thrombolysis. Many of us wonder if this is any better than standard catheter-based therapy. [cite]24226805[/cite], [cite]23601295[/cite] See the PulmCCM Post on the Circulation RCT of EKOS Interventional Mechanical Clot Disruption AngioJet-a catheter that breaks up the clot with a high speed jet of saline,... We now have way too many treatment options for sub-massive and massive pulmonary embolism (PE) patients who aren't coding in front of you. How do you decide which one is right for your patient? To help answer this question,
We now have way too many treatment options for sub-massive and massive pulmonary embolism (PE) patients who aren't coding in front of you. How do you decide which one is right for your patient? To help answer this question, I am joined today by Oren Friedman, pulmonary critical care doc and one of the members of the Cornell PEAC team.
Cornell Pulmonary Embolism (PE) Advanced Care Team (PEAC), aka the CLOT Team
Oren Friedman MD, Pulm Crit Care; James Horowitz MD, Cardiology; Arash Salemi MD, Cardiac Surgery; Akhilesh Sista MD, Interventional Radiology

You can shoot the team an email: peadvancedcare at gmail dot com
Who Should We Treat?


30% normotensive patients have RVD; 10% progressed to shock; 5% in hospital mortality[cite]10859287[/cite]
The Better Risk Categories for Pulmonary Embolism

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

PEITHO Trial
NEJM 2014;370(15):1402

Full dose tenecteplase with concurrent heparin

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

Also see my bud, Salim Rezaie's post on PEITHO and Konstantinides' prior study [cite]12374874[/cite]

Ryan Radecki made some great observations in his post on PEITHO

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

TOPCOAT Trial
Jeff Kline's trial was stopped midway through due to an institution change. Complicated primary endpoint with promising, but unusable results [cite]24484241[/cite]

For the scoop on this one see the Bottom Line Review post on TOPCOAT
MOPETT Trial
Half-dose alteplase led to a marked reduction in pulmonary hypertension without sig. complications

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

See this prior EMCrit Wee as well on MOPPETT

Update: This meta-analysis states that the half-dose may be appropriate, effective, and safe [cite source='pubmed']24412030[/cite]
Meta-Analysis
Chatterjee et al. have the most current meta-analysis on this topic (JAMA. 2014;311(23):2414-2421)

See the Bottom Line Review post on this study

Nakamura just published another MA this week; see Rory Spiegel's take on the two here
Is it just in the Oldies?
Markedly lower risk in <75 y/o in PEITHO and <65 in the Meta-Analysis
The Treatment Options
Heparin Alone
tried and true.]]> Scott D. Weingart, MD clean 33:08 Podcast 127 – The Oxylator with Jim DuCanto https://emcrit.org/emcrit/oxylator/ Sun, 29 Jun 2014 19:15:45 +0000 http://emcrit.org/?p=3881 BVMs are ridiculously crappy and downright dangerous. The solution? the Oxylator BVMs are ridiculously crappy and downright dangerous. The solution? the Oxylator
Today on the show, I talk with my friend Jim DuCanto, MD about the oxylator. Jim is an anesthesiologist extraordinaire with a constant drive to perfect new airway techniques and document them on video along the way.
What is the Oxylator?
A mainly plastic device about the size of your fist with a incredibly quick magnetic valve

It runs on pressurized wall or tank oxygen

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

Manual Resuscitator Mode

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

Automatic Ventilator Mode

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

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

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

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



Feedback

The device indicates when you are obstructing by clicking and tells you when there is a mask seal leak by not cycling to the next breath
It Solves the 5 Problems of the BVM

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

How we use it
We both use an inline hepa filter, ETCO2 port, and sometimes extension tubing. If you want to use it on a spontaneously breathing patient, OR mask straps are a great addition.
Two models
EMX (25-45 cm H20) and HD (15-30). There are also specialty models for chemical/explosive situations.
Here is Jim's Overview on the Device
https://vimeo.com/99412812
And here are the Slides from a lecture Jim gave at SAM

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


 
Nasal CPAP in Unconscious Patient is More Effective than Full-Face Masks
Crit Care. 2013 Dec 23;17(6):R300.
Oxylator Product Page
This is the EMX Model
Disclaimer and COI
Neither Jim nor I take any money, kickbacks, or incentives from the manufacturer. Both Jim and I have been provided with Oxylators to test and research.
Now on to the Podcast...]]>
Scott D. Weingart, MD clean 20:19
SMACC-Back – On the Beliefs of Early Adopters and Straw Men https://emcrit.org/emcrit/on-the-beliefs-adopters-straw-men/ Tue, 24 Jun 2014 19:45:36 +0000 http://emcrit.org/?p=9899 The First SMACC-Back from SMACCgold The First SMACC-Back from SMACCgold

This is the first SMACC-Back for SMACCgold. The creator of the lecture that led to this was Simon Carley. Simon is a brilliant emergency physician and lecturer who practices at St. Emlyn's. I can only imagine he was expecting this SMACC-Back as he all but threw his metal glove on the ground in front of me (all in good fun). Unfortunately, I was in another session during this lecture, but I've been eagerly awaiting it as many of the EMCritters came up to me afterwards to tell me about it.

My response will make no sense if you don't listen to Simon's talk first, so here it is. I advise watching the video, because I love watching the emotions flash across his face whenever he is lecturing–truly a captivating speaker.



Audio Only Version [right-click and choose save-as to download]

Also, please read the original post on St. Emlyn's.
Technology Adoption Curves
Diffusion of Innovations was a book I read in college. It explains how technology and ideas get taken up by a population. Here is an entry from wikipedia:
Diffusion of innovations is a theory that seeks to explain how, why, and at what rate new ideas and technology spread through cultures. Everett Rogers, a professor of communication studies, popularized the theory in his book Diffusion of Innovations; the book was first published in 1962, and is now in its fifth edition (2003).[1] The book says that diffusion is the process by which an innovation is communicated through certain channels over time among the members of a social system. The origins of the diffusion of innovations theory are varied and span multiple disciplines. The book espouses the theory that there are four main elements that influence the spread of a new idea: the innovation, communication channels, time, and a social system. This process relies heavily on human capital. The innovation must be widely adopted in order to self-sustain. Within the rate of adoption, there is a point at which an innovation reaches critical mass. The categories of adopters are: innovators, early adopters, early majority, late majority, and laggards (Rogers 1962, p. 150). Diffusion of Innovations manifests itself in different ways in various cultures and fields and is highly subject to the type of adopters and innovation-decision process.
The book posits that uptake is a bellshaped curve that looks like this:


Bayesian Approach to New Ideas
Anyone who looks at new evidence with tabula rasa is missing the point and is likely to get things wrong. Not only do we filter new evidences through out beliefs, we must do so. It is not irrational, it is essential-the process should be a willful and deliberate filtration of new information through your existing schema.

Update:

Simon responded to this SMACC-Back with a SMACC-Back-Back. Here it is:

https://twitter.com/EMManchester/statuses/482033046187950080
Update 2:
Rob Cooney weighs in
Now on to the SMACC-Back:]]>
Scott D. Weingart, MD clean 16:30
Podcast 126 – TTM Trial Right from Niklas Nielsen’s Mouth https://emcrit.org/emcrit/ttm-trial-niklas-nielsen/ Sun, 15 Jun 2014 19:29:40 +0000 http://emcrit.org/?p=7745 In this episode, I speak with Niklas Nielsen on his thoughts on the TTM trial. In this episode, I speak with Niklas Nielsen on his thoughts on the TTM trial.
In this episode, I speak with Niklas Nielsen on his thoughts on the TTM trial.
Coverage of the TTM Trial

* EMCrit Coverage
* John Rittenberger's take
* Read this incredible TTM Post on LitFL

Kee Polderman's Editorial

* Crit Care 2014;18:130

 ]]>
Scott D. Weingart, MD clean 18:09
EMCrit Wee – Four More Minutes with Rob Mac Sweeney https://emcrit.org/emcrit/rob-mac-sweeneys-stuff/ Wed, 11 Jun 2014 17:45:26 +0000 http://emcrit.org/?p=9485 I told you today we would have a bit of discussion on Rob Mac Sweeney's FOAM. Well here it is... I told you today we would have a bit of discussion on Rob Mac Sweeney's FOAM. Well here it is... Intra-Arrest Meds. On that cast, I told you today we would have a bit of discussion on Rob's FOAM. Well here it is...



Critical Care Reviews
It's amazing, it's hugely helpful, and it is free. Subscribe ASAP at criticalcarereviews.com.

 

Critical Care Horizons
Here is Rob describing this new journal:
Announcing a new development in critical care publishing.
It is with great delight we announce the launch of a new open access critical care journal. Critical Care Horizons is a fresh, original voice in the critical care literature, offering thought-provoking, cutting-edge commentary and opinion papers, plus state-of-the-art review articles. As a Journal, we see discussion, commentary, and the sharing of insight, experience and ideas, as central to progress in our speciality. We are free to publish with, free to read, opening authorship opportunity to all working with the critically ill. We are driven by a desire to improve the care we offer our patients, and operate without financial aim or incentive.
We strive to be different, combining the rapidity, broad exposure, and dynamic discussion characteristic of social media with the academic standards of an indexed, peer-reviewed journal. Covering the full spectrum of clinical care, we welcome submissions from all disciplines involved in the care of the critically ill and injured, from pre-hospital resuscitation to Emergency Department care to ICU-based management to post-discharge follow-up, and anywhere else.
The Journal publishes dynamically, releasing material to the website as the final PDF as soon as it has cleared peer-review and editorial processes. Issues will be published quarterly, with additional special editions and articles as required. The Journal is run on a not-for-profit basis, with editorial staff operating on a voluntary basis without monetary reimbursement.
Critical Care Horizons is aligned with the altruistic ethos of the FOAMed movement, and affiliated with several of the leading critical care and emergency medicine blogs. We have an energetic editorial board, consisting of a deliberate mix of clinicians active in social media and world renowned academics. This is a journal for the critical care community, by the critical care community, without access impediment or financial bias. This is your journal. We hope you will enjoy the content, get involved in the discussions available with each article, and, by publishing with us, share your thoughts and opinions with the world.
With this, we issue a call for both papers and peer reviewers. Neither finance nor profile will be an impedement to publication. The only barrier is you - your willingness to commit time to write and your ability to produce an engaging, skillfully written manuscript. If you have something interesting to say, but feel locked outside the traditional publishing environment, this is your opportunity. If you are an inexperienced author, please enlist the help of an experienced colleague, as formal scientific writing is a skill to be mastered. If you have an idea for a themed issue, and would like to act as a guest editor, please contact the editor-in-chief. Further affilitations from similar altruistic bodies and websites are welcome. The first articles will be published on January 1st 2015.
Join us on an amazing journey.
 

Rob Mac Sweeney - Editor-in-Chief

]]>
Scott D. Weingart, MD clean 4:32
EMCrit Wee – Rob Mac Sweeney on Intra-Arrest Meds https://emcrit.org/emcrit/rob-mac-sweeney/ Tue, 10 Jun 2014 18:28:46 +0000 http://emcrit.org/?p=9471 Rob Mac Sweeny on the Intra-Arrest Talk Rob Mac Sweeny on the Intra-Arrest Talk

Rob Mac Sweeney is an anaesthetist-intensive care doc. His gig is evidence: analysis, assimilation, and dissemination. Tomorrow, you'll hear a ton more about the great stuff he does on sites such as Critical Care Reviews. For today, we discuss the topics raised in my recent posting of my SMACC Intra-Arrest Talk.

 ]]>
Scott D. Weingart, MD clean 16:40
Mind of the Resuscitationist – Errors of Commission and Omission https://emcrit.org/emcrit/motr-commission-and-omission/ Fri, 06 Jun 2014 18:20:58 +0000 http://emcrit.org/?p=9389 Should we err towards errors of commission or omission? Should we err towards errors of commission or omission?

I received an email from a friend and colleague on how to build mental toughness in our trainees. After hearing the case that spurred the question, I actually began to believe the problem is actually one of self-granted permission to act and the conflict between erros of commission and errors of omission.
Recommended Reading/Listening

* Combating omission errors through task analysis and good reminders
* Rick Body has a great post on the silliness of the interpretation that, "First, do no harm," should inspire passivity
* Casey Parker could not be restrained by words in the comment section so he recorded his response discussing the 2 modes of a part-time resuscitationist

Listen to the wee to understand what the frack I am talking about...]]>
Scott D. Weingart, MD clean 5:22
Podcast 125 – The New Intra-Arrest (Cardiac Arrest Management) https://emcrit.org/emcrit/new-intra-arrest/ Mon, 02 Jun 2014 15:59:28 +0000 http://emcrit.org/?p=9246 Enough with cook book medicine and courses for dermatologists--let's provide cutting edge intra-arrest care Enough with cook book medicine and courses for dermatologists--let's provide cutting edge intra-arrest care

Here's my first lecture from SMACCgold: The New Intra-Arrest. It generated a bit of controversy amongst my critical care friends, so we'll be discussing various parts in more detail in the coming weeks.
Best Article of Arrest Physiology
Physio of Cardiopulmonary Resuscitation (Anesth and Analg 2016;122(3):767)
Pitches

* Please, please sign up for EMCrit CME

 Links and References

* See this EMCrit Podcast on Hemodynamic Dosing of EPI
* The Music to Code By Compilation
* Waveform ETCO2 is the only way to confirm tube placement during a code (Anaesthesia 2011;66:1183)
* Max Harry Weil’s Disease-a-Month on CPR
* Steve Smith has the references for PCI during arrest in this ECG Blog Post
* Vent Settings for Arrest: Volume AC, Vt 500, Peak Flow 30 lpm, RR 10, PEEP 0, FiO2 100%, Pressure limit 100 cm H20
* EDECMO.org
* Eliminate the Peri-Shock Pause--it is crucial (Resuscitation. 2014 Mar;85(3):336-42.)
* See the Slides Below for all the rest of the references

VSE Stuff
JAMA 2013;310(3):270

1 mg Epi and 20 IU Vasopressin Q3 minutes for 5 cycles, plus 40mg methylprednisolone for the 1st cycle. Hydrocortisone if in persistent shock

Journal Club Crit Care 2014;18:308
Why Epi and not Phenylephrine
From MH Weil's Article Above:
Adrenergic agents with predominant a2 effect have been shown to be more effective as vasoconstrictor drugs, presumably because extrajunctional a2-receptors are more accessible to circulating catecholamines than postjunctional a1-receptors. This may explain why adrenergic amines that have predominant a1 actions such as methoxamine (Vasoxyl) and phenylephrine (Neo-Synephrine) are less effective than epinephrine after prolonged cardiac arrest.
Mechanical CPR
LUCAS seems equivalent to excellent manual compressions (from ResusMe)
Cardiac Arrest: To the cath lab with ongoing chest compressions?
Steve Smith has a great post on the topic with a ton of evidence

Consider Dual-Shock for Non-Converting VF/VT
Charles Bruen has a great post with the evidence

Esmolol
Beta-blockade should be considered in all patients with RVF in the ED prior to cessation of resuscitative efforts.

The Slides

Now on to the Podcast...
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Scott D. Weingart, MD clean 21:11
EMCrit Wee – Cricolol by Dr. John Hinds https://emcrit.org/emcrit/cricolol/ Wed, 28 May 2014 15:29:42 +0000 http://emcrit.org/?p=9170 My favorite part of SMACCgold; buy some Cricolol My favorite part of SMACCgold; buy some Cricolol

John Hinds, Critical Care and Irish Road Racing Doc, gave my absolute favorite lecture from SMACCgold. It was the con side of a debate on Cricoid Pressure for Emergency Airway Management. Well, it was actually a rep pitch for a new drug called Cricolol. You will enjoy it!

Here is the conference write-up version in ACEP Now

Note: This is a remixed version from the one up on Intensive Care Network (love those guys!), so watch it again...


Update
Ideal Cricoid Pressure Is Biomechanically Impossible During Laryngoscopy.  Acad Emerg Med. 2017 Sep 28. doi: 10.1111/acem.13326. [Epub ahead of print]
References

* Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet 1961;2:404-6.
* Koziol CA, Cuddeford JD, Moos DD. Assessing the force generated with application of cricoid pressure. AORN journal 2000;72:1018-28, 30.
* Smith KJ, Dobranowski J, Yip G, Dauphin A, Choi PT. Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging. Anesthesiology 2003;99:60-4.
* Hartsilver EL, Vanner RG. Airway obstruction with cricoid pressure. Anaesthesia 2000;55:208-11.
* Allman KG. The effect of cricoid pressure application on airway patency. Journal of clinical anesthesia 1995;7:197-9.
* Levitan RM, Kinkle WC, Levin WJ, Everett WW. Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy. Annals of emergency medicine 2006;47:548-55.
* Garrard A, Campbell AE, Turley A, Hall JE. The effect of mechanically-induced cricoid force on lower oesophageal sphincter pressure in anaesthetised patients. Anaesthesia 2004;59:435-9.
* Chassard D, Tournadre JP, Berrada KR, Bouletreau P. Cricoid pressure decreases lower oesophageal sphincter tone in anaesthetized pigs. Canadian journal of anaesthesia = Journal canadien d'anesthesie 1996;43:414-7.
* Heath KJ, Palmer M, Fletcher SJ. Fracture of the cricoid cartilage after Sellick's manoeuvre. British journal of anaesthesia 1996;76:877-8.
* Ralph SJ, Wareham CA. Rupture of the oesophagus during cricoid pressure. Anaesthesia 1991;46:40-1.

 ]]>
Scott D. Weingart, MD clean 8:36
Podcast 124 – The Logistics of Proning for ARDS https://emcrit.org/emcrit/logistics-proning/ Mon, 19 May 2014 00:10:08 +0000 http://emcrit.org/?p=8001 Proning is one of the only evidence-based techniques to affect the mortality of ARDS patients. I've been wanting to do an episode on proning for a while. Proning is one of the only evidence-based techniques to affect the mortality of ARDS patients. I've been wanting to do an episode on proning for a while.

Proning is one of the only evidence-based techniques to affect the mortality of ARDS patients. I've been wanting to do an episode on proning for a while. Serendipitously, Joseph Tonna recently published a piece on the topic in the ACEP Critical Care Section Newsletter. Dr. Tonna is a fellow in Anesthesia Critical Care at the University of Washington. He recently did a rotation on a refractory ARDs unit (read about all of his experiences below) and learned the way they prone. We discuss it on the podcast today.
ResusReview's Checklist
Proning Checklist
Article on the Physiology of Proning
Eur Resp J 2002;20(4):1017
Meta-Analysis of RCTs on Proning
Crit Care Med 2014;42(5):1252
LITFL's CCC Entry on Proning
Lots of good stuff here
Video on Proning from the Guerin Study

Here is the Dr. Tonna's Original Piece:
Prone Positioning: An experience of actually doing it
by Joseph E. Tonna, MD, Associate Newsletter Editor. This piece was originally published in the ACEP Critical Care Section Newsletter

 

Most intensivists have read Guérin’s 2013 NEJM study on the mortality benefit of prone positioning. Previous studies [1,2] have established that dorsal consolidations improve when the patient is placed prone. Taken together, the practice of prone positioning in select patients makes sense. Despite this, I haven’t found that it is done as often as one might infer from the robustness of its benefit in this study or others. In my experience, while we are likely to notice the profound dorsal pulmonary consolidations on our patient’s CT scans, we don’t take the next step and actually prone the patient until we have already progressed further down the path towards worsening hypoxemia—often only when the pO2/FiO2 ratio is well below 150 on upwards of 70% FiO2. At this stage, we begin to consider the patient “refractory” and allow ourselves to begin the intellectual path of discussing the evidence for and risk/benefit or cost/benefit of therapies like inhaled nitric oxide (iNO), epoprostenol, prone positioning, high frequency ventilation, paralysis or extracorporeal membrane oxygenation (ECMO). The evidence for many of these therapies is thin at best, and given how infrequently we reach these states of worsening refractory hypoxemia, and gain personal experience with implementing them, many newly trained intensivists will finish training having managed no more than a handful of patients on these therapies. As we all know, increased volume leads to increased comfort and competence; so as part of my fellowship training, I wanted to know what it looked like to routinely implement these therapies. Did they work? What did this process actually look like?



I had the opportunity recently to train at Legacy Emanuel Medical Center in Portland, OR at the Randall & Emanuel Severe Cardiopulmonary Failure and ECMO (RESCUE) Center under two talented surgical intensivists, Drs. Andrew Michaels and Sandra Wanek. Patients brought to this unit have already failed conventional therapies for hypoxemic respiratory failure, and often already have a P/F of <100 on 80-100% FiO2. These patients have not only failed excellent critical care, but most have failed alternative therapies such as airway pressure release ventilation (APRV), iNO, or paralysis. Among the therapies implemented the RESCUE center for this subset of patients, prone positioning is routine.
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Scott D. Weingart, MD clean 23:21
EMCrit Wee – Sean Townsend of the SSC and the ProCESS Trial https://emcrit.org/emcrit/ssc-process-trial-response/ Fri, 09 May 2014 19:36:30 +0000 http://emcrit.org/?p=8239 I talk with a member of the surviving sepsis campaign steering committee re: ProCESS I talk with a member of the surviving sepsis campaign steering committee re: ProCESS

Recently, I got to talk to Sean Townsend, MD; a critical care doc and a member of the Surviving Sepsis Campaign (SSC) steering committee. The spark for this conversation was the recent SSC response to the ProCESS trial (read below) as well as the elimination of CVP and ScvO2 from the National Quality Forum (NQF) sepsis bundle.

* Harmonization Paper that Dr. Townsend Mentioned (Intensive Care Med. 2013 Oct;39(10):1760-75.)
* Definitely read this editorial on legislating sepsis care
* Here is the SSC response to ProCESS:

Surviving Sepsis Campaign Responds to ProCESS Trial
The Surviving Sepsis Campaign (SSC) has received many inquiries regarding the recent publication of the Protocol-Based Care for Early Septic Shock (ProCESS) trial’s effect on the continuing activities of the Campaign.

* The ProCESS trial reflects the consensus that early diagnosis of septic shock is essential. Notably, all groups in the study received on average more than 2 liters of fluid prior to randomization and more than 75% received antibiotics prior to randomization--both elements of the 3-hour Surviving Sepsis Campaign bundle. (2) The editorial accompanying the ProCESS study highlights these points. (3)
* The 18% mortality rate in the “usual care” arm of ProCESS illustrates a dramatic change in the management and outcomes of patients with septic shock. (1) In comparison, septic shock mortality was 46.5% in the 2001 early goal-directed therapy trial by Rivers. (4) Given that 70% of the hospitals in ProCESS had some form of “sepsis protocol,” we believe this mortality rate demonstrates the success of the SSC in increasing awareness and attention to the challenge of early identification and management of these vulnerable patients.
* Given the remarkably low mortality rate in the control arm of ProCESS, the existence of sepsis protocols in the majority of participating study institutions, and the pending results of 2 large ongoing trials (the Australian Resuscitation In Sepsis Evaluation Randomised Controlled Trial [ARISE] and The Protocolised Management in Sepsis Trial [ProMISe]), the SSC has no plans to revise the bundles or National Quality Forum (NQF)-endorsed measures at this time.
* ProCESS does not address the protocolized management of patients with severe sepsis without septic shock, a group of patients for whom early detection and treatment remain critical. The aggressive protocolized management of these patients who do not yet have shock has likely lowered severe sepsis and septic shock mortality since the inception of the SSC. The recently formed Society of Critical Care Medicine/Society of Hospital Medicine (SCCM/SHM) Early Diagnosis and Treatment of Severe Sepsis on the Hospital Floors Collaboratives will focus in large part on this population. Further, the ProCESS results have no impact on the 3-hour bundle, which is the primary focus for the Collaboratives.
* Regarding the SSC 6-hour bundle:



* A companion paper appears to support a mean arterial pressure (MAP) target of 65 mm Hg, which is one of the indicators in this bundle. (5)
* The ProCESS paper does not address repeating lactate measures in patients with elevated lactate while literature supports doing so. (6,7)
* The majority of the patients in the usual care (56.5%) and protocol-based standard care arms (57.9%) of ProCESS had central lines inserted as part of clinical care. (1) The 6-hour bundle asks only that central venous pressure (CVP) be measured and that a venous blood gas be sent fr...]]>
Scott D. Weingart, MD clean 17:33
Podcast 123 – Selective Aortic Arch Perfusion (SAAP) with Jim Manning https://emcrit.org/emcrit/selective-aortic-arch-perfusion/ Tue, 06 May 2014 14:50:06 +0000 http://emcrit.org/?p=8441 What if you had a REBOA catheter through which you could give blood and drugs? What if you had a REBOA catheter through which you could give blood and drugs?
Jim Manning, MD has been working on these issues for over two decades in his lab in North Carolina. This may very well be the future of CPR for medical and traumatic arrests.

Here are Dr. Manning's Disclosures: Inventor on patents for the Selective Aortic Arch Perfusion technology that are assigned to the University of North Carolina at Chapel Hill; Co-Founder of Resusitech, Inc., a medical device company developing invasive resuscitation technologies.
Selective Aortic Arch Perfusion
 



The following slide shows where SAAP may fit in with the other therapies for cardiac arrest:



And this one shows a possible progression during arrest:


Update: Want More?
Jim gave a lecture for GSA HEMS that is fantastic!
What do you think? Comment Below.
Now on to the Podcast...]]>
Scott D. Weingart, MD clean 28:31
EMCrit Wee – A Cric Case with Rob Bryant https://emcrit.org/emcrit/cric-case-rob-bryant/ Thu, 24 Apr 2014 23:07:14 +0000 http://emcrit.org/?p=8147 Rob Bryant presents a case Rob Bryant presents a case
The Case:
Rob got permission to share:

INITIAL PRESENTATION:

30 year old male with past history of SCC of the tongue at age 14 who presented with cough, and dyspnea with concerns for recurrent pneumonia. He was still on antibiotics and steroids after a recent hospitalization for pneumonia.

His cancer recovery was hampered by osteo-radio-necrosis of his jaw, and he was left with a scarred larynx, baseline trismus with incisor to incisor distance of <2cm, and some thickening of the anterior neck tissues. He had a G-tube for feeding.

He had normal room air sats, no stridor, productive cough and no fever. Chest Xray was normal, and he was considered safe to go home and follow up with his pulmonologist the next day. The family was nervous about going home so he was observed overnight in the ED.

A very specific discussion was has with the patient regarding the challenges emergent management of his airway would represent:

“I love to manage airways, but your airway scares me, and I would never want to be the one to intubate you”

“If you have an airway emergency on the floor, it would take longer for someone to cric you than if you had an airway emergency at home, and had to present via ems and have a surgical airway performed in the ED”

He was discharged from the ED the next morning with some racemic Epi to try at home.

 

RE-PRESENTATION:

He represented 4 days later in respiratory distress with 36 hours of ‘anxiety’ symptoms that had not been helped by escalating doses of benzodiazepines.

No fever, no cough, very hoarse voice at home.

 

HR 140, BP 160/110, RR 29. Sats 86% RA, 98% 15L NRB

ETCO2 84.

 

Altered, sweaty, moving minimal air, and non verbal with significant stridor.

Initial interventions:

Racemic epi nebs,

125mg solumedrol iv

Glycopyrollate 0.2 mg iv.

Lido 4% neb.

 

VBG: pH 7.17, pCO2 104.

 

Anesthesia was called for Awake FiberOptic Intubation (AFOI) if a trial of BiPAP failed. Due to concerns that NIV could worsen his laryngeal irritation, or that giving Ketamine to help him tolerate the BiPAP could cause laryngospasm (est 1:200 risk) BiPAP was not started until anesthesia was present and ready to perform AFOI.

 

Anesthesia presented promptly and agreed with AFOI plan after BiPAP.

Beside table was set up with 4x4’s with betadine, trach (6.0mm), pocket bougie, and #10 blade scalpel, and gloves. Lido 1% w epi was prepared.

Pt kept at 20 degrees HOB elevation, NC at 15L, then BiPAP at 15/5 was started with no decrease in his work of breathing.

 

3 AFOI attempts were made, with each attempt aborted once sats hit 90%, the patient was hard to bag due to laryngeal stenosis, but with assisted spontaneous ventilations additional attempts were considered appropriate.

The neck was palpated, and prepped prior to first AFOI, and injected w lido w epi after 2nd AFOI.

3rd AFOI was with glidescope assist. Glidescope could barely fit into the mouth, and there were no obviously recongnizable laryngeal structures.

During 3rd AFOI cricothyroid membrane was punctured with 27g needle on the Lidocaine with epi syringe and air was aspirated to confirm location.

The patient received 1mg per kg Ketamine iv prior to incision for cricothyrotomy.

With sats of 92%, a midline 3cm incision made, then horizontal incision 1.]]>
Scott D. Weingart, MD clean 12:12
Podcast 122 – Cardiac Arrest after the Toxicology of Smoke Inhalation with Lewis Nelson https://emcrit.org/emcrit/cardiac-arrest-after-smoke-inhalation/ Mon, 21 Apr 2014 02:46:07 +0000 http://emcrit.org/?p=8131 What is the proper care for a patient in cardiac arrest or shock after smoke inhalation if they don't have severe burns? What is the proper care for a patient in cardiac arrest or shock after smoke inhalation if they don't have severe burns?

We had a case a few months ago at Janus General--very sad and very scary. The patient came in after a house fire. He had some burns, but not enough to be the cause of his arrest. Instead, it had to be the asphyxia and possible toxicology of the smoke inhalation. I wanted to get a better idea of ideal care for these patients; for that I needed a toxicologist.

Few tox folks are smarter than Lewis Nelson, MD of the NYC Poison Center.

Note: In this episode we don't deal with the thermal injury of smoke inhalation
Cyanide Toxicity

* Empiric administration of  Hydroxocobalamin 5 g rapid IV drip x 1
* Even better if this can be given at the scene as soon as the patient arrests or is profoundly hypotensive
* Messes with labs that use colorimetric probes (cooximetry, lactate, LFTs, etc.) Get blood for cooximetry before giving the med if at all possible
* Dr. Nelson doesn't recommend giving sodium thiosulfate in addition to the Hydroxocobalamin
* An IM version is in the pipeline--this will be easier for EMS/emergency use




Carbon Monoxide

* Put the patient on 100% fiO2
* Not much to do beyond that until the patient stabilizes
* See LITFL for more on CO

Methemoglobinemia

* Caused by Hb oxidation from the heat of the fire
* Administer Methylene Blue 2 mg/kg x 1 IVP
* May be worthwhile to start a drip if patient has resistant hypotension, but this is an unproven therapy

Now on to the Podcast...]]>
Scott D. Weingart, MD clean 18:01
EMCrit Podcast 121 – REBOA https://emcrit.org/emcrit/reboa/ Sun, 06 Apr 2014 19:05:12 +0000 http://emcrit.org/?p=7061 This episode, we discuss REBOA (resuscitative endovascular balloon occlusion of the aorta). This episode, we discuss REBOA (resuscitative endovascular balloon occlusion of the aorta).

Today, I got to interview one of the superstars at Shock Trauma on REBOA (resuscitative endovascular balloon occlusion of the aorta).

Balloon occlusion of the aorta was first described in 1954 (Surgery 1954;36(1):65). Other older articles include (Ann Emerg Med 1986;15(12):1466, J Endovasc Ther 2000;7(1):1, Endovasc Ther 2005;12(5):556).
The Shock Trauma Center (STC) Approach to REBOA
Gain Access to the Common Femoral Artery with Femoral A-line Kit

* Just like normal, except make sure you are hitting common femoral and not superficial femoral artery. The point of entry should be 2cm below inguinal ligament (estimate ligament by anterior superior iliac to pubic tubercle). This may be much higher than you are used to.
* Use either 18 arterial line set or Cook 5f Central Venous Cath (G02070)

Float the Wire

* STC uses Boston Scientific Amplatz superstiff wires (0.035in/260 cm/straight floppy tip)
* Measure externally from the catheter to the level of the 2nd rib--mark this level on the wire (At STC, they use Avery 5422 stickers)
* Advance the wire floppy-end first to the marked depth
* Confirm location with either radiograph or fluoro before proceeding
* Mark the proximal end of the wire with a pen on the sterile drape

Place the Sheath

* At STC, they use a Check-Flo Performer Introducer (12 fr, 30cm)
* Remove the femoral artery catheter
* Measure the introducer externally from groin to just below the umbilicus (make sure you are measuring the catheter, not the dilator). Mark with a sticker
* In some cases, you need to dilate the vessel to accept the introducer; in most cases the internal dilator is sufficient
* Place the introducer to the previously marked level
* Critical Move: Removal of the dilator can screw everything up. The operator should lock the sideport of the dilator between their fingers and grip tight and with the other hand, hold the wire proximally. Allow assistant to pin and pull the dilator. If they mess up, you are still controlling the sheath and the wire. If some of the wire gets pulled, have your assistant reinsert without you letting go of sheath or wire.

Place the Coda Catheter/Balloon

* Grab a CODA balloon catheter (32 mm-balloon)
* Measure externally; Zone 1 is measured to the xiphoid, Zone 3 is measured to just above the umbilicus. Measure at the proximal portion of the balloon



 

* Remove all air from the balloon using saline syringe
* Insert the CODA catheter
* The wire stays stationary throughout

Inflate the Balloon

* Use a 30 ml syringe, ideally filled with 20 ml of NS and 10 ml of omnipaque (lohexol); use just saline if contrast not available
* Inflate until resistance goes to moderate (would love to know what luminal pressure this corresponds to). In general, this corresponds to 12-22 mls depending on the size of the aorta--but this must be individualized to the patient. The actual infaltion is far harder than you may think. For me, it is the maximal force I can apply with 1 hand.

Secure Everything for Transport

* Here's how they do it at STC



* Mark the levels of everything so you can verify there has been no migration

Get an Xray when time allows



Go to Definitive Management

* The introducer sheath will need to be removed under direct observation after cutdown,]]>
Scott D. Weingart, MD clean 20:31
Podcast 120 – The ProCESS Trial with Derek Angus https://emcrit.org/emcrit/process-trial/ Mon, 24 Mar 2014 23:55:24 +0000 http://emcrit.org/?p=7717 I speak to the lead author of the ProCESS trial, Dr. Derek Angus I speak to the lead author of the ProCESS trial, Dr. Derek Angus

The ProCESS trial was published less than a week ago (The night before my SMACC lecture on severe sepsis--dohhh!)

If you have no idea what I'm talking about, climb down from your mountain-top monastery, find a damn iphone and read this:

ProCESS Trial in the NEJM

As soon as I returned to the states, I begged and pleaded with the study author, Dr. Derek Angus, to give us his thoughts, he kindly acceded.

Dr. Angus is chair of the Department of Critical Care Medicine and Distinguished Professor and Mitchell P. Fink Endowed Chair of Critical Care Medicine at the University of Pittsburgh Schools of the Health Sciences and UPMC Health System. His accomplishments are too numerous to list here, so check out his bio page.

I will be adding a ton of stuff to this page regarding the trial ASAP; for now I just wanted to get Dr. Angus's interview up on the site.
Most Important Table


 
Other Stuff Mentioned
Supplementary Material for ProCESS (this is the corrected version)

High versus Low Blood-Pressure Target in Patients with Septic Shock
Excellent Posts in the FOAMcc World

* From ResusMe
* From ALIEM
* From PulmCCM
* From St Emlyn's

Now on to the Podcast...]]>
Scott D. Weingart, MD clean 25:35
Wee – What the heck is a Mapleson B Circuit and Why You Probably Shouldn’t Care https://emcrit.org/emcrit/what-the-heck-is-a-mapleson-b-circuitu-probably-shouldnt-care/ Tue, 11 Mar 2014 21:47:14 +0000 http://emcrit.org/?p=6781 There is a really smart anesthesiologist out there called Nicholas Chrimes. He along with his mate Peter Fritz invented the Vortex Approach to Airway Management. He also runs a blog called Clinical CrEd. He did a post advocating the Mapleson B Circuit as the Ultimate Preox Device What is the Mapleson B? The Mapleson circuits were used for anesthetics in the good old days. At least in the US, we have move to bigger, and arguably better designs for our operative patients. Many would have thought this device would have been consigned to the trash heap, but seemingly not. My Recommended Approaches I recommend two approaches to preox: standard and shunt physiology strategies. I outlines these strategies in the paper Rich Levitan and I wrote. Standard: NRB @ >=15 lpm and NC @ 10-15 lpm for 3 minutes Shunt Physio: Choose 1 BVM with PEEP Valve & NC @ 10-15 lpm NIPPV Ventilator with NIPPV Mask or BVM Mask & NC @ 10-15 lpm Nick makes a number of arguments as to the superiority of the Mapleson circuit over these standard techniques. His points are excellent, but I disagree with pretty much all of them--I think it becomes a question of perspective. Automatic Checking Yes, using the same device for reox and preox makes sure the reox device is there and hooked up, but this for me is an inadequate argument to dispense with NRB/NC set-up. Multiple BVM Masks We don't have these readily available in any ED or ICU I've worked in. We have neonate, peds, and adult. Our masks also are not inflatable. PEEP PEEP is good, Mapleson may or may not be a good way to provide this for the reasons I've mentioned in the wee, but a BVM with a PEEP valve or a vent are at least as good. ApOx Mapleson may provide this better than BVM, but not as well as a NC, which should be on during any intubation. ETCO2 No advantage of Mapleson Low resistance Maybe this matters, as soon as you put on the PEEP, I can't imagine this difference persisting Room Air Entrainment Release your seal for even one breath and you have blown denitrogenation. Always, always use a strapped system if possible=NRB/NC, NIV mask, or BVM mask with OR straps. Troubleshooting Leaks This is the real area in which Nick and I differ. Nick makes the point that a good seal in preox guarantees a good seal in reox--this may be true, but it is unimportant. What I care about is does a bad, one-handed seal in preox mean I won't be able to reox with the BVM--this is entirely untrue. If I did to an awake patient what I will do to them when asleep and desaturating, they would, quite rightfully, punch me in the face. Anesthesiologists should use Mapleson B/C; ED/ICU should only use BVM +/- PEEP Valve with two hands and oral airway and a rocking triple maneuver (that no pt should experience if they are conscious) otherwise they should be NIV mask with straps or (BVM mask with straps). This is the same reason I tell my residents to just train with Macintosh blades. Primary and secondary leaks are the main thrust of Nick's love for the old-timey circuits. But all of us have appreciated this easily by squeezing the bag-valve-mask: Easy-squeezy or Hard Squeezy ETCO2 with a monitor you can see Is he holding or squeezing? I can feel compliance with a BVM if I squeezed it, but I don't unless the pt needs it during reox. But are they squeezing the Mapleson? If they are, they may be doing damage. This study (Anesthesiology 2014;120:326) talks about the myths of Gentle Facemask Ventilation: >15 cmH20 may be entraining gas into the stomach via the LES (in some patients, even 10 cmH20 may be a problem) UES will withstand at least 20 cmH20 until NMB at which point again 15 seems to be the number (The latter is why we don't bag during apnea unless we have to) Two hands ALWAYS on the mask Recently, I spent 2 weeks intubating 10-15 patients per day. One hand mask skills got better and better--all for naught. Train how you want to Fight Hands free There is a really smart anesthesiologist out there called Nicholas Chrimes. He along with his mate Peter Fritz invented the Vortex Approach to Airway Management. He also runs a blog called Clinical CrEd. -

There is a really smart anesthesiologist out there called Nicholas Chrimes. He along with his mate Peter Fritz invented the Vortex Approach to Airway Management. He also runs a blog called Clinical CrEd.

He did a post advocating the Mapleson B Circuit as the Ultimate Preox Device

What is the Mapleson B? The Mapleson circuits were used for anesthetics in the good old days. At least in the US, we have move to bigger, and arguably better designs for our operative patients. Many would have thought this device would have been consigned to the trash heap, but seemingly not.




My Recommended Approaches
I recommend two approaches to preox: standard and shunt physiology strategies. I outlines these strategies in the paper Rich Levitan and I wrote.

Standard: NRB @ >=15 lpm and NC @ 10-15 lpm for 3 minutes

Shunt Physio: Choose 1

* BVM with PEEP Valve & NC @ 10-15 lpm
* NIPPV Ventilator with NIPPV Mask or BVM Mask & NC @ 10-15 lpm

Nick makes a number of arguments as to the superiority of the Mapleson circuit over these standard techniques. His points are excellent, but I disagree with pretty much all of them--I think it becomes a question of perspective.
Automatic Checking
Yes, using the same device for reox and preox makes sure the reox device is there and hooked up, but this for me is an inadequate argument to dispense with NRB/NC set-up.
Multiple BVM Masks
We don't have these readily available in any ED or ICU I've worked in. We have neonate, peds, and adult. Our masks also are not inflatable.
PEEP
PEEP is good, Mapleson may or may not be a good way to provide this for the reasons I've mentioned in the wee, but a BVM with a PEEP valve or a vent are at least as good.
ApOx
Mapleson may provide this better than BVM, but not as well as a NC, which should be on during any intubation.
ETCO2
No advantage of Mapleson
Low resistance
Maybe this matters, as soon as you put on the PEEP, I can't imagine this difference persisting
Room Air Entrainment
Release your seal for even one breath and you have blown denitrogenation. Always, always use a strapped system if possible=NRB/NC, NIV mask, or BVM mask with OR straps.
Troubleshooting Leaks
This is the real area in which Nick and I differ. Nick makes the point that a good seal in preox guarantees a good seal in reox--this may be true, but it is unimportant. What I care about is does a bad, one-handed seal in preox mean I won't be able to reox with the BVM--this is entirely untrue. If I did to an awake patient what I will do to them when asleep and desaturating, they would, quite rightfully, punch me in the face.

Anesthesiologists should use Mapleson B/C; ED/ICU should only use BVM +/- PEEP Valve with two hands and oral airway and a rocking triple maneuver (that no pt should experience if they are conscious) otherwise they should be NIV mask with straps or (BVM mask with straps).

This is the same reason I tell my residents to just train with Macintosh blades.

Primary and secondary leaks are the main thrust of Nick's love for the old-timey circuits. But all of us have appreciated this easily by squeezing the bag-valve-mask: Easy-squeezy or Hard Squeezy

ETCO2 with a monitor you can see
Is he holding or squeezing?
I can feel compliance with a BVM if I squeezed it, but I don't unless the pt needs it during reox. But are they squeezing the Mapleson? If they are,]]>
Scott D. Weingart, MD clean 19:11
Podcast 119 – Rich Levitan on the Surgical Airway https://emcrit.org/emcrit/levitan-surgical-airway/ Mon, 10 Mar 2014 16:50:49 +0000 http://emcrit.org/?p=7174 Rich Levitan on Surgical Airway from EMCrit/ISMMS 2014 Conference Rich Levitan on Surgical Airway from EMCrit/ISMMS 2014 Conference

My friend and all-around incredible guy, Rich Levitan, speaking on the Surgical Airway.
Update:
1. See here for the EMCrit take on Surgical Airway

2. Subsequent to publication of the podcast, Rich Levitan received this letter:
Rich,

I met you about 4 years ago and we had talked about airway training as you can see in the email below. First off I would like to thank you for your presentation at SOMA (or SOMSA) 2013. It was enlightening for me and I appreciated the discussion.

I am writing you about an airway lecture that you gave in a 2014 conference which was subsequently posted on EMCrit as podcast 119. Although the lecture was excellent, I would like to bring two small inconsistencies about the video portion to your attention:

1)      Just for the sake of clarity, the soldiers featured in the video were actually from the 101st airborne, which is a conventional airborne unit staged out of Ft Campbell KY and they were performing operations in Afghanistan. These are not Special Forces soldiers and in fact, are not affiliated with Special Operations at all. The medics in the video received entry level medical training at Ft Sam Houston, home to AMMED. The scope of their training is relatively narrow in comparison to that of the Special Operations Medic.

The majority of Special Operations medics are more familiar with the cricothyrotomy procedure and are competent/confident enough to perform it when the injury pattern dictates the need. In fact, the majority of the cricothyrotomies performed at the point of injury, in combat, are performed by SOF Medics and not by conventional medics. This is not to take away from the amazing work that Dr Bob Mabry has done with the entry level training at Ft Sam.

2)      The injured soldier in the video is actually an Afghan soldier working alongside American Troops. This is not one of their buddies. This is not to say that bonds never get formed between American Troops and the members of the local population because they certainly do, but a safe assumption here might be that the provider and the casualty do not even know each other’s names.

I don’t know why I am so compelled to address this, maybe it is a little bit of foolish pride in my Special Forces lineage but nevertheless being a man of science I am sure you desire the same level of accuracy in medicine as you do in all things.

Thank you again for all the support, hard work and passion you bring to emergency medicine!
 
Rich Levitan's New Advanced Airway and Endoscopy Course
http://www.ceme.org/advanced-airway-endoscopy-course
Now on to the Vodcast...
]]>
Scott D. Weingart, MD clean 26:45
Podcast 118 – EMCrit Book Club – On Combat by Dave Grossman https://emcrit.org/emcrit/emcrit-book-club-on-combat-by-grossman/ Sun, 23 Feb 2014 15:00:28 +0000 http://emcrit.org/?p=6686 Cliff Reid joins me for the 1st EMCrit book club on the book, On Combat by Dave Grossman Cliff Reid joins me for the 1st EMCrit book club on the book, On Combat by Dave Grossman resus.me and the Rage Podcast. In the first ever EMCrit Book Club, we discuss a book I read years ago and recently reread:



On Combat by Dave Grossman has enormous relevance to resuscitationists. I feel the entire book is worth reading, but we zoned in on the really juicy bits.
Section I - Physiology of Combat
Chapter Two - Stress Responses to Combat
We briefly discuss bowel and bladder control as they relate to stress
Chapter Three - Sympathetic & Parasympathetic Responses
Parasympathetic backlash-a time of cognitive danger
"The moment of greatest vulnerability is the instant immediately after victory" --Napoleon
Adapt a 360 degree visual sweep for threats (keep looking at all of your patients vitals and remember to bag)

SWAT Team Acronym-L.A.C.E. liquids, ammunition, casualties, equipment; For us--check your team, immediate reset of resus bay, drink something, debrief

Burn off the adrenaline dump

Conflict with colleagues. Exercise, Punching Bags? If a horrible call is reported on the EMS phone, but never shows--run a sim to burn the epi.

Sleep Deprivation-Caffeine can be our friend, nicotine not so much. If you are too exhausted to perform, tell a colleague and take a nap.
Chapter Four - Colored Conditions
originally from Bruce Siddle, Sharpening the Warriors Edge

Heart rate and task performance: heart rates are a guide, getting there by exercise is not the same as by fear/stress, so HR is merely an associated marker
Yellow 90-120, Over 115 and fine motor skills performance degrades significantly
Red 120-150, a 145 HR seems to be the break-point for optimal performance of complex skills
Black >150 and badness ensues, (or >175 in the highly trained, they get a gray zone)

* Fine motor skills-precision tasks
* Gross Motor Skills-ape skills
* Complex-a combination of maneuvers or use of multiple body parts

SWAT team breaking down door function in condition red (or gray), but they have trained until the necessary tasks that require fine motor have been practiced till automaticity

Unified Model of Stress and Performance







 

We need to train how we fight
Stress Inoculation Training and (Academic Medicine 2009;84(10):S25)

We are currently wasting high fidelity simulation, it should purely be for stress training. Perhaps, we should create a hell week for our 2nd years.

Stay in yellow (alert, but with fine motor control) - yellow dot stickers to remind you
"I understand a fury in your words, but not the words" --Shakespeare from Othello
Tactical/combat breathing to stay in the color zone

Hicks' Law - procedures should only be learned one way-preflush central lines, one way to RSI.
Section 2 - Perceptual Distortions
Chapter 1 - Auditory exclusion and tunnel vision
tunnel vision - the toilet paper tube
Chapter 2 - Auto-pilot
What is drilled in during training comes out the other end in combat, no more no less
]]>
Scott D. Weingart, MD clean 34:42
Practical Evidence 014 – ACEP Procedural Sedation Update for 2013 https://emcrit.org/practicalevidence/acep-procedural-sedation-update-2013/ Tue, 18 Feb 2014 22:26:30 +0000 http://emcrit.org/?p=6812 This one is really good! This one is really good!
Here is the policy:
Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department
They addressed 4 questions:
1. In patients undergoing procedural sedation and analgesia in the emergency department, does preprocedural fasting demonstrate a reduction in the risk of emesis or aspiration?
Level B recommendations. Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia.
2. In patients undergoing procedural sedation and analgesia in the emergency department, does the routine use of capnography reduce the incidence of adverse respiratory events?
Level B recommendations. Capnography* may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone in patients undergoing procedural sedation and analgesia in the ED.
3. In patients undergoing procedural sedation and analgesia in the emergency department, what is the minimum number of personnel necessary to manage complications?
Level C recommendations. During procedural sedation and analgesia, a nurse or other qualified individual should be present for continuous monitoring of the patient, in addition to the provider performing the procedure. Physicians who are working or consulting in the ED should coordinate procedures requiring procedural sedation and analgesia with the ED staff.
4. In patients undergoing procedural sedation and analgesia in the emergency department, can ketamine, propofol, etomidate, dexmedetomidine, alfentanil, and remifentanil be safely administered?
Level A recommendations. Ketamine can be safely administered to children for procedural sedation and analgesia in the ED. Propofol can be safely administered to children and adults for procedural sedation and analgesia in the ED.
Level B recommendations. Etomidate can be safely administered to adults for procedural sedation and analgesia in the ED. A combination of propofol and ketamine can be safely administered to children and adults for procedural sedation and analgesia.
Level C recommendations. Ketamine can be safely administered to adults for procedural sedation and analgesia in the ED. Alfentanil can be safely administered to adults for procedural sedation and analgesia in the ED. Etomidate can be safely administered to children for procedural sedation and analgesia in the ED.

Tell me what you think in the comments
Now on to the Podcast...]]>
Scott D. Weingart, MD clean 8:42
Podcast 117 – Everyday Emergency Kits with Keith Conover https://emcrit.org/emcrit/everyday-emergency-kits-keith-conover/ Mon, 10 Feb 2014 16:09:36 +0000 http://emcrit.org/?p=5153 If you are an EM:RAP listener, you have probably heard Mel Herbert's story of 2 cars crashing right outside of his house. Mel realized he did not stock a medical kit in his house with the necessary crucial supplies for an emergency scene. I realized I don't either (there is one in my car). So, I reached out to the master of preparedness, Dr. Keith Conover. If you are an EM:RAP listener, you have probably heard Mel Herbert's story of 2 cars crashing right outside of his house. Mel realized he did not stock a medical kit in his house with the necessary crucial supplies for an emergency scene.

If you are an EM:RAP listener, you have probably heard Mel Herbert's story of 2 cars crashing right outside of his house. Mel realized he did not stock a medical kit in his house with the necessary crucial supplies for an emergency scene. I realized I don't either (there is one in my car). So, I reached out to the master of preparedness, Dr. Keith Conover.
Everyday Emergency Kit
We spend the 1st part of the show discussing the everyday kit which Dr. Conover has with him (or in eye shot) pretty much always. He carries it in a fanny pack--I'm not sure if I can be persuaded to do this, but you should probably keep a kit with at least these items in your car or house.

On the topic of fanny packs...



Well anyhooooo, here is the list


We also discussed the Daypack Medical Kit for your House/Car

* Daypack Med Kit

Digital Intubation

* Rich Levitan has an amazing article on the topic of Digital Intubation (Note: I can't find this online anymore so this is a Crashing Pt Copy)
* Here is an amazing entry on the Life in the Fast Lane CCC

Equipment we Discussed
Tourniquet


The CAT Tourniquet is the best one yet
Disposable Laryngoscopes for Kits

* Surescope
* Truphatek Trulite (This one folds up and is Rich Levitan's Rec)

Headlamp
I recommend the Zebralights, this is the one I use:



Zebralight H502W
SAM Splint


The SAM Splint is EMS standard stock
Trauma Bag
In his trunk, Dr. Conover has this prestocked trauma kit.
Pelvic Binder
Dr. Conover actually carries a pelvic binder in his trunk as well (no comment), he stocks the SAM II Pelvic Splint.
Other Crucial Links

* SAR Gear
* Wilderness Medical Kit
* Dr. Conover's Full File Repository

Stuff EMCrit Likes - The Anesthetic Crisis Manual
I reached out to the creator of the Anaesthetic (Anesthetic) Crisis Manual after I s...]]>
Scott D. Weingart, MD clean 30:42
Podcast 116 – the tPA for Ischemic Stroke Debate https://emcrit.org/emcrit/tpa-for-ischemic-stroke-debate/ Mon, 27 Jan 2014 15:30:02 +0000 http://emcrit.org/?p=6532 Dr. Andy Jagoda debates my friend Dr. Anand Swaminathan on the use of tPA for Ischemic Stroke in the Emergency Department Dr. Andy Jagoda debates my friend Dr. Anand Swaminathan on the use of tPA for Ischemic Stroke in the Emergency Department

Here is one of my favorite segments from the 2014 EMCrit/ISMMS Conference. My chair Dr. Andy Jagoda debates my friend Dr. Anand Swaminathan.

The debate seemed relevant because ACEP, a major US emergency medicine organization, released clinical guidelines markedly increasing stress on thrombolysing stroke. These clinical guidelines were sent back by ACEP's council for further commentary and assessment, a move unprecedented in the history of the organization.

ACEP Clinical Guidelines from 2013
Pro Side
Dr. Jagoda took the Pro stance.

Here are his slides
Con Side
Dr. Swaminathan took the con stance. Check out his site, EM Lyceum for more FOAM goodness.

Here is his slideset
Now on to the Podcast...
]]>
Scott D. Weingart, MD clean 52:21
Podcast 115 – A New Paradigm for Post-Intubation Pain, Agitation, and Delirium (PAD) https://emcrit.org/emcrit/post-intubation-sedation-2014/ Mon, 13 Jan 2014 21:00:48 +0000 http://emcrit.org/?p=4297 What you do in the ED for post-intubation sedation will determine whether your patient lives or dies What you do in the ED for post-intubation sedation will determine whether your patient lives or dies
All the way back on Podcast 21, I advocated for better post-intubation sedation in the ED. Well, now it turns out that if you are still using just lorazepam and vecuronium you are now even further from the ideal.
It is all about Sleep and Orientation
Bad sedation strategies destroy sleep architecture and orientation, then patients become crazy.
Delirium=Death

* The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med 2001; 27:1892–1900
* Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291:1753–1762
* Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med 2009; 35:1276–1280
* Delirium leads to long-term cognitive impairment (N Engl J Med 2013; 369:1306-1316) HT to @icudelirium
* Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med 2009; 180:1092–1097
* Deep sedation associated with higher mortality (Critical Care 2015, 19:197 )

It doesn't matter if we screw it up Downstairs, they can Fix it in the ICU
Ummm, not so much if you believe the SPICE Study-In 251 critically ill patients at multiple centers, we identified deep sedation within 4 hours of commencing ventilation as an independent negative predictor of the time to extubation, hospital death, and 180-day mortality. The early phase of ICU sedation is usually unaccounted for in randomized controlled trials due to late randomization. (Am J Respir Crit Care Med Vol 2012;186(8):724–731)[cite source='doi']10.1164/rccm.201203-0522OC[/cite]
A1 Sedation - Analgesia First
Stick your finger down your throat--now leave it there

Strom et al. evaluated this: RCT of 140 patients-analgesia vs. analgesia+sedation. Analgesia only showed shorter vent time and ICU LOS.[cite source='pubmed']20116842[/cite]

Analgosedation: a paradigm shift in intensive care unit sedation practice,[cite source='doi']10.1345/aph.1Q525[/cite].

Just put patients on a fentanyl drip. If not go with dilaudad IV. When remifentanil is cheap, we'll switch to that in a bunch of patient categories.[cite]15329588[/cite]

Then evaluate pain and decide if the patient needs additional pushes of pain meds.

Consider using the Behavioral Pain Scale (Crit Care Med 2001;29(12):2258) HT to Nikolay Yusupov


Myth - We can prevent PTSD if we Black Out the ICU Experience
just the other way around
Myth - Benzos are just Swell
Not so much-Benzos lead to longer length of stay, longer vent time, and increased delirium.

Benzodiazepine versus nonbenzodiazepine-based sedation for mechanically ventilated, critically ill adults: a systematic review and meta-analysis of randomized trials,[cite source='doi']10.1097/CCM.0b013e3182a16898[/cite].
Myth - Short-Acting Sedatives and Analgesics Go Away Quickly
You need a goal, like RASS
Here is the RASS Scale from the amazing ICU Delirium Site
Myth-Pain is a Great Pressor
Patients should never be undersedated due to hemodynamics
Patient Scenarios
Standard Critically Ill Patients
Fentanyl and Dexmedetomidine (or Propofol)

 


Neuro Patients/DTs
If you have ICP issues, propofol and fentanyl
Hemodynamically Compromised Patients
Fentanyl and then,

]]>
Scott D. Weingart, MD clean 21:21
Best of 2013 – Eight is Enough & Social Media Update https://emcrit.org/emcrit/best-of-2013/ Tue, 31 Dec 2013 21:43:29 +0000 http://emcrit.org/?p=4657 Best of 2013 Best of 2013
Social Media Update

* Use either RSS or the email updates feature (find both on the home page)
* If you have a comment on an EMCrit Podcast or Post, please put it on the blogpost on emcrit.org
* If you have something pithy to say, use twitter
* If you have a case or a question unrelated to an EMCrit Podcast or Post, use Google Plus or post to the FOAMcc Google Community
* If you like being screwed and having your information manipulated, use Facebook

 
Best of 2013
Blogs

* Expensive Care Blog by David Anderson? (See Own The Bronchial Blocker, Rent The Double Lumen Tube)
* Resus Review Blog by Charles Bruen (See the tPA Mixing Tutorial)
* Scancrit Blog by Thomas and K (See Central vs. Peripheral Pressure)
* The Short Coat Blog by Lauren Westafer (See Metacognition for the Pragmatist )
* Emnerd Blog by Rory Spiegel (See The Adventure of the Speckled Band)

Niche Sites

* Closing the Gap by Brian Lin (See the Running Subcuicular Suture)



Podcasts

* Maryland CC Project by John Greenwood, Jim Lantry, and Michael McCurdy (See Changing the Face of Massive Transfusion)
* SGEM Podcast by Ken Milne (See Should I Stay or Should I Go (Biphasic Anaphylactic Response)

Social Media Guidelines

* Health on the Net HONcode Principles
* Time for a FOAM Charter

Previous Year's Best ofs

* Sexy Six for 2014
* Natural 7 for 2012
* Hard Six for 2011
* Dirty Dozen for 2010

A Product I Recommend


Toxicology-in-a-Box

by Brian Kloss and Travis Bruce
Happy Solstice Everyone!]]>
Scott D. Weingart, MD clean 20:45
Podcast 114 – Post-Arrest Care in 2013 with Stephen Bernard – Part II https://emcrit.org/emcrit/post-arrest-care-2013-ii/ Mon, 16 Dec 2013 18:19:58 +0000 http://emcrit.org/?p=5607 Part 2 of an interview with Stephen Bernard on the Care of the Post-Arrest Patient in 2013 Part 2 of an interview with Stephen Bernard on the Care of the Post-Arrest Patient in 2013
 

Professor Stephen Bernard
Senior Intensivist, The Alfred Hospital
Professor Stephen Bernard is a senior Intensive Care Physician at the Alfred Hospital and Director of Intensive Care at Knox Private Hospital in Victoria, Australia. He is also Medical Advisor to Ambulance Victoria.

 

Last Week, I posted Part I of this interview on Post-Arrest Care 2013
This is Part II.

My discussion with Dr. Bernard was based on a talk he gave at the Australasian College for Emergency Medicine


MAP Goals
SBP of 120 mm hg? The paper was just published ahead-of-print

The other paper Dr. Bernard Mentioned is Gaieski et al. (Resuscitation 2007;73:29-39)
Sedate
If cooling to 36, it is a lot easier to get away with standard sedation practice as the hypothermia-slowed metabolism is no longer a big problem
Cath lab with ECMO or LUCAS2 for refractory arrest
It can be done! And if we can do it, is "stay-and-play" on scene still a good strategy?
CHEER trial (CPR, Hypothermia, ECMO and Early Reperfusion)
CHEER Trial Protocol

15 F arterial cath and a 17-19 F venous catheter under ultrasound guidance, with the only pause during compressions being the initial vessel puncture and 1st wire advancement
Intraarrest Hypothermia?
The animal data look good, but need human trials that show benefit. If you do it, then these patients may need a deeper degree of hypothermia (33 C?).
Prehospital Hypothermia and is Quicker Better?
Dr. Bernard's trial did not show benefit for prehospital cooling [cite source='pubmed']20679551[/cite]

and the in-press study by Kim et al. showed the same [cite source='pubmed']24240712[/cite]
More from Steve can be found at the EDECMO Podcast Site
Now, on to the Podcast...]]>
Scott D. Weingart, MD clean 19:13
Podcast 113 – Post-Cardiac Arrest Care in 2013 with Stephen Bernard – Part I https://emcrit.org/emcrit/post-arrest-care-2013-i/ Sun, 08 Dec 2013 17:14:27 +0000 http://emcrit.org/?p=5453 Dr. Stephen Bernard on the topic of post-arrest care Dr. Stephen Bernard on the topic of post-arrest care
Professor Stephen Bernard
Professor Stephen Bernard is a senior intensivist at the Alfred Hospital and Director of Intensive Care at Knox Private Hospital in Victoria, Australia. He is also Medical Advisor to Ambulance Victoria. Dr. Bernard was the lead author on one of the original establishing studies for post-arrest temperature management.

 


My discussion with Dr. Bernard was based on a talk he gave at the Australasian College for Emergency Medicine


Maintain 36 C for 24 Hours
Dr. Bernard and the Alfred Hospital in Australia are moving to the protocol outlined in the TTM trial
Is there anyone who still deserves to be cooled to 33 C?
Dr. Bernard feels patients that get intra-arrest cooling may still benefit until we have further trial results.
Neuro-Prognosticate as per the protocol in the Nielsen trial
Chris Nickson summarized the Neuro-Prognostication Protocol wonderfully
Time Zero Prognostication
It is tough. Unwitnessed asystole is probably one situation in which you can choose a palliative route if the situation otherwise supports it.
Pt should be taken to a 24/7 cardiac interventional center
This doesn't necessarily mean the patient needs to go to the lab immediately, they just need to be able to go when needed
Lower FiO2
Maintain an SpO2/SaO2 between 90-95%
Normal PaCO2
No hypocapnea, Perhaps slight hypercapnea
Tune in Next Week for Part II of the Interview
More on the TTM Trial

* My initial Wee
* A quick interview with Jon Rittenberger

The Thoughts of Others
https://twitter.com/JAMyburgh/statuses/402940221630603264

https://twitter.com/JAMyburgh/statuses/403351251791781888
More from Steve can be found at the EDECMO Podcast Site
Now, on to the Podcast...]]>
Scott D. Weingart, MD clean
Podcast 112 – A Response to the Marik Sepsis Fluids Lecture https://emcrit.org/emcrit/fluids-severe-sepsis/ Sun, 24 Nov 2013 17:36:23 +0000 http://emcrit.org/?p=5407 Last week I posted a lecture by Paul Marik on Fluid Management in severe sepsis. The lecture is the equivalaent of a bucket of ice water poured over your head. Now let's give you a towel and discuss. Last week I posted a lecture by Paul Marik on Fluid Management in severe sepsis. The lecture is the equivalaent of a bucket of ice water poured over your head. Now let's give you a towel and discuss.

Last week I posted a lecture an incredible by Paul Marik on Fluid Management in severe sepsis. The lecture is the equivalent of a bucket of ice water poured over your head. Now let's give you a towel and discuss.
Want to add a journal club to this flipped classroom?
Then read these pieces in Critical Care:

* Bellomo on Norepinephrine and the Kidney
* Rethinking Resus Goals by Dunser
* Response: Rethinking Resus Goals by Marik and Bellomo
* Pharmacodynamic Analysis of a Fluid Challenge (Crit Care Med 2016;44:880)

The Low-Fluid Volume Early Pressor Experiment has Already Been Tried
It was called standard care 15-20 years ago--patients did not do all that well.
Should we Increase DO2?
We know from that shooting for supranormal DO2 is actually harmful. The original goal-directed therapy trials did not pan out and this may be why.

There is definitely a group of Severe Sepsis patients that are receiving inadequate oxygen delivery. I have treated these patients; I have documented ScvO2s in the 50's and 60's on initial check in a EGDT-type algorithm.

Far more commonly, patients are in pure vasodilatory shock (Jones' trial patients). The latter fact doesn't disprove the former. Using the studies demonstrating the deleterious effects of shooting for above normal delivery doesn't say anything about normalizing patients with low delivery.
Marik's Goals

* Achieve adequate perfusion pressure
* Improve microcirculatory flow
* Limit Tissue Edema

All right on point; how do we get there is the question.
Rivers Trial as a Waterfall?
This is not actually what that trial showed. And the way CVP was used was not actually debunked by the 7 mares article (Note: I'm not advocating you use CVP, I'm just pointing this out! We have better ways to accomplish assessing fluid responsiveness so CVP should be sent to the junk bin)

I will make the utterly blasphemous statement that Dr. Rivers and Dr. Marik are actually in near-complete agreement if you followed both of their protocols explicitly in the ED.
MAP and Association to Survival
Not sure what this is proving: both groups (the flow-optimizers and the desert-inducers) believe in shooting for MAP goals. Patients in whom it is impossible to get the MAP up will die more frequently.
But is it Flow or Pressure that Matters?
I must say, I am still in the tissue flow camp
On to the Glycocalyx
Now this is where stuff gets really interesting. Every day, there is increasing research and more publications on the fundamental role of the vascular glycocalyx. But how do we integrate this clinically?

Chris Nickson tweeted this amazing lecture from Rob Wise. It will explain the Glycocalyx in 5 minutes. It lives on Life in the Fast Lane.



 

Now as to its relation to fluids in sepsis, we are being told hypervolemia is bad. But if the fluids are leaking from the vascular space are we ever seeing hypervolemia in the vasculature or is the problem whole body volume overload--not if we believe BNP/ANP are the root of the problem, they only respond to vasculature fluids. If we are doing a fluid responsiveness strategy, we should not be seeing the vascular overload.

Do balanced vs.]]>
Scott D. Weingart, MD clean 30:31
Five Minutes with Jon Rittenberger on the TTM Trial https://emcrit.org/emcrit/five-minutes-jon-rittenberger-ttm-trial/ Mon, 18 Nov 2013 22:56:43 +0000 http://emcrit.org/?p=5422 More on TTM Trial More on TTM Trial

Just posted a wee on the game-changing TTM Trial

Managed to get Jon Rittenberger, MD on the line to discuss the implications. Jon wrote the editorial that accompanied the TTM trial and he is an accomplished Resuscitationist and a clinical leader for the U. Pitt post-arrest management team.

Here are Jon's thoughts on what we should do with this trial tomorrow. I add my own opinion at the end. In the next couple of weeks, you'll hear from Stephen Bernard to get his take on the study.

The 2nd article mentioned by Jon is this one:

Kim, F et al. Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac Arrest A Randomized Clinical Trial JAMA 2013

Prehospital hypothermia in this study and the Bernard trial has not seemed to pan out. Intra-arrest is still in play however.
My Take as of Now







* In the setting of advanced post-arrest care, active temperature management, and protocolized neuro-prognostication; the TTM trial demonstrated no significant outcome difference or trend towards outcome difference when patients were cooled to either 33 or 36C
* Hemodynamics were poorer in the 33C group (This was not mismatching, SOFA-C same on day 1 and much worse in 33C group on day 3; this was a secondary outcome and therefore the study can't demonstrate if this was a significant finding) [Table S2 Supplement]
* Complications were less frequent in the 36C group
* A majority of patients are probably best managed at or near 36C
* In the neurocritical care literature, 35C seems to offer moderation of intracranial pressure
* At Janus General, we will target a temperature range between 35-36C for our V-fib, V-tach, and PEA patients in whom we are pursuing an aggressive treatment path
* Unwitnessed asystolic arrest patients were left out of the HACA, Bernard, and TTM trial. In this group there is little guidance and it may be reasonable to continue cooling to 33C as this group is most likely to have the most severe post-arrest neurologic injury.







Interview with the Lead Author of Trial from the ICN
Matt MacPartlin interviewed Niklas Nielsen, the author of TTM. He is joined by Anders Aneman, one of the local site investigators to discuss this game-changing study.
Other Thoughts
See this great post from the folks at the Intensive Care Network as well.

The folks at St. Emlyn's offer a  more cautious approach.
Updates
JAAM-OHCA TTM Trial
Now on to the Wee...]]>
Scott D. Weingart, MD clean 5:35
EMCrit Wee – The Targeted Temperature Trial Changes Everything https://emcrit.org/emcrit/emcrit-wee-targeted-temperature-trial-changes-everything/ Mon, 18 Nov 2013 20:28:29 +0000 http://emcrit.org/?p=5416 Cold, but not all that cold may be the way Cold, but not all that cold may be the way

The TTM Trial was just published today in the NEJM (Nielsen et al. Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest NEJM 2013;epub Nov 17, 2013)

For my take and the take of Jon Rittenberger, come to the 2nd TTM Post

but even more important is to hear from the primary author himself: Niklas Nielsen on the TTM Trial
Study Design
International multicenter RCT

Inclusion criteria: Age >= 18 years, out-of-hospital cardiac arrest of presumed cardiac cause, unconsciousness (Glasgow Coma Score <8) after sustained return of spontaneous circulation (ROSC) (20 minutes of circulation).

Exclusion criteria: Conscious patients, pregnancy , out-of-hospital cardiac arrest of presumed non-cardiac cause, cardiac arrest after arrival in hospital, known bleeding diathesis, suspected or confirmed acute intracranial bleeding, suspected or confirmed acute stroke, temperature on admission <30°C, unwitnessed asystole, persistent cardiogenic shock, known limitations in therapy, known disease making 180 day survival unlikely, known pre-arrest cerebral performance category 3 or 4, >240 minutes from ROSC to randomisation.

Primary outcome: Survival to end of trial (at least 180 days).

Secondary outcomes: Composite outcomes of all-cause mortality and poor neurological function (Cerebral Performance Category (CPC) 3 and 4 and modified Rankin Scale (mRS) 4 and 5) at 180 days. All - cause mortality and CPC and mR S at 180 - days. Adverse events: Bleeding, pneumonia, sepsis, electrolyte disorders, hyperglycaemia, hypoglycaemia, cardiac arrhythmia, renal replacement therapy.

Tertiary outcomes: Complete neurological recovery. Best neurological outcome during trial perio d. Quality of life according to SF - 36. Biomarkers at 24, 48 and 72 hours

Intervention: The core body temperature will be set as quickly as possible at the predefined target temperature, according to intervention allocation, with 4°C intravenous solutions, 43 ice - packs 8, 44 and commercially available cooling devices 45 at the discretion of the treating physician . The target core temperature is then maintained for 24 h. After the maintenance period core temperature is gradually raised to normothermia of 37°C during 8 hours with a rewarming rate of 0.5°C/hour in both groups. Body temperature is then maintained at normothermia 37 ±0.5°C until 72 hours from sustained ROSC in both treatment groups, as long as the patient is in the ICU, using pharmacological treatment and temperature management systems when applicable

See all of the nitty-gritty in the appendix
rewarmed at 0.5 C/hr and then induced normothermia (37.5 C) for 36 hrs post arrest

Nonblinded to temp allocation, but neuro assessment was blinded

fluids icepacks surface and intravasc cooling-- 1/4 intravasc and rest surface
900 pts give 90% power to detect 20% difference
80% shockable, 12% asystole
Table S2 - SOFA-C Scores in the first 72 hours



*SOFA denotes Sequential Organ Failure Assessment, SOFA-C denotes the cardiovascular subcomponent of the SOFA score. SOFA-C=0 No need for inotrope or vasopressor, mean arterial pressure (MAP) > 70mmHg, SOFA-C =1 MAP < 70mmHg, SOFA-C=2 any dose of dobutamine or dopamine <5 ìg/kg/minute,]]>
Scott D. Weingart, MD clean 2:53
Podcast 111 – Fluids in Sepsis, A New Paradigm – Paul Marik https://emcrit.org/emcrit/paul-marik-fluids-sepsis/ Sat, 09 Nov 2013 17:50:58 +0000 http://emcrit.org/?p=5394 Our favorite critical care skeptic, Dr. Paul Marik, on fluids in severe sepsis Our favorite critical care skeptic, Dr. Paul Marik, on fluids in severe sepsis
Dr. Paul Marik is a renowned intensivist and a confirmed critical care skeptic. He has broken down many myths such as the use of CVP for volume assessment. I recorded a lecture he gave to the Sepsis Collaborative I co-chair. It is an amazing lecture.
I agree with some of it and have quibbles with other parts, but it is a must-listen. In one week, I will publish a wee with the areas I see differently; in the interim think about your own viewpoint so that we can discuss it all in the comments.
Dr. Marik's Previous Visits to EMCrit

* CVP and Fluid Assessment
* Maybe Groin Lines Aren't that Bad

Dr. Marik's Updated Hemodynamic Management Flowsheet


 
Now on to the Podcast...]]>
Scott D. Weingart, MD clean 51:37
SMACC Back 3 – Simon Carley on Leadership https://emcrit.org/emcrit/simon-carley-on-leadership/ Wed, 06 Nov 2013 20:44:47 +0000 http://emcrit.org/?p=5385 A SMACC back on Simon Carley's talk on Educational Leadership A SMACC back on Simon Carley's talk on Educational Leadership

Now I should be doing a SMACC Back on Roger Harris' talk on the Right Heart as he surely cast a gauntlet in my path, but that would probably just encourage him : ). Instead, lets talk about...
Simon Carley on Educational Leadership and Subversion
This SMACC-Back deals with Simon Carley's lecture from SMACC 2013. If you haven't seen it yet, watch now--it is incredibly good:



The line that resonated with me was,
The first principle of Leadership is Excellence. The most important thing for an educational leader is that they are clinically credible. "Those that can't do--teach," is crap in medicine.
So utterly true!

 

Tangentially, one of my colleagues recommended a book to me entitled, Multipliers: How the Best Leaders Make Everyone Smarter.



Wow, what a horribly misguided tome. To hear why I think this, listen to the wee.
Get your SMACC 2014 Abstracts in ASAP
The closing date for abstracts for SMACC is Friday the 22nd of November

Be part of the action!

Submit here.
Now on to the SMACC Back...]]>
Scott D. Weingart, MD clean 7:51
Podcast 110 – Exsanguinating Hemorrhage from Mid-Face Fractures https://emcrit.org/emcrit/exsanguinating-hemorrhage-mid-face-fractures/ Fri, 01 Nov 2013 19:33:56 +0000 http://emcrit.org/?p=5242 Management of Severe Hemorrhage from Mid-Face Blunt Trauma Management of Severe Hemorrhage from Mid-Face Blunt Trauma

Just got back from Toronto, where I learned about Chubby Bunny.



But what we are actually going to talk about today is the management of Severe Hemorrhage from Mid-Face Blunt Trauma
Algorithm
Ann Plast Surg 2012;69:474


Take the Airway
Suction-as-you-go ETT Set-up

Partner Suction a la Strayer

These airways are all Cricon 3
Anterior Packing
I use Rapid-Rhino 5.5 cm but you go with whatever you are comfortable with. Soak it in STERILE WATER, not saline despite what i blathered in the audio (Thanks Brent!)
Posterior Packing
We use foleys in preference to commercial devices for standard epistaxis. This series explains why: (Injury. 2003 Dec;34(12):901-7. Complications with use of the Epistat in the arrest of midfacial haemorrhage.)

Use 12 - 14F (or whatever you got)

Witness passage into the posterior pharynx from both foleys with laryngoscope

Inflate a smaller volume first (6-8 mL) and then apply traction until it wedges, this allows the balloon to wedge in the posterior choana

Inflate to 20 ml

Apply traction

I use the system at the end of this video on Blakemore Passage

Reapply the anterior packs bilaterally
Temporary Fracture Fixation


Image from Injury  Volume 34, Issue 12, December 2003, Pages 901–907 Holmes et al. From that article, "When there is a mid-palatal split, however, this haemostatic technique will possibly fail and additional measures will be required to achieve haemostasis. The split palate should be stabilised with a transpalatal circumdental wire , before placing packing."
Angiography
IR of the internal maxillary is usually what is needed

May also be branches of ethmoidal in skull base fx
TXA for Epistaxis
EM Lit of Note's Review
McKesson Oral Prop?
EMJ 2010; 27 :156 e 158. doi:10.1136/emj.2008.070219

Anyone know about this? Comment in the show notes.
Additional References


* Case Discussion (Ann Plast Surg 2--1;46:159)
* Case Series on IR (J Trauma 2003;55:74)
* Another Case Series on Management (J Trauma 2008;65:994)
*  A Decade's experience with balloon tamponade fro traumatic hemorrhage (The Journal of Trauma: Injury, Infection, and Critical Care Issue: Volume 70(2), February 2011, pp 330-333)

]]>
Scott D. Weingart, MD clean 18:39
Practical Evidence 013 – ACEP Management of Asymptomatic Blood Pressure 2013 https://emcrit.org/practicalevidence/2013-acep-management-of-asymptomatic-htn/ Tue, 22 Oct 2013 21:17:17 +0000 http://emcrit.org/?p=5354 Management of asymptomatic markedly elevated blood pressure Management of asymptomatic markedly elevated blood pressure

We discuss the management of asymptomatic markedly elevated blood pressure as evaluated by the ACEP Clinical Policies Committee in Sept 2013.
The Policy
ACEP Management of Asymptomatic HTN 2013
The Questions and the Recs


In ED patients with asymptomatic elevated blood pressure, does screening for target organ injury reduce rates of adverse outcomes?

Patient Management Recommendations

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations.

* In ED patients with asymptomatic markedly elevated blood pressure, routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) is not required.
* In select patient populations (eg, poor follow-up), screening for an elevated serum creatinine level may identify kidney injury that affects disposition (eg, hospital admission).

 

In patients with asymptomatic markedly elevated blood pressure, does ED medical intervention reduce rates of adverse outcomes?

Patient Management Recommendations

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations.

* In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required.
* In select patient populations (eg, poor follow-up), emergency physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control. [Consensus recommendation]
* Patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up. [Consensus recommendation]

What is EMCrit Drinking?

Now on to the Podcast...
 

]]>
Scott D. Weingart, MD clean 10:26
Podcast 109 – Mind of the Resuscitationist from SMACC 2013 https://emcrit.org/emcrit/mind-of-the-resuscitationist-smacc/ Mon, 14 Oct 2013 09:00:13 +0000 http://emcrit.org/?p=5305 Mind of the Resuscitationist Lecture from SMACC 2013 and Blakemore Placement Mind of the Resuscitationist Lecture from SMACC 2013 and Blakemore Placement
This lecture was from the final day of SMACC 2013. It was based on a case I saw at Janus General Hospital.

[vimeo 76743429 w=620]
Blakemore Placement
In the lecture I talk about a life-saving Blakemore Tube placement. I suspect some of you may need a reminder of the intricacies of this device, so I made a video and cheat-sheet.
Now on to the Podcast...
 ]]>
Scott D. Weingart, MD clean 17:07
Blakemore Tube Placement for Massive Upper GI Hemorrhage https://emcrit.org/emcrit/blakemore-tube-placement/ Sun, 13 Oct 2013 19:31:45 +0000 http://emcrit.org/?p=5306 How to place a Blakemore tube for esophageal varices with massive bleeding. How to place a Blakemore tube for esophageal varices with massive bleeding.

In recent lectures, I talk about a life-saving Blakemore Tube placement. I suspect some of you may need a reminder of the intricacies of this device, so I made a video and cheat-sheet.


Improved HD Video
Jess Mason took the moves in my original video and had it recorded professionally


Securement using ETAD Device
Jess Mason made this nice video on how to secure the Blakemore


What you need:

* Blakemore
* Salem Sump
* 60 ml Luer-lock Syringe
* 60 ml Slip-tip Syringe
* 2 x-mas tree to male luer lock converters
* 3 three-way stopcocks
* 3 medlock caps
* Surgilube
* Roller-bandage
* 1 1-liter bag of crystalloid
* Optional: 2 Hollister ETAD ET tube securing devices
* Possibly: Laryngoscope, Magill Forceps





 
How to Do it:

* Patient should be intubated and the head of the bed up at 45 degrees.
* Test balloons on Blakemore and fully deflate. Mark salem sump at the 50 cm mark of the Blakemore with the tip 2 cm above gastric balloon and then 2 cm above esophageal balloon.
* Insert the Blakemore tube through the mouth just like an NGT. You may need the aid of the laryngoscope and sometimes McGill forceps. Make sure the depth-marker numbers face the patient’s right-side.
* Stop at 50 cm. Test with slip syringe while auscaltating over stomach and lungs. Inflate gastric port with 50 ml of air or saline.
* Get a chest x-ray to confirm placement of gastric balloon in stomach.
* Inflate with additional 200 ml of air (250 ml total)
* Apply 1 kg of traction using roller bandage and 1 liter IV fluid bag hung over IV pole. Mark the depth at the mouth. The tube will stretch slightly over the next 10 minutes as it warms to body temperature.
* After stretching, the tube may be secured to the ETAD tube holder.
* Insert the salem-sump until the depth marked gastric is at 50 cm on the Blakemore. Suction both Blakemore lavage port and salem sump. You may need to wash blood clots out of the stomach with sterile water or saline.
* If bleeding continues, you will need to inflate esophageal balloon.
* Pull salem sump back until the esoph. mark is at the 50 cm point of the Blakemore. Attach a manometer to the second 3-way stopcock on the esophageal port of the Blakemore. Inflate to 30 mm Hg. If bleeding continues, inflate to 45 mm Hg.
* Consider switching traction to Hollister ETAD Device.

Here is a cheat sheet for Blakemore Placement in PDF Form

How to Build a Simulator
Paper from JEM
Bougie Aided Placement Technique by Whitford
From Youtube
Questions to be answered?

* Can ultrasound obviate the need for radiographic confirmation prior to inflation? One letter to the editor says yes, but the image doesn't seem to confirm anything. (Emerg Med J 2006;23:487)

 ]]>
Scott D. Weingart, MD clean 10:30
Podcast 108 – How to Be a Hero with Cliff Reid https://emcrit.org/emcrit/how-to-be-a-hero/ Mon, 30 Sep 2013 18:34:05 +0000 http://emcrit.org/?p=5252 This was my favorite lecture from SMACC 2013. If you are not moved and inspired then your heart is made of stone. This was my favorite lecture from SMACC 2013. If you are not moved and inspired then your heart is made of stone.
This was my favorite lecture from SMACC 2013. If you are not moved and inspired then your heart is made of stone.

This is a Cliff Reid lecture; if you want more Cliff, see these incredible lectures and podcasts:

* Chicken Bombs and the Muppet Factor
* Mind of the Resuscitation Interviews Part I
* Mind of the Resuscitation Interviews Part II
* Own the Resus Room

I'll post my own final SMACC lecture in 1 week and then we are done with SMACC 2013.
Want the Slides and a Beautiful Blogpost on the Lecture?
Head on over to the post on the Resus.me Site
Need an Audio-Only Version?
Right-Click Here and Choose Save-as
Now on to the Vodcast...
]]>
Scott D. Weingart, MD clean 24:33
Podcast 107 – Peripheral Vasopressor Infusions and Extravasation https://emcrit.org/emcrit/peripheral-vasopressors-extravasation/ Mon, 16 Sep 2013 14:59:35 +0000 http://emcrit.org/?p=5074 Can we give vasopressors peripherally? And if we do, what if they leak? Can we give vasopressors peripherally? And if we do, what if they leak?
This episode was inspired by an article that Mike "the Rock" Stone asked me to take a look at:
Central or Peripheral Catheters for Initial Venous Access of ICU Patients: A Randomized Controlled Trial by Ricard JD et al. [cite]23782969[/cite]



In this interesting RCT, patients were randomized to either peripheral or central access. The study was analyzed by intention-to-treat, meaning if the pts in the peripheral group got central access, the complications were still assigned to the peripheral group. While the results listed less major complications with central rather than peripheral access (0.64 vs. 1.04, p<0.02), that is not the whole story.

A majority of the complications in the PIV group were actually the inability to insert a PIV. The other complications seem to the same in both groups. But what about what we really want to know...were there extravastion injuries in the PIV group. They did not exclude patients on vasopressors until they were on very high doses (e.g. >33.3 mcg/min of norepinephrine), so this study can actually give us some answers. There were 19 pts in the PIV group with the major complication of subcutaneous diffusion (i.e. extravasation). Neither the original study nor the supplemental material listed the severity and needed treatment for these extrav. injuries. I therefore wrote to the author who graciously replied. None of these patients required anything more than observation and conservative management.

So can we use peripheral lines for vasopressors? Folks like my friend Paul Mayo would say, "yes!" In his unit, pts are getting peripheral or mid lines almost exclusively. Rob Green, a Canadian resuscitationist, was also working on this topic last time I spoke with him.
But vasopressors can cause problems in Extravasation
I'm not going to bother to list the data on norepi, b/c everyone is already familiar and fearful with that drug peripherally.
Dopamine Extravasation
[cite]9606475[/cite]



Vasopressin Extravasation
[cite]12163813[/cite]

[cite]16505698[/cite]

Have not found any evidence for phenylephrine problems, but I'm sure there is some out there (though I think it is the safest agent)
IO is not a panacea
Extravasation may result from misplacement/dislodgement and in rare cases even Compartment Syndrome. IOs (and probably IVs) can be confirmed by ultrasound with a squeeze test [PMID 24036195]



Push-Dose Pressors
You should also check out the Push-Dose Pressor Episode for another option in these situations.
Extravasation Injuries from Vasopressors
Prevention

* Avoid the hand/wrist (and maybe the AC fossa)
* Avoid Ultrasound-Guided IVs that are Crappy
* Avoid Crappy IVs in general
* You need a protocolized extremity check
* You need the antidotes and a worksheet in the room with the patient.
* 10 mg of Phentolamine can be added to each liter of solution containing norepinephrine. The pressor effect of norepinephrine is not affected. [cite]13788877[/cite]





Treatment
Step I

If the pt is relying on the agent for their hemodynamics, switch the pressor to another IV or place an immediate IO or central line.

Step II

Do not pull the cannula yet

Step III

Suck out as much as you can

Step IV

Administer subcutaneous phentolamine mesylate (Regitine) using 25 G or smaller needle
Scott D. Weingart, MD clean 20:08
SMACC Gold Promo https://emcrit.org/emcrit/smacc-gold-promo/ Sat, 07 Sep 2013 20:20:37 +0000 http://emcrit.org/?p=5164 SMACC Gold is March 18-21st on the Gold Coast of Australia--best ED conference you will ever attend SMACC Gold is March 18-21st on the Gold Coast of Australia--best ED conference you will ever attend

I interview Roger Harris about SMACC Gold. Come to smacc.net.au to hear more.]]>
Scott D. Weingart, MD clean 8:16
Podcast 106 – Making Things Happen with Cliff Reid https://emcrit.org/emcrit/making-things-happen/ Tue, 03 Sep 2013 00:04:15 +0000 http://emcrit.org/?p=5133 Cliff Reid runs the amazing Resus.me site and any listener of EMCrit knows that I have an enduring (and purely platonic) love for Cliff and all of his teachings. Cliff Reid runs the amazing Resus.me site and any listener of EMCrit knows that I have an enduring (and purely platonic) love for Cliff and all of his teachings.
Mind of the Resuscitationist
This was Cliff Reid's opening lecture from SMACC 2013. Cliff Reid runs the amazing Resus.me site and any listener of EMCrit knows that I have an enduring (and purely platonic) love for Cliff and all of his teachings.This lecture was on Making Things Happen and it is my #2 favorite lecture from the conference. My number one favorite was also by Cliff, but you'll have to wait a bit for that one.
Want More Reid?

* Chicken Bombs and the Muppet Factor
* Mind of the Resuscitation Interviews Part I
* Mind of the Resuscitation Interviews Part II
* Own the Resus Room

Want the Slides?

Need an Audio-Only Version?
Right-Click Here and Choose Save-as
Now on to the Vodcast...
]]>
Scott D. Weingart, MD clean 24:55
Podcast 105 – The Path to Insanity https://emcrit.org/emcrit/path-to-insanity/ Tue, 20 Aug 2013 13:38:49 +0000 http://emcrit.org/?p=5041 This was my favorite lecture assigned to me at SMACC 2013. It discusses the search for excellence in our profession. I hope you enjoy! This was my favorite lecture assigned to me at SMACC 2013. It discusses the search for excellence in our profession. I hope you enjoy!

This was my favorite lecture assigned to me at SMACC 2013. It discusses the search for excellence in our profession. I hope you enjoy!
Knowledge
Full list of journals I read

The Pareto Reduction to 12 for EM Critical Care

* Ann Emerg Med - Acad Emerg Med
* Am J Emerg Med
* Emerg Med J
* Br J Anaesth
* Anesthesiology
* Anesth & Analg
* Resuscitation
* J Trauma
* Crit Care Med
* Crit Care
* Intens Care Med

Insight comes from Knowledge (Psychol Sci. 2006 Oct;17(10):882-90. The prepared mind: neural activity prior to problem presentation predicts subsequent solution by sudden insight.)

More

* Mastery by Robert Greene
* Pragmatic Thinking by Andy Hunt
* Reading non-clinically is just as important to become an excellent physician and person, so go listen to Michelle Johnston's lessons from the classics lecture
* The 10,000 hour rule is essentially bullshit

Procedures
More

* Siamak Moayedi has one of the best lectures on procedural knowledge. The lecture is now available in video form as well

Critical Thinking
Rhetological Fallacies
I have a copy of this poster in both of my offices
PSYBlogs List of Cognitive Biases
If you don't know them, you are probably committing them
More
Mastermind by Maria Konnokova

Thinking Fast and Slow by Kahneman
Potholes
Dunning-Kruger Effect

* Kruger J, Dunning D. Unskilled and Unaware of It: How Difficulties in Recognizing One's Own Incompetence Lead to Inflated Self-Assessments. Journal of Personality and Social Psychology 1999;77(6):1121.
* Dunning D, Johnson K, Ehrlinger J. Why people fail to recognize their own incompetence. Current Directions in 2003 Jan.;Available from: http://cdp.sagepub.com/content/12/3/83.short
* Caputo D, Dunning D. What you don't know: The role played by errors of omission in imperfect self-assessments [Internet]. Journal of Experimental Social Psychology 2005 Jan.;Available from: http://www.sciencedirect.com/science/article/pii/S0022103104001210
* Carter T, Dunning D. Faulty Self?Assessment: Why Evaluating One's Own Competence Is an Intrinsically Difficult Task [Internet].]]>
Scott D. Weingart, MD clean 22:57
Podcast 104 – Laryngoscope as a Murder Weapon (LAMW) Series – Hemodynamic Kills https://emcrit.org/emcrit/intubation-patient-shock/ Mon, 05 Aug 2013 19:02:17 +0000 http://emcrit.org/?p=4945 A lecture from SMACC2013 on how not to kill the shocked patient when intubating A lecture from SMACC2013 on how not to kill the shocked patient when intubating
The Airway Moratorium is Over!
In this podcast I talk about how not to kill the shocked/hypotensive patient in the peri-intubation. I gave this talk at SMACC 2013.

This lecture is part of the Laryngoscope as a Murder Weapon Series:

* Hemodynamic Kills
* Oxygenation Kills
* Ventilatory Kills

Eleni Salakidou's SmaccBYTE Entry

Nickson's Hierarchy of Resus Airway Needs

Literature
Best Review Article

Anaesthesia 2009;64:532

STC Review Article

Curr Anesthesiol Rep 2014;4:225

Hypotension in the peri-intubation is bad and is a source of mortality

Hemodynamically unstable or on pressors prior to intubation is the biggest factor assoc. with death and complications. (Schwartz et al. Anesthesiology 1995;82:367)

Heffner et al. J Crit Care 2012 Aug;27(4):417
Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department. (PMID 25402500)
Etomidate

Etomidate is probably safe in moderately shocked patients (Acad Emerg Med 2006;13:378)

Etomidate can definitely drop Blood Pressure (Crit Care 2012;16:R224)

Ketamine

Ketamine given to patients with horrible ejection fractions (Thangathurai et al.; Anesth 1988;69(3a):A79), in OR anesthetized pts (Prakt Anaesth. 1976 Dec;11(6):397-404) and In-Vitro human-tissue studies show Ketamine to be least cardio-depressant (Anesthesiology 1996;84:397). Another anesthesia study showed no drop from initial values after large and repeated doses (Br J Anaesth 1976;48:1071)

Best study, reasonable doses (CCM 1983;11(9):730) showed excellent stability

A further anesthesia study (Anesth and Analg 1980;58(5):355) 1/12 patients dropped HR with no effect on CI.

Cats did fine (Canad Anesth Soc J 1975;22(3):339). However if you give 10-100-fold doses to canine heart tissue then maybe (J Cardiovasc Pharmacol 1986;8:414) and (Anesthesiology 1992;76:564), in the latter, dogs got infusions at 25-100 mg/kg/hr.

Case report of 2 arrests post-ketamine (J Inten Care Med 2012; Dewhirst et al.)

Ketamine in ICP (Emerg med australia 2006;18(1):37-44)

Two RCTs of etomidate vs. ketamine showed both are equally hemodynamically stable, but this was full dose ketamine (Am J Emerg Med 2013;31:1124 and Lancet. 2009 Jul 25;374(9686):293-300). Middle dose may be even better.
Paralytics
Anesth Analg. 2000 Jan;90(1):175-9.
Other References Reviewed
Nickson's Pyramid

Want the Slides
Slides for Hemodynamic Kills Lecture
Need the Audio-Only Format?
Right Click Here and Choose Save-as
Now on to the Podcast...
]]>
Scott D. Weingart, MD clean 30:43
EMCrit Wee – Vasopressin, Steroids, and Epinephrine for Cardiac Arrest https://emcrit.org/emcrit/vasopressin-steroids-epinephrine-for-cardiac-arrest/ Fri, 02 Aug 2013 22:08:02 +0000 http://emcrit.org/?p=4934 New medication therapy for cardiac arrest New medication therapy for cardiac arrest
New Study in JAMA:
JAMA. 2013 Jul 17;310(3):270-9. doi: 10.1001/jama.2013.7832.
Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial
Mentzelopoulos SD, Malachias S, Chamos C, Konstantopoulos D, Ntaidou T, Papastylianou A, Kolliantzaki I, Theodoridi M, Ischaki H, Makris D, Zakynthinos E, Zintzaras E, Sourlas S, Aloizos S, Zakynthinos SG.

Source  First Department of Intensive Care Medicine, University of Athens Medical School, Athens, Greece. sdmentzelopoulos@yahoo.com

Abstract

IMPORTANCE:  Among patients with cardiac arrest, preliminary data have shown improved return of spontaneous circulation and survival to hospital discharge with the vasopressin-steroids-epinephrine (VSE) combination.

OBJECTIVE:  To determine whether combined vasopressin-epinephrine during cardiopulmonary resuscitation (CPR) and corticosteroid supplementation during and after CPR improve survival to hospital discharge with a Cerebral Performance Category (CPC) score of 1 or 2 in vasopressor-requiring, in-hospital cardiac arrest.

DESIGN, SETTING, AND PARTICIPANTS:  Randomized, double-blind, placebo-controlled, parallel-group trial performed from September 1, 2008, to October 1, 2010, in 3 Greek tertiary care centers (2400 beds) with 268 consecutive patients with cardiac arrest requiring epinephrine according to resuscitation guidelines (from 364 patients assessed for eligibility).

INTERVENTIONS:  Patients received either vasopressin (20 IU/CPR cycle) plus epinephrine (1 mg/CPR cycle; cycle duration approximately 3 minutes) (VSE group, n?=?130) or saline placebo plus epinephrine (1 mg/CPR cycle; cycle duration approximately 3 minutes) (control group, n?=?138) for the first 5 CPR cycles after randomization, followed by additional epinephrine if needed. During the first CPR cycle after randomization, patients in the VSE group received methylprednisolone (40 mg) and patients in the control group received saline placebo. Shock after resuscitation was treated with stress-dose hydrocortisone (300 mg daily for 7 days maximum and gradual taper) (VSE group, n?=?76) or saline placebo (control group, n?=?73).

MAIN OUTCOMES AND MEASURES:  Return of spontaneous circulation (ROSC) for 20 minutes or longer and survival to hospital discharge with a CPC score of 1 or 2. RESULTS:  Follow-up was completed in all resuscitated patients. Patients in the VSE group vs patients in the control group had higher probability for ROSC of 20 minutes or longer (109/130 [83.9%] vs 91/138 [65.9%]; odds ratio [OR], 2.98; 95% CI, 1.39-6.40; P?=?.005) and survival to hospital discharge with CPC score of 1 or 2 (18/130 [13.9%] vs 7/138 [5.1%]; OR, 3.28; 95% CI, 1.17-9.20; P?=?.02). Patients in the VSE group with postresuscitation shock vs corresponding patients in the control group had higher probability for survival to hospital discharge with CPC scores of 1 or 2 (16/76 [21.1%] vs 6/73 [8.2%]; OR, 3.74; 95% CI, 1.20-11.62; P?=?.02), improved hemodynamics and central venous oxygen saturation, and less organ dysfunction. Adverse event rates were similar in the 2 groups.

CONCLUSION AND RELEVANCE:  Among patients with cardiac arrest requiring vasopressors, combined vasopressin-epinephrine and methylprednisolone during CPR and stress-dose hydrocortisone in postresuscitation shock, compared with epinephrine/saline placebo, resulted in improved survival to hospital discharge with favorable neurological status.]]>
Scott D. Weingart, MD clean 3:54
SMACC Back 2 – IVC for Decisions on Fluid Status https://emcrit.org/emcrit/ivc-for-decisions-on-fluid-status/ Mon, 29 Jul 2013 15:45:02 +0000 http://emcrit.org/?p=4837 A SMACC Back on Justin Bowra's IVC Ultrasound bashing. A SMACC Back on Justin Bowra's IVC Ultrasound bashing.

Justin Bowra gave a fantastic lecture on the use of IVC ultrasound at SMACC.



Here is the audio, if you want to hear the original lecture:



There was a post on Life in the Fast Lane by Justin as well.

His slides from the talk are here:


Now let's get to the SMACCing back...
I agree with 90% of Justin's talk, but as to the other 10%:

D-Dimer????
Mech Ventilated Patients
Collapse???
Diagnosis of Undifferentiated Shock
Quick look at size and collapsibility gives huge amounts of information
Fluid Responsiveness
Need a strategy for Spontaneously Breathing Patients

* Go bronze and give a bunch of fluid until you feel slightly uncomfortable
* Then go for the silver and resus until IVC starts to lose easily discernible collapse (20-30%)
* If you want to be really cool, at this point go for the gold-use some marker of stroke volume to see if additional fluid will be of benefit (either with empiric add. bolus or passive leg raise). If you want to be lazy, just put them on some norepi at this point.

Now if you use this strategy, you need to look at the operator receiver thingy-me-bobs [sic]

Spont. breathing IVC-CI trials fail due to the misfounded desire for dichotomy.

Lanspa



(Lanspa M et al. Shock 2013. 39(2). pp. 155-160)

Muller



(Muller L et al. Critical Care 2012, 16:R188)

This makes sense as respiratory-dynamic CVP demonstrates the same thing (Shock 2006;26(2):140)

Confounders:
Splint IVC open-Tamponade, Tension PTX, Massive PE, Status Asthmaticus, Right heart disease

Don't sniff test, don't tell the pt to do weird abdominal yoga breathing
Fluid Tolerance
IVCCI 15% had good accuracy (92% sens/84% spec) for CHF (Blehar et al. The American Journal of Emergency Medicine 2009;27(1):71)

and (Miller at al. Am J Emerg Med 2012;30:778) showed similar text characteristics.

by all means add in the Lichtenstein Lung Ultrasound, but only if negative when you start
We need more and better Studies

* Get a bunch of sick patients
* Do an IVCCI with a cut off of something like 30%
* Give fluid (500-1000 ml crystalloid)
* See if there was a 15% increase in SVi with a REAL cardiac output monitor or skilled evaluation of LV VTI
* AND
* see if there was a >5 mm Hg increase in arterial line MAP

and now on to the SMACC Down...]]>
Scott D. Weingart, MD clean 17:21
Podcast 103 – Avoiding Resuscitation Medication Errors – Part II https://emcrit.org/emcrit/avoiding-resuscitation-medication-errors-2/ Sun, 21 Jul 2013 20:32:12 +0000 http://emcrit.org/?p=4795 I am joined by Bryan Hayes for Part II of our discussion on the avoidance of critical medication errors during resuscitations. I am joined by Bryan Hayes for Part II of our discussion on the avoidance of critical medication errors during resuscitations.

A few weeks ago, I interviewed Bryan Hayes, the Pharm ER Tox Guy, on the subject of avoiding medication errors during resuscitation. That was Part I; today we move on to Part II.

Bryan is a pharmacist with a fellowship in toxicology. He tweets as PharmERToxGuy and blogs at Academic Life in EM.
Insulin Drip Preparation
Flush 20- 50 cc of Insulin/NS drip through all IV tubing, before infusion begins (to saturate the insulin binding sites in the tubing) [UMD's protocol + Yale's]... Goldberg PA, et al. Diabetes Technol Ther 2006;8(5):598-601.
This article states you must prime 20 ml from a 100 ml bag containing Regular Insulin 1 unit/mL (Crit Care Med 2012;40(12):3266)

Nalaxone Dosing
 big doses are out, smaller doses are in.
I use 0.4 mg diluted in 10 ml of saline to yield 0.04 mg/ml. Give 1-2 ml at a time. If you think this is an opioid, but that amount didn't work, keep going--some overdoses require a ton of nalaxone

Hydromorphone
Hydromorphone dosing - why are our residents scared to give more than 4 mg of morphine, but have no problem giving 1 mg of hydromorphone (equal to 7 mg of morphine)?

Hydralazine
Hydralazine and its erratic blood pressure lowering in hypertensive emergency

Infusion Deadspace can delay drug initiation
Deadspace when initiating infusions on low ml/hr drips: this may result in an hour between initiation and drug reaching bloodstream. Should we infuse into flowing line? Draw up and inject until it hits vein?

(Anaesthesia 2013;68:640)

This article (Emerg Med J 2007;24:558–559) discusses the perils of ignoring deadspace for infusions
Syringe Labeling
Importance of labeling syringes properly
Should be Generic Drug Name and then concentration based contents (e.g. Succinylcholine 20 mg/ml)
(Br. J. Anaesth 2013;110:1056.)
Top Ten Drug Error Commandments (Abridged for ED Relevan ce)

* Never inject a drug from a non-labelled syringe
* Never inject a drug that you are not familiar with
* Keep all empty vials until you conclude resuscitation
* Whoever injects the drug is responsible for the drug

(Anaesthesia 2013;68:640)

and I would add a 5th

* Show the vial with the syringe you just mixed to whomever will be injecting

EMS Educast has a great podcast on human factors in medication errors]]>
Scott D. Weingart, MD clean 17:51
Podcast 102 – Don’t Half-Ass your FAST! https://emcrit.org/emcrit/fast-exam/ Sun, 07 Jul 2013 15:58:52 +0000 http://emcrit.org/?p=3902 I've wanted to discuss tips and pitfalls for the FAST exam for a while now, but I needed a master to talk with. Luckily at Castlefest, I met Laleh Gharahbaghian, MD. I've wanted to discuss tips and pitfalls for the FAST exam for a while now, but I needed a master to talk with. Luckily at Castlefest, I met Laleh Gharahbaghian, MD.

I've wanted to discuss tips and pitfalls for the FAST exam for a while now, but I needed a master to talk with. Luckily at Castlefest, I met Laleh Gharahbaghian, MD. She is the Ultrasound Director at Stanford's Dept. of Emergency Medicine as well as being too cool for school. She is also FOAMY with what I think is the best blog on all things point-of-care ultrasound: sonospot.com.

Sonospot Posts on the FAST
I was going to write up comprehensive show notes for this episode, but thankfully Laleh published a post that encompasses EVERYTHING we we spoke about. So go read the ultimate blogpost on the FAST exam.
The Right-Upper Quadrant

* SonoTutorial: The FAST Part 1: The right upper quadrant – the right way to do it
* SonoTutorial: The FAST Part 1a: The Right Upper Quadrant: Images That Could Fool You
* SonoTutorial: The FAST Part 1b: The Right Upper Quadrant: More images that could fool you
* Optimizing RUQ images

Update: Here is the article on Trendelenburg for Optimal RUQ (Am J Emerg Med 1999;17(2):118)
The Left-Upper Quadrant

* The FAST Part 2: Left Upper Quadrant
* SonoTutorial: The FAST Part 2a: Left Upper Quadrant – Images that could fool you…
* SonoTutorial: The FAST Part 2b: Left Upper Quadrant – More images that could fool you

The Pelvic View

* Sonospot will have a post on this coming up soon

The Heart

* SonoTips & Tricks: The FAST scan: The Cardiac views #FOAMed


* SonoTip&Trick: “I can’t tell if it’s a pleural or pericardial effusion.” Really? well here’s a tip

Why do we mess up the exam?
Laselle et al. published on why false-negative FASTs occurred [Ann Emerg Med 2012;60:326]. See this wonderful post from the Sonospot blog on the Laselle article and false-negative FASTs.
Want more?
Head on over to the Ultrasound Podcast for more from my friend Cliff Reid
Updates:
Finally a study demonstrating that you MUST see the liver tip (Caudal Edge of the Liver in the Right Upper Quadran...]]>
Scott D. Weingart, MD clean 28:27
SMACC-Back – Myburgh on Catecholamines https://emcrit.org/emcrit/myburgh-on-catecholamines/ Wed, 26 Jun 2013 22:49:57 +0000 http://emcrit.org/?p=4754 SMACC Back 1 on Catecholamines SMACC Back 1 on Catecholamines

One of the best lectures from SMACC 2013 was Dr. John Myburgh on Catecholamines.



 

Here is the Video Version of the Lecture:



Or you can listen to the audio on the SMACC Feed or in Itunes
Now on to the SMACC-Back...
 ]]>
Scott D. Weingart, MD clean 4:52
Podcast 101 – Avoiding Resuscitation Medication Errors – Part I https://emcrit.org/emcrit/avoiding-resuscitation-medication-errors/ Sun, 23 Jun 2013 17:26:49 +0000 http://emcrit.org/?p=4714 I am joined by Bryan Hayes to discuss the avoidance of critical medication errors during resuscitations. I am joined by Bryan Hayes to discuss the avoidance of critical medication errors during resuscitations.
Bryan Hayes
Today I am lucky to have the opportunity to interview Bryan Hayes, the Pharm ER Tox Guy, on the subject of avoiding medication errors in the ED. Bryan is a pharmacist with a fellowship in toxicology. He tweets as PharmERToxGuy and blogs at Academic Life in EM.

Medication Errors during Resuscitations

* It is extremely easy to make errors during resuscitations. (Resuscitation 2012;83(4):482-7) Also, read the review by EMLitofNote
* Pharms in the ED may help (Ann Emerg Med 2010;55(6):513-21)
* Boarding Patients and Temp Nurses may make things worse (Ann Emerg Med 2010;55(6):522-6 and ( J Healthc Qual 2011;33(4):9-18)
* Excellent post on code medication error prevention

High-Risk Drugs
Bryan mentioned the PINCH acronym

Potassium, Insulin, Narcotics, Chemotherapy Agents, and Heparin
TPA dosing in stroke and PE
High stress and low use make this drug error-prone
The Resus Review wrote up tPA mixing instructions
The Drip Sheet Project

No calculators or mental math should ever be involved with Resus medication administration. Our drip sheet project attempts to prevent this. These sheets are printed out for mixing and then taped to the infusion pumps.

My tPA Drip sheet for acute stroke and PE

Here is Bryan's TPA Sheet as well:


EPINEPHrine
The root of all evil for drug errors!

Great article from the Nursing Literature (J Emerg Nurs 2013;39:151)

* Why the ridiculous dilution-dosing notation?
* Should we have multiple concentrations?
* Should we be giving IM dosing?

Are Epipens the Solution?
Bryan had an error where a 1 mg dose was given IV for anaphylaxis. Patient developed ECG changes and troponin leak. He removed the 1 mg/mL vials and replaced them with the much more expensive EPIpens. Other solutions: premade pharmacy IM Syringes or just dispense with IM and give IV infusion for all patients.
Kanwar M. Ann Emerg Med 2010;55(4):341-4
Why are premix bags not readily available everywhere? - Bryan outsources for 6.25mg in D5W 250ml (25mcg/ml) and 2mg in D5W 250ml (6mcg/ml)

Insulin Issues
HyperK

What is the proper accompanying dose of D50 when giving insulin IVP for hyperkalemia?
- 10 units of regular insulin in 500 mL of 10 percent dextrose, given over 60 minutes.
- 10 units of regular insulin bolus, followed immediately by 50 mL of 50 percent dextrose (25 g of glucose) is inadequate! This regimen may provide a greater reduction in serum potassium since the potassium-lowering effect is greater at the higher insulin concentrations attained with bolus therapy. However, hypoglycemia occurs in up to 75 percent of patients treated with the bolus regimen, typically about one hour after the infusion. To avoid this complication, infuse 10 percent dextrose at 50 to 75 mL/hour or give 2 amps of D50 (50 grams) and ensure close monitoring of blood glucose levels.
Update: One of the commenters below asked for a reference for the up to 75% statistic. Took some time to track it down,]]>
Scott D. Weingart, MD clean 23:50
Podcast 100 – What is Critical Care and What is EMCrit? https://emcrit.org/emcrit/essence-critical-care/ Sun, 09 Jun 2013 20:06:27 +0000 http://emcrit.org/?p=4702 Keynote from SMACC 2013 Keynote from SMACC 2013

Thanks for joining me on the wild ride of these first 100 episodes!

This was the opening lecture of SMACC 2013. Chris Nickson assigned me the lecture: What is the essence of critical care? In ruminating on that topic what I really came to is the essence of this blog and podcast. The video is here:



but I think I agree with Brother Minh that it works even better as a podcast.


Now on to the Podcast...]]>
Scott D. Weingart, MD clean 21:45
EMCrit Wee – Is Lactate Clearance a Flawed Paradigm? https://emcrit.org/emcrit/lactate-clearance-flawed/ Wed, 05 Jun 2013 20:27:48 +0000 http://emcrit.org/?p=4751 Is lactate clearance a flawed paradigm? I don't think it is. Is lactate clearance a flawed paradigm? I don't think it is.
A listener, Øyvind S Holen, and the PrecordialThumper both alerted me to an article recently published by Paul Marik and Rinaldo Bellomo:
Lactate clearance as a target of therapy in sepsis: a flawed paradigm

In the paper, they discuss many of the misunderstandings re: lactate and lactate clearance. This wee is my response. I'd love to hear your opinions.
Update
New article on the Kinetics of Lactate Clearance
Now on to the Wee...]]>
Scott D. Weingart, MD clean 7:28
Podcast 99 – Combat Aviation Paradigms for Resuscitationists https://emcrit.org/emcrit/combat-aviation-paradigms/ Sun, 26 May 2013 18:42:58 +0000 http://emcrit.org/?p=4720 Aviation is to anesthesia as Combat Aviation is to Resuscitation Aviation is to anesthesia as Combat Aviation is to Resuscitation

Joe Novak, MD was an F-15 Combat Pilot and now is an Emergency Physician. In this fantastic lecture, he brings the concepts of Combat Aviation to the art of Resuscitation.

The Boldface
aka the no-shitters things that must be absolutely incorporated into your memory and available for immediate execution. You should not need to think about what to do in these situations.
Checklists
Cognitive unloading and guarantee of the performance of critical actions. Use after addressing the boldface
Prioritization of Attention and Tasks
In combat aviation:

* Aviate
* Navigate
* Communicate

In EM & Critical Care:

* Resuscitate
* Differentiate
* Communicate

The Cross-Check
Keep coming back to the global patient picture before diving into any minutiae
Efficient and Unambiguous Communication

* Directive
* Descriptive
* Informative

Briefing
Pre-Brief

Planning: Mission, Defined Roles, and Set the tone

De-brief

Learning happens in the debrief

Perception-Decision-Execution
Pre-Flight Read Files
Can't fly until you have read and signed-off on any new procedures or techniques

 
Need an Audio-Only Option?
Right-Click Here and Choose Save-As
Now on to the Podcast...


]]>
Scott D. Weingart, MD clean 26:06
Podcast 98 – Cyclic (Tricyclic) Antidepressant Overdose https://emcrit.org/emcrit/tricyclic-antidepressant-overdose/ Tue, 14 May 2013 21:44:44 +0000 http://emcrit.org/?p=4633 Tricyclic overdoses are not uncommon and these patients can be incredibly ill. Tricyclic overdoses are not uncommon and these patients can be incredibly ill.


I had a crazy case of Tricyclic Overdose while on an overnight shift at Janus General.
Initial and Post-Treatment EKGs



List of Tricyclic Agents from Wikipedia.org

* Amitriptyline (Tryptomer, Elavil)
* Amitriptylinoxide (Amioxid, Ambivalon, Equilibrin)
* Butriptyline (Evadyne)
* Clomipramine (Anafranil)
* Demexiptiline (Deparon, Tinoran)
* Desipramine (Norpramin, Pertofrane)
* Dibenzepin (Noveril, Victoril)
* Dimetacrine (Istonil, Istonyl, Miroistonil)
* Dosulepin/Dothiepin (Prothiaden)
* Doxepin (Adapin, Sinequan)
* Imipramine (Tofranil, Janimine, Praminil)
* Imipraminoxide (Imiprex, Elepsin)
* Lofepramine (Lomont, Gamanil)
* Melitracen (Deanxit, Dixeran, Melixeran, Trausabun)
* Metapramine (Timaxel)
* Nitroxazepine (Sintamil)
* Nortriptyline (Pamelor, Aventyl, Norpress)
* Noxiptiline (Agedal, Elronon, Nogedal)
* Pipofezine (Azafen/Azaphen)
* Propizepine (Depressin, Vagran)
* Protriptyline (Vivactil)
* Quinupramine (Kevopril, Kinupril, Adeprim, Quinuprine)

Additionally...

* Amineptine (Survector, Maneon, Directim) Norepinephrine-dopamine reuptake inhibitor
* Iprindole (Prondol, Galatur, Tetran) 5-HT2 receptor antagonist
* Opipramol (Insidon, Pramolan, Ensidon, Oprimol) ? receptor agonist
* Tianeptine (Stablon, Coaxil, Tatinol) Selective serotonin reuptake enhancer
* Trimipramine (Surmontil) 5-HT2 receptor antagonist and moderate-potency norepinephrine reuptake inhibitor.

And of course, the non-TCA agents...



* Diphenhydramine
* Cocaine
* Cyclobenzaprine (I add this one to the list, b/c there can be TCA-like effects in toxicity, but it seems the potential for cardiac effects is markedly less though still possible. (J Emerg Med 1995;13(6):781-5) This one is from Bryan Hayes)

Pharmacologic Effects of TCAs



K+ Channel Blockade
QTC Prolongation


NE & Serotonin Reuptake Inhibition
Initial hypertension quickly followed by hypotension


Na+ Channel Blockade
QRS Prolongation
Hypotension — depresses myocardial contractility
Ventricular dysrhythmias
Brugada-like findings on EKG


Muscarinic Anticholinergic Receptor Antagonism
Anticholinergic Toxidrome


Antihistaminergic
CNS stimulation or sedation


Alpha1 Adrenergic Antagonism
Hypotension


GABA-A Receptor Blockade
Seizures



This chart was taken from the excellent Resus Review Blog by Charles Bruen
Sodium Bicarbonate
Increases amount of drug in non-ionized form and may decrease binding to Na-channels [cite]11482860[/cite]

May need many, many amps. For some reason the sodium and the bicarb don't rise significantly in severe toxicity

My goals are QRS duration <100, hemodynamically stable, Na ~150, pH ~7.5
Electrolyte Abnormalities
Beware of hypokalemia and hypocalcemia

Send VBG with lytes at least Q1 hour
Hyperventilation
To promote alkalosis
Hypertonic Saline
If the patient is too alkalotic or out of amps of Bicarb

Sodium Acetate

Can substitute for NaBicarb. This article gives dosing recommendations and precautions. [cite]23636658[/cite]
Intubation & Sedation
]]>
Scott D. Weingart, MD clean 22:39
EMCrit Wee – Janus General and Service Update https://emcrit.org/emcrit/janus-general-service-update/ Mon, 06 May 2013 23:00:23 +0000 http://emcrit.org/?p=4639 Learn about Janus General Learn about Janus General Janus General is a virtual hospital where I will set all of my future cases. The inspiration for a virtual hospital comes from my friends at the St. Emlyn's Blog.
Where to Comment/Question
If it is about a blogpost/podcast, comment here on the EMCrit.org site

If it is a clinical question or discussion, go to the EMCrit G+ Community Page

If it is a quick comment or question, hit me on Twitter

If it is a problem with the EMCrit Site or the CME Site, come to the Contact Page
Direct Link to CME for Each Episode
Starting with episode 97, at the bottom of each post, there is a direct link to get CME:

]]>
Scott D. Weingart, MD clean 7:40
Podcast 97 – Acid-Base VI – Chloride-Free Sodium https://emcrit.org/emcrit/chloride-free-sodium/ Thu, 02 May 2013 17:16:18 +0000 http://emcrit.org/?p=4591 So last podcast, I bashed on sodium bicarbonate or as John Kellum and David Story call it: chloride-free sodium. This episode I talk about all the good reasons to use NaBicarb. So last podcast, I bashed on sodium bicarbonate or as John Kellum and David Story call it: chloride-free sodium. This episode I talk about all the good reasons to use NaBicarb.

Just returned from Castlefest 2013--best ultrasound conference ever!

So last podcast, I bashed on sodium bicarbonate or as John Kellum and David Story call it: chloride-free sodium. This episode I talk about all the good reasons to use NaBicarb. This is part of a series

* Part I lays out the background of the quantitative approach
* Part II puts it in mathematical terms to allow calculation of acid base status
* Part III takes you through some real world examples
* Part IV discusses the Acid-Base Effects of IV Fluids
* Part V down with the Bicarb
* Part VI is this one: ok, bicarb is not all bad

The Acid Base Series

A physiology quandary
Owen, an anaesthesia registrar, wrote with this comment:

[...On increasing minute ventilation on vented patients with any bicarb given: Great idea and probably what most of us do, but even if you don't then with each breath the patient will be getting rid of more CO2 than previously so there should be more weak acid loss.]

This is one of those situations where I was gobsmacked for a second. When I started to think about this, it seemed intuitively wrong and yet conceptually right. I knew I needed to find someone far smarter than me. I reached out to Mel Herbert, who recommended David Story. Dr Story is Chair of Anaesthesia at the Melbourne Medical School and a physiology god. Here is his response:

Dr. Story, Here is the quandary. As you saw, I did that acid-base show with Dr. Kellum discussing NaBicarb use for the critically ill. Both Dr. Kellum and I believe and the evidence bares out that in a patient who can't get rid of the excess CO2, there will be negligible changes in pH from the bicarb administration.Now in an apneic patient, I think this is inarguable. However, in a mech. ventilated patient with no resp drive (let's say a pt we gave NMBs to), I perpetrated the situation would be the same. In response of my listeners brought up this question: If the minute ventilation is kept the same, but the ETCO2 rises (and by extension, the return of CO2 to the alveoli), this would seem to indicate that each breath is actually eliminating more CO2. Say the ETCO2 went from 40 to 80 with the same Vt. Is more CO2 being eliminated and if so, would this alone clear the transitory excess CO2 from the bicarb? This made me think of the opioid overdose patient. As their CO2 rises, are they too eliminating more CO2 with each of their breaths? My cursory understanding has always been simply that CO2 elimination is directly proportional to minute ventilation. That is what i took from West and never really gave it much thought. Now I am thinking and it is puzzling. --Scott
Response from Dr. Story: I agree it is confusing but this is how I see it. I wrote a letter the Anesthesiology years ago on a related topic.

The short answer is it is all relative.

The universal alveolar air equation for any gas (x) is:
PAx = PIx +/- Vx / VA; where PA is alveolar partial pressure, Vx is production or consumption of the gas

For an excreted gas like CO2 this will be:
]]>
Scott D. Weingart, MD clean 18:01
Podcast 96 – Acid Base in the Critically Ill – Part V – Enough with the Bicarb Already https://emcrit.org/emcrit/enough-with-the-bicarb-already/ Sun, 14 Apr 2013 15:33:56 +0000 http://emcrit.org/?p=4572 More on Bicarb in the Critically Ill and a discussion with John Kellum, MD More on Bicarb in the Critically Ill and a discussion with John Kellum, MD

This is Part V of the EMCrit Acid-Base Talks. If you haven't listened to the initial series, you may be better off starting there:

* Part I lays out the background of the quantitative approach
* Part II puts it in mathematical terms to allow calculation of acid base status
* Part III takes you through some real world examples
* Part IV discusses the Acid-Base Effects of IV Fluids
* Part V is this one, down with the Bicarb
* Part VI ok, bicarb is not all bad

The Acid Base Series

Acid-Base Sheet
EMCrit Acid-Base Sheet
Today's topic comes from a debate I have been having with Steve Smith of the amazing EKG Blog. The main thrust of the debate started with this question...
Does Bicarb Fix pH if You Can't Increase Minute Ventilation?
 

When you can adjust PaCO2 to maintain a certain value (i.e. you increase minute ventilation), bicarb will raise pH as evidenced by this animal study (Crit Care Med 1996; 24:827-834). However, if you can't blow off the CO2 then the effects on pH will not be there (J Pediatr 1977;91(2):287).

In this study, NaBicarb did not correct the pH, while CarbiCarb did (Carbicarb: an effective substitute for NaHCO3 for the treatment of acidosis. (Surgery 102:835–839).

This review article recommends against bicarb for permissive hypercapnia (Intensive Care Med (2004) 30:347–356).

This study furthers the idea that NaBicarb is not all that great in closed systems (J Pediatr 1972;80(4):671) and then this discussion explores all of the biochemical reasons why administering bicarbonate as a rapid push in a closed system is a bad idea (J Pediatr. 1972 Apr;80(4):681-2.).

Here is a quote from another review article (Anesthesiology 1990;72(6):1064):
The key concept in the equation [above] is that pH is not related to the absolute value of either bicarbonate concentration nor PCo2, but rather to their ratio.
When exogenous bicarbonate is administered during acidemia, bicarbonate reacts with hydrogen ions to form carbonic acid. Physicochemical equilibrium is shifted, favoring dissociation of carbonic acid to C02 and water. C02 partial pressure increases. The degree of alkaliniza- tion resulting from increased [HC03“] is limited by the rise in Pco2* In (open) systems where increases in PCo2 are prevented (by ventilation) alkalination occurs. When CO2 cannot be eliminated, the pH of the system is only minimally changed. Ostrea and Odel demonstrated in vitro that when isotonic sodium bicarbonate was added to whole blood in a (closed) system where generated C02 could not escape, PCo2 increased and pH was unchanged. Only when C02 was eliminated was the system alkalinized. Similarly, Steichen and Kleinman noted in hypoxic acidotic dogs that administration of 2 mEq/kg of sodium bicarbonate over 3 min when ventilation was unchanged resulted in no net change in arterial pH, although PaCo2 rose from 46 to 61 mmHg. If C02 elimination cannot keep pace with increased C02 generation, administration of bicarbonate during acidemia produces hypercarbia (respiratory acidosis) with little net improvement in pH.]]>
Scott D. Weingart, MD clean 20:07
Episode 12 – New Trauma Guidelines: ATLS and Spine https://emcrit.org/practicalevidence/atls-and-spine/ Sun, 14 Apr 2013 02:06:29 +0000 http://practicalevidence.org/?p=318 New Trauma Guidelines: ATLS and Spine New Trauma Guidelines: ATLS and Spine Today, we discuss two new Trauma Guidelines
ATLS 9th Ed.
The 9th edition of ATLS has been published. In this episode, I review the changes from the 8th edition.
Management of C-Spine Injuries
We also go over the new management of spinal cord injuries from the Neurosurgeons
Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries from the American Association of Neurological Surgeons

(Neurosurgery 2013;72(supplement 2):1-259 Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries)

What's EMCrit Drinking?

]]>
Scott D. Weingart, MD clean 11:37
Podcast 95 – Thomas Scalea on Cutting-Edge ICP Management https://emcrit.org/emcrit/cutting-edge-icp-management/ Tue, 02 Apr 2013 05:46:57 +0000 http://emcrit.org/?p=4563 Thomas Scalea discusses new frontiers in the management of ICP and TBI Thomas Scalea discusses new frontiers in the management of ICP and TBI
For the basics of ICP Management, check out this prior podcast.
Slides
Here is a pdf of Dr. Scalea's Slideset
Audio-Only Version
Need just the mp3? Right-click here and choose save-as.
Now on to the podcast...
]]>
Scott D. Weingart, MD clean 44:34
EMCrit Wee – The Vortex Approach https://emcrit.org/emcrit/vortex-approach/ Thu, 28 Mar 2013 15:38:44 +0000 http://emcrit.org/?p=4351 The vortex approach is a new paradigm for airway management in all areas of the hospital The vortex approach is a new paradigm for airway management in all areas of the hospital


What these two gentlemen have crafted is a paradigm called the vortex approach. It is best represented by this diagram:



And here are versions with even more information:



I could write about the method, but to do it true justice, it is better to watch this video:

http://www.youtube.com/watch?feature=player_embedded&v=HE_uy_1Skq8
The Shock Trauma Algorithm
Now you folks know I am partial to a modified-version of the Shock Trauma Algorithm for Failed Airway Management. It is bar none the simplest, most effective (and validated) algo I have come across. Or at least it was until I started parsing the Vortex Approach. The reason is that the Vortex Approach encompasses the STC algorithm in a way that is universal to all specialties and settings.
Ebook
Nicholas and Peter wrote a free ebook about the concept, which is available in a number of formats.


Websites
They also have a website set up for the Vortex Approach as well as other projects on their Clinical CrEd Site. The Vortex site also has videos demonstrating the approach in action in both an emergency department and operating theater intubation.
Podcast
Minh Le Cong did an interview with the two of them on his PHARM podcast site that is definitely worth a listen.
Apps I Liked
I was sent free evaluation copies of 2 IOS applications:

* The IOS version of PressorDex from the EMRA folks. The pocket-book was good; the app is even better.
* An application listing the most important critical care papers and a short summary of their impact. The app is called ICU Trials by Sean Kane. The link goes to the free lite version; if you like it buy the full version.

Now on to the Wee...]]>
Scott D. Weingart, MD clean 9:33
EMCrit Wee – The Holy Grail of Fluid Resuscitation is just a Tin Cup https://emcrit.org/emcrit/holy-grail-fluid-resuscitation/ Thu, 21 Mar 2013 18:34:07 +0000 http://emcrit.org/?p=4513 Chad Meyers' lecture on fluid resus in severe sepsis Chad Meyers' lecture on fluid resus in severe sepsis
I will be bringing Roger Harris, MD of SMACC and Sydney ICU fame on the show in the very near future to debate this very issue.

Need the audio-only version? Right Click Here and Choose Save-as.
CME is available for this episode
Now on to the Wee...
]]>
Scott D. Weingart, MD clean 17:40
EMCrit WEE – SMACC 2013 Summary and Learning Points https://emcrit.org/emcrit/smacc2013/ Mon, 18 Mar 2013 22:24:17 +0000 http://emcrit.org/?p=4501 SMACC - The best Critical Care Conference...EVER!! SMACC - The best Critical Care Conference...EVER!! SMACC 2013 was, bar none, the best Critical Care Conference I have ever attended!
The People
I got to meet people like...



Doug Lynch (@thetopend)

Victoria Brazil (@SocraticEM)

and Most Importantly,

to all of the wonderful listeners that introduced themselves--I Love You!
Jetlag
Great Article (CLEVELAND CLINIC JOURNAL OF MEDICINE 2011;78(10):675)
SMACC-Backs are coming...
The Clinical Stuff
IVC Ultrasound
SIMWars


* BP Rep Time
* Drip Sheets - See the EHCED drip-sheet project
* Tension Pneumo
* Bind the Pelvis

 ]]>
Scott D. Weingart, MD clean 19:32
Episode 11 – Ischemic Stroke 2013 https://emcrit.org/practicalevidence/ischemic-stroke-2013/ Mon, 04 Mar 2013 04:26:53 +0000 http://practicalevidence.org/?p=261 2013 Ischemic Stroke Guidelines from AHA/ASA and ACEP 2013 Ischemic Stroke Guidelines from AHA/ASA and ACEP Ischemic Stroke Guidelines from the ASA
Hot off the presses; the 2013 Ischemic Stroke Guidelines from AHA/ASA (Stroke 2013;44:870)

Want the full recommendations as written by the AHA/ASA?
Stroke Centers

* Comprehensive Stroke Centers are god
* Should have neurocritical care unit
* EMS should bypass hospitals that can’t care for stroke
* Should have tele-rads if no in-house radiologists

Initial Eval

* Door to Drug within 60 minutes (80% compliance)
* Use a Stroke Scale, preferably NIHSS
* Get labs, but glucose is the only one that needs to be done before tPa
* Get EKG and troponin, don’t delay tPA for this

 


Imaging

* Get either a NCCT or MRI to exclude hemorrhage prior to tPA
* tPA indicated even if ischemic signs, unless a frank hypodensity is noted
* A non-invasive intracranial vascular study is strongly recommended during initial imaging if IA tPA or mechanical thrombectomy is contemplated. This should not delay tPA administration
* In tPA candidates, the CT or MRI should be read within 45 minutes of arrival by a physician with expertise in reading CTs or MRIs of the brain
* Consider CT Perfusion or MRI perfusion in patients outside of the window for IV tPA
* If frank hypodensity involves more than 1/3 of the MCA territory, IV tPA should be withheld

TIAs

* They should get imaging of their cervical vasculature
* Noninvasive imaging by CTA or MRA of the intracranial vasculature is rec. to exclude proximal intracranial stenosis or occlusion. Intracranial lesions may need confirmatory angio if occlusion seen on CTA
* Pts with transient sx should receive imaging within 24 hours, preferably by MRI

Acute Treatment

* Cardiac Monitoring
* New BP meds allowed to get the pt <180/110. Shoot for 180/105 for first 24 hours
* Intubate airway compromise or bulbar dysfunction
* Shoot for pulse ox > 94%. Don’t give supplemental O2 in patients with normal RA pulse ox
* Lower temps >38 C
* Until further evidence, use the same BP goals for IA/mech treatments
* In Non-tPA, only treat if SBP>220 or DBP>120
* Treat hypovolemia with NS and treat CO-reducing dysrhythmias
* Treat hypoglycemia
* May restart home anti-hypertensives after 24 hours
* Treat hyperglycemia to achieve a Blood Sugar of 140–180 mg/dl

IV Fibrinolysis

* Give IV tPA in patients who meet 3 hour criteria (IA)
* Getting it within window is not enough, shoot for the <60 minutes timeframe
* Give IV tPA to pts who meet criteria within 4.5 hours (IB)
* Be prepared to treat complications including bleeding and angioedema
* tPA is reasonable if pt had a seziure if treating team feels deficit is from stroke and not post-ictal state (IIaC)
* Benefits of sono-thrombolysis are unknown at this time
* Other agents besides tPA should only be used in clinical trials
* Benefit of tPA unknown in patients in the 3–4.5 hr range with one of the additional contra-indications
* Use of tPA in pts with mild deficits, rapidly improving deficits, major surgery in prior 3 months, and recent MI may be considered and should be based on risk benefit assessment
* Don’t use streptokinase
* The use of intravenous rtPA in patients taking direct thrombin inhibitors or direct factor Xa inhibitors may be harmful and is not recommended unless sensitive laboratory tests such as aPTT, INR, platelet count, and ECT, TT, or appropriate direct factor Xa activity assays are normal, or the patient has not received a dose of these agents for >2 days (assuming normal renal metabolizing function). Similar consideration should be given to patients being considered for intra-arte...]]>
Scott D. Weingart, MD clean 15:15
Podcast 94 – Has Video Laryngoscopy Killed the Direct Laryngoscope? https://emcrit.org/emcrit/has-video-laryngoscopy-killed-the-dl-star/ Sun, 03 Mar 2013 23:05:36 +0000 http://emcrit.org/?p=4462 I debate Paul Mayo on whether standard laryngoscopy still has a role in emergency and critical care intubation I debate Paul Mayo on whether standard laryngoscopy still has a role in emergency and critical care intubation
Last year, we debated whether paralytics should be used for emergent intubations.

This year, the topic was Should All Intubations be Performed with Video Laryngoscopy?

I think you will enjoy the debate, because we don't mind attacking our opponent.

If you enjoyed this podcast and the others on the EMCrit site, please consider supporting the show at CME.EMCrit.org.
Need an audio-only version?
Right click here and choose save-as
Now, on to the debate...


 ]]>
Scott D. Weingart, MD clean 23:02
Podcast 93 – Critical Care Palliation with Ashley Shreves https://emcrit.org/emcrit/critical-care-palliation/ Mon, 18 Feb 2013 04:40:08 +0000 http://emcrit.org/?p=4412 One of the best palliative care lectures I have ever heard. One of the best palliative care lectures I have ever heard. podcast episode on critical care palliation a year or so ago.

At this year's EMCrit Conference, Ashley Shreves gave the ultimate lecture on the topic. Twenty minutes jam-packed with goodness.

* The End-of-Life and Palliation Education Resource Center

A listener, Don Zweig, wrote with this summary:

* We (as in ED docs) in general deal with End of Life Care and palliative care situations poorly.
* Our job as physician is to understand the family goals and values and then give a professional recommendation- it is not to give a menu--they have no medical knowledge to reasonably make this choice.
* Three things we should never say:



*  "Do you want us to do everything?"  Of course they do, but if you offer "everything" who wouldn't want mom to get everything? Could they say…."no, whatever you do , don't do everything for mom!" This also makes the family feel that everything (whatever that entails) is reasonable or possible. Instead use the 'Pal Care' approach and say, "What would be most important to you and your mom now?"  On the basis of what you hear make a reasoned professional recommendation.
* "Do you want us to resuscitate her?"  This implies that we think it is possible or reasonable to do this!  Since you ask this it must be reasonable.  "You can just bring her back?  Great, go ahead!" Use natural death language.  So it sounds like your mom would want a natural death?  When her heart stops we will not interfere with that process
* " I am so sorry, there is nothing more we can do"  There is a lot that can be done and it involves maximizing comfort and minimizing suffering. They need palliative care or hospice.    So call a consult and give palliative meds.



* Try to get private room and take them off the monitor!  There is no place for monitor in the dying patient for which you are providing comfort care.
* Treat discomfort with morphine or dilaudid in very small doses.  Double every 15 minutes until decreased suffering.

Addendum
This amazing post on the blog Expensive Care is a must read on the topic of the ethics of CPR

Treating Pain in Palliative Patients
Need an Audio-Only version?
Right-Click here and choose save-as
Now on to the Vodcast...
]]>
Scott D. Weingart, MD clean 25:03
EMCrit Wee – Tacit Knowledge and Medical Podcasting https://emcrit.org/emcrit/tacit-knowledge-podcasting/ Wed, 13 Feb 2013 20:36:01 +0000 http://emcrit.org/?p=4400 I received a distressed email from a fan who was dismayed that other residents in her program were bashing medical podcasting; this is my response. I received a distressed email from a fan who was dismayed that other residents in her program were bashing medical podcasting; this is my response.

I received a distressed email from a fan who was dismayed that other residents in her program were bashing medical podcasting; this is my response.
What is Tacit Knowledge?

* Wikipedia Entry

Slide Show on Tacit Knowledge and Wicked Problems

Social Media as a Transmission Tool for Tacit Knowledge

* Social Media and Tacit Knowledge Sharing
* Potentials of Social Media for Tacit Knowledge Sharing - Preliminary Findings
* Conceptual Model for Social Media and Tacit Knowledge

Next horizon is to answer the question of how to solve Wicked Problems and can social media and FOAM help?

* Wicked Problems

What do you think?]]>
Scott D. Weingart, MD clean 10:46
EMCrit Conference Blast Winner: Peri-Mortem C-Section https://emcrit.org/emcrit/peri-mortem-c-section/ Tue, 12 Feb 2013 21:02:44 +0000 http://emcrit.org/?p=4378 Peri-Mortem C-Section Peri-Mortem C-Section EMCrit 2013 Conference we had a Blast Competition. The BLAST rules are easy:



The winner this year was Salil Bhandari with an incredible presentation on peri-mortem caesarean section.
Here is an article:
Eur J Emerg Med. 2011 Aug;18(4):241-2. doi: 10.1097/MEJ.0b013e328344f2c5. Prehospital resuscitative hysterotomy.
Want to know more about peri-mortem c-section? Check out these insanely good posts:

* The post Perimortem C-section at St.Emlyn’s appeared first on St Emlyns.
* A personal take from a doc, Greg Press, who has performed two of these (2 more than me)

Update
Neonatal outcome: mean times from arrest to delivery were 14±11 min and 22±13 min in survivors and non-survivors respectively (Resuscitation. 2012 Oct;83(10):1191-200.)
And here is a simulator video:
Video on Vimeo
And the best video on the procedure I have seen on life-identical model
https://www.youtube.com/watch?v=1v9x4jPQwE8
Update:
In one case series, 12 of 20 women had return of spontaneous circulation immediately after delivery (EMCNA, Vol. 30, pg. 949). HT to emedhome.

Rob Bryant has another great video on resuscitative hysterotomy
Now on to the Wee...
]]>
Scott D. Weingart, MD clean 12:55
Join the EMCrit G+ Community Page https://emcrit.org/emcrit/emcrit-google-community-page/ Sun, 10 Feb 2013 18:56:48 +0000 http://emcrit.org/?p=4383 A place for your Clinical Cases and Questions that are not podcast specific A place for your Clinical Cases and Questions that are not podcast specific
But I get a ton of clinical cases and questions by email or the contact form that have not been covered on a podcast yet. I love this--it exposes me to some great cases I would never hear about otherwise. Problem is, up until this point, it has been a 1 on 1 conversation. This is sort of a waste because nobody else benefits except you and me. So in the future, when you have a  case or question like this, I would love it if you posted to the Google Plus EMCrit Community page. This allows a few things:

* it allows my answer to be seen by a much larger group of people
* it allows folks smarter than me to chime in as well
* it keeps a record of these case interactions so I can refer people to them in the future

So how do you do it? Easiest way to learn is to watch this video:


]]>
Scott D. Weingart, MD clean 2:38
Podcast 92 – EMCrit Intubation Checklist https://emcrit.org/emcrit/emcrit-intubation-checklist/ Tue, 05 Feb 2013 19:14:18 +0000 http://emcrit.org/?p=3036 Since Peter Pronovost's landmark study on how a simple checklist can nearly abolish central line infections, checklists have been the darling of the medical literature Since Peter Pronovost's landmark study on how a simple checklist can nearly abolish central line infections, checklists have been the darling of the medical literature Intubation Checklist
Checklists
Since Peter Pronovost's landmark study on how a simple checklist can nearly abolish central line infections, checklists have been the darling of the medical literature. But central lines generally are for elective procedures, allowing us the time and patience to run through the list. Can we gain the same safety and cognitive benefits in an adrenaline-laden procedure like intubation? Hell yeah!
It all starts with the EMCrit Intubation Checklist


Download the checklist
The Components
HOp Killers
Here is the wee on the HOp Killers: Hemodynamic Kills, Oxygenation Kills, and pH Kills

* Intubating the Hemodynamically Unstable Patient
* Intubating the Patient at Risk for Critical Hypoxemia
* Intubating the Patient with Metabolic Acidosis

RSI or Awake? · DSI? · RSA? · ICP/Vascular?

* Awake Intubation Lecture
* More info on Delayed Sequence Intubation (DSI)
* Rapid Sequence Airway (RSA)
* ICP/Vascular Intubation

Are the peri-intubation medications ready?

Push-Dose Pressors

* Push-Dose Pressor Podcast and Mixing Sheet

What is the plan for unexpected difficult or failed airway?

* I use a modified version of the Shock Trauma Center Failed Airway Algorithm
* Cook Gas ILA (My preferred Extraglottic Airway)

Can the cricothyroid membrane be palpated?

* Cric-Con Approach to Cricothyrotomy Preparation

What is the plan for post-intubation sedation?

* A bad sedation package traps your patient in a nightmare

Is the patient positioned adequately?

Would the patient benefit from pre-intubation NGT?

* Intubating the GI Bleeder

Skills of Intubation
Laryngoscopy
http://vimeo.com/17542057
Video Laryngoscopy
Here are some tips
Cricothyrotomy
See this post for all things surgical airway
Post Intubation Management

* Ventilator Lecture
* The Package

Building Checklists

* The Checklist Project and their Checklist for Checklists
]]>
Scott D. Weingart, MD clean 28:36
2012 Surviving Sepsis Campaign Guidelines https://emcrit.org/emcrit/2012-surviving-sepsis-campaign-guidelines/ Thu, 24 Jan 2013 17:48:23 +0000 http://emcrit.org/?p=4318 2012 Surviving Sepsis Campaign Guidelines from my Practical Evidence Podcast 2012 Surviving Sepsis Campaign Guidelines from my Practical Evidence Podcast
The 2012 SSC Guidelines were just published and I saw the preview in Puerto Rico
2012 Surviving Sepsis Campaign Guidelines
See the Guidelines at (CCM 2013;41(2):580)
Diagnosis of Sepsis

Diagnosis of Severe Sepsis

The New Bundles

A. Initial Resuscitation

* Protocolized, quantitative resuscitation of patients with sepsis- induced tissue hypoperfusion (defined in this document as hypotension persisting after initial fluid challenge or blood lactate concentration ? 4 mmol/L). Goals during the first 6 hrs of resuscitation:

* Central venous pressure 8–12 mm Hg
* Mean arterial pressure (MAP) ? 65 mm Hg
* Urine output ? 0.5 mL/kg/hr
* Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively (grade 1C).


* In patients with elevated lactate levels targeting resuscitation to normalize lactate (grade 2C).

B. Screening for Sepsis and Performance Improvement

* Routine screening of potentially infected seriously ill patients for severe sepsis to allow earlier implementation of therapy (grade 1C).
* Hospital–based performance improvement efforts in severe sepsis (UG).

C. Diagnosis

* Cultures as clinically appropriate before antimicrobial therapy if no significant delay (> 45 mins) in the start of antimicrobial(s) (grade 1C). At least 2 sets of blood cultures (both aerobic and anaerobic bottles) be obtained before antimicrobial therapy with at least 1 drawn percutaneously and 1 drawn through each vascular access device, unless the device was recently (<48 hrs) inserted (grade 1C).
* Use of the 1,3 beta-D-glucan assay (grade 2B), mannan and anti-mannan antibody assays (2C), if available and invasive candidiasis is in differential diagnosis of cause of infection.
* Imaging studies performed promptly to confirm a potential source of infection (UG).

D. Antimicrobial Therapy

* Administration of effective intravenous antimicrobials within the first hour of recognition of septic shock (grade 1B) and severe sepsis without septic shock (grade 1C) as the goal of therapy.
* Initial empiric anti-infective therapy of one or more drugs that have activity against all likely pathogens (bacterial and/or fungal or viral) and that penetrate in adequate concentrations into tissues presumed to be the source of sepsis (grade 1B). Antimicrobial regimen should be reassessed daily for potential deescalation (grade 1B).
* Use of low procalcitonin levels or similar biomarkers to assist the clinician in the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infection (grade 2C).
* Combination empirical therapy for neutropenic patients with severe sepsis (grade 2B) and for patients with difficult-to-treat, multidrugresistant bacterial pathogens such as Acinetobacter and Pseudomonas spp. (grade 2B). For patients with severe infections associated with respiratory failure and septic shock, combination therapy with an extended spectrum beta-lactam and either an aminoglycoside or a fluoroquinolone is for P. aeruginosa bacteremia (grade 2B). A combination of beta-lactam and macrolide for patients with septic shock from bacteremic Streptococcus pneumoniae infections (grade 2B). Empiric combination therapy should not be administered for more than 3–5 days. De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility profile is known (grade 2B).
* Duration of therapy typically 7–10 days; longer courses may be appropriate in patients who have a slow clinical response, undrainable foci of infection, bacteremia with S.]]>
Scott D. Weingart, MD clean 18:35
Podcast 91 – Treatment of Aortic Dissection https://emcrit.org/emcrit/aortic-dissection/ Thu, 24 Jan 2013 02:25:41 +0000 http://emcrit.org/?p=4298 You can't pick a more critical diagnosis than acute aortic dissection. Mess it up and the patient dies. You can't pick a more critical diagnosis than acute aortic dissection. Mess it up and the patient dies. Lower Dp/Dt and Blood Pressure
Control Pain with fentanyl
Control Heart Rate/Inotropy with esmolol
See the esmolol drip sheet (YOU MUST CHECK ALL NUMBERS WITH YOUR OWN PHARMACY)
Control Blood Pressure
With in order of preference: clevidipine, nicardipine, nitroprusside, nitroglycerin
What about if the patient can't get beta-blockers?
What about labetalol?
A-lines
Why is the Patient's Blood Pressure Low?

*
Myocardial Infarction


Andy Neill thankfully addressed my erroneous assumption that MIs in Dissection would only be right coronary infarctions
Does an anterior STEMI rule out dissection? - Emergency Medicine Ireland
and check out this article as well (J Emerg Trauma Shock 2011;4:273-278)


*
Site of Blood Pressure Measurement

*
Rupture of the Aorta

*
Aortic Insufficiency

*
Pericardial Tamponade


Neurodeficits
Intubation
Do a high-icp/vascular intubation (More to come on this)
Update

* Nicardipine and Esmolol are compatible and can be given through the same IV

 ]]>
Scott D. Weingart, MD clean 24:01
Episode 10 – Surviving Sepsis Campaign (SSC) Guidelines 2012 https://emcrit.org/practicalevidence/surviving-sepsis-campaign-guidelines-2012/ Thu, 24 Jan 2013 02:12:55 +0000 http://practicalevidence.org/?p=217 SSC Guidelines 2012 SSC Guidelines 2012
See the Guidelines at (CCM 2013;41(2):580)
Diagnosis of Sepsis

Diagnosis of Severe Sepsis

The New Bundles

A. Initial Resuscitation

* Protocolized, quantitative resuscitation of patients with sepsis- induced tissue hypoperfusion (defined in this document as hypotension persisting after initial fluid challenge or blood lactate concentration ? 4 mmol/L). Goals during the first 6 hrs of resuscitation:

* Central venous pressure 8–12 mm Hg
* Mean arterial pressure (MAP) ? 65 mm Hg
* Urine output ? 0.5 mL/kg/hr
* Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively (grade 1C).


* In patients with elevated lactate levels targeting resuscitation to normalize lactate (grade 2C).

B. Screening for Sepsis and Performance Improvement

* Routine screening of potentially infected seriously ill patients for severe sepsis to allow earlier implementation of therapy (grade 1C).
* Hospital–based performance improvement efforts in severe sepsis (UG).

C. Diagnosis

* Cultures as clinically appropriate before antimicrobial therapy if no significant delay (> 45 mins) in the start of antimicrobial(s) (grade 1C). At least 2 sets of blood cultures (both aerobic and anaerobic bottles) be obtained before antimicrobial therapy with at least 1 drawn percutaneously and 1 drawn through each vascular access device, unless the device was recently (<48 hrs) inserted (grade 1C).
* Use of the 1,3 beta-D-glucan assay (grade 2B), mannan and anti-mannan antibody assays (2C), if available and invasive candidiasis is in differential diagnosis of cause of infection.
* Imaging studies performed promptly to confirm a potential source of infection (UG).

D. Antimicrobial Therapy

* Administration of effective intravenous antimicrobials within the first hour of recognition of septic shock (grade 1B) and severe sepsis without septic shock (grade 1C) as the goal of therapy.
* Initial empiric anti-infective therapy of one or more drugs that have activity against all likely pathogens (bacterial and/or fungal or viral) and that penetrate in adequate concentrations into tissues presumed to be the source of sepsis (grade 1B). Antimicrobial regimen should be reassessed daily for potential deescalation (grade 1B).
* Use of low procalcitonin levels or similar biomarkers to assist the clinician in the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infection (grade 2C).
* Combination empirical therapy for neutropenic patients with severe sepsis (grade 2B) and for patients with difficult-to-treat, multidrugresistant bacterial pathogens such as Acinetobacter and Pseudomonas spp. (grade 2B). For patients with severe infections associated with respiratory failure and septic shock, combination therapy with an extended spectrum beta-lactam and either an aminoglycoside or a fluoroquinolone is for P. aeruginosa bacteremia (grade 2B). A combination of beta-lactam and macrolide for patients with septic shock from bacteremic Streptococcus pneumoniae infections (grade 2B). Empiric combination therapy should not be administered for more than 3–5 days. De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility profile is known (grade 2B).
* Duration of therapy typically 7–10 days; longer courses may be appropriate in patients who have a slow clinical response, undrainable foci of infection, bacteremia with S. aureus; some fungal and viral infections or immunologic deficiencies, including neutropenia (grade 2C).
* Antiviral therapy initiated as early as possible in patients with severe sepsis or septic shock of viral origin (grade 2C).
]]>
Scott D. Weingart, MD clean 18:35
Podcast 90 – Mind of the Resuscitationist Series: Cliff Reid’s Own the Resus Room https://emcrit.org/emcrit/own-the-resus-room/ Tue, 08 Jan 2013 00:41:08 +0000 http://emcrit.org/?p=4258 Cliff Reid on owning the resuscitation room Cliff Reid on owning the resuscitation room
*
 A Resuscitationist Agonizes

* Part I of an Interview with Cliff
*
Part II of the Interview


And of course, Cliff's blog, resus.me, is some of the best retrieval and resuscitation information around.

I brought Cliff up to speak in my Critical Care Track at the 2012 Essentials of Emergency Medicine. Mel Herbert was kind enough to give me permission to post the lecture here. I think you'll love it as much as I do.

Need the audio-only version of Cliff's talk? Right click the link and choose save-as.
Now, on to the podcast...]]>
Scott D. Weingart, MD clean 15:23
Natural Seven for 2012 https://emcrit.org/emcrit/picks-for-2012/ Sun, 30 Dec 2012 23:08:36 +0000 http://emcrit.org/?p=3791 The rundown of things I liked from 2012 The rundown of things I liked from 2012
* PHARM Podcast (Subscribe on Itunes)
* Intensive Care Network Podcast Podcast (Subscribe on Itunes)

Blogs

* Mojo RN
* PulmCCM.org
* Sonospot
* EM Ireland
* St Emlyns

Also See for more Best ofs

* Sexy Six for 2014
* 2013 Eight is Enough
* 2011 Hard Six
* 2010 Dirty Dozen

Thanks for Listening and Supporting EMCrit!
 ]]>
Scott D. Weingart, MD clean 6:01
Podcast 89 – Lessons from the STOP Sepsis Collaborative https://emcrit.org/emcrit/lessons-sepsis-collaborative/ Wed, 26 Dec 2012 04:00:25 +0000 http://emcrit.org/?p=4229 We have hit the 10,0000 patient mark in the NYC STOP Sepsis collaborative. Here are some of the lessons learned... We have hit the 10,0000 patient mark in the NYC STOP Sepsis collaborative. Here are some of the lessons learned...
Want to See the Protocols?
Recognition

* Let nurses handle recognition

Lactate

* Send lots of lactates
* Lactate turn-around 30 minutes or get Point-of-Care
* Run the lactates on a blood gas machine
* Make lactate >=4 a panic value

Treatment

* Prompt palliative vs. curative
* Non-invasive protocols have evidence and seem to be working

Want to See the Protocols?
Early appropriate antibiotics

* Empiric Abx Guidelines
* First dose of those antibiotics in the ED
* Simultaneous Infusions

Intubation

* Safe Intubation

Fluids

* Echo Assessment of Cardiac Output
* IVC ultrasound (Also check out the Stone Debate)
* If empiric fluid-loading, give 4-6 liters

Pressors

* Do a sterile neck line or a non-sterile femoral (which should be yanked and replaced as soon as the patient gets upstairs)
* Norepi should be your 1st pressor choice

Check Your Work

* Mandate repeat lactates

More Sepsis Resources

* Manny Rivers on Early Goal Directed Therapy
* A tirade on Sepsis Care in the ED (And additional follow-up) Back then there was no Non-Invasive Path
* That was until Alan Jones published his lactate clearance study
* Find a ton of evidence and other good stuff on the EMCrit Severe Sepsis Deep Dive Pages

 The Proposed NQF Measure
Read it and weep

Please contact the folks in your hospital that will be voting on the measure
On a Side Note...
EMCrit just broke the 3 Million Downloads mark. Yeah!!!!
Like this post? Then tweet the hell out of it
https://twitter.com/emcrit/status/283784412196392960]]>
Scott D. Weingart, MD clean 18:08
EMCrit Wee – MOPETT Trial https://emcrit.org/emcrit/mopett-trial/ Wed, 12 Dec 2012 01:57:24 +0000 http://emcrit.org/?p=4188 A new trial on half-dose thrombolysis for PE for sub-massive PE A new trial on half-dose thrombolysis for PE for sub-massive PE The MOPETT Trial took sub-massive PE patients and randomized them to half-dose tPA vs. standard care. No bleeds in either group. 41% ARR of pulmonary hypertension at 28 months.
Study Description from the Author
PDF of his MOPETT presentation slides
 Does this change your game?
Update:
A new trial using a similar protocol showed benefit without complications (Clinical Cardiology Volume 37, Issue 2, pages 78–82, February 2014)]]>
Scott D. Weingart, MD clean 4:08
EMCrit Podcast 88 – Oxygen Physiology with Daniel Davis https://emcrit.org/emcrit/oxygen-physiology/ Mon, 10 Dec 2012 18:00:40 +0000 http://emcrit.org/?p=3471 One of the last few airway topics for a little while: Pulse Ox Lag and an Understanding of the Oxyhemoglobin Dissociation Curve One of the last few airway topics for a little while: Pulse Ox Lag and an Understanding of the Oxyhemoglobin Dissociation Curve

Articles:

* Latency of Pulse Oximetry Signal with use of Digitial Probes Associated with Inappropriate Extubation (J Emerg Med 2012;42(4):424)
* Latency and loss of pulse oximetry signal with the use of digital probes during prehospital rapid-sequence intubation. (Prehosp Emerg Care. 2011 Jan-Mar;15(1):18-22.)
* Rate of decline in oxygen saturation at various pulse oximetry values with prehospital rapid sequence intubation. (Prehosp Emerg Care. 2008 Jan-Mar;12(1):46-51.)

Dan Davis at his best:
http://vimeo.com/55375806
Did you like this episode? Then tweet the hell out of it...
https://twitter.com/emcrit/status/278344444653207552
Now on to the Podcast...]]>
Scott D. Weingart, MD clean 19:07
Episode 9 – Blunt Cardiac Injury from EAST https://emcrit.org/practicalevidence/blunt-cardiac-injuries/ Fri, 07 Dec 2012 06:33:59 +0000 http://practicalevidence.org/?p=166 EAST Trauma Guidelines on Blunt Cardiac Injury EAST Trauma Guidelines on Blunt Cardiac Injury
Michael McGonigal has a great summary of the BCI guidelines on his Trauma Professional's Blog


Click here to download the blunt cardiac injury algorithm
What's EMCrit Drinking?





]]>
Scott D. Weingart, MD clean 8:35
SMACC Conference https://emcrit.org/emcrit/smacc-conference/ Fri, 07 Dec 2012 00:53:04 +0000 http://emcrit.org/?p=4177 SMACC Conference and SIMWars SMACC Conference and SIMWars
Ummm hello! It is SMACC!
SMACC
March 11-13, 2013

Sydney Australia

Submit Abstracts to the Conference

Find out More about SIMWars

See all of the amazing SIMWars Entry Videos on the ICN

 ]]>
Scott D. Weingart, MD clean 4:07
Podcast 87 – Mind of the Resuscitationist: Stop Points https://emcrit.org/emcrit/stop-points/ Mon, 26 Nov 2012 23:40:08 +0000 http://emcrit.org/?p=4147 In this Mind of the Resuscitationist Episode, I discuss stop points: one for when you are using multiple vasopressors and especially about a cognitive stop point whenever things are going south. In this Mind of the Resuscitationist Episode, I discuss stop points: one for when you are using multiple vasopressors and especially about a cognitive stop point whenever things are going south. Mind of the Resuscitationist Episode, I discuss stop points: one for when you are using multiple vasopressors and especially about a cognitive stop point whenever things are going south.
2nd Vasopressor Stop Point

Rapid Ultrasound for Shock and Hypotension (RUSH) Exam
The RUSH Exam will allow rapid diagnosis of the cause of non-trauma hypotension
Abdominal Compartment Syndrome
See this crashing patient chapter for more on Abdominal Compartment Syndrome
Update: Added....

* Systolic Anterior Motion

* systolic anterior motion


* Consider Tox
* Is this actually cardiogenic shock from ischemia/MI rather than sepsis

Cognitive Stop Points for the Resuscitationist
Use this method whenever the situation doesn't add up or is going bad:

* Announce you have no idea what the f**k is going on
* Eliminate ALL assumptions
* Troubleshoot like an engineer

Shoutouts
Ken Grauer sent me a copy of his new book, ACLS 2013 Pocket Brain Book. Check it out and check out his blog site as well.

My friend Clay Smith of the KeepingUp Podcast has just put out a new, FREE!, IOS app called Upshot that combines his literature reviews and podcasts into one beautiful package.
Did you Like this Episode? Then tweet the hell out of it:
https://twitter.com/emcrit/status/273210644298334208
Now on to the Podcast...]]>
Scott D. Weingart, MD clean 23:32
Podcast 86 – IVC Ultrasound for Fluid Tolerance in Spontaneously Breathing Patients – EAT IT STONE https://emcrit.org/emcrit/ivc-ultrasound-for-fluid-tolerance-in-spontaneously-breathing-patients/ Mon, 12 Nov 2012 00:23:36 +0000 http://emcrit.org/?p=4050 Can the Inferior Vena Cava Ultrasound guide our fluid administration in the ED? Of course it can! Can the Inferior Vena Cava Ultrasound guide our fluid administration in the ED? Of course it can! So I was getting on the plane to Las Vegas for Essentials 2012, on my iphone was the latest from Mike and Matt of the Ultrasound Podcast. Up pops Mike "the Rock" Stone interviewing my buddy, Haney Mallemat; these two ultrasound gurus discuss some ultrasound soundbites, but then... They both state that IVC ultrasound is useless for determining fluid responsiveness. It is worth taking a listen to that episode if you have a moment. So how can two brilliant guys get it so wrong? They just had their focus knob turned all the way to the right. Lets optimize their settings with an EMCrit Podcast.
Mechanically Vented Patients
Now, most of the podcast bashed IVC in spont breathing patients, but there was some overflow disparaging of IVC in mech vented patients, so let's get that out of the way first. There is plenty of literature for these patients. Put them on a temporary, high tidal volume (10 ml/kg). Get an IVC shot and if it increases in size by 15-18% (depending on the study), the patient is fluid responsive.

* Intensive Care Med. 2004 Sep;30(9):1740
* Intensive Care Med. 2004 Sep;30(9):1834
* Neurocrit Care. 2010;13:3
* J Trauma. 2007;63:495
* J Intensive Care Med. 2011 Mar-Apr;26(2):116

Spontaneously Breathing Patients
Now as the two ultrasound masters allude to, there have been a few studies showing IVC ultrasound assessment merely correlates with CVP  (it actually correlates with respirophasic CVP) and then use that fact to write off the IVC. Now we have maligned CVP as a marker of fluid responsiveness so IVC is crap as well, right?

There is evidence for the use of IVC as a marker of fluid status. In patients with ultrafiltration for congestive heart failure (Intensive Care Med. 2010 Apr;36(4):692-6) as well as fluid removal during hemodialysis (Clin J Am Soc Nephrol 2006;1:749 and Nephrol Dial Trans 1989;4:563). There was also a trauma study showing that fluid resuscitated patients with IVC collapse were more likely than those without to have recurrent hypotension (J Trauma. 2007 Dec;63(6):1245).

There was also a study just published in the Aussie EM Journal. This study was severely limited by the fact that none of these patients had any significant IVC collapse and the criterion standard is not a test any of us consider useful for cardiac index measurements; further, looking at the tables, some of the responder group did not seem to have any sig. increase in their CI in response to fluid. (Emerg Med Aust 2012;24:534).

And a meta-analysis study showing IVC's relation to fluid status (AJEM 2012;30:1414).

Luckily, there was also a recently published study with the table below (Crit Care 2012;16:R188).

Here is figure 1 from the study



Here is the area under the cure (AUC); you notice there are points with much higher specificity.


Update:
Hot off the presses, this study is more reassuring: (Shock 2013;39(2):155)

It lends additional credence to the use of dynamic IVC for fluid responsiveness.
It's not Fluid Responsiveness, It's Fluid Tolerance!
This is the crux of the matter. In the ED, we want to give a bunch of fluid, but not if we are going to cause pulmonary edema. The term, fluid tolerance, is a perfect description of this idea. Responsiveness is great, but all we want to make sure of is that we are not going to d...]]>
Scott D. Weingart, MD clean 20:52
Episode 8 – ACEP Opioid Prescription Policy https://emcrit.org/practicalevidence/acep-opioid-prescription-policy/ Sat, 03 Nov 2012 03:51:17 +0000 http://practicalevidence.org/?p=146 ACEP 2012 Opioid Prescription Policy ACEP 2012 Opioid Prescription Policy
Should we be prescribing opioids from the ED? This question is explored in the recent ACEP Clinical Policy on ED Opioid Prescriptions.

 ]]>
Scott D. Weingart, MD clean 9:19
Podcast 85 – A Confirmation of Prejudices: Chloride and Pressure Poisoning https://emcrit.org/emcrit/chloride-pressure-poisoning/ Mon, 29 Oct 2012 22:05:11 +0000 http://emcrit.org/?p=4027 In this Hurricane Sandy episode of the EMCrit podcast, I talk about the confirmation of two of my clinical prejudices. In this Hurricane Sandy episode of the EMCrit podcast, I talk about the confirmation of two of my clinical prejudices. Chloride Poisoning
So I've always preached that grabbing normal saline for every ED patient is poor thinking and poor practice. We discussed this topic in the 4th Acid-Base Podcast on Fluids. Up until now, I did not have great evidence for my prejudice; now at least, I have reasonably good evidence:

Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte (Ann Surg. 2012 May;255(5):821-9)

Association Between a Chloride-Liberal vs Chloride-Restrictive Intravenous Fluid Administration Strategy and Kidney Injury in Critically Ill Adults (JAMA. 2012 Oct 17;308(15):1566-72)

Definitive? Nope, but it just seems like good medicine to treat fluids like any other drug and actually choose the ideal one for the clinical situation.

Resus.me Post: What’s with all the chloride? An assault on salt | Resus M.E!

Upate:

Association Between the Choice of IV Crystalloid  and In-Hospital Mortality Among Critically Ill Adults With Sepsis
Karthik Raghunathan (Crit Care Med 2014 citation pending)
A Diversion on Osmolality
Peter Sherren made a great comment in the podcast on the Brain Code regarding my statement that lactated ringers is an inappropriate fluid in high ICP. So I had a bit of a think on the topic and then was baffled as to why LR has a Na of 130 and yet a Osm of 272-5.



Brian Hayes responded to a tweet on the topic with what is probably self-evident to everyone but me: the Osm calculation we use is actually a crappy short cut; all components of a fluid need to be calculated to get the real Osm. Yet, when I thought about this still further, I realized that what is written on the bag is not actually the in-vivo Osm effects. Instead, the Na is probably the key.

Want proof of this concept? D5W has an Osm of 252 on the bag, but the effective Osm is 0 as soon as your cells take up the glucose.

So can you use LR in high ICP, yes probably not too big a deal, but the net Osm effects will probably be to lower the serum Na and Osm. If you buy choosing the ideal fluid for acid-base, it probably makes sense to choose the ideal fluid for Osm as well. Maybe this prejudice will be verified 5 years from now with a real article.

Here is the article I mentioned on the Osm effects of LR on healthy volunteers: (Anesth Analg 1999;88:999 –1003)

Here is an Osm calculator from GlobalRPH.
A Diversion on the need for Conversion of the Buffer Bases
Want what I think is the ideal resus fluid? Mix this on the fly:

Ultimate Resus Fluid? 1 amp of 44.6 bicarb in 500 ml of NS makes 550 of total volume= Na 121.6 Cl 77 Bicarb 44.6   to extended out to 1 liter= Na 217 Cl 138.6 BiCarb 80   1.3% Balanced Saline solution

There is ABSOLUTELY no evidence for this. If someone wants to do the study,]]>
Scott D. Weingart, MD clean 18:53
Podcast 84 – The Post-Intubation Package https://emcrit.org/emcrit/post-intubation-package/ Tue, 16 Oct 2012 19:00:56 +0000 http://emcrit.org/?p=4003 There is a ton of stuff to do post-intubation besides confirming the tube and giving the team high-fives. What we do in the ED has ramifications on the patient's course in the hospital. There is a ton of stuff to do post-intubation besides confirming the tube and giving the team high-fives. What we do in the ED has ramifications on the patient's course in the hospital. There is a ton of stuff to do post-intubation besides confirming the tube and giving the team high-fives. What we do in the ED has ramifications on the patient's course in the hospital. Preventing badness starts with us.
Achieve Adequate Analgesia and Sedation
I won't belabor this, because I've discussed it in so many other podcasts, such as the one about not leaving your patient in a nightmare
Secure the Tube Well
We use the Hollister Anchor Fast (as always, no conflicts of interest).
Raise the Head of the Bed to at Least 30°
May or may not help prevent VAP, but it definitely helps lung mechanics
Confirm Lung Protective Vent Settings
See the Dominating the Vent Lecture for more on all that
Humidify the Air
Either with a humidification circuit on the vent or a Heat-Moisture-Exchanger (HME)
Place In-Line Suction and then Actually Use It
In-line is probably no better than intermittent with sterile technique, but who is actually going to use sterile technique

Suction the mouth each time you suction the tube as well
Hook Up the ETCO2
You read NAP4 right? Continuous waveform ETCO2 until the ET tube gets pulled
Cuff Pressure
Too low and you risk micro-aspiration and VAP, too high and the patient has the potential for ischemia. The ideal pressure is between 20-30 cm H20. Use a cufflator.
Gastric Tube
Empty the stomach to reduce the chances of aspiration
Nebulizers/MDI
If they were intubated for reactive airway disease, then they need frequent nebs. In some hospitals, all patients get intermittent MDIs. Make sure to remove the HME for nebulizer or MDI treatments.
Prevent Aspiration past the Cuff of the ETT
Cuff Lube
Lube on the tube cuff may help avoid micro-aspiration (Anesthesiology 2001; 95:377–81 & Anaesthesia. 2006 Feb;61(2):133-7.)
Continuous Subglottic Suction ETTs


BestBets: Continuous subglottic suction is effective for prevention of ventilator associated pneumonia

May prevent 4 cases annually if used for all patients in an average US hospital (Critical Care 2012, 16:446)

A listener, Dan Hierholzer, DO (last name:  Here-Hole-Zer) reports on 1 issue with these tubes: they have a wider external diameter so if you are trying to pass them through an intubating supra-glottic airway, you need to go 1 size lower. Dan demanded a shout-out to the residents at Geisinger Medical Center in exchange for this excellent tip.
Get a Blood Gas
I like arterial,]]>
Scott D. Weingart, MD clean 23:46
Podcast 83 – Crack to Cure – ED Thoracotomy https://emcrit.org/emcrit/procedure-of-thoracotomy/ Tue, 02 Oct 2012 05:37:16 +0000 http://emcrit.org/?p=3890 Crack to cure; in the right circumstances you may save a life. ER thoracotomy--do it improperly and you put you and your team at risk. Crack to cure; in the right circumstances you may save a life. ER thoracotomy--do it improperly and you put you and your team at risk.
Crack to Cure
All the way back at podcast 36, I discussed traumatic arrest in the ED. In that episode, I laid out a general approach to patients coding from trauma, in this one I discuss only the performance of the procedure of ED thoracotomy.

This lecture was given at the 2012 ALLNYC EM Conference.
Here are the videos from the lecture:

* ER thoracotomy.MP4 - YouTube
* Open Thoracotomy - YouTube
* thoracotomy.flv - YouTube

Articles to Read

* Why You Should Consider Empiric Clamshell

You Also Need to Watch

* John Hinds on Crack the Chest, Get Crucified

Nice Diagram
I quibble with some of this, but it is beautiful none-the-less



from @learnEDjon
Most Recent Guidelines from EAST
Full Text of EAST Resus Thoracotomy Guidelines

Strayer's Summary Slide


Update

* If cardiac wall motion or pericardial fluid, go forward--if not, don't. From Surgical Lit

Need the audio-only version?
Right click here and choose save-as
Now on to the Vodcast...
]]>
Scott D. Weingart, MD clean 37:16
Episode 7 – Rule-Out Criteria and Screening https://emcrit.org/practicalevidence/rule-out-criteria-screening/ Tue, 25 Sep 2012 01:49:41 +0000 http://practicalevidence.org/?p=140 For Ariel... For Ariel...
The difference between screening, rule-out, and risk prediction criteria.]]>
Scott D. Weingart, MD clean 10:20
Podcast 82 – Mind of the Resuscitationist with Cliff Reid https://emcrit.org/emcrit/mind-resuscitationist-reid/ Mon, 17 Sep 2012 17:25:24 +0000 http://emcrit.org/?p=3941 Today, I put on my head-shrinker cap (it is a fez) and get Cliff Reid on the coach Today, I put on my head-shrinker cap (it is a fez) and get Cliff Reid on the coach
* Interview with Cliff Reid: Part I
* Interview with Cliff Reid: Part II
* Cliff's Tips for Occasional Intubaters
* A Discussion regarding NAP4

and his insanely good blog:



Cliff discusses a case of an out-of-hospital cardiac arrest that he has been ruminating about for the past few days. Here are the teaching points that came out of the case:
Can we lyse intra-arrest?
We will discuss this question in a future show. For now, I would say if you strongly suspect PE or MI and you have exhausted other options, intra-arrest lysis is still an option.
The pulse you feel in the groin may be the vein
During the discussion Cliff mentions that he demonstrated to his whole team that the pulse they felt in the groin was the femoral vein. Use ultrasound for all intra-arrest groin catheter placements.
Securing lines during a code
I use 2" tape. Cliff mentions during the discussion and on his blog, using tissue glue instead.
Continue CPR if there is an a-line pulse, but the pressure is low
Otherwise these patients will just re-arrest. Here is an article on thoracic pump vs. cardiac pump.
Percussion Pacing
Never heard of this? Read this manuscript on percussion pacing.
The Ethics of Different Capabilities at Geographically Close Hospitals
I want to hear what you folks think about this. Should all sick patients be taken to the closest hospital that has the most potential life-saving capabilities? Is there ny reason to bring really sick patients to tiny hospitals if the trip to a more advanced hospital only adds a few minutes? Let me know in the comments what you think.
The Mind of a Resuscitationist - A Resuscitationist Agonizes
This is why I really wanted to post this podcast. I run a series called the Mind of a Resuscitationist. For instance, the episode on

* Logistics not Strategy

Today's episode hits another key point to a resuscitationist's mind: we agonize. We dissect every case that did not go perfectly to figure out if there was ANYTHING that could have gone better, been done smoother. This obsession leads to ulcers and interrupted sleep patterns AND better outcomes in the future.
Please share your thoughts below. Now, on to the podcast...]]>
Scott D. Weingart, MD clean 29:40
Episode 6 – ACCP Antithrombotics and VTE Guidelines https://emcrit.org/practicalevidence/antithrombotic-therapy/ Fri, 07 Sep 2012 06:47:16 +0000 http://practicalevidence.org/?p=99 Antithrombotic Therapy and Prevention of Thrombosis, 9th ed Guidelines from the American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis, 9th ed Guidelines from the American College of Chest Physicians
From American College of Chest Physicians
Antithrombotic Therapy and Prevention of Thrombosis, 9th ed Guidelines

Chest 2012;141:7S-47S (Executive Summary)

For outpatient treatment, start 10 mg daily for the first 2 days followed by INR measurements

Give 1 day of LMWH or UFH before initiation, if treating VTE

If the patient is on VKAs, avoid NSAIDs and certain ABX (table 8 from full guidelines)



Avoid anti-plt agents unless clinical condition warrants

Normal goal is 2-3, including antiphospholipid

No need to taper when d/cing

Heparin – 80/18 for VTE, 70/15 for cardiac or stroke patients

For outpatients with VTE treated with SC UFH, they suggest weight-adjusted dosing (first dose 333 units/kg, then 250 units/kg) without monitoring rather than fixed or weight-adjusted dosing with monitoring
High INRs
4.5-10, no bleeding: no vitamin K necessary

> 10, no bleeding: Oral Vitamin K

If anticoagulant related major bleeding: 4-factor PCC and Vitamin K Slow IV Injection

See Michelle Lin’s Paucis Verbis on the same
Critically Ill Patients
Recommend against routine screening

Use LMWH or LDUH in all patients unless contra-indicated

For travelers at risk of VTE, use graded compression stockings; do not prescribe aspirin or anticoagulants
Diagnosis of DVT
Low Risk
moderate sens d-dimer, high sens d-dimer, or CUS of proximal veins only. D-dimers are preferred

If d-dimer is positive, get Compression Ultrasound (CUS) of proximal veins
Moderate Risk
Use High sens d-dimer, CUS of prox, or CUS of whole leg

Can stop if high-sens D-dimer is negative

If no d-dimer or d-dimer postive, need a second CUS 1 week later if only prox CUS done

If whole leg CUS is negative, you are done
High Risk
Prox CUS or Whole Leg CUS

If prox CUS and d-dimer negative as well, done

If d-dimer positive or only prox CUS, get 1 week f/u CUS

If whole leg CUS is negative, you are done
Recurrent
In patients with past DVT, recommend high-sens d-dimer, if positive get Prox CUS and 1 week Prox CUS

If negative, get just one Prox CUS

If the old CUS is not available, confirm with venography if positive CUS
Upper Ext
Go right to Doppler CUS for upper extremity dvt suspicion
Treatment of DVT
Start with IV or SQ UFH, LMWH, or fondaparinux (Latter two preferred)

If high pretest, start heparin immediately; If moderate, start heparin only if diagnostic tests are expected to be > 4 hours delayed

Isolated distal DVT-serial CUS rather than treatment unless severe symptoms or risk factors for extension (see full text)

Ambulate DVTs, no bed rest

In patients with hypotension (SBP) < 90 and PE, give systemic thrombolytics (through peripheral, rather than PA cath)
Atrial Fib
Chads 0 – nothing

Chads 1/2 – VKA/oral anti-coag; Dabi is preferred

If a-fib > 48 hours; give 3 weeks of VKA/dabi before cardioversion. Or get TEE with LMWH. Follow with 1 month of Vka/oral anti-coag

If a-fib < 48 hours; Start LMWH and then VKA for 4 weeks

If hemodynamically unstable, treat with anticoagulation ASAP preferably before cardioversion and then continue for 4 weeks

Treat a-flutter like a-fib for all of the above
Stroke
If hemorrhagic,]]>
Scott D. Weingart, MD clean 8:40
Podcat 081 – An Interview on Severe Trauma with Karim Brohi https://emcrit.org/emcrit/severe-trauma-karim-brohi/ Sun, 02 Sep 2012 21:23:58 +0000 http://emcrit.org/?p=3895 Let's talk trauma. I interview Karim Brohi on traumatic arrest, massive transfusion and hypotensive resuscitation. Let's talk trauma. I interview Karim Brohi on traumatic arrest, massive transfusion and hypotensive resuscitation. Today I got a chance to interview Karim Brohi (@karimbrohi). He is a trauma and vascular surgeon in London and runs the incredible Trauma.org site. Dr. Brohi has consistently been on the cutting edge of hypotensive resuscitation, hemostatic resuscitation, and massive transfusion.
Dr. Brohi's Lecture on Hypotensive Resuscitation
Dr. Brohi gave an amazing lecture on hypotensive resuscitation. I highly recommend giving it a viewing.

You can view the lecture here;



or on the trauma.org site.

Here are the questions that remained after watching that lecture:

What is the MAP goal you use for resuscitation of unstable hemorrhage patients?

What are you doing with your suspected intracranial bleed patients with concomitant hemorrhage on call today?

What do you think of Dutton's idea of high flow, low pressure resuscitation using solely FFP/Blood as resus fluid and fentanyl to cause sympatholysis?
Traumatic Arrest
Is there any role for closed chest CPR in arrest from hemorrhage. If not, why is it so pervasive amongst EM and Gen Surg doctors? How do we abolish this practice?

Any role for drugs?

Do you bother with cross-clamping?

Check out this previous podcast on traumatic arrest.
Massive Transfusion
Are you using any of the scoring systems or instead, gestalt?

Are you using TXA? If so, when and in which pts?

When does TEG or ROTEM enter the picture?

Hypertonic saline?

Tell us a bit about Cryostat?
More Podcasts on the Above

* First listen to Richard Dutton on his vision of hypotensive resuscitation.
* Next, listen to one of the Crash2 authors, Tim Cook, to discuss the use of tranexamic acid in trauma.

To Close
https://twitter.com/karimbrohi/status/234663124567990273
Did you Like this Post? If so, then retweet it...
https://twitter.com/emcrit/status/242372176546770944
What do you think about ACLS and Traumatic Arrest? Comment below...
Now on to the Podcast:]]>
Scott D. Weingart, MD clean 20:21
Podcast 80 – Uhmmmm, Maybe Groin Lines Are Not So Bad with Paul Marik https://emcrit.org/emcrit/femoral-central-lines/ Mon, 20 Aug 2012 00:14:38 +0000 http://emcrit.org/?p=3863 When I read a recent meta-analysis by Paul Marik on femoral central lines, the first thing I did was bang my head against the wall 10 or 20 times. When I read a recent meta-analysis by Paul Marik on femoral central lines, the first thing I did was bang my head against the wall 10 or 20 times. fluid responsiveness a few months ago. He is a Professor and Division Chief of Pulmonary Critical Care at Eastern Virginia Medical Center.

Well, let's get to the actual meta-analysis on femoral central lines first...
The Meta-Analysis
Marik, Flemmer, et al. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: A systematic review of the literature and meta-analysis. Crit Care Med. 2012 Aug;40(8):2479-85.
Some of the Component Articles
Nagashima et al. To reduce catheter-related bloodstream infections: is the subclavian route better than the jugular route for central venous catheterization? J Infect Chemother. 2006 Dec;12(6):363-5.

Lorente et al. Central venous catheter-related infection in a prospective and observational study of 2,595 catheters. Crit Care. 2005; 9(6): R631–R635.

The Two Studies from Wales by Harrision et al.: 2009 data, 2010 data
The Plots

Femoral vs. Subclavian

Femoral vs. IJ
What to make of all this?
I believe the data from this meta-analysis still show that neck lines have less infection risk than groin. But what this article does establish quite a bit of doubt on this answer. I think this will allow for further trials, though the numbers will have to be large and the study well done. ANZICS can you help us please???
Update:
This trial looked at IJ vs. femoral by using data from 2 RCTs of biopatchs. Up until the 5 day mark, no difference between the two sites. ( American Journal of Respiratory and Critical Care Medicine 2013;188: Jugular versus Femoral Short-Term Catheterization and Risk of Infection in Intensive Care Unit Patients. Causal Analysis of Two Randomized Trials )

This newest trial puts subclavian definitively on top (N Engl J Med 2015; 373:1220-1229)
What do you think? Leave your thoughts in the comments below.
Now on to the Podcast:
 

 

 ]]>
Scott D. Weingart, MD clean 27:29
Podcast 79 – Reducing Door to tPA Time in Ischemic Stroke https://emcrit.org/emcrit/reducing-door-to-tpa-time/ Mon, 06 Aug 2012 00:16:36 +0000 http://emcrit.org/?p=3828 Reducing door to tPA time in Ischemic Stroke. Strategies and tips to optimize patient care. Reducing door to tPA time in Ischemic Stroke. Strategies and tips to optimize patient care. David and Ashley and make your own decision. What we will talk about today is reducing door to tPA time.

There was a recently published study that gave an excellent description of one center's interventions to get their door to tPA time down to a ridiculously low level.



(PMID 22622858)

Here are the interventions they used:



The American Heart/Stroke Associations also have some resources on reducing door to tPA time.
The EMCrit Checklist
Here is the checklist of my interventions to reduce door-to-tPA-time:


EMCrit Art Contest
Click on over to see the finalists and vote
What do you think about consent for tPA or anything else we spoke about today--leave a comment. Now on to the podcast...]]>
Scott D. Weingart, MD clean 25:17
Podcast 78 – Increased Intra-Cranial Pressure (ICP) and Herniation, aka Brain Code https://emcrit.org/emcrit/high-icp-herniation/ Sun, 22 Jul 2012 23:51:54 +0000 http://emcrit.org/?p=3780 Today we are going to discuss increased intracranial pressure (ICP) and herniation Today we are going to discuss increased intracranial pressure (ICP) and herniation Screen for Increased Intracranial Pressure
Matt & Mike's Ultrasound Podcast on Ocular Ultrasound
Tier 0
Head of Bed Up

Temp Normal

PaCO2 35-38 mm Hg

Control Pain/Sedate if Intubated
Tier 1
Osmotic Therapy

Mannitol

Hypertonic Saline

Sodium Bicarb
Tier 2
Propofol (or Phenobarb) Drip titrated to take patient to low levels of sedation scales (5-200 mcg/kg/min)

CPP Optimization
Tier 3
Decompressive Craniectomy

Induced Hypothermia

Pentobarb

Moderate Hyperventialtion (I reserve for patients who are herniating)
Want more Tier 3 therapies?
Get Thomas Scalea's Lecture on TBI/ICP

* Already a EMCrit CME Member, go to the CME Learning Site.
* Want to become a member? Go to the CME Signup Page.
* Are you in-training in a medical profession, go to the EMCrit In-Training Page.

Now, on to the podcast...]]>
Scott D. Weingart, MD clean 23:54
EMCrit Wee – Airway Outsourcing and Suction Henching https://emcrit.org/emcrit/airway-outsourcing-and-suction-henching/ Mon, 16 Jul 2012 22:00:22 +0000 http://emcrit.org/?p=3764 Further discussion of prepassing the bougie and why fiberoptic laryngoscopy may obviate all of the classic teaching on bimanual laryngoscopy. Further discussion of prepassing the bougie and why fiberoptic laryngoscopy may obviate all of the classic teaching on bimanual laryngoscopy.
I now outsource external laryngeal manipulation to my assistant; or I do it for the intubator when one of my residents is that intubator. This outsourcing concept was first introduced to me by my friend, Reuben Strayer. He realized you could outsource suctioning. It was a natural progression for me to start outsourcing thyroid manipulation and now tube-prepassage.

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Scott D. Weingart, MD clean 4:39
Left Ventricular Assist Devices (LVADS) https://emcrit.org/emcrit/left-ventricular-assist-devices-lvads-2/ Mon, 09 Jul 2012 00:21:32 +0000 http://emcrit.org/?p=3495 LVADs are complicated especially when the patient starts going downhill. Zack Shinar is going to attempt to make it a bit easier. LVADs are complicated especially when the patient starts going downhill. Zack Shinar is going to attempt to make it a bit easier. These patients are super-complicated, luckily I got Zack Shinar, MD from Sharp Memorial in San Diego to try to wade through the morass.
All Situations

* Call the patient's VAD coordinator ASAP
* These patients may not have a palpable pulse. Listen over the heart to hear if the motor is working. Then use mental status, skin color/temp, and the machine flashing Low Flow as indicators that perfusion badness is occurring. Do a bedside echo. The MAP should be ~65 on manual doppler BP, Automated BP devices may give you a MAP as well. A-line MAP is the most accurate.
* Try not to cut or yank out the drive-line, 'cause that is embarrassing.

Poor Perfusion

* When in doubt, consider a fluid bolus. VADS love volume. If you need to improve hemodynamics with a working LVAD, consider preload augmentation and possibly afterload reduction (if MAP is high).
* Consider inotropes--if you think it is right heart failure, give dobutamine. If you think the patient is septic and has markedly reduced afterload, consider norepinephrine.


* On echo:
* Big RV, small LV=pulm hypertension or right heart strain/stemi. Correct hypoxemia and acidosis, consider volume, screen for RV STEMI, consider inotropes.
* Small RV-give volume
* Big RV & LV-pump failure or pump thrombosis.

Consider pump thrombosis--Signs of pump thrombosis are LVAD is hot, working hard, with high RPM, low flow, dilated RV/LV, and low MAP. Zack would give a bolus of 5000 U of Heparin in the decompensating LVAD that he thought was secondary to thrombosis (or if he just couldn't figure out what was wrong with a failing device). He would also consider tPA if he really thought it was pump thrombosis and the patient was decompensating and peri-code.

On ECHO, a dilated RV/LV could be from pump thrombosis or non-working pump (electrical issue for example).if you think that is the problem, heparinize.
Machine Not Running
Check batteries. Make sure all of the lines are connected.
Bleeding
These folks are prone to bleeding from the anticoag (and probably additional plt dysfunction from the device if I had to guess). So if they have altered mental status or neuro findings--consider hemorrhagic stroke.
Patient appears Infected
Drive-line infection-look at the site at entry to the skin. If the patient appears septic and you can't find a source, consider it a device infection until proven otherwise. Don't yank the device. Treat for health-care associated infection covering both hospital gram negatives and MRSA.
Patient is Coding
We need to AVOID CPR until the patient needs it and at point, what is the alternative? Can you rip out the device with CPR-yes! Many of the CT surgeons recommend not to do CPR, but you can't get deader than dead (I was not a philosophy major, so I could be wrong). Avoid CPR if at all possible, some of the 1st gen devices had hand-pumps you could use--the current generation don't. If you're the point where there is NOTHING else to do except CPR you need to use your clinical judgment.

Here is Zack's clinical judgment:
CPR is not recommended by the manufacturers secondary to potential cannula dislodgement.  I would not do CPR unless the pump was NOT working and the patient had lost their BP (MAP of 0).  This is the one scenario where you have to perfuse the brain no matter what the cost.  All other scenarios I would focus on how to get that pump operating better (at all).
Joe Bellezo then adds:
Just agreeing with Zack's thoughts on this. My approach to this is 'Look, Listen, and feel" - assuming a comatose LVAD patient.

Look: ...at all the connections. Everything connected? Ok. Look at the controller.]]>
Scott D. Weingart, MD clean 19:39
Episode 5 – Upper GI Bleed Guidelines https://emcrit.org/practicalevidence/acute-upper-gi-bleeding-guidelines/ Sat, 07 Jul 2012 07:14:32 +0000 http://practicalevidence.org/?p=105 National Institute for Health and Clinical Excellence: Acute upper GI bleeding: NICE guideline National Institute for Health and Clinical Excellence: Acute upper GI bleeding: NICE guideline
Acute upper GI bleeding: NICE guideline
http://guidance.nice.org.uk/CG141/NICEGuidance/pdf/English

Great Britain’s National Health Service has a group called the National Institute for Health and Clinical Excellence (NICE); this group has recently put out guidelines for the management of Upper GI Bleeds. Thanks to my friend, Cliff Reid, for bringing these guidelines to my attention.
The Guidelines
Before endoscopy, calculate a Blatchford Score consider discharge if the score is zero.

After endoscopy, calculate a Rockall Score, this helps determine disposition

Transfuse massively bleeding patients as per local protocols, realizing that both under- and over-transfusion are bad

Do not give platelets if the patient is not bleeding. If they are bleeding, give plts for count < 50,000.

Offer FFP to pts with fibrinogen < 1 g/L or INR > 1.5

Use PCC for patients taking warfarin and are actively bleeding

Do not use Factor VIIa until other methods have failed

Offer endoscopy for severe acute bleeding immediately after resuscitation

Do not offer PPI to patients with non-variceal upper GI bleeding unless endoscopy reveals an ulcer

Offer them if the patient has stigmata of recent hemorrhage on endoscopy

If patient still bleeding after intial endocscopy or rebleeds after repeat endoscopy, go to IR, then to surgery

In variceal bleed, they recommend terlipressin until definitive haemostasis or for 5 days

GIVE PROPH ABX for suspected variceal bleeds

Go to TIPS if endoscopic treatment is unsuccessful
What is EMCrit drinking?
Rodenbach, an amazing Flemish Sour Ale
Now on to the Podcast…]]>
Scott D. Weingart, MD clean 10:49
EMCrit Wee – Bougie Prepass and CricCon for Difficult Airway https://emcrit.org/emcrit/bougie-prepass-and-criccon/ Thu, 05 Jul 2012 03:00:35 +0000 http://emcrit.org/?p=3736 So my friend, Darren Braude and a colleague had a horrible airway case, which they presented on EM:RAP. I wanted to comment on the case. So my friend, Darren Braude and a colleague had a horrible airway case, which they presented on EM:RAP. I wanted to comment on the case. EM:RAP. I wanted to comment on the case, because there is so much great teaching fodder. If you have access to EM:RAP, go listen to this portion on the July episode first. I say it in the show, but let me be very clear here as well--the folks involved did an incredible job. These comments are solely Monday-morning quarterbacking.

I introduce two concepts in this wee:
Prepassing the bougie in the mouth and CricCon
Prepassing the bougie
I am fed up with having to look away from the cords on difficult airways, so I've taken to putting the bougie in the mouth at the level of the right molars before lifting to expose the glottis. A partner can do the same for you. Listen to the audio to get the full idea.
CricCon Readiness Level
Similar to the DefCon, the prior measure of US military alertness level, CricCon is what level of readiness you have to perform a cricothyrotomy. Hopefully this image explains it all:



All airways should be level 5. Predicted difficult airways should always be at least a 4. In a "forced-to-act" situation you should be a 3. If the first attempt fails, I would move to a 2.

Update: CricCon2 has been released, check it out
Art Contest
Draw your vision of the EMCrit mascot and win a copy of Mike Winters' Emergency Department Resuscitation of the Critically Ill



See here for all the rules and details
Now on to the Wee...]]>
Scott D. Weingart, MD clean 29:35
Podcast 76 – Severe Pediatric Trauma with Michael McGonigal https://emcrit.org/emcrit/severe-pediatric-trauma/ Sun, 24 Jun 2012 20:52:59 +0000 http://emcrit.org/?p=3627 I got to speak with Michael McGonigal, MD of the Trauma Professional's Blog about severe pediatric trauma in the ED. I got to speak with Michael McGonigal, MD of the Trauma Professional's Blog about severe pediatric trauma in the ED. Pediatric Glasgow Score
Best eye response: (E)

Eyes opening spontaneously
Eye opening to speech
Eye opening to pain
No eye opening or response

Best motor responses: (M)

Infant moves spontaneously or purposefully
Infant withdraws from touch
Infant withdraws from pain
Abnormal flexion to pain for an infant (decorticate response)
Extension to pain (decerebrate response)
No motor response

Best verbal response: (V)

Smiles, oriented to sounds, follows objects, interacts.
Cries but consolable, inappropriate interactions.
Inconsistently inconsolable, moaning.
Inconsolable, agitated.
No verbal response.

Any combined score of less than eight represents a significant risk of mortality.
Articles Mentioned in the Episode

* Cerebral hemodynamic predictors of poor 6-month Glasgow Outcome Score in severe pediatric brain injury. J Neurotrauma 26(5):657-663, 2009.
* CPR for bradycardia with poor perfusion vs pulseless cardiac arrest. Pediatrics 124(6): 1541-1548, 2009.
* Osmolar therapy in pediatric  traumatic brain injury. Crit Care Med 40(1): 208-215, 2012.

The Trauma Professional's Blog
Want to read more of Dr. McGonigal's stuff; hell yeah you do. Go on over to the The Trauma Professional's Blog.
Now, on to the podcast...]]>
Scott D. Weingart, MD clean
Are Extraglottic Airways Harmful in Cardiac Arrest? https://emcrit.org/emcrit/extraglottic-airways-harmful-cardiac-arrest/ Sun, 17 Jun 2012 21:23:53 +0000 http://emcrit.org/?p=3680 Are we creating a blockage of blood flow to the brain with EGAs in cardiac arrest? Are we creating a blockage of blood flow to the brain with EGAs in cardiac arrest? This article has created quite a stir in the resuscitation community:
Impairment of carotid artery blood flow by supraglottic airway use in a swine model of cardiac arrest.  Segal N, Yannopoulos D, Mahoney BD, Frascone RJ, Matsuura T, Cowles CG, McKnite SH, Chase DG.  Resuscitation. 2012 Mar 28.
 

Are EGAs harming carotid blood flow during CPR and therefore making neurological outcomes worse? At least in pigs, this is worrisome. Human data to follow.

What am I going to do with this? At least for now, keep using LMAs (the device associated with the least problems), but now I will check cuff pressure to make sure it stays below 40 cm H20
Additional Reading:
Andy Neill has an amazing Anatomy for Emergency Medicine Post on this very issue
Now, on to the wee...]]>
Scott D. Weingart, MD clean 7:07
EMCrit Podcast 75 – Live Show # 2 https://emcrit.org/emcrit/emcrit-live-2/ Wed, 13 Jun 2012 05:07:18 +0000 http://emcrit.org/?p=3672 The 2nd EMCrit Live Show The 2nd EMCrit Live Show Here are some of the things we discussed:
Should we be using the femoral route for central lines?
Minh Le Cong posed that question.

Seth (@mdaware) has a great post with a talk by Matt Pirotte

All of the evidence is there.
Who to lyse in submassive PE?
Casey Parker of Broome Docs fame asked this one.
Who needs Cath after Cardiac Arrest?
Karen from down under asked this one. Luckily I have a post just waiting to go with the answer.
Should we be using NIPPV for ARDS or Pneumonia?
Andy Buck (@edexam) chimed in with this one.
What should you do if your cath lab refuses to take therapeutic hypothermia patients?
Rebecca, a PA Student, wrote in with this question.

Alexander a prehospital and ED doc from Spain wrote and asked:
Should we be using CPAP or BiPAP for Preoxygenation?
and finally, the Rogue Medic wants to know why I don't talk about
Not needing to Intubate once DSI has been used?]]>
Scott D. Weingart, MD clean 27:57
Episode 4 – Subarachnoid Hemorrhage Guidelines https://emcrit.org/practicalevidence/aha-sah-guidelines-2012/ Thu, 07 Jun 2012 07:19:37 +0000 http://practicalevidence.org/?p=108 The New AHA/ASA SAH Guidelines The New AHA/ASA SAH Guidelines  

* Use Hunt & Hess or WFN Scores
* Risk of early rebleeding is high – be quick and decisive in getting the aneurysm secured
* Still recommending LP if negative CT
* Get CTA if CT or LP is positive
* MRI may be useful if negative CT, but if negative you still need a LP
* Keep SBP < 160 until clip/coil
* If delay until clip/coil, use aminocaproic acid or TXA
* Give nimodipine to prevent delayed cerebral ischemia
* Need CSF drainage if acute, symptomatic hydrocephalus
* Consider anti-convulsants in acute SAH management
* Use isotonic fluids, keep fluid balance positive
* Keep patient Normothermic
* Control Hyperglycemia

from:
Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage
doi: 10.1161/?STR.0b013e3182587839
What is EMCrit drinking?
An insanely good aged sour ale: Rodenbach 2009 Vintage

 ]]>
Scott D. Weingart, MD clean 10:15
EMCrit Podcast 74 – Who the Heck to Cool after Cardiac Arrest with Ben Abella https://emcrit.org/emcrit/who-to-cool-after-arrest/ Tue, 29 May 2012 00:26:43 +0000 http://emcrit.org/?p=3615 Today we are joined by Benjamin Abella, MD to discuss who to cool after cardiac arrest. Today we are joined by Benjamin Abella, MD to discuss who to cool after cardiac arrest. Who is Ben Abella?
Dr. Benjamin Abella is an Assistant Professor of Emergency Medicine and the Clinical Research Director of the Center for Resuscitation Science at the Perelman School of Medicine of the University of Pennsylvania. His research focuses on the clinical care of cardiac arrest victims, with a special emphasis on methods to improve the quality and training of cardiopulmonary resuscitation (CPR). He also maintains an active research program in the use of therapeutic hypothermia to improve survival after resuscitation from cardiac arrest. He is the medical director for the nation's only therapeutic hypothermia intensive training and certification course, based at the University of Pennsylvania. Dr. Abella also serves on the Medical Advisory Board of the Sudden Cardiac Arrest Association.
Want More?

* See the EMCrit Hypothermia Deep Dive
* Center for Resuscitation Science
* The free course Ben mentioned is starting in July

Now on to the Podcast:
 ]]>
Scott D. Weingart, MD clean 25:06
Pain and Terror as Effective Pressors https://emcrit.org/emcrit/pain-terror-pressor/ Wed, 16 May 2012 22:42:58 +0000 http://emcrit.org/?p=3588 Psychic Terror as an Effective Pressor Psychic Terror as an Effective Pressor Scott,

I am writing to comment on a trend that I'm noticing among my residents, and I wonder if others are noticing a similar trend.  I am an emergency physician and an intensivist at the University of XXXXXXX, and I have a number of EM residents who avidly listen to your podcasts.

 

Over the course of the last year, most of our residents have made the transition to using rocuronium for RSI (mostly based on recommendations from your podcast, I think).  I use rocuronium preferentially as well, for many of the same reasons that you cite.

 

What has not accompanied the use of rocuronium, though, is an accompanying willingness to provide adequate sedation and pain control.  I find that this is especially true with trauma intubations.  I would say that the usual course of events goes something like this: etomidate and rocuronium for RSI, tube goes in, patient is hypotensive (trauma patient), so patient gets crystalloid or blood during emergent evaluation.  After 5-10 minutes, blood pressure and HR start to trend back up, and most everyone in the trauma bay is patting themselves on the back because they have resuscitated a hypotensive trauma patient.  They are going to CT.

 

In the old world order (the etomidate and sux days) -- which I do NOT think was better -- the clinical course would be the same ... except.  After 10-15 minutes, that hypotensive trauma patient would start coughing (with better vitals), then would sit up and give someone the finger while he was preparing to pull his endotracheal tube out.  The janitor would peer into the trauma bay and would recognize a trauma patient who needs sedation, and sedation would be provided.

 

Now, everyone is hesitant to give long-acting sedative medications to our patients immediately post-intubation, because pts are "sedated" and we're worried about hypotension.

 

I think that this is an unintended consequence to the transition of moving to rocuronium as a paralytic agent for RSI.  I think it's a great drug, but I think that when the tube goes through the cords, the intubator needs to announce to everyone in the room "I've given a paralytic drug that lasts for an hour, the sedative agent that I gave does not, so we are going to give ___ right now so that this guy does not wake up paralyzed."  Propofol infusion +/- fentanyl, bolus of midazolam and dilaudid -- I don't really care what people use, but I think that the way that people are starting to practice is to unintentionally use pain and awareness as a pressor, and I hate to see this happen.  I also think that people need to think to watch the vitals and respond with sedation as necessary.  I had one case of a SAH that started with intubation and ended with a resident using labetalol IVP for HTN that started about 20 minutes after intubation.  In many of these patients, propofol can be a very effective antihypertensive.

 

I have not done in depth analyses to see what our patients remember (perhaps we should), but I'm a little worried that someone out there is aware of their resuscitation while they are paralyzed because we are not rigorously applying the pharmacokinetics we know about the agents we are using.  I think that in some cases, their physiology would suggest that they might.

 

Thanks for all the good work you do for our community,

N.
 
This wee is my audio response. But to sum it up:

* If you are going to use roc, you better be starting sedation the second you are done securing the tube
* There is no patient so unstable that they do not deserve analgesia and sedation.
* For more see this previous clean 6:24
Podcast 73 – Airway Tips and Tricks with Jim DuCanto, MD https://emcrit.org/emcrit/james-ducanto-airway-tips/ Mon, 14 May 2012 00:15:07 +0000 http://emcrit.org/?p=3556 James DuCanto on fiberoptics and airway management in general. James DuCanto on fiberoptics and airway management in general.
* Some anaesthetists I talk to argue that if you are going to get an optical or video assisted airway device then having it in the same design or functional shape as your traditional devices like the Macintosh laryngoscope, makes more sense than having devices that are of different designs. The Levitan FPS stylet is clearly no Macintosh shape design. What are your thoughts on video laryngoscopes more akin to the traditional Macintosh device like the CMAC versus the Levitan FPS?
* We describe a technique of insertion of an intubating LMA then fibreoptic guided stylet assisted intubation. In what situations have you found this helpful, in your experience?
* In an earlier post you mention having performed a needle cricothyrotomy and rescue jet oxygenation using a dedicated jetting device. It was successful?
* What about ketamine assisted awake intubation?
* How do you intubate through a laryngeal tube airway?

and boy did Jim have answers.

Jim DuCanto is an incredibly prolific anesthesiologist from Wisconsin.

 
Links Mentioned in the Show

*
Jim DuCanto's Intubating Videos
* Jim's Guide to the Cookgas
* Reference for Mouth, Screen, Mouth, Screen (Anesth Anal 2007;104:1611)
* My skills of laryngoscopy video
* Seth Manoach Cric-ing a Sheep
* My Awake Intubation Video

Minh Le Cong has a new podcast--check it out to hear a 1-hour Q&A with Jim DuCanto: prehospitalmed.com
If you are listening to the show, why not get CME as well?
need an audio-only version of the video podcast below? Right Click Here and Choose Save-as
Now on to the podcast...
 ]]> Scott D. Weingart, MD clean 29:59 Episode 3 – ACEP 2012 Management of Early Pregnancy https://emcrit.org/practicalevidence/management-of-early-pregnancy/ Mon, 07 May 2012 07:47:25 +0000 http://practicalevidence.org/?p=110 ACEP's Policy on the Management of Early Pregnancy Presenting to the ED ACEP's Policy on the Management of Early Pregnancy Presenting to the ED ACEP guidelines can be found here.

This table from (Annals of Emergency Medicine  Volume 58, Issue 1, July 2011, Pages 12–20) shows the IUPs eventually discovered on f/u vs. what was seen in the ED at various thresholds of bHCGs.


 What is EMCrit drinking?
Rare Vos by Omegang
Now on to the Podcast:]]>
Scott D. Weingart, MD clean 16:34
How to Post a Case or Question to EMCrit Google Plus https://emcrit.org/emcrit/post-a-case-emcrit-google-plus/ Tue, 01 May 2012 19:08:13 +0000 http://emcrit.org/?p=3528 How to Post a Case or Question to EMCrit Google Plus How to Post a Case or Question to EMCrit Google Plus
 

 ]]>
Scott D. Weingart, MD clean 5:09
Severe Pelvic Trauma https://emcrit.org/emcrit/severe-pelvic-trauma/ Mon, 30 Apr 2012 20:59:49 +0000 http://emcrit.org/?p=3447 Hemodynamically unstable pelvic fractures are a talk-and-die situation. These folks require aggressive, rapid treatment if they are going to survive the injury. Inspired by my mentor, Thomas Scalea, I discuss the management of the unstable pelvic trauma patient. Hemodynamically unstable pelvic fractures are a talk-and-die situation. These folks require aggressive, rapid treatment if they are going to survive the injury. Inspired by my mentor, Thomas Scalea, I discuss the management of the unstable pelvic traum... Read these Incredible Posts by Chris Nickson
Part I
Part II
Young-Burgess Shock Trauma Pelvic Fracture Classification
(J Trauma 30(7): 848-856)

Open Iliac Artery Clamping
Dubose and Inaba (J Trauma. 2010;69: 1507?1514)How to Kill when IntubatingForgot to mention on the podcast--The combination of an open-book pelvis that you have not bound yet and paralytics is a great way to cause massive bleeding. Bind the open pelvis before tubing!!!

New East Pelvic Trauma Guidelines
(J Trauma 2011;71(6):1850)

* external fixation doesn’t limit blood loss, but reduces fracture displacement (III)
* unstable patients should get angio (I)
* pts with blush may require angio even if stable (I)
* ongoing bleeding after angio should get repeat angio (II)
* >60 y/o with major fx should get angio even if stable (II)
* anterior fxs assoc with ant vessel injury and posterior = posterior (III)
* Bilateral non-selective is safe, gluteal ischemia is more likely from injury not angio (III)
* And doesn’t affect male potency (III)
* FAST is insensitive in pelvic trauma (I)–don’t agree with this one
* Adequate Specificity (I)
* DPA is test of choice (II)
* Use CT if stable (II)
* Fracture pattern doesn’t predict need for angio (II)
* Nor hematoma location (II)
* Absence of ICE doesn’t exclude active hemorrhage (II)
* Volume > 500 cm3 predicts need for angio (III)
* Isolated acetabular fx may still need angio (III)
* Perform cystogram after ct (III)
* Binders reduce fx as well as definitive stabilization and decrease pelvic volume (III)
* And they limit hemorrhage (III)
* They work as well or better than external fixation in controlling hemorrhage (III)
* RetroP Packing can be used to salvage after failed angio (III)
* Can be used as primary in an integrated protocol (III)

]]>
Scott D. Weingart, MD clean 26:42
EMCrit Wee – ETCO2 with EGA? https://emcrit.org/emcrit/emcrit-wee-etco2-with-ega/ Sun, 22 Apr 2012 15:18:18 +0000 http://emcrit.org/?p=3475 Can we monitor ETCO2 with extraglottic airways? The answer is definitively: I don't know. Can we monitor ETCO2 with extraglottic airways? The answer is definitively: I don't know. Scott D. Weingart, MD clean 5:08 Podcast 71 – Critical Questions on Massive Transfusion Protocols with Kenji Inaba https://emcrit.org/emcrit/massive-transfusion-kenji/ Mon, 16 Apr 2012 16:33:18 +0000 http://emcrit.org/?p=3184 Today, I got to interview Kenji Inaba; an incredibly prolific trauma surgeon from LA County, California. Today, I got to interview Kenji Inaba; an incredibly prolific trauma surgeon from LA County, California. Kenji Inaba; an incredibly prolific trauma surgeon from USC/LA County, California. He is the SICU director and surgical critical care fellowship director. If you flip through any issue of the Journal of Trauma, odds are good that Kenji will have an article there.
Here are the questions I got to ask:
From the military studies, 1:1 (PRBCs to FFP) has emerged as the goal during hemostatic resuscitation. The civilian data is less robust, but there are cohort studies out there. Some of them suffer from survival bias and confounding by indication, but enough is out there for most of US trauma centers to attempt to meet the 1:1 goal? What are you folks doing at USC?

This excellent editorial (Resuscitation 82 (2011) 627–628) discusses the problems with 1:1 civilian studies and why we should shoot for this ratio anyway.

What is your transfusion goal with your 1:1. We are giving a mix of PRBC and FFP whenever the patient’s MAP drops below 65 and we don't even bothering looking at the labs to determine which of these two products the patient needs. We are using them just like some saline in the dehydrated patient. If their MAP drops below our goal, they get the PRBC and FFP 1:1 until we get the MAP back up. How about you folks?

For more on this see Rich Dutton's Interview

Where do platelets fit into the mix? At many hospitals they are not available in large amounts and most places are using old platelets and non-type-specific platelets. Some of your own work is on this very subject, should we be matching 1:1 with platelets as well? How about if we only have old, non-type-specific products?

See Kenji's Paper on the topic of old platelets.

Now most of our European and Canadian Colleagues have moved to concentrates instead of FFP and platelets. They use PCCs and fibrinogen concentrates in the initial stages of the hemostatic resuscitation. Is this the future?

 

Are you using TEG or ROTEM, if so how does this fit into the picture? Should it be available in the ED, the OR?

 

Let’s talk TXA. I interviewed Tim Coats, one of the lead authors of Crash 2, last week—he advocates using it with any trauma patient who will need any amount of PRBCs, and to give it as early as possible. I think I agree with him. When are you USC guys giving TXA?

 

MATTERs trial shows that intermittent boluses may be effective rather than starting the infusion. We are giving the 10-minute bolus in the trauma room and then deferring infusion to the STICU if the patient still has active bleeding. Starting an infusion in the trauma bay can be frustrating when we are trying to pour blood products in. How about you?

 

Are you using Rh specific in males? If you give O+ to an Rh - male are you giving rhogam?

This is the AAST Plenary Paper (J Trauma 2012;72(1):48) we mentioned

I am a member of the Kenji fan club; I think you folks will be as well after hearing his sincerity and brilliance.]]>
Scott D. Weingart, MD clean 21:18
Episode 2 – ACEP 2011 Clinical Policy on Pulmonary Embolism (PE) https://emcrit.org/practicalevidence/acep-pulmonary-embolism/ Sat, 07 Apr 2012 07:22:48 +0000 http://practicalevidence.org/?p=111 Welcome to the second episode of Practical Evidence, a podcast about the evidence you NEED to know but may not have time to read. Welcome to the second episode of Practical Evidence, a podcast about the evidence you NEED to know but may not have time to read.
This month we discuss the American College of Emergency Physicians’ Pulmonary Embolism Clinical Policy(2011)
What’s EMCrit Drinking?
This month, I’m drinking a Dreamweaver by Troeg Brewery
Please visit our bandwidth sponsor:
Please check out our bandwidth sponsor EB Medicine for great offers exclusively for our listeners.]]>
Scott D. Weingart, MD clean 9:57
EMCrit Wee – Abandon Epinephrine? https://emcrit.org/emcrit/abandon-epinephrine/ Thu, 05 Apr 2012 21:42:02 +0000 http://emcrit.org/?p=3404 Should we stop using Epi in the field for cardiac arrest Should we stop using Epi in the field for cardiac arrest Hagihara A, et al. Prehospital Epinephrine Use and Survival Among Patients With Out-of-Hospital Cardiac Arrest. JAMA. 2012;307(11):1161-1168
See Ryan's blog for some great commentary.

&
The PACA Trial: Jacobs et al. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation. 2011 Sep;82(9):1138-43.
 ]]>
Scott D. Weingart, MD clean 5:31
Podcast 70 – Airway Management with Rich Levitan https://emcrit.org/emcrit/rich-levitan-airway-lecture/ Sun, 01 Apr 2012 19:38:05 +0000 http://emcrit.org/?p=3379 Rich Levitan is one of the best teachers on the skills of airway management and laryngoscopy--or as he would probably put it, epiglottoscopy. Here is an hour long lecture he delivered last month at Mount Sinai School of Medicine. Rich Levitan is one of the best teachers on the skills of airway management and laryngoscopy--or as he would probably put it, epiglottoscopy. Here is an hour long lecture he delivered last month at Mount Sinai School of Medicine. Rich Levitan is one of the best teachers on the skills of laryngoscopy--or as he would probably put it, epiglottoscopy. Here is an hour long lecture he delivered last month at Mount Sinai School of Medicine. It is surely one of the best airway lectures I have ever heard.

Want to hear more from Dr. Levitan? Visit his airway site at airwaycam.com.

or, read his incredible book:


Get a big discount on the Emergency Medicine Critical Care Journal


Just go to ebmedicine.net/emcrit
Want the handout?
Here are Rich Levitan's Slides
Audio-Only Version
Right-Click on this Link and Choose Save-as
This episode is eligible for CME
Now, on to the Vodcast...]]>
Scott D. Weingart, MD clean 1:15:13
EMCrit Wee – On Editing Comments and Ad Hominem Attacks https://emcrit.org/emcrit/editing-comments-and-ad-hominem-attacks/ Mon, 19 Mar 2012 22:15:34 +0000 http://emcrit.org/?p=3333 On the editorial policy of EMCrit On the editorial policy of EMCrit
This wee was prompted by comments on episode 69.

This post is closed for comments, please go to the link above to make comments regarding this post.]]>
Scott D. Weingart, MD clean 5:05
EMCrit Podcast 69 – The Future of CPR with Keith Lurie and Demetris Yannopoulos https://emcrit.org/emcrit/future-of-cpr/ Mon, 19 Mar 2012 04:16:36 +0000 http://emcrit.org/?p=3195 Drs. Keith Lurie and Demetris Yannopoulos elaborate on the future of CPR Drs. Keith Lurie and Demetris Yannopoulos elaborate on the future of CPR I got to interview two cutting edge researchers on what CPR will look like in the next decade; their answers were fascinating.
Flow-Enhanced CPR
They discuss the use of the impedance threshold device and the active-compression/decompression device to augment flow during CPR. See the results of the ResQ trial listed below to see what this does in cardiac arrest patients.

Note: Dr. Lurie is the founder, chief medical officer, and a major shareholder of the company that manufactures these two devices. Dr. Yannopoulos has no conflicts of interest.

Reperfusion Injury Protection
Stutter CPR is giving 3 cycles of 20 seconds of compressions/ventilations, 20 seconds of pause. In pigs, this has markedly reduced the reperfusion injury when resuscitating a patient with prolonged arrest.
New Medications
Sodium nitroprusside (in addition to small doses of epi and flow-enhanced CPR) increases flow to the heart and the brain. May also blunt reperfusion injury to heart and brain. In addition adenosine and cyclosporine A may have a role as well.
Note: None of this is ready for clinical use--this may be the future, it is not the present
Want More?

* A presentation on the topic by Dr. Yannopoulos
* Read the ResQ Trial (Lancet  2011;377(9762):301–311)

Supplemental Audio
More on the ROC-Primed Trial and the ResQ Trial (MP3 File--Right Click and choose Save As)

More on Dosing and Intra-Arrest Hypothermia and Cath (MP3 File--Right Click and choose Save As)
Update

* Recent 15-minute pig cardiac arrest study provides continued evidence of ischemic post-conditioning (Resuscitation  Volume 84, Issue 8, August 2013, Pages 1143–1149)
* Review article on the physiology of CPR

This podcast is eligible for EMCrit CME
And Now to the Podcast...
 ]]>
Scott D. Weingart, MD clean 25:33
EMCrit Wee – Cliff Reid’s Tips for Occasional Intubators https://emcrit.org/emcrit/emcrit-wee-cliff-reids-tips-for-occasional-intubators/ Wed, 14 Mar 2012 16:47:16 +0000 http://emcrit.org/?p=3307 Prehospital Doc Cliff Reid's tips for intubation Prehospital Doc Cliff Reid's tips for intubation
Cliff Reid discusses some tips for occasional intubators.]]>
Scott D. Weingart, MD clean 5:01
Episode 1 – Penetrating Neck Trauma Guidelines https://emcrit.org/practicalevidence/penetrating-neck-trauma-guidelines/ Wed, 07 Mar 2012 07:23:34 +0000 http://practicalevidence.org/?p=112 Welcome to the first episode of Practical Evidence, a podcast about the evidence you NEED to know but may not have time to read. Welcome to the first episode of Practical Evidence, a podcast about the evidence you NEED to know but may not have time to read.
This month we discuss the Eastern Association for the Surgery of Trauma’s (EAST) guidelines on the management of penetrating trauma.
What’s EMCrit Drinking?
This month, I’m drinking a Mary’s Maple Porter from Brooklyn Brewery
Please visit our bandwidth sponsor:
Please check out our bandwidth sponsor EB Medicine for great offers exclusively for our listeners.]]>
Scott D. Weingart, MD clean 9:32
EMCrit Live Show # 1 https://emcrit.org/emcrit/emcrit-live-show-1/ Wed, 07 Mar 2012 04:16:04 +0000 http://emcrit.org/?p=3273 The first ever live EMCrit Podcast The first ever live EMCrit Podcast
Please check out the new EMCrit CME Site!]]>
Scott D. Weingart, MD clean 26:38
Podcast 67 – Tranexamic Acid (TXA), Crash 2, & Pragmatism with Tim Coats https://emcrit.org/emcrit/tranexamic-acid-trauma/ Mon, 20 Feb 2012 01:21:51 +0000 http://emcrit.org/?p=3084 One of the most exciting and underutilized therapies for trauma is tranexamic acid (txa). One of the most exciting and underutilized therapies for trauma is tranexamic acid (txa). One of the most exciting and underutilized therapies for trauma is tranexamic acid (txa). TXA inhibits the breakdown of clot--it is an anti-fibrinolytic. Is there evidence for using this in trauma patients?

First came the Crash 2 Trial (Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; 376: 23–32),

then the subgroup reanalysis (Lancet. 2011 Mar 26;377(9771):1096) showing the benefit of treatment as early as possible.

Recently, the MATTERS trial (Arch Surg. 2012; 147:113-119) was published demonstrating the benefits of TXA in military situations, particularly massive transfusion.

How about an incredible review from the J Trauma (2011; 71(1) Supplement S9)

Then there is this paper describing current military protocol rationale.

To discuss TXA in Trauma, I got to interview Dr. Tim Coats, one of the primary authors of Crash 2.
Here is a List of Resources from the Crash 2 Investigators
This is the official resource page from Crash 2

 

We also discussed the concept of the pragmatic trial...
Future Research in Emergency Medicine: Explanation or Pragmatism
(Emerg Med J 2011;28(12):1004)



Listen to the podcast excerpt on pragmatic trials (mp3--right click the link and choose save-as if you want to download)

In an amazing demonstration of synchronicity, Jeff Guy of the ICU Rounds Podcast put out a tranexamic acid episode on the same day.

Minh Le Cong provided this prehospital protocol for TXA use.

An incredible review article can be found at this citation (Journal of TRAUMA 2011;71(1) July Supplement)
Update...
This article published in J Trauma (74(6), May 2013, p 1587–1598) gives an excellent summary of the current evidence as of 5/2013


Summary: What Do We Know?

* TXA is associated with a 1.5% reduction in 28-day all-cause mortality in adult trauma patients with signs of bleeding (SBP < 90 mm Hg, heart rate > 110 beats per minute, or both, within 8 hours of injury) in a large pragmatic prospective randomized placebo-controlled trial.
* What is critical is the modest effect on the overall population: All-cause mortality was “significantly” reduced from 16.0% to 14·5% (NNT, 67). The risk of death caused by bleeding overall was “significantly” reduced from 5.7% to 4·9% (NNT, 121).
* TXA signal for benefit was in the most severe shock group (admission SBP <= 75 mm Hg), 28-day all-cause mortality of 30.6% for the TXA group versus 35.1% for the placebo group (RR, 0.87; 99% CI 0.76–0.99).
* 1,063 deaths (35%) were caused by bleeding in the CRASH-2 Trial.
* TXA had greatest impact on reduction of death caused by bleeding in the severe shock group (SBP <= 75 mm Hg) (14.9% vs. 18.]]>
Scott D. Weingart, MD clean 22:00
EMCrit Wee – More on C-Spine Imaging https://emcrit.org/emcrit/more-on-c-spine-imaging/ Fri, 17 Feb 2012 21:18:06 +0000 http://emcrit.org/?p=3219 A response to a question on c-spine imaging A response to a question on c-spine imaging episode on c-spine imaging approach and the follow-up regarding the evidence behind it.

 

Mike Wells from Scotland Writes:
Hi Scott,

Your two excellent podcasts on C spine imaging really got me thinking.
I work in the UK where resource constraints within our public
healthcare system mean that even if I wanted to, I would not be able
to obtain CTs as the first imaging port of call for all my neck trauma
patients. I can however argue individual cases with the radiology
department and therefore effectively need to try to choose high risk
patients.

I pulled the Canadian C spine and NEXUS studies and looked back
through their methodology and results. In both studies ordering a neck
CT was at the discretion of the treating physicians - but most
patients only got plain C spine films (in CCspine 436 patients got CTs
= 7% of total patients who were imaged; for NEXUS I could find data to
allow me to make this calculation). I also went through the further
NEXUS study looking at missed fractures - another way of looking at
their data is that in the 581 patients with technically adequate C
spine films, only 3 unstable fractures were missed - giving a
sensitivity of 99.4% for the unstable injuries which I am most scared
of missing.

I absolutely agree with you though that very often plain films are
technically inadequate and that their sensitivity is therefore much
lower.

However I would argue that the real sensitivity we are interested in
is not that of C spine films alone, but rather than the sensitivity of
the combination of plain C spine films and clinical examination and
acumen. CTs in the NEXUS and Canadian studies were after all ordered
at clinician discretion. It's possible that fractures were missed in
the patients who weren't scanned but both studies did seem to attempt
follow up (NEXUS in particular checked local 'event logs' although I'm
not clear on what these are).

So I think over here in the NHS I would argue that in 'minor' trauma
patients failing the CCspine rule I am still obliged to use plain C
spine films as my first imaging step. On the basis of what you have
said I'll will set the bar higher in terms of making sure films are
technically adequate (over here we still use Swimmer's views, which I
detest). However for patients with adequate films and the roughly 3%
prevalence of fractures in the group failing Canadian C spine, I would
hope that my clinical exam would then identify those patients with
normal films but underlying injuries.

Utimately I think from my view what this is about is not the
sensitivity of plain films on their own - which I agree is
unacceptably low - but about the sensitivity of plain films + clinical
skills.

Please feel free to put this in your comments section if you wish!

Thanks again for your fantastic podcast and blog.

Best wishes

Mike Wells
Here is my response to Mike and the others who voiced similar questions about what to do when CT is not easily obtained...]]>
Scott D. Weingart, MD clean 3:27
EMCrit Wee: The Lewis Lead and a course in ECGs with Christopher Watford https://emcrit.org/emcrit/lewis-lead/ Wed, 15 Feb 2012 17:22:25 +0000 http://emcrit.org/?p=2880 The Lewis Lead (S5) allows you detect atrial activity that cannot be discerned on the standard 12-lead The Lewis Lead (S5) allows you detect atrial activity that cannot be discerned on the standard 12-lead How to place the electrodes for the Lewis Lead (S5)
from Christopher Watford's blog My Variables Only Have 6 Letters...

S5 Lead: You can produce this using many variations of the electrodes, however, for simplicity's sake we will stick with Kelly's description:

* Place the Right Arm electrode on the patient's manubrium.
* Place the Left Arm electrode on the 5th intercostal space, right sternal border.
* Place the Left Leg electrode on the right lower costal margin.
* Monitor Lead I.



Lewis Lead Enhances Atrial Activity Detection in Wide QRS Tachycardia

The Lewis Lead - Making Recognition of P Waves Easy During Wide QRS Complex Tachycardia
Christopher's ideal path to learning ECGs if he had to do it all again
1. Structured Learning: Garcia and Holtz "12-Lead ECG: The Art of Interpretation"

2. Depth of Knowledge: skip Dubin, get Chou's/Goldman's/Marriott's (something with meat)

3. Deliberate Practice: read 1000's of ECGs. Brady & Mattu "ECGs for the Emergency Physician", Marriott's "Challenging ECGs", Harvard's WaveMaven

4. Participate!

* Dr. Smith's ECG Blog
* The EKG Club
* EMS 12-Lead Blog

Structured Learning/Depth of Knowledge links:

http://library.med.utah.edu/kw/ecg/ (Alan E. Lindsay's ECG Learning Center)

http://lifeinthefastlane.com/ecg-library/
 CCTMC Conference
The Air Medical Physician Association is co-sponsoring an upcoming conference called CCTMC: Critical Care Transport Medicine Conference—info and brochure available here.

It’s 4.2.12 through 4.4.12 in Nashville.

This year’s opening talk at the conference, is “Upstairs Care Outside: Top Ten Tricks of the Trade for Bringing ICU-Level Care to the Transport Environment.”
And now on to the wee...]]>
Scott D. Weingart, MD clean 7:57
Podcast 66 – …Until they are warm and dead: Severe Accidental Hypothermia https://emcrit.org/emcrit/severe-accidental-hypothermia/ Tue, 07 Feb 2012 17:14:18 +0000 http://emcrit.org/?p=3166 It is winter and that means cardiac arrests coming in with extremely low body temperatures after environmental exposure. How do you treat these patients? How do you rewarm if you don't have bypass? It is winter and that means cardiac arrests coming in with extremely low body temperatures after environmental exposure. How do you treat these patients? How do you rewarm if you don't have bypass? It is winter and that means cardiac arrests coming in with extremely low body temperatures after environmental exposure. How do you treat these patients? How do you rewarm if you don't have bypass?
Predisposing factors
hypoglycemia, malnutrition, ETOH, Addison’s, infection, and Myxedema (especially if failure to rewarm)

In urban environments, in patients > 32° C, failure to passively rewarm at least 1 C per hour should make you suspect one of the above factors. (Acad Emerg Med 2006;13(9):913)

Do not need to worry much until temp hits ~32° C

Bradycardia (refractory to atropine), but should not be treated anyway as it is appropriate to body temperature as long as it is sinus brady; but if you needed to, you can pace hypothermia internally (Ann Emerg Med 2007;49(5):)
Labs
FS, CBC, Lytes, TFTs, Cortisol, and blood cultures if you can't figure out why a patient got hypothermic or is not warming appropriately
Get Temperature Probe in early for sick patients
Place rectal probe in 15 cm or much better IMNHO is an esophageal probe

See this post for how to place the esophageal temperature probe
Active Rewarming
Active rewarming if pt temp <32° C, CNS sx, or age extremes
Rewarming Methods
Shivering 1.5° C/hr

Warming Blanket 2° C/hr

Warm O2 1 C/hr with mask; 1.5° C/hr ET tube

IV Fluids do not add, but do not take away either

Peritoneal Lavage 3° C/hr

Thoracic Lavage with Chest Tubes 3-6° C/hr

Cardiac Bypass 9-18° C/hr
When to Stop Rewarming
If K>10, pt is not coming back, even if cold and dead

Must be greater than 30-32° C degrees to be considered dead
Rewarming with Chest Tubes
32-36 F Chest tubes one anterior and one posterior lateral

Use Level 1 Device or similar to pump warm fluids into the anterior chest tube

attach auto-transfuser or pleur-evac to posterior-lat chest tube to allow cont. emptying

Review article with two case reports (Resuscitation 2005;66:99-104)

Update:

Instead of salem-sump adaptors, use the luer to XMAS tree adapters made for this purpose. See the Blakemore Post for more on this item.
Extra-corporeal rewarming
Easiest method is to place an HD catheter and then get a dialysis machine to do CVVH or standard HD
CAVR Level I Rewarming


Here is an actual protocol from a Trauma Nursing Journal

J Trauma 1991;31:1151 and 1992;32:316 both by Gentilello
Bypass Rewarming
Crit Care Med 2011;39:1064

---
Update
Best Review Article (NEJM 2012 367(20):1930)
Give a bunch of fluids
Afterdrop is a myth
30-32 is cutoff

ICAR MEDCOM Guidelines (Scand J Trauma, Resus, & Emerg Med 2016;24:111)
Now on to the Podcast...
 ]]>
Scott D. Weingart, MD clean 20:50
Podcast 65 – A Primer on BVM Ventilation with Reuben Strayer https://emcrit.org/emcrit/bvm-ventilation/ Mon, 23 Jan 2012 01:44:26 +0000 http://emcrit.org/?p=3129 Today I want to talk about proper ventilation with a Bag-Valve-Mask, aka the BVM. I am joined by my friend Reuben Strayer, MD of EM Updates. You'll see Reub's talk from this year's EMCrit ED Critical Care Conference and hear some of my thoughts as well. Today I want to talk about proper ventilation with a Bag-Valve-Mask, aka the BVM. I am joined by my friend Reuben Strayer, MD of EM Updates. You'll see Reub's talk from this year's EMCrit ED Critical Care Conference and hear some of my thoughts as well. Today I want to talk about proper ventilation with a Bag-Valve-Mask, aka the BVM. I am joined by my friend Reuben Strayer, MD of EM Updates. You'll see Reub's talk from this year's EMCrit ED Critical Care Conference and hear some of my thoughts as well.

After Reuben's lecture, I made a few points of my own:

* Anesthesiologists can't do one hand BVM as well as they think, at least according to this article: (Anesthesiology 2010; 113:873-9)
* How about the best article on how to manipulate the jaw for optimal BVMing
* Here is a link to an article where I discuss Vent as a Bag and here is the video as well.

need an audio-only version, (right click here and choose save-as), otherwise
Updates:
Please use the Ultimate BVM



* Pressure Gauge
* One-Way Exhalation Port
* PEEP Valve
* ETCO2

Head Rotation for BVM

* ResusME

Or Consider the Oxylator

* The Oxylator Podcast

More on BVM Use

* Kovacs from AIME
* How to Grade Quality of BVM Vent

And now to the Vodcast...]]>
Scott D. Weingart, MD clean 23:00
Podcast 64 – Fluid Responsiveness with Dr. Paul Marik https://emcrit.org/emcrit/fluid-responsiveness-with-dr-paul-marik/ Sun, 08 Jan 2012 16:43:41 +0000 http://emcrit.org/?p=3003 Today I had the pleasure to interview Dr. Paul Marik, Professor and Division Chief of Pulmonary Critical Care at Eastern Virginia Medical Center. We got to speak on the topic of fluid responsiveness--one of the toughest questions in critical care. Today I had the pleasure to interview Dr. Paul Marik, Professor and Division Chief of Pulmonary Critical Care at Eastern Virginia Medical Center. We got to speak on the topic of fluid responsiveness--one of the toughest questions in critical care. Fluid Responsiveness
The definition we are using for fluid responsiveness is an increase of stroke volume of 10-15% after the patient receives 500 ml of crystalloid over 10-15 minutes
Dr. Marik's Path through the Morass
this is a modification of the algorithm from Dr. Marik's upcoming paper

* if using passive leg raise, give a 500 ml bolus if the response is positive
What is Passive Leg Raising?


For a brief period of time, a bolus of fluid is sent to the heart, allowing you to test fluid responsiveness without doing anything permanent to the patient's fluid status.
What is the Monitor that Dr. Marik mentioned?


The NICOM Monitor by Cheetah Med uses bio-reactance to yield cardiac output/stroke volume non-invasively. I have been trialing the monitor and have been very impressed so far. It is inexpensive and correlates with my echocardiograms.
Articles of Interest

* This systematic review basically was the end of using CVP in the ICU for fluid responsiveness: Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares
* Marik's review of hemodynamic parameters to guide fluid therapy
* An even better review by Dr. Marik will be published in the journal Resuscitation, as soon as it is published, I'll put it up on the site
* If using Pulse Pressure Variation, probably only helpful if <9 or >13: Assessing the diagnostic accuracy of pulse pressure variations for the prediction of fluid responsiveness: a "gray zone" approach. by Maxime Cannesson (Anesthesiology. 2011 Aug;115(2):231-41.)

Neither Dr. Marik nor I have any Conflicts of Interest!
Update 6-10-12
Here is an amazing review article by Dr. Marik on this topic
and Now to the Podcast...]]>
Scott D. Weingart, MD clean 24:07
More on a Diagnostic Strategy for C-Spine Injuries https://emcrit.org/emcrit/why-should-we-kill-off-plain-films-c-spine/ Tue, 03 Jan 2012 00:00:18 +0000 http://emcrit.org/?p=3074 Podcast 63 set off some expected controversy given my take that plain films are a dead imaging modality for c-spine injuries. I wanted to briefly outline my impression of the existing evidence: Podcast 63 set off some expected controversy given my take that plain films are a dead imaging modality for c-spine injuries. I wanted to briefly outline my impression of the existing evidence: Podcast 63 set off some expected controversy given my take that plain films are a dead imaging modality for c-spine injuries. I wanted to briefly outline my impression of the existing evidence:
Worst Case Scenario for Sensitivity
Mathen R, Inaba K, et al. (J Trauma 2007;62:1427)

Showed a sensitivity of 45% for plain films.

Prospective study of trauma patients who could not be cleared by NEXUS. Got 3-view plain films and CT. Gold standard was evidence of injury during entire hospitalization.

Post NEXUS Prevalence was ~10%, so probably a mix of moderate and high risk patients.
Best Case Scenario for Sensitivity
Mower WR, Hoffman JR, et al. Use of Plain Radiography to Screen for Cervical Spine Injuries (Ann Emerg Med 2001;38(1):1)

It is a reanalysis of the NEXUS Data (NEJM 2000;343(2):94)

818 Patients with 1496 c-spine injuries

Missed 320 and found 498 of the c-spine injuries in those 818 patients

Of the 320 misses, 237 were deemed inadequate plain films

So 498 out of 581 patients with adequate plain films

So sensitivity of the exam is 85%; We'll assume a specificity of 100%

If you evaluate the performance by fracture instead of patient, the numbers become worse

I will say in the Mower paper, they tried to exclude SCIWORA patients, but from what I can glean from this paper (J Trauma 2002;53:1-4), these patients had their MRI without CT scans preceding it. CT may have picked up most of these injuries.

Now how can we get away with such a crappy sensitivity

The reason quoted is the NPV is excellent, they state 99.6% NPV. But NPV is a really crappy number, why...

Because as you change the prevalence, the NPV changes.

So now we need to go to a second enormous study...

Let's look at the Canadian C-Spine Studies (JAMA 2001;286(15):1841 & NEJM 2003;349(26):2510), why? Because their entry criteria are exactly the patients we want to discuss--namely, acute trauma with alert mental status, an injury within the past 48 hours, and in stable condition. The prevalence of c-spine injuries in these patients was ~2% and in the NEXUS trial it was 2.4% So now we have some numbers for a low risk cohort. However, after you get a group of patients who could not be excluded by CCR, the prevalence of the group increases to ~4%. I would argue these patients are now moderate risk. If you pursue plain film strategy in this group, from the best numbers I can gather, you will miss 1 in 100 c-spine injuries and half of these will be clinically significant injuries.

75% of your plain films will be inadequate and require a CT scan

Plain films read as normal but which have loss of lordosis or soft tissue swelling were interpreted as abnormal by NEXUS folks and demand CT scan, this will account for patients going on to CT as well

Finally, patients with persistent midline pain probably deserve a CT prior to d/c in a collar as well
Let's Put it all Together
The authors of this paper from the journal Medical Physics (Med Physics 2009;36(10):4461) attempted to take all the variables: radiation risk, cancer, missed injuries, etc. and evaluate whether plain films or CT is a better strategy. The results...in all risk levels, CT was the smarter move. This was with factoring in the putative cancer risks.
What about MRI for patients with persistent Midline Tenderness
BF asked about this in the comments

(Ann Emerg Med 2011;58:521)

44% of patients with persistent pain had an MRI abnormality

]]>
Scott D. Weingart, MD clean 17:28
Podcast 63 – A Pain in the Neck – Part I https://emcrit.org/emcrit/cervical-spine-injuries-i/ Sun, 25 Dec 2011 23:07:04 +0000 http://emcrit.org/?p=3058 In this episode, I discuss the diagnosis of c-spine injuries. I argue that we should not send patients to imaging unless we have used the NEXUS rule and then added the Canadian C-spine Rule to the sequence. If we are imaging, it should be with a 3-view reconstructed CT scan. And even after that is done, you still need a clearance exam before removing the collar. In this episode, I discuss the diagnosis of c-spine injuries. I argue that we should not send patients to imaging unless we have used the NEXUS rule and then added the Canadian C-spine Rule to the sequence. If we are imaging, In this episode, I discuss the diagnosis of c-spine injuries. I argue that we should not send patients to imaging unless we have used the NEXUS rule and then added the Canadian C-spine Rule to the sequence. If we are imaging, it should be with a 3-view reconstructed CT scan. And even after that is done, you still need a clearance exam before removing the collar.
 The Fine Print of the NEXUS rule


The folks from Virginia think (J Trauma. 2011 Apr;70(4):829-31. & J Trauma2011;70(4):829-831) Nexus can't be used, but I think if you follow my advice in the podcast, you are probably going to come as close to 100% as a rule can provide. The Canadians also showed less than 100% Sens when using NEXUS (N Engl J Med. 2003 Dec 25;349(26):2510-8), but I would make the same argument--did they really do it the same as the NEXUS study advocates? Do you do it the same? If not, you may be missing injuries.
Then add the Canadian C-Spine Rule if there is Midline Tenderness, but no other NEXUS Criteria

Plain Films Suck!
Want the evidence, check out the Spinal Cord Injury chapter at CrashingPatient
Injuries Missed on CT scan


Cervical spine magnetic resonance imaging in alert, neurologically intact trauma patients with persistent midline tenderness and negative computed tomography results. (Ann Emerg Med. 2011 Dec;58(6):521-30)
Computed tomography alone for cervical spine clearance in the unreliable patient--are we there yet? (J Trauma. 2008;64:898 –904.)

Update: this article is hot off of the presses: JAMA Surg. 2014 Sep;149(9):934-9. doi: 10.1001/jamasurg.2014.867. Clinical relevance of magnetic resonance imaging in cervical spine clearance: a prospective study.

Guidelines
Check out the c-spine guidelines from the Eastern Assoc of Surgeons for Trauma (EAST)
And now to the podcast...
]]>
Scott D. Weingart, MD clean 21:58
EMCrit Podcast – Hard Six – My Picks from 2011 https://emcrit.org/emcrit/emcrit-picks-from-2011/ Sun, 25 Dec 2011 23:05:47 +0000 http://emcrit.org/?p=3055 My favorite discoveries in the medical blogosphere and podcast land My favorite discoveries in the medical blogosphere and podcast land EMCrit's favorites from 2011
An Ultrasound Podcast
The Emergency Ultrasound Podcast is some of the best emergency medicine podcasting out there. Matt and Mike have a fabulous teaching style and I can't get enough of their ultrasound education.
A New Blog on EM Evidence
EM Literature of Note provides concise and incisive commentary from Ryan Radecki
EM Posts with Care Pathways and some Ketamine
My friend Reuben Strayer doesn't post often, but when he does, it is pure gold: Emergency Medicine Updates
A Flying Doctor who seems to love Airway
Minh Le Cong is brilliant and I hope he posts on the EMCrit blog as much as he likes.
An Intensive Care Blog with Lectures
The Intensive Care Network is a fantastic blog with lectures, videos, and board preparation resources.
A Surgeon who can communicate--Who would have thunk it?
The Trauma Professionals Blog is the fantastic perspective of a trauma surgeon, Dr. Michael McGonigal.
For more of my favorite things, check out the
Want more Best of?

* Sexy Six for 2014
* Eight is Enough for 2013
* Natural Seven for 2012
* Dirty Dozen from 2010

 ]]>
Scott D. Weingart, MD clean 3:14
Replay of the Emergency Ultrasound Podcast – Wall Motion Abnormality Lecture https://emcrit.org/emcrit/replay-emergency-ultrasound-podcast/ Fri, 16 Dec 2011 21:33:30 +0000 http://emcrit.org/?p=3030 Replay of the incredible Wall Motion Abnormality Talk from the Emergency Ultrasound Podcast Replay of the incredible Wall Motion Abnormality Talk from the Emergency Ultrasound Podcast Emergency Ultrasound Podcast with Matt Dawson and Mike Mallon. If you haven't checked it out yet, I am replaying their wall motion abnormality talk here on the podcast, because it is so damn good.

If you like it please subscribe to these guys at their website: http://ultrasoundpodcast.com

Here is the handout from the lecture.

Audio only would not be helpful for this lecture.

 

 ]]>
Scott D. Weingart, MD clean
Podcast 62 – Needle vs. Knife II: Needle Thoracostomy? https://emcrit.org/emcrit/needle-finger-thoracostomy/ Sun, 11 Dec 2011 18:10:24 +0000 http://emcrit.org/?p=1815 In this podcast, I explain why I don't think needle compression is such a clever idea. Main points are: most people can't find anterior target, most angiocaths won't reach, and if used diagnostically you may not be in the pleura leading to an unidentified pneumo or hemothorax. Also, when used diagnostically, if the chest was negative you just caused a pneumothorax. In this podcast, I explain why I don't think needle compression is such a clever idea. Main points are: most people can't find anterior target, most angiocaths won't reach, and if used diagnostically you may not be in the pleura leading to an unidentif... In this podcast, I explain why I don't think needle compression is such a clever idea. Main points are: most people can't find anterior target, most angiocaths won't reach, and if used diagnostically you may not be in the pleura leading to an unidentified pneumo or hemothorax. Also, when used diagnostically, if the chest was negative you just caused a pneumothorax.

If you haven't already, you should listen to Needle vs. Knife Part I with Minh. Also, may of the issues discussed here are also mentioned in the finger thoracostomy episode and the traumatic arrest episode.
Why the standard approach to needle decompression sucks
Normal IV catheters do not reach in up to 65% of the cases
Can J Surg. 2010 Jun;53(3):184-8.

Prehosp Emerg Care. 2009 Jan-Mar;13(1):14-7

J Trauma. 2008 Jan;64(1):111-4

J Trauma 2008 Oct;65(4)":964

Accid Emerg Med 1996;6:426–7

Injury 1996;5:321–2.

Brand New Study state failure in 42% of cases (Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax Arch Surg. 2012 Sep 1;147(9):813-8)

 
Anterior Approach is not Where You Think it is
Emerg Med J 2003;20:383-384

ED Docs got it wrong a lot! (Emerg Med J 2005;22:788)


Use the Lateral Approach if you are going to do Needle Thoracostomy
ANZ J Surg. 2004 Jun;74(6):420-3
Study says Anterior is closer, but (smooth concept here) the patients had their arms in the air
(Acad Emerg Med 2011;18:1022)
Even if you get it right, Cannula may kink, occlude, or compress
Emerg Med J 2002;19:176-177
Traumatic Arrest is not Dismal until Tension Pneumo is Ruled Out
Emerg Med J. 2009 Oct;26(10):738-4
This device makes much more sense to me
Evaluation of ThoraQuik: a new device for the treatment of pneumothorax and pleural effusion (Emerg Med J 2011;28:750-753)

Michelle Lin did a great blog post about the stuff in this podcast on her Academic Life in EM Blog.
Update:
Hot off the press is this swine simulation demonstrating that even when a 14G catheter reached, it may not be sufficient to drain a tension pneumo (Journal of Trauma and Acute Care SurgeryIssue: Volume 73(6), December 2012, p 1410–1415)
A Video Demonstrating Finger Thoracostomy by Cliff Reid

Additional References
Deakin, C., Davies, G., & Wilson, A. (1995) Simple thoracostomy avoids chest drain insertion in prehospital trauma. The Journal of Trauma: Injury, Infection, and Critical Care. 39(2). 373-374.

Masarutti, D., Trillo, G., Berlot, G., Tomasini, A., Bacer, B., D’Orlando, L., Viviani, M., Rinaldi, A., Babuin, A., Burato, L., & Carchietti, E. (2006) Simple thoracostomy in prehospital trauma management is safe and effective: a 2-year experience by helicopter emergency medical crews. European Journal of Emergency Medicine. 13. 276-280
Want a recorded lecture on the topic?
Michael McGonigal had me to his Trauma Conference for this lecture on the finger
Updates
See these observations from the military
]]>
Scott D. Weingart, MD clean 17:21
Podcast 061 – Debate: Paralytics for ICU Intubations? https://emcrit.org/emcrit/paralytics-for-icu-intubations/ Mon, 28 Nov 2011 00:04:38 +0000 http://emcrit.org/?p=2907 I recently spoke at a symposium at the Greater NY Hospital Assoc's with the title: Controversies in Critical Care. I debated Paul Mayo, MD on the topic of whether paralytics should be used for ICU emergent intubations. Of course, I took the pro side of the debate. Dr. Mayo based his con side on an amazing study that came out of his ICU at LIJ hospital in NY. I recently spoke at a symposium at the Greater NY Hospital Assoc's with the title: Controversies in Critical Care. I debated Paul Mayo, MD on the topic of whether paralytics should be used for ICU emergent intubations. Of course,
Here is the abstract of that study:
Seth Koenig, MD; Viera Lakticova, MD*; Abhijeth Hegde, MD; Pierre Kory, MD; Mangala Narasimhan, DO; Peter Doelken, MD and Paul Mayo, MD
The Safety of Emergency Endotracheal Intubation Without the Use of a Paralytic Agent
Here is some literature you may want to cast a more informed vote:
Mort on Complications of Repeated Laryngoscopic Attempts
Here is the article I wrote with Rich Levitan on Preoxygenation for Intubation:

* Weingart, S. Levitan, R. Preoxygenation and Prevention of Desaturation During Emergency Airway Management (In Press, For Review Only)

Update

* Annals ATS. First published online 26 Feb 2015 as DOI: 10.1513/AnnalsATS.201411-517OC Neuromuscular Blockade Improves First Attempt Success for Intubation in the Intensive Care Unit: A Propensity Matched Analysis Jarrod M Mosier , John C Sakles , Uwe Stolz , Cameron D Hypes , Harsharon Chopra , Josh Malo , and John W Bloom    Read More: http://www.atsjournals.org/doi/10.1513/AnnalsATS.201411-517OC#.VPN3bOFGxsk
* BMC Anesthesiol. 2014 Jan 1;14:39

Need an audio only version:
Mp3 of the Paralytic Debate (right click and choose save as)
Now on to the Podcast...]]>
Scott D. Weingart, MD clean
How to generate constant CPAP with a BVM for Preoxygenation and Reoxygenation https://emcrit.org/emcrit/bvm-preoxygenation-and-reoxygenation/ Fri, 04 Nov 2011 20:09:51 +0000 http://emcrit.org/?p=2785 How to make your crappy BVM into a powerful preoxygenation device--on the cheap. How to make your crappy BVM into a powerful preoxygenation device--on the cheap.
Email me if you need further explanation.

Here's the Video:

 ]]>
Scott D. Weingart, MD clean
Podcast 059 – Bath Salts with Leon Gussow https://emcrit.org/emcrit/bath-salts/ Wed, 26 Oct 2011 03:35:45 +0000 http://emcrit.org/?p=2713 Today I am joined by toxicology master, Leon Gussow to discuss a new quasi-legal class of drugs: Bath Salts. I saw my first OD of this a month ago; despite the drug's name, this patient was neither clean nor pleasantly refreshed. He was violent, agitated, and overheated. Today I am joined by toxicology master, Leon Gussow to discuss a new quasi-legal class of drugs: Bath Salts. I saw my first OD of this a month ago; despite the drug's name, this patient was neither clean nor pleasantly refreshed. He was violent,
This class of drugs are chemically altered hallucinogenic stimulants. Depending on which chemical is used in the salts, the patient can look like they took meth or ecstasy. They will present with a sympathomimetic toxidrome including hyperadrenergic vitals and profound hyperthermia.

How many folks out there have ever used the Bellevue-style metal tub to immerse these patients in ice baths? Let me know in the comments.

Here is a link to Leon's bath salt article in EM News.]]>
Scott D. Weingart, MD clean 18:02
Podcast 058 – Interview with Cliff Reid – Part II https://emcrit.org/emcrit/ems-physician-2/ Tue, 11 Oct 2011 00:16:05 +0000 http://emcrit.org/?p=2576 Part II of an interview with EMS Physician Cliff Reid of the amazing blog, resus.me. Part II of an interview with EMS Physician Cliff Reid of the amazing blog, resus.me. resus.me. Cliff is truly a doc after my own heart as you will hear from the cast.

If you haven't already, please listen to Part I of Cliff's interview as well.

He is currently an EMS physician and Director of Training at the New South Wales Ambulance Service.

Cliff's blog, resus.me is an incredible collection of timely articles on emergency medicine, ems, critical care and resuscitation.



Here are some details on what Cliff carries on a mission.
Prehospital Amputation
One of the topics we discuss is prehospital amputation. For more information on this topic, check out the deep-dive page on prehospital amputation.

Come visit me at ACEP and AOCEP Scientific Assemblies.
Now to the Podcast...]]>
Scott D. Weingart, MD clean 23:41
Podcast 057 – Resuscitative Extra-Corporeal Life Support (ECMO) https://emcrit.org/emcrit/ecmo/ Mon, 26 Sep 2011 23:03:16 +0000 http://emcrit.org/?p=2479 Joe Bellezzo, MD along with his partner-in-crime, Zack Shinar, MD have started an ED ECMO service at Sharp Memorial Hospital in San Diego. I am so jealous! In this episode of the podcast, I get to talk to Joe about how it works. Joe Bellezzo, MD along with his partner-in-crime, Zack Shinar, MD have started an ED ECMO service at Sharp Memorial Hospital in San Diego. I am so jealous! In this episode of the podcast, I get to talk to Joe about how it works. Joe Bellezzo, MD along with his partner-in-crime, Zack Shinar, MD have started an ED ECMO service at Sharp Memorial Hospital in San Diego. I am so jealous! In this episode of the podcast, I get to talk to Joe about how it works.
Want to hear more about all things cardiac arrest and ECPR, then come to EDECMO.org
What is ECMO?
ECMO is actually a misnomer. Extra-corporeal life support (ECLS) is probably a better term. If a catheter is placed in a major artery and a major vein (VA ECMO), the patient can be provided with full hemodynamic and respiratory support, aka cardiopulmonary bypass. If catheters are placed in two major veins (VV ECMO), the patient's respiratory status can be maintained, but without the hemodynamic augmentation. Dr. Bellezzo's shop is using VA ECMO to treat refractory cardiac arrest patients.

This is not the first attempt to use ECMO in this patient group, (see the articles in the EMCrit Hypothermia/Post-Arrest Section) but I think this is the first ED physician initiated service.
Which patients are they crashing on to ECMO?

What are the stages to placing a patient on ECMO?
Stage I-get catheters into a femoral artery and femoral vein

Stage II-exchange these catheters for the enormous ECMO catheters vias guidewire and serial dilations





Stage III-attach them to the ECMO machine, which is run by specially trained ICU nurses for the first 45-60 minutes and then by a perfusionist.


Don't you have a video?
Dr. Bellezzo was kind enough to let me post this video


If you have any questions, place them in the comments and anything I can't answer, I'll forward to Dr. Bellezzo
Update:

* Mosier on EDECMO
* Review of ECMO

Now, on to the Podcast:]]>
Scott D. Weingart, MD clean 28:03
Podcast 056 – Dr. Rivers on Severe Sepsis – Part III https://emcrit.org/emcrit/rivers-sepsis-iii/ Tue, 13 Sep 2011 06:21:29 +0000 http://emcrit.org/?p=2411 Part III of an amazing talk by Dr. Emanuel Rivers on Severe Sepsis, Septic Shock, and early goal directed therapy. Part III of an amazing talk by Dr. Emanuel Rivers on Severe Sepsis, Septic Shock, and early goal directed therapy. Dr. Emanuel Rivers brought the concept of aggressive therapies for sepsis down to the Emergency Department with his seminal article on EGDT published in the NEJM in 2001. We were lucky enough to get an hour of his time to do a conference call with the NYC STOP Sepsis collaborative.

I broke the ~1 hour lecture into 3 parts.

If you haven't already, check out Part I and Part II.

In Part III, Dr. Rivers discusses:

*  Protein C?
* Can you do EGDT in small community EDs?
* How do you handle the tachycardic patient with severe sepsis?
* Steroids in the ED?
* Procalcitonin?

Win a Free Iphone App
Sign Up to the Mailing list to win a copy of the PICU Calculator Iphone App. The box is on the bottom of the page or just click here.


Audio Only Version
(right click here to save)
The Video Podcast]]>
Scott D. Weingart, MD clean 20:00
Podcast 055 – Dr. Rivers on Severe Sepsis – Part II https://emcrit.org/emcrit/rivers-sepsis-ii/ Tue, 06 Sep 2011 00:17:31 +0000 http://emcrit.org/?p=2388 Part II of an amazing talk by Dr. Emanuel Rivers on Severe Sepsis. Part II of an amazing talk by Dr. Emanuel Rivers on Severe Sepsis. Dr. Emanuel Rivers brought the concept of aggressive therapies for sepsis down to the Emergency Department with his seminal article on EGDT published in the NEJM in 2001. We were lucky enough to get an hour of his time to do a conference call with the NYC STOP Sepsis collaborative.

I broke the ~1 hour lecture into 3 parts.

If you haven't already, check out Part I and Part III for more fun

In Part II, Dr. Rivers discusses:

* CVP and Fluid Responsiveness
* Should End-Stage Renal Failure patients get lots of fluids?
* Should we be using albumin?
* Should vasopressin be a first line pressor?
* Steroids/Etomidate (See a paper by Dr. Marik on steroids in sepsis)

Here is a pdf of Dr. Rivers' Slides
Remember--Get a Free Trial of EM Critical Care Journal


Click Here for a 6 Month Free Trial of the New EMCC Journal
How do I get the videos to work on my IPOD
View here in Full Screen
and now the Podcast...
Right Click Here for an Audio-Only Version
Video]]>
Scott D. Weingart, MD clean
Podcast 054 – Dr. Rivers on Severe Sepsis – Part I https://emcrit.org/emcrit/rivers-sepsis-i/ Mon, 29 Aug 2011 16:40:24 +0000 http://emcrit.org/?p=2196 Part I of an amazing talk by Dr. Emanuel Rivers on Severe Sepsis. Part I of an amazing talk by Dr. Emanuel Rivers on Severe Sepsis. Dr. Emanuel Rivers brought the concept of aggressive therapies for sepsis down to the Emergency Department with his seminal article on EGDT published in the NEJM in 2001. We were lucky enough to get an hour of his time to do a conference call with the NYC STOP Sepsis collaborative.

I broke the ~1 hour lecture into 3 parts. In Part I, Dr. Rivers discusses:

* Prehospital Antibiotics
* Comparison between the original EGDT Study and the Jones study (showing the non-inferiority of the non-invasive approach).
* Alactemic Septic Shock

Find Part II and Part III for more fun

Here is a pdf of Dr. Rivers' Slides
Get a Free Trial of EM Critical Care Journal


Click Here for a 6 Month Free Trial of the New EMCC Journal
and now the Podcast...
Right Click Here for an Audio-Only Version
Video]]>
Scott D. Weingart, MD clean 24:00
Minh Discusses Three Examples of Airway Management gone Bad https://emcrit.org/emcrit/three-airway-disasters/ Tue, 09 Aug 2011 23:46:31 +0000 http://emcrit.org/?p=2227 In this podcast short, Minh Le Cong discusses three airway disasters. In this podcast short, Minh Le Cong discusses three airway disasters. In this podcast short, Minh Le Cong discusses three airway disasters.
Case I
The first case Minh mentions is Just a Routine Operation: The Tragedy of Elaine Bromiley. Here is the incredible and saddening video:



The conclusions of the investigation and coroner's report are chilling.
Update: See  the new videos on this topic
Case II
The second case Minh mentions is the Jankowski Case from Perth in 2001.

Full PDF Transcript is Here

This case really highlights how crucial quantitative ETCO2 is at every intubation. Further, needle cric failed 3 times before someone finally grabbed a scalpel.
Case III
The final case mentioned is the Rasmussen case; the best description of the case is at an medical indemnity site: Invivo.

 
Minh's Acronyms:
Minh Le Cong

MBBS(Adelaide), FRACGP, FACRRM, FARGP, GDRGP, GCMA,GEM, Dip AeroMedical Retrieval & Transport(Otago),Cert IV TAA Senior Lecturer ( Aeromedical retrieval), JCU School of Public health Tropical Medicine & Rehabilitation Sciences Medical Education Officer - Royal Flying Doctor Service, Queensland Section]]>
Scott D. Weingart, MD clean 5:59
Podcast 053 – Needle vs. Knife: Part I https://emcrit.org/emcrit/cricothyrotomy-needle-or-knife/ Tue, 09 Aug 2011 05:37:03 +0000 http://emcrit.org/?p=2203 What technique should we use in the can't intubate/can't oxygenate (CICO) situation: Needle Cricothyrotomy vs. Bougie Cricothyrotomy. What technique should we use in the can't intubate/can't oxygenate (CICO) situation: Needle Cricothyrotomy vs. Bougie Cricothyrotomy. In this episode, I debate Minh Le Cong, a retrieval physician from Australia. The question is what technique should we use in the can't intubate/can't oxygenate (CICO) situation.

Throughout the podcast, you will hear reference to Dr. Andrew Heard, who has written some fantastic papers on the subject. Perhaps most pertinent is his description of the formation of a CICO protocol based on his experience with a wet sheep airway instruction lab.
Heard AM, Green RJ, Eakins P. The formulation and introduction of a 'can't intubate, can't ventilate' algorithm into clinical practice. Anaesthesia. 2009 Jun;64(6):601-8.
 

Here is the algorithm from the paper (Click for full size)



Here is his video on the cannula cricothyrotomy technique

http://www.youtube.com/watch?v=Pzf29LT6VJQ

Here is his video on the scalpel-finger-cannula technique

http://www.youtube.com/watch?v=waGiiEyzqX8

Here is a video describing why Dr. Heard prefers the 14G Insyte Catheter for Needle Cric

http://www.youtube.com/watch?v=d_k_zJEYYrE

Here is his preferred method for oxygenation through the cannula



And here is the jet ventilation video:



The paper on the use of ultrasound to find the cricothyroid membrane is quite interesting.

See my prior posts on how to perform the bougie-aided cricothyrotomy and the cric show.

One of the best things Minh expressed is the need to say OUT LOUD: "This is a can't intubate/can't oxygenate situation." Saying it out loud lets everyone in the room know, there will be no more screwing around with attempts at direct laryngoscopy.

Go to the Broome Docs Blog for more Minh Le Cong.

He is an incredible guy, expect to hear more from Minh on the podcast.

I also gave a shout-out to a new podcast, the Emergency Ultrasound Podcast.
and now the EMCrit Podcast 53...]]>
Scott D. Weingart, MD clean 36:22
Podcast 052 – Organ Donation in the ED https://emcrit.org/emcrit/organ-donation-brain-death/ Wed, 27 Jul 2011 04:53:30 +0000 http://emcrit.org/?p=2092 Organ Donation in the Emergency Department Though it may not seem as important as some of the things we do in ED Critical Care, managing the potential organ donor can lead to many lives saved. In this episode I interview Isaac Tawil, an Emergency Intensivist of University of New Mexico Health Sciences and associate medical director of New Mexico Organ Donor Services. Here are the current standards for determining brain death Wijdicks et al. Evidence-based guideline update: Determining Brain Death in Adults Brain Death Checklist brain death statement Here is a video of Dr. Tawil demonstrating the brain death exam Now on to the Podcast... Organ Donation in the Emergency Department Though it may not seem as important as some of the things we do in ED Critical Care, managing the potential organ donor can lead to many lives saved. In this episode I interview Isaac Tawil, Though it may not seem as important as some of the things we do in ED Critical Care, managing the potential organ donor can lead to many lives saved. In this episode I interview Isaac Tawil, an Emergency Intensivist of University of New Mexico Health Sciences and associate medical director of New Mexico Organ Donor Services.
Here are the current standards for determining brain death
Wijdicks et al. Evidence-based guideline update: Determining Brain Death in Adults
Brain Death Checklist
brain death statement
Here is a video of Dr. Tawil demonstrating the brain death exam

Now on to the Podcast...]]>
Scott D. Weingart, MD clean 33:30
Podcast # 51: Fibrinolysis in Pulmonary Embolism https://emcrit.org/emcrit/fibrinolysis-in-pulmonary-embolism/ Mon, 11 Jul 2011 05:00:07 +0000 http://emcrit.org/?p=2055 Jeff Kline is the master of all things pulmonary embolism in emergency medicine. This is a lecture he gave on fibrinolysis for pulmonary embolism. He discusses both massive and sub-massive PE. Jeff Kline is the master of all things pulmonary embolism in emergency medicine. This is a lecture he gave on fibrinolysis for pulmonary embolism. He discusses both massive and sub-massive PE. podcast 128

Jeff Kline is the master of all things pulmonary embolism in emergency medicine. This is a lecture he gave on fibrinolysis for pulmonary embolism. He discusses both massive and sub-massive PE.

Here is a pdf of the slides.

If you haven't already, you should also check out the AHA PE guidelines. I have a summary and the diagrams in another post.
Fibrinolysis in Pulmonary Embolism with Dr. Jeff Kline
The lecture starts with a few non-fibrinolytic points:

* Use PERC with clinical gestalt
* You can use a high-senstivity d-dimer in ALL risk groups
* Use a d-dimer with elevated cut-offs based on trimester in pregnant patients
* A high-sensitivity CTPA is the best thing we have and a negative is negative for all risk groups

Feel free to discuss any of those in the comments
Massive PE
In the guidelines, the definition is PE with SBP < 90 for > 15 minutes

Dr. Kline basically says that if you have an SBP < 90 at any point, the patient MUST be given fibrinolysis or you better have a good reason why on your chart.
Sub-Massive PE
Here are the points Dr. Kline can state definitively:
After lytics,

* The patient will feel better
* The clot will resolve more quickly
* There will be no increase in serious bleeding (Note in the original study, 2 patients with pre-lytic ICH were coded as complications)

What he can't say yet (but he has the largest RCT going on now) is mortality reduction

So who does he think should get lytics in sub-massive PE?

* BNP >90 or Pro-BNP >900 elevation (he states BNP is his go to marker). SENSITIVE
* Troponin positive SPECIFIC
* Echo with RV dysfunction, hypokinesis, dilation

He also states a low room air pulse ox is an indicator of needing lytics.
Choice of Drugs
Alteplase-he continues heparin during the infusion. He also feels you can just give the 100 mg as a bolus if you need to.

Tenecteplase-this is what he would want to receive if he had a PE. He gives it simultaneously with LMWH.

Mentions that lytics don't destroy all of the clot they just chew away at the big ones a bit.

 

For more PE stuff see the diagnosis protocol post and the PE debate insanity.

 ]]>
Scott D. Weingart, MD clean 30:36
EMCrit Podcast 50 – Acid Base Part IV – Choose the Solution Based on the Problem https://emcrit.org/emcrit/acid-base-4-use-of-fluids/ Mon, 27 Jun 2011 03:16:37 +0000 http://emcrit.org/?p=1817 This is Part 4 of the Acid Base saga. In this episode, I discuss the acid base effects of fluids and when and how to use sodium bicarbonate. This is Part 4 of the Acid Base saga. In this episode, I discuss the acid base effects of fluids and when and how to use sodium bicarbonate.
If you haven't checked out the previous episodes, you should definitely do that first:

* Part I lays out the background of the quantitative approach
* Part II puts it in mathematical terms to allow calculation of acid base status
* Part III takes you through some real world examples
* Part V specifically discusses some of the Bicarb Controversy

The Acid Base Series


You may need the EMCrit Acid Base Sheet to follow along
The Acid Base of Fluids
Crystalloids will have acid-base effects by their SID and the dilution of extracellular Atot



"Balanced Fluids" are fluids with a SID just low enough to balance the dilution of the weak acid, albumin (SID of 24-28)

For the effects on a patient with altered pH, any fluid with a SID the same as the pt's bicarb will keep the patient at the same pH. If the SID is greater than the pt's bicarb, then the fluid will be alkalotic and if less than the pt's bicarb--acidotic (Intens Care Med 2011;37:461).

Hypertonic fluids are even more acidifying b/c they draw pure water into the extracellular space



Chart with a bunch more fluids is on crashingpatient.com
Sodium Bicarbonate
If not stored in glass, bicarb containing solutions leech CO2 and become not so much bicarbonate.

If given at all, should be given slowly by push over 5-10 minutes or by drip; never by rapid push

In hyperkalemia, NaBicarb isotonic is essentially a potassium-free, non-acidic fluid that dilutes down the potassium.

NaBicarb can be used as a substitute for hypertonic saline in increased ICP (Neurocrit Care 2010;13:24). They used 85 ml of 8.4% sodium bicarb infused over 30 minutes.
Articles
Best Review of the Stewart/Quant Approach to Fluids

Best Review of Sodium Bicarb Use Ever

Balanced solutions (p-lyte) led to lower Cl and higher bicarb (Am J Emerg Med. 2011 Jul;29(6):670-4)

Another incredible review on fluids including the rec. that we use 3 amps of bicarb (J Intens Care Med 2010;25(5):271)

Also of interest may be the previous episode on intubating the patient with the severe metabolic acidosis
Update:
Josh Farkas has done a lit review showing that the body may not change gluconate to bicarb, leading plasmalyte to be neutral rather than extremely basic (which is a good thing)]]>
Scott D. Weingart, MD clean 21:23
Hemostatic Resuscitation by Richard Dutton, MD https://emcrit.org/emcrit/hemostatic-resuscitation/ Sun, 12 Jun 2011 01:41:56 +0000 http://emcrit.org/?p=1962 Richard Dutton is a trauma anesthesiologist who was one of the primary formulators of the concept of 1:1:1 resuscitation. Here he is speaking on hemostatic resuscitation. Richard Dutton is a trauma anesthesiologist who was one of the primary formulators of the concept of 1:1:1 resuscitation. Here he is speaking on hemostatic resuscitation.
Hear more from Rich in Podcast 30

Here he is speaking on hemostatic resuscitation.

This lecture was recorded at the EMCrit Conference 2011.

]]>
Scott D. Weingart, MD clean 51:35
EMCrit Podcast 49 – The Mind of a Resus Doc: Logistics over Strategy https://emcrit.org/emcrit/mind-resus-doc-logistics/ Tue, 07 Jun 2011 05:48:07 +0000 http://emcrit.org/?p=1938 This Part I of the Mind of a Resus Doc Series, in which we delve into the philosophies that make a good resuscitationist. This Part I of the Mind of a Resus Doc Series, in which we delve into the philosophies that make a good resuscitationist. --Napoleon?


This Part I of the Mind of a Resus Doc Series, in which we delve into the philosophies that make a good resuscitationist.]]>
Scott D. Weingart, MD clean 9:41
EMCrit Podcast 48 – PhD in EKGs Part II: Left Bundle Branch Block https://emcrit.org/emcrit/left-bundle-branch-block/ Mon, 23 May 2011 03:56:35 +0000 http://emcrit.org/?p=1879 A few months ago, we had Dr. Stephen Smith on the podcast to discuss a variety of EKG issues. Dr. Smith has an EKG blog that is required reading for every ED and ICU doc. This is Part II and I think it discusses an incredibly important issue: right now major medical societies including the AHA and ACEP are asking us to fibrinolyse or PCI patients with new or presumed new LBBB. However, your interventionalists will tell you that this strategy is a ridiculous waste given how few acute occlusions will actually be found. Why this discrepancy? A few months ago, we had Dr. Stephen Smith on the podcast to discuss a variety of EKG issues. Dr. Smith has an EKG blog that is required reading for every ED and ICU doc. This is Part II and I think it discusses an incredibly important issue: right now... A few months ago, we had Dr. Stephen Smith on the podcast to discuss a variety of EKG issues. Dr. Smith has an EKG blog that is required reading for every ED and ICU doc. This is Part II and I think it discusses an incredibly important issue: right now major medical societies including the AHA and ACEP are asking us to fibrinolyse or PCI patients with new or presumed new LBBB. However, your interventionalists will tell you that this strategy is a ridiculous waste given how few acute occlusions will actually be found. Why this discrepancy?

 
Dr. Smith actually created a post specifically for this podcast; here is the full text:
A 45 year old male with no history of cardiac disease presented with new onset pulmonary edema.  He was intubated prehospital.  BP before and after intubation was 110 systolic, with HR of 120.








There is sinus tach with LBBB.  There is no concordant ST elevation.  V4 has 2 mm of discordant ST elevation (at the J-point, relative to the PR segment) following a 5 mm S-wave.  The ST/S ratio is 0.40 in this lead. Lead II has proportionally excessively discordant ST depression, with 1.25 mm STD and only 4.0 mm R-wave, for a ratio of 0.31.  This is also a sign if ischemia (reciprocal inferior ST depression).              Also, look at V3: complexes vary slightly: 2nd complex has approx 2.5-3.0 mm STE following a 14 mm S-wave; complex 4 has 2-2.5 mm STE following a 10.5 mm S-wave.   So these approach an ST/S ratio of 0.20, but it is not definite.




In a study of 19 patients with LAD occlusion, vs. 129 controls with ischemic symptoms and LBBB, at least one complex in V1-V4 with at least 2mm of STE and an ST/S ratio > 0.20 was highly specific for LAD occlusion (1).   Here is the reference for the abstract on proportionally excessively discordant ST depression (2).

Cases with excessive discordance of at least 5mm [Sgarbossa criteria 3] that did not have proportional discordance, did not have LAD occlusion.  The mean highest ST/S ratio for those without occlusion was 0.10 (95% CI: 0.09-0.11); the mean highest ST/S ratio for those with occlusion was 0.44 (95% CI: 0.19-1.05)

Because of this study, I believe the following rule is as good for diagnosis of STEMI in the setting of LBBB as standard interpretation of STEMI in the absence of BBB (and that it is more sensitive and specific than the Sgarbossa rule):

Smith modified Sgarbossa rule:

1) at least one lead with concordant STE (Sgarbossa criterion 1) or
2) at least one lead of V1-V3 with concordant ST depression (Sgarbossa criterion 2) or
3) proportionally excessively discordant ST elevation in V1-V4, as defined by an ST/S ratio of equal to or more than 0.20 and at least 2 mm of STE. (this replaces Sgarbossa criterion 3 which uses an absolute of 5mm)

It is important to remember that this is not sensitive for "MI" which is diagnosed by biomarkers. The lack of sensitivity of the Sgarbossa rule in previous studies is because the ECG is always (even without BBB) insensitive for MI.  It is, however, much more sensitive for occlusion.

Followup:
Because of proportionally excessive discordance in lead V4, (and, of course, clinical instability), the patient was taken for immediate angiography, which confirmed a 100% mid-LAD occlusion.

For a case with more than 5 mm of ST elevation in V1-V4, but without excessive proportional discordance, see this post:
clean 17:56
EMCrit Podcast 47 – Failure to Plan for Failure: A Discussion of Airway Disasters and the NAP4 Study https://emcrit.org/emcrit/nap4-airway-disasters/ Mon, 09 May 2011 15:42:38 +0000 http://emcrit.org/?p=1771 Cliff Reid of Resus.Me fame put out an incredible post on NAP4, the audit done on all of the airway complications in Great Britain. It was such a phenomenal post that I got in touch with Cliff and asked if he wanted to come on the podcast to speak about it. He did me one better and got an interview with one of the authors of the Emergency and Critical Care Section. Cliff Reid of Resus.Me fame put out an incredible post on NAP4, the audit done on all of the airway complications in Great Britain. It was such a phenomenal post that I got in touch with Cliff and asked if he wanted to come on the podcast to speak abou... Cliff Reid of Resus.Me fame put out an incredible post on NAP4, the audit done on all of the airway complications in Great Britain. It was such a phenomenal post that I got in touch with Cliff and asked if he wanted to come on the podcast to speak about it. He did me one better and got an interview with one of the authors of the Emergency and Critical Care Section.

So in this podcast, we interview Dr. Jonathan Benger, professor of Emergency Medicine with a particular interest in the management of the airway.
Points that came out of the show

* Mortality is higher in the ED and ICU compared to the operating room. Our patients are sicker, so we must be more diligent in planning
* Quantitative wave-form ETCO2 should be the standard of care for EVERY ED and ICU intubation
* Needle cricothyrotomy seems to fail more often than surgical cricothyrotomy
* Awake intubation was not used when it was indicated
* Junior resident anesthesiologists were often responding to the ED and ICU
* There was a failure to plan for failure
* Obesity figured into a large percentage of the airway disasters
* Airway operators were not prepared or just did not properly progress to surgical airway

For more from the NAP4
Executive Summary

Full Report (Skip to the EM/ICU Chapter)
How to subscribe to Cliff Reid's Brand New Podcast

* Go to itunes
* Choose Podcasts
* Go to the advanced menu and choose subscribe to podcast
* Paste this link: http://feeds.feedburner.com/ResusMePodcasts


Great Conferences Coming Up

* Essentials of Emergency Medicine in San Francisco - November 9-12
* Emergency Medicine in the Developing World in Capetown - November 15-17


]]> Scott D. Weingart, MD clean 32:57 EMCrit Podcast 46 – Acid Base: Part III https://emcrit.org/emcrit/acid-base-part-iii/ Wed, 04 May 2011 03:00:35 +0000 http://emcrit.org/?p=1789 In part III, we go through 2 cases of acid base abnormalities step by step. In part III, we go through 2 cases of acid base abnormalities step by step.
* You should listen to Acid-Base Part I first where you will learn about the underlying chemisty of acid base.
* Part II then delves into the underpinnings of the mathematics of acid base.
* In part III, we will go through two actual problems and show how the EMCrit method plays out.
* Part IV delves into the acid-base of solutions.
* Part V specifically discusses some of the Bicarb Controversy

The Acid Base Series


For this podcast to be optimally effective, you need to print out my acid base sheet:
EMCrit Acid Base Method
Here is the 1st problem from last podcast:


 
Here is the same patient after we treated his DKA:


Mike asked if there was any literature to support the simplification I am using to make the incredible complex quantitative formula more approachable. The answer is yes and here is the pdf you want to read:
Story DA, Morimatsu H, Bellomo R. Strong ions, weak acids and base excess: a simplified Fencl-Stewart approach to clinical acid-base disorders. Br J Anaesth. 2004 Jan;92(1):54-60.
 

Want an incredible program that will do all of the work for you and teach you about the quantitative method at the same time? Look no further than this incredible site:

AcidBase.org's analysis model
Here is one of the must read articles by an EM Intensivist
Kyle Gunnerson on Acid Base

Need an Audio Only Version?
Acid Base Part III MP3 (Right Click and Choose Save as)

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Scott D. Weingart, MD clean 18:42
Bonus – Passing the Esophageal Temperature Probe https://emcrit.org/emcrit/passing-the-esophageal-temperature-probe/ Sat, 30 Apr 2011 19:33:14 +0000 http://emcrit.org/?p=1780 It can be a b*tch to pass the esophageal temperature probe for hypothermia. Here's how to get er done. It can be a b*tch to pass the esophageal temperature probe for hypothermia. Here's how to get er done.
Here is the reference mentioned:

Appukutty J, Shroff PP. Anesth Analg. 2009 Sep;109(3):832-5. Nasogastric tube insertion using different techniques in anesthetized patients: a prospective, randomized study.
Update: This new article adds a bougie to get the tube down the esophagus

Endotracheal tube-assisted orogastric tube insertion in intubated patients in an emergency department Oh. Sung Kwon, M.D.

]]>
Scott D. Weingart, MD clean
EMCrit Podcast 45 – Acid Base: Part II https://emcrit.org/emcrit/acid-base-part-ii/ Sun, 24 Apr 2011 20:59:45 +0000 http://emcrit.org/?p=1758 This second lecture discusses a quantitative approach to acid base management. I lay out the formula I use to approach an acid-base problem. This second lecture discusses a quantitative approach to acid base management. I lay out the formula I use to approach an acid-base problem.
* You should listen to Acid-Base Part I first.
* In Part III, we solve the problem below and reunify everything.
* Part IV discusses the acid-base of administered solutions.
* Part V specifically discusses some of the Bicarb Controversy

The Acid Base Series


For this podcast to be optimally effective, you need to print out my acid base sheet:
EMCrit Acid Base Sheet
Here is the problem to work on for the next podcast:


 
I gave some shout-outs during the talk, here are the links:

* The Air Medical Memorial honors those flight medics, docs, pilots, and nurses who have fallen in the line of duty.
* Josh Mularella developed the free app call ERRES, search for it on itunes.
* Casey Parker created a site for outback EM and Crit Care called Broome Docs.
* Ivor Kovic donated three free codes to his cpr app, CPRPRO. Sign up for the mailing list if you want to enter to win one.

 



 

Need an Audio Only Version?
Acid Base Part II MP3  (Right Click and Choose Save as)

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Scott D. Weingart, MD clean
EMCrit Podcast 44 – Acid Base: Part I https://emcrit.org/emcrit/acid-base-i/ Mon, 11 Apr 2011 23:02:29 +0000 http://emcrit.org/?p=1714 This lecture discusses a quantitative approach to acid base management. This is also known as the Fencl-Stewart approach, the strong-ion approach or the physicochemical approach. It provides explanations for why acid base disorders occur in human pathophysiology. This lecture discusses a quantitative approach to acid base management. This is also known as the Fencl-Stewart approach, the strong-ion approach or the physicochemical approach. It provides explanations for why acid base disorders occur in human path...
The podcast is going to be in 5 parts. They are segmented from a lecture I gave to my residents recently.

* Part I lays out the background of the quantitative approach
* Part II puts it in mathematical terms to allow calculation of acid base status
* Part III takes you through some real world examples
* Part IV discusses the Acid-Base Effects of IV Fluids
* Part V specifically discusses some of the Bicarb Controversy

The Acid Base Series

For the next part of the series, you will need a print out of this sheet:
EMCrit Acid-Base Sheet
 

This lecture discusses a quantitative approach to acid base management. This is also known  as the Fencl-Stewart approach, the strong-ion approach or the physicochemical approach. It provides explanations for why acid base disorders occur in human pathophysiology. The classic method used in the USA is the Henderson-Hasselbalch (misspelled on my slides) approach. I find this method to provide no comprehensive explanation for why things are as they are. Through the quantitative approach, you can also understand the H&H approach and continue to use it with new insight.

This first part deals with the preliminaries. Part II will go into clinical applications.
For the next part of the series, you will need a print out of this sheet:
EMCrit Acid-Base Sheet
Want to read more?

* AcidBase.org
* Anaesthetist.com
* facing-acid-base-disorders-in-the-third-millennium
* Propofology Quick-Ref PDF

After listening to the podcasts, I recommend reading these articles

* Kaplan LJ,Frangos S. Clinical review: Acid–base abnormalities in the intensive care unit. (Critical Care 2005;9(2):198)
* Clinical review The meaning of acidbase abnormalities in the intensive care unit
* Facing Acid-Base Abnormalities in the Third Millenium
* (Am J Emerg Med 2015;33(3):378)  Evaluation of acid-base status in patients admitted to ED—physicochemical vs traditional approaches
* Story D. (Open Mind) Stewart Acid-Base: A Simplified Bedside Approach. Anesthesia and Analgesia, 2016 (ePub ahead of print)
* 10 Acid Base Assertions

Need an Audio Only Version?
clean 25:00
Listener Questions – Episode 1 https://emcrit.org/emcrit/listener-questions-episode-1/ Wed, 30 Mar 2011 01:47:36 +0000 http://emcrit.org/?p=1686 Since we had the Kayexalate episode, I did not want to do a full podcast, so I thought I would just air some listener questions: Since we had the Kayexalate episode, I did not want to do a full podcast, so I thought I would just air some listener questions:
* Adrian wrote asking about why A/C over SIMV when choosing a vent mode
* Cory wanted to know if NIV is any good for COPD
* Michael was worried about the level of dogma that has crept into EM/Critical Care podcasts
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Scott D. Weingart, MD clean 11:48
Bonus – Is Kayexalate Useless? https://emcrit.org/emcrit/is-kayexalate-useless/ Wed, 23 Mar 2011 03:58:35 +0000 http://emcrit.org/?p=1661 Dr. Siamak (Mak) Moayedi, MD found nothing to indicate that kayexalate is effective for the acute management of hyperkalemia. Dr. Siamak (Mak) Moayedi, MD found nothing to indicate that kayexalate is effective for the acute management of hyperkalemia. EMCrit Podcast 32
, we discussed the management of hyperkalemia. Of course, I recommended kayexalate (sodium polystyrene sulfonate) in the treatment regimen. It is standard of care, right? So I thought, until I heard a brilliant piece by Dr. Siamak (Mak) Moayedi, MD. Dr. Moayedi reviewed the evidence and he found nothing to indicate that kayexalate is effective for the acute management of elevated potassium.

This was too good not to share with you folks, so first I got permission from Amal Mattu (EKG deity). Dr. Mattu had interviewed Dr. Moayedi for this piece and had placed it on the February episode of  his excellent EMcast podcast. I also got permission from Rick Nunez, MD who runs the incredible educational resource, EMEDhome.

For more from Dr. Moayedi, listen to his fantastic piece on how to teach procedures from Rob Roger's, EM:RAP Educators Edition.

References Mentioned in the Piece:

* Levine M, Nikkanen H, Palin DJ. The effects of intravenous calcium in patients with digoxin toxicity. J Emerg Med 2011;40:41-46.
* Sterns RH, Rojas M, Bernstein P, Chennupati S. Ion-exchange resins for the treatment of hyperkalemia: Are they safe and effective? J Am Soc Nephrol 21: 733-5, 2010.
* Scherr L, Ogden DA, Mead AW, et al. Management of hyperkalemia with a cation-exchange resin. N Engl J Med 264: 115-9, 1961.
* Flinn RB, Merrill JP, Welzan WR. Treatment of the oliguric patient with a new sodium ion exchange resin and sorbitol: A preliminary report. N Engl J Med 264: 111-5, 1961.
* Gruy-Kapral C, Emmett M, Santa Ana CA, et al. Effect of single dose resin-cathartic therapy on serum potassium concentration in patients with end-stage renal disease. J Am Soc Nephrol 9: 1924–30, 1998.
* Mahoney BA, Smith WAD, Lo D, et al. Emergency interventions for hyperkalaemia (review).
Cochcran Database of Systematic Reviews 2005, issue 3, 2009.
* Kamel K, Wei C. Controversial issues in the treatment of hyperkalaemia. Nephrol Dial Transplant 18: 2215-8, 2003.
* Rogers BR, LI SC. Acute colonic necrosis associated with sodium polystyrene sulfonate (kayexalate) enemas in a critically ill patient: Case report and review of the literature. J Trauma 51: 395-7, 2001.
* Nyirenda MJ, Tang JI, Padfield PL, Seckl JR. Hyperkalaemia. BMJ 339: 1019-24, 2009.
* Bomback A, Woosley JT, Kshirsagar AV. Colonic necrosis due to sodium polystyrene sulfate (kayexalate). Am J of EM 27: 753.e1-753.e2, 2009.
* Welsberg LS. Management of severe hyperkalemia. Crit Care Med 36: 3246-51, 2008.
* Sood MM, Sood AR, Richardson R. Emergency management and commonly encountered outpatient scenarios in patients with hyperkalemia. Mayo Clin Proc 82: 1553-61, 2007.

Review
J Am Soc Nephrol. 2010 May;21(5):733-5. Ion-exchange resins for the treatment of hyperkalemia: are they safe and effective?
If you want to just hand the Gen Med Residents a Single Article:
Then I think this one by Sterns et al. is the one.
Update:
Systematic review of adverse events caused by kayexalate (The American Journal of Medicine Volume 126, Issue 3 , Pages 264.e9-264.e24, March 2013)
Here is the Audio:]]> Scott D. Weingart, MD clean 16:31 Video for Podcast 43 – Inserting the Air-Q https://emcrit.org/emcrit/air-q-video/ Wed, 16 Mar 2011 21:23:15 +0000 http://emcrit.org/?p=1634 Here is a video to go along with podcast 43 on the insertion and use of the Air-Q intubating laryngeal airway Here is a video to go along with podcast 43 on the insertion and use of the Air-Q intubating laryngeal airway Podcast 43 and as always I do what folks ask for.

 ]]>
Scott D. Weingart, MD clean 6:06
EMCrit Podcast 43 – Laryngeal Airways with Daniel Cook, MD (Part I) https://emcrit.org/emcrit/supraglottic-airway/ Sun, 13 Mar 2011 00:40:50 +0000 http://emcrit.org/?p=1626 My favorite supraglottic airway is the Cookgas Air-Q; it was created by an anesthesiologist, Dr. Daniel Cook. He just created a new device that allows the placement of an esophageal blocker through the laryngeal airway. I gave him a call to hear about the new product and in the course of that conversation, he gave me a ton of tips on the placement of laryngeal airways. Part II will specifically discuss the new device. My favorite supraglottic airway is the Cookgas Air-Q; it was created by an anesthesiologist, Dr. Daniel Cook. He just created a new device that allows the placement of an esophageal blocker through the laryngeal airway. Cookgas Air-Q; it was created by an anesthesiologist, Dr. Daniel Cook. He just created a new device that allows the placement of an esophageal blocker through the laryngeal airway. I gave him a call to hear about the new product and in the course of that conversation, he gave me a ton of tips on the placement of laryngeal airways. Part II will specifically discuss the new device.
Placement of the ILA

* Put the patient in sniffing position
* Lube it really well (get the bottom, the cuff, and the horizontal ridges up front)
* Dr. Cook recommends an insertion using a tongue depressor to pull the tube forward. He inserts straight back instead of riding the hard palate. If the LMA doesn’t quite turn the corner, he inserts his left index finger just posterior to the tip and flexes his finger to get the LMA to make the curve into the lower pharynx
* He gently advances until the LMA comes to a rest—don’t push too hard
* At this point he puts 4-5 cc of air in for the 4.5 size and 3-4 cc of air for the 3.5 size (same amount of air as the size of the LMA)

Blind Intubation through the ILA

* First step is to lube the inside of the ILA. Use the ET tube itself—put a big glob of lube on the distal portion of the ETT and then advance it until it is just about to pop out of the keyhole opening of the ILA. This distance will be 20 cm in the 4.5 size and 18 cm in the 3.5 size (keep subtracting 2cm for each downsizing)
* Now readvance the ETT to that same point, put your index finger on the top and use it to ever so slowly advance the ET. You can have a hand over the cricoid to feel the ETT as it passes.
* Inflate and confirm by listening over the stomach and looking for End-Tidal CO2.
* If you missed, pull back to that same point that is just before the opening of the cuff and inflate the ETT cuff with 1-2 cc of air. You can now reoxygenate the patient before your next attempt.
* The second attempt should probably be with a fiberoptic device or a bougie.

Bougie Intubation through the ILA

* First lube the ILA using the ETT, then remove the ETT
* Advance the bougie using the coude end with the coude facing towards the ceiling.

 
Here is the podcast:]]>
Scott D. Weingart, MD clean 21:27
EMCrit Podcast 42: A phD in EKG with Steve Smith https://emcrit.org/emcrit/phd-in-ekg/ Sun, 27 Feb 2011 21:34:26 +0000 http://emcrit.org/?p=1564 Electrocardiograms can be subtle; but you can't miss them or patients die. Today, I interview, Dr. Stephen Smith of the incredible blog: Dr. Smith's EKG Blog. Electrocardiograms can be subtle; but you can't miss them or patients die. Today, I interview, Dr. Stephen Smith of the incredible blog: Dr. Smith's EKG Blog. The ECG in Acute MI.

Dr. Smith's EKG Blog is probably the best free EKG site out there for Emergency Physicians and Intensivists.

Here are the points we covered:
1. Ischemia Doesn't Localize
If you see depressions in just one anatomic area, think reciprocal changes to subtle ST-elevations elsewhere
2. If you see Inferior Depressions, think High Lateral Wall STEMI
here are two good cases from Dr. Smith's Blog:

* Case: This is a 35 yo woman who had LAD occlusion that was very subtle on ECG, but easily seen with inferior ST depression
* Case: This is one of a high lateral MI due to OM-2 occlusion that shows up mostly with inferior ST depression.

3. Lateral Wall STEMIs are often Subtle

* Case: A patient had chest pain, went to his doctor who did an EKG, said it was fine, and sent my friend home. He had a cardiac arrest at home and was resuscitated because of good CPR by his wife.  Later, I asked him to find the ECG.  I told him I’m pretty sure it was not normal.  And here it is: a very subtle high lateral MI detected by subtle ST depression in II and aVF
* Another Case

4. Absolute millimeter criteria for STEMI will often fail you, it is the Pattern that Matters.
5. Benign Early Repolarization and LAD Occlusion can look very similar--You may need to do the math.
Dr. Smith derived this formula:

(1.196 x STE60 in V3 in mm) + (0.059 x computerized QTc in milliseconds) - (0.326 x RA in V4 in mm),

where RA is R-wave amplitude and STE60 is ST elevation at 60ms after the J-point relative to the PR interval.

If the value of the formula is greater than or equal to 23.4, it is MI (Sens, spec, accuracy all around 90%); if less, then it's early repolarization.

* Case: Here is a case that illustrates this, it shows a very subtle anterior STEMI, and how use of the complicated new rule that he developed. One need not use the complicated rule; among other  features, it was the long QTc of 455ms that made it unlikely to be normal.   The followup ECG is also very instructive.

You can also see a video of the concept
6. If you are calling it BER, there need to be R waves in the Precordial Leads
7. Q-waves can develop instantly after a STEMI
qR waves can develop instantly and are not indicative of poor response to lytics or PCI (J Am Coll Cardiol 1995;25:1084); this concept is not  applicable to a QS pattern.
8. If you see a wide (>190 ms) QRS, think Hyperkalemia
9. The treatment for VT with hyper-K is Calcium, Calcium, Calcium

* Check out this Case, it says it all

10. Check Out these Two Other Great Sites
HQMEDED: High Quality Medical Education and Ultrasound

The Prehospital 12-lead ECG Blog which despite the name,]]>
Scott D. Weingart, MD clean 28:30
EMCrit Podcast 41 – Interview with Cliff Reid of RESUS.me https://emcrit.org/emcrit/ems-physician-1/ Mon, 14 Feb 2011 18:04:53 +0000 http://emcrit.org/?p=1538 I was lucky to cajole Cliff Reid of the amazing blog, resus.me on to the EMCrit program. Cliff is truly a doc after my own heart as you will hear from the cast. I was lucky to cajole Cliff Reid of the amazing blog, resus.me on to the EMCrit program. Cliff is truly a doc after my own heart as you will hear from the cast. resus.me on to the EMCrit program. Cliff is truly a doc after my own heart as you will hear from the cast.

He is currently an EMS physician and Director of Training at the New South Wales Ambulance Service.

Cliff's blog, resus.me is an incredible collection of timely articles on emergency medicine, ems, critical care and resuscitation.



Cliff mentions the HEMS service in London. This amazing service sends a physician/paramedic team to the scenes of bad traumas by helicopter and response cars. A well done video is available on youtube:

http://www.youtube.com/watch?v=G0EENc_zNR0

The winner of the Toxicology Handbook is Jenny Mendelson. Yeah!!!
photo by Mad Scientist
Click Here to Play the Podcast]]>
Scott D. Weingart, MD clean 25:00
EMCrit Podcast 40 – Delayed Sequence Intubation (DSI) https://emcrit.org/emcrit/dsi/ Mon, 31 Jan 2011 17:57:51 +0000 http://emcrit.org/?p=1242 Delayed Sequence Intubation (DSI) is a procedural sedation, the procedure in this case being effective preoxygenation. Give ketamine, put them on the mask, and in 3 minutes paralyze and intubate. Delayed Sequence Intubation (DSI) is a procedural sedation, the procedure in this case being effective preoxygenation. Give ketamine, put them on the mask, and in 3 minutes paralyze and intubate. EMCrit Delayed Sequence Intubation (DSI) Page

 

 
]]>
Scott D. Weingart, MD clean 19:51
EMCrit Podcast 39 – Hyponatremia https://emcrit.org/emcrit/hyponatremia/ Mon, 17 Jan 2011 18:18:14 +0000 http://emcrit.org/?p=1184 Hmm… he’s tasty, but he just needs a little salt! In this podcast, I discuss the management of hyponatremia in the ED. Hmm… he’s tasty, but he just needs a little salt! In this podcast, I discuss the management of hyponatremia in the ED.
In this podcast, I discuss the management of hyponatremia in the ED. After reading countless articles from the nephrology literature…I can still attest that I have not a friggin’ clue about renal physiology. But I think I have found a simpler path to the work-up and treatment of low sodium in the ED.

When they are <130 is when I get a little worried
Step I-Send Lots of Labs
Here is what you need:

Serum-electrolytes, LFTs, osmolality, uric acid (if on diuretics), and you might as well send a TSH and cortisol as well (if you have any suspicion of an endocrine cause)

Urine-UA, urine lytes, urine urea, urine uric acid (if on diuretics), urine osm, urine creatinine

Want to learn more about FENa and FEUrea? Well I have an article for you.
Step II-Treat CNS dysfunction
If the patient is altered, comatose, seizing, or has neurologic findings, then raise the sodium by a little bit

Give 3% saline, 100 ml over 10-60 minutes (2 cc/kg up to a max of 100 cc)



10 minutes later, may repeat X 1

may be given peripherally through any reasonable IV

each 100 ml will raise sodium by ~2 mmol/l
Step III-Hang tight
Do not feel the need to do anything else, just fluid restrict the patient

Place a foley

Do not feel tempted to give NS

Do not be clever, just fluid restrict and admit.

Patients are at a fall risk with hyponatremia

Get a CT scan if they are still a little wacky

Remember the rules of 6’s (from the Stern article below)



Be incredibly careful when correcting hypokalemia, potassium repletion will raise the Na
Step IV-What to do when you couldn’t follow step III
dDAVP 1-2 mcg IV or SubQ x 1

Consult renal

Consider D5W 6ml/kg over 1 hour in consultation with renal if you have really screwed up

For more on this, see the Emergency Pharm D Blog
Additional Info
Drugs-Thiazides, SSRI, Sufonylureas, Opioids

1 liter of saline will allow a solute-low hyponatremia to make 6 L of urine

SIADH-need to get rid of a 600 mmol salt load/day. Can fluid restrict to 900 ml (400 insensible).
Articles
Read this excellent case report from Stern
Excellent Review by Schrier (Curr Opin Crit Care 2008;14:627)
Review of Drug-Induced Hyponatremia (Am J Kidney Dis 2008;52:144)
Understanding Lab Testing for Hyponatremia (Clin J Am Soc Nephrol 2008;3:1175)
The hyponatremia formulas do not work so well (Clin J Am Soc Nephrol 2007;2:1110 and Nephrol Dial Transplant 2006;21:1564)
Fantastic Review Article on Hyponatremia and SIADH]]>
Scott D. Weingart, MD clean 21:26
EMCrit Podcast 38 – The ED Critical Care Dirty Dozen for 2010 https://emcrit.org/emcrit/dirty-dozen-2010/ Sun, 02 Jan 2011 22:15:54 +0000 http://emcrit.org/?p=1127 My favorite ED things for 2010...the EMCrit dirty dozen. My favorite ED things for 2010...the EMCrit dirty dozen.
12. SmartEM by David Newman and Ashley Shreves

11. The Poison Review by Leon Gussow

10. Academic Life in Emergency Medicine by Michelle Lin

9. Zdoggmd--the funniest internist I have ever come across

8. Emergency Medicine Cases Podcast by Anton Helman

7. One Night in the ED, an incredible radiology blog for EM folks by a radiologist, Daniel Cornfeld

6. Steve Smith's EKG Blog-even the cardiologists are not giving the same amount of detail as you will find here

5. Resus.me by Cliff Reid

4. EM:RAP by med ed hero, Mel Herbert

3. Ercast by my friend, Rob Orman

2. the Life in the Fast Lane Blog headed up by the amazing Mike Cadogan and Chris Nickson

1. Well for #1, you are just going to have to listen
Want more Best of?

* Eight is Enough for 2013
* Natural Seven for 2012
* Hard Six for 2011
]]>
Scott D. Weingart, MD clean 13:09
EMCrit Podcast 37 – Lactate in Sepsis https://emcrit.org/emcrit/lactate/ Mon, 20 Dec 2010 15:16:14 +0000 http://emcrit.org/?p=1050 When an ED starts providing advanced care for severe sepsis, lactate testing is an absolute requirement. Lactate use brings up a lot of questions, especially if it is not commonly ordered in your department. In this podcast, I discuss all of the lactate questions that have come up in the course of the NYC Sepsis Collaborative. When an ED starts providing advanced care for severe sepsis, lactate testing is an absolute requirement. Lactate use brings up a lot of questions, especially if it is not commonly ordered in your department. In this podcast,
For the past few months, I have been co-chairing this NYC-wide sepsis collaborative under the auspices of a hospital organization. 56 hospitals have joined the collaborative with the goal of breaking down the barriers to aggressive sepsis care in the ED.

The protocols and educational materials for the project will always be cross-posted here:

http://emcrit.org/sepsis/

Many of the questions we have been getting relate to the use of lactate as a screen and an indicator of adequate treatment. Last week, I discussed these issues during a webinar. This podcast is the recording of that cast.
Here is the Lactate Reference Sheet
Other important info:
The emcrit webtext is now at crashingpatient.com and the blog has moved to http://emcrit.org

Scott Gallagher sent in the comment regarding commotio cordis as a cause of v-fib/v-tach in trauma patients. He is quite right to point out that ACLS works for these folks. Shock and use anti-dysrhythmics.

Here is a reference from the New England Journal:
NEJM 2010;362:917
Update:
Another article demonstrating the equivalence of arterial and venous lactates (The American Journal of Emergency Medicine  Volume 31, Issue 7, July 2013, Pages 1118–1120)

A review by some of the Lactate Doubters

A balanced perspective on lactate from NEJM [cite source='pubmed']25494270[/cite]

Another article demonstrating the >=4.0 threshold is a good one (10.1097/CCM.0000000000000742)

A small study demonstrates that venous lactate may be even a better prognostic predictor than arterial (Effectiveness of arterial, venous, and capillary blood lactate as a sepsis triage tool in ED patients. Am J Emerg Med. 2014 doi: 10.1016/j.ajem.2014.11.003)]]>
Scott D. Weingart, MD clean 28:56
EMCrit Podcast 36 – Traumatic Arrest https://emcrit.org/emcrit/traumatic-arrest/ Sat, 04 Dec 2010 23:04:00 +0000 http://emcrit.org/?p=969 Management of traumatic arrest. Many things to do in these patients, but two things you definitely should not be doing are closed-chest CPR or giving ACLS medications. We discuss who gets a thoracotomy, what to do if a thoracotomy is not indicated, and when to stop. Management of traumatic arrest. Many things to do in these patients, but two things you definitely should not be doing are closed-chest CPR or giving ACLS medications. We discuss who gets a thoracotomy, what to do if a thoracotomy is not indicated,
Here is a great review article:
Hunt PA, Greaves I, Owens WA.  Emergency thoracotomy in thoracic trauma-a review. Injury. 2006 Jan;37(1):1-19.
This is one of the figures from the text. I think it is a great algorithm to determine who gets a thoracotomy:



Update: This article lends further support that all patients should have tension pneumo excluded (Resus 2007;75:276)

Place comments or questions here or on the facebook page at facebook.com/emcrit.

.

]]>
Scott D. Weingart, MD clean 20:19
EMCrit Podcast 35 – Extubation in the ED https://emcrit.org/emcrit/extubation/ Thu, 18 Nov 2010 22:28:11 +0000 http://emcrit.org/?p=879 In this podcast, I discuss extubating patients in the ED. Specifically, I deal with patients who have only been intubated for a few hours in distinction to extubation of the patient who has been lingering in your ED for 2-3 days. The best patients for this short-term extubation are those intox folks with a low GCS and signs of trauma, overdoses, or endoscopy cases. In this podcast, I discuss extubating patients in the ED. Specifically, I deal with patients who have only been intubated for a few hours in distinction to extubation of the patient who has been lingering in your ED for 2-3 days.

In this podcast, I discuss extubating patients in the ED. Specifically, I deal with patients who have only been intubated for a few hours in distinction to extubation of the patient who has been lingering in your ED for 2-3 days. The best patients for this short-term extubation are those intox folks with a low GCS and signs of trauma, overdoses, or endoscopy cases.

My approach is outlined in this article; click on the link for the full text:
Weingart SD, Menaker J, et al. Trauma Patients Can Safely Be Extubated in the Emergency Department. J Emerg Med. 2009 Aug 22. [Epub ahead of print]
Here are the steps from the article:

Photo by EddieB55
Update

* George Douros has written another excellent guideline for ED extubation.
* Sara Gray has also done a swell job discussing SaraGray-ED Extubation

More on Extubation from the EMCrit Crew

* PulmCrit Wee – The meaning of nocturnal extubation is 42
* High-flow nasal cannula to prevent post-extubation respiratory failure

Now on to the Podcast...]]>
Scott D. Weingart, MD clean 14:27
EMCrit Podcast 34 – 2010 ACLS Guidelines https://emcrit.org/emcrit/acls-guidelines-2010/ Tue, 26 Oct 2010 03:51:44 +0000 http://emcrit.org/?p=823 The brand new ACLS & BCLS guidelines were published last week. Not huge changes, but some good stuff! The free full text is available at the Circulation website. It takes hours to make your way through all of it. I boiled it down to just the facts and posted a summary on the EMCrit site. In this EMCrit Podcast I discuss some of the highlights that I think are particularly important. The brand new ACLS & BCLS guidelines were published last week. Not huge changes, but some good stuff! The free full text is available at the Circulation website. It takes hours to make your way through all of it.
ACLS 2010 Guidelines Summary

In this EMCrit Podcast I discuss some of the highlights that I think are particularly important.

There have also been many questions about the head impulse testing discussed in episode 33. I have an easier method; check out this post.]]>
Scott D. Weingart, MD clean 19:59
Video for Diagnosing Posterior Stroke https://emcrit.org/emcrit/posterior-stroke-video/ Sun, 10 Oct 2010 03:11:00 +0000 http://emcrit.org/?p=765 This is the video for cerebellar stroke diagnosis. Listen to the podcast first. This is the video for cerebellar stroke diagnosis. Listen to the podcast first. Listen to the podcast first. Video clips are from Dr. David Newman-Toker's site and from the article: Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009 Nov;40(11):3504-10.]]> Scott D. Weingart, MD clean EMCrit Podcast 33 – Diagnosis of Posterior Stroke https://emcrit.org/emcrit/posterior-stroke/ Sun, 10 Oct 2010 02:52:17 +0000 http://emcrit.org/?p=755 What if I told you that I think that patient you just sent home with vertigo may have been a missed cerebellar stroke? Would you be dialing risk management or could you tell me all of the reasons why I'm wrong? Isolated vertigo without other neurological findings can't be a stroke, right? That is true, if you are doing the right exam, but if you are just doing your standard ED neuro screening exam then you might be missing serious pathology. In this episode of the EMCrit podcast, I discuss how to perform the tests that will differentiate a peripheral cause of continuous vertigo from a cerebellar stroke. What if I told you that I think that patient you just sent home with vertigo may have been a missed cerebellar stroke? Would you be dialing risk management or could you tell me all of the reasons why I'm wrong?
Drs. David Newman-Toker & Jorge Kattah, neurologists at John Hopkins, have done a ton of work on this topic. They have created an mnemonic for the exam you should be doing on all of your patients with continuous vertigo (as opposed to positional, intermittent vertigo, i.e. BPPV). Benign positional paroxysmal vertigo is not ED critical care. Continuous vertigo, also known as acute vestibular syndrome, may be. The mnemonic is HiNTS.

Hi for head impulse testing, or head thrust testing.
N for nystagmus to remind you to look for direction-changing or vertical nystagmus
TS for test of skew.

I will discuss what all of these terms mean and how to perform the exams in the podcast.

Here is the HiNTS article.

Here is a link to another study by the same authors on head impulse testing.

Here is a fantastic review article by James A. Nelson on the topic.

Here is a video demonstrating the exam with positives and negative examples.
Update
Insanely good systematic review on Dizzy Stroke Patients (CMAJ 2011;183(9):E571)

and maybe the best review on Vertigo ever!

Until this one was published: Edlow's New Approach to Dizziness ( 2016 Nov;34(4):717-742.)

and here is a fantastic journal club from EM Journal Club with Dr. Newman-Toker himself

TiTrATE (Neuro Clin 2015;33:577)]]>
Scott D. Weingart, MD clean 11:38
EMCrit Podcast 32 – Treatment of Severe Hyperkalemia https://emcrit.org/emcrit/hyperkalemia/ Wed, 22 Sep 2010 18:36:40 +0000 http://emcrit.org/?p=744 Hey folks. As I get ready for ACEP, I just wanted to get a quick podcast put up. One of the listeners requested an episode on the treatment of hyperkalemia in the ED. Hey folks. As I get ready for ACEP, I just wanted to get a quick podcast put up. One of the listeners requested an episode on the treatment of hyperkalemia in the ED. kayexalate, see Mak Moayedi's Lecture

Hey folks. As I get ready for ACEP, I just wanted to get a quick podcast put up. One of the listeners requested an episode on the treatment of hyperkalemia in the ED.

There was a fantastic article published in Critical Care Medicine on the topic by a Dr. Weisberg. I go through my management and discuss some of the pearls from the article.
Weisberg LS. Management of severe hyperkalemia. Crit Care Med. 2008 Dec;36(12):3246-51.

Additional References added Feb 2012
ECG is insensitive and non-specific for severe hyperkalemia issues; essentially is crap (Clin J Am Soc Nephrol 3: 324-330, 2008). ECG peaked T waves, that resolved after K normalized were noted in only 1 of the 14 hyperkalemic patients who went on to have arrhythmia or cardiac arrest. Only half of them had any T-wave changes.
Calcium Gluconate doesn't require Hepatic Metabolization before it is active
[cite source='pubmed']2360741[/cite]
Hyperkalemia and the ECG
Slow A-Fib
from Steve Smith's Blog

Learning Points:
1.  When a patient is bradycardic, especially if irregular, one must always think of hyperK and one must get a 12-lead ECG.
2. One must recognize this pattern as hyperK
3. Calcium's effect is almost miraculous
4. Slow atrial fibrillation implies an sick AV node, or one affected by electrolytes, ischemia, or medications/drugs.  Otherwise, the ventricular response should be fast.
Updates

* Fantastic EMPharm Review with my bud, Bryan Hayes
* Lactated Ringers is Safe and Probably Recommended
* This recent article showed a 100% preceding of bad events by altered ecg

and now to the podcast...]]>
Scott D. Weingart, MD clean 12:57
EMCrit Podcast 31 – Intra-Arrest Management https://emcrit.org/emcrit/intra-arrest/ Sun, 05 Sep 2010 21:47:53 +0000 http://emcrit.org/?p=734 This week we talk about managing the intra-arrest period of cardiac arrest. My paradigm has changed dramatically over the past few years. In the past, I viewed the arrest as a period to teach my residents how to place a subclavian central line, how to intubate when the patient is moving, and how to cram as many drugs as possible into a patient in a short period of time. Looking at how I manage an arrest today, so much has changed. This week we talk about managing the intra-arrest period of cardiac arrest. My paradigm has changed dramatically over the past few years. In the past, I viewed the arrest as a period to teach my residents how to place a subclavian central line, podcast 125; so click on over there.
This week we talk about managing the intra-arrest period of cardiac arrest. My paradigm has changed dramatically over the past few years. In the past, I viewed the arrest as a period to teach my residents how to place a subclavian central line, how to intubate when the patient is moving, and how to cram as many drugs as possible into a patient in a short period of time.

Looking at how I manage an arrest today, so much has changed.

I use the ACLS ABCDABCD mnemonic, though I've changed some of the intent:

A
Place an Oropharyngeal Airway

B
Place the patient on the ventilator with a BVM mask.
Set the vent to VT 500, Flow 30 lpm, Rate 10, FiO2 100%. Increase the pressure limit to 80-100 cm H20.

C
Compressions, Compressions, Compressions

The most important thing these days are continuous, rhythmic, chest compressions. If you want to get perfusion to the coronaries and get a chance at shocking (the only other effective therapy for arrest), you need perfect compressions.

I use a metronome and switch out providers every 1-2 minutes. Got the idea from this article.

Here is the metronome I use.

ETCO2 can be used as a marker of how well compressions are being performed.

D

Defib. Shock early and shock often.

You can shock without having the compressor stop compressions if they are wearing gloves and you have a biphasic defib with pads. (Circulation 2008;117:2510-2514.)

A

Advanced airway = LMA, not an ET Tube
Here is my LMA video

B
Advanced Breathing

Put the patient back on the vent. If you know how, switch them to pressure control at 20 cm H20, with an insp time of 1-2 seconds

C
Advanced circulation

pop in an IO

listen to the podcast for my feelings on meds

D
Differential

I recommend the RUSH exam created by my colleagues and me.

Last, we talk about when to stop: for me ETCO2 < 10 and no heart motion = stop, if I have been trying for 10-20 minutes.]]>
Scott D. Weingart, MD clean 22:33
ACEP Preview – Hemostasis: Stopping the bleeding in a crashing trauma patient https://emcrit.org/emcrit/hemostasis-acep/ Mon, 23 Aug 2010 03:25:35 +0000 http://emcrit.org/?p=704 I'm lecturing at ACEP in Las Vegas this year. This is one of two lectures I'm giving there. If you are going to the conference and plan on coming to my lecture, don't listen to this lecture; I'd rather you here the real one in person. I'm lecturing at ACEP in Las Vegas this year. This is one of two lectures I'm giving there. If you are going to the conference and plan on coming to my lecture, don't listen to this lecture; I'd rather you here the real one in person. Here is the Handout Here are the Slides  ]]> Scott D. Weingart, MD clean 53:03 EMCrit Podcast 30 – Hemorrhagic Shock Resuscitation https://emcrit.org/emcrit/trauma-resuscitation-dutton/ Sun, 15 Aug 2010 17:33:15 +0000 http://emcrit.org/?p=694 This week we discuss the resuscitation of the hemorrhagic shock patient with Dr. Richard Dutton, MD. This week we discuss the resuscitation of the hemorrhagic shock patient with Dr. Richard Dutton, MD.
This week we discuss the resuscitation of the hemorrhagic shock patient with Dr. Richard Dutton, MD.

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

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

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

ITACCS Damage Control Anesthesia

Updates:

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

You can see a full lecture by Rick from the EMCrit Conference

Great Article from STC on choice of Anesthetics (Curr Anesthiol Rep 2014;4:225)]]>
Scott D. Weingart, MD clean 31:07
EMCrit Podcast 29 – Procedural Sedation, Part II https://emcrit.org/emcrit/procedural-sedation-part-2/ Mon, 02 Aug 2010 00:19:36 +0000 http://emcrit.org/?p=682 It seems the government and other specialties are trying hard to make sedation as difficult as possible in the ED. We must persevere to provide the best procedural sedation to allow maximal comfort and safety for our patients. This continues the discussion started in Part I. It seems the government and other specialties are trying hard to make sedation as difficult as possible in the ED. We must persevere to provide the best procedural sedation to allow maximal comfort and safety for our patients. Part I, where we discussed etomidate, ketamine, and versed/fentanyl. In this podcast, I discuss propofol, ketofol, and dexmedetomidine.

the emcrit procedural sedation chapter has tons of references for all of this
Propofol
great propofol articles:
Ann Emerg Med 2008;52:392-398
Ann Emerg Med. 2007;50:182-187
Start with fentanyl 1-1.5 mcg/kg

Then give propofol 0.5-1 mg/kg

may need additional injections of 0.5 mg/kg

When patient is where you want them, begin the procedure

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

Burns on injection, you can precede with 20-40 mg of lidocaine to numb the vessels
Ketofol
read more here: (Ann Emerg Med. 20