Since we were talking about Na-channels in the last podcast, Sean Smith suggested this video:

You just read the post: Vaughan Williams Video from EMCrit Blog - Emergency Department Critical Care.

I had a crazy case of Tricyclic Overdose while on an overnight shift at Janus General.

Initial and Post-Treatment EKGs

Initial

Post-Treatment

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

Pharmacologic Effects of TCAs

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 [1]

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. [2]

Intubation & Sedation

Be very careful the patient doesn’t become hypercapneic

Sedate with benzo or propofol to raise seizure threshold

Gastric Decon and/or Lavage

If time of ingestion <1 hour ago and airway is protected

We use a commercial device: the Easi-Lav system

Magnesium

May help, though risk of Torsades is low as long as the patient remains tachycardic

Lidocaine

Even though lidocaine is another Na-Channel Blocker, it actually antagonizes the effects of the TCA-like mediciations. As a Vaughan Williams Class IB agent, For additional information, this review discusses the pertinent issues.[3]

VasoPressors

Norepi or Epi

Intralipids

Certainly for cardiac arrest and probably for hypotension/increasing pressor necessity

For this or any other Lipid Question, you need to go immediately to the Lipid Rescue Site

You can find the Lipid Administration Instruction Sheet there, which should be hanging somewhere on the wall of your ED.

ECMO

The last resort for tox instability

Want More?

My friends Sean Nordt and Stu Swadron did a great EM:RAP episode on this 2 months ago

Here is a review and guideline article.

Shout-Outs

Medcalc sent me some freebie codes for their new IOS version of the app. Join the mailing list to be in the running (see the area below to sign up for the mailing list)

Daren Lewis of leadingvisually.com designed the wonderful Janus General logo; consider him if you need any message design.

Now on to the podcast…

References

1. K. Blackman, S.G. Brown, and G.J. Wilkes, "Plasma alkalinization for tricyclic antidepressant toxicity: a systematic review.", Emergency medicine (Fremantle, W.A.), 2001. http://www.ncbi.nlm.nih.gov/pubmed/11482860
2. M.J. Neavyn, E.W. Boyer, S.B. Bird, and K.M. Babu, "Sodium Acetate as a Replacement for Sodium Bicarbonate in Medical Toxicology: a Review.", Journal of medical toxicology : official journal of the American College of Medical Toxicology, 2013. http://www.ncbi.nlm.nih.gov/pubmed/23636658
3. A. Foianini, T. Joseph Wiegand, and N. Benowitz, "What is the role of lidocaine or phenytoin in tricyclic antidepressant-induced cardiotoxicity?", Clinical toxicology (Philadelphia, Pa.), 2010. http://www.ncbi.nlm.nih.gov/pubmed/20507243

You just read the post: Podcast 98 – Cyclic (Tricyclic) Antidepressant Overdose from EMCrit Blog - Emergency Department Critical Care.

Janus General Hospital

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:

You just read the post: EMCrit Wee – Janus General and Service Update from EMCrit Blog - Emergency Department Critical Care.

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.

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:
PACO2 = PICO2 + K (VCO2 / VA)

The constant is due to VCO2 being STPD and VA being BTPS and is about 800 if you are using mmHg and ml/min.

So usually PACO2 = 40, PIcO2 = 0, VCO2 = 250 ml/min and VA = 5,000 ml / min  (10 X 500ml)
Also PACO2 is directly proportional to VCO2 and inversely to Va.
Now if  we give NaBic and Bic forms CO2 VCO2 will increase. If it went up 50% it would be from 250 ml / min to 375 ml / min. If VA is fixed then
PACO2 = 800 X 375 / 5,000 = 60 mmHg

However I agree that Va will go up which will be due to the increase in VCO2, ie the EXPIRED VA will increase

(inspired unlikey = expired when VO2  does not equal VCO2, that is the respiratory exchange ratio does not equal 1, that is what the F in the alveolar gas equation corrects)

Therefore the VA is now 5,125 ml / min

PACO2 = 800 (375 / 5,125) = 58.5 mmHg.

We have had a 50% increase in VCO2 but only a 2.5% increase in VA this will lead to a new equilibrium point in alveolar and arterial CO2 at around 58mmHg.

I have exaggerated the effects of NaBic or as I call it chloride-free sodium to demonstrate the effects as I see it.

Therefore, yes the alveolar ventilation increases due to greater CO2 excretion but it is a relatively small effect on VA. To reduce the PACO2 back to 40 will require a 50% increase in VA. This will be transient as the VCO2 returns to the rate prior to the NaBic infusion.

I hope the above helps. If not let me know.

Cheers

Dave Story

So what do I take from all of that? I think regardless of any increase in minute ventilation, the CO2 will eventually go back to baseline after an adminsitration of sodium bicarbonate and you will see the alkalizing effect, but unless you increase the minute ventilation it will take much longer.

Use of Sodium Bicarbonate

If not stored in glass, bicarb containing solutions exchange CO2 and become not so much bicarbonate.

When to use Bicarb

• Na Channel Blockade in Tox (Slow Push; Hyperventilate if on Vent)
• Alkalinization for Tox, such as Salicylate Toxicity (Slow Push and then Drip; Hyperventilate if on Vent) [Thanks, Ben!]
• Non-SIG Acidosis (Drip or IV Fluid)
• SIG Acidosis (As an IV Fluid)
• Increased ICP (Drip)
• Hyperkalemia (As an IV Fluid)
• Hyponatremia (Drip)

ICP

NaBicarb can be used as a substitute for hypertonic saline in increased ICP (Neurocrit Care 2010;13:24 & Neurocrit Care 2011;15:42). They used 85 ml of 8.4% sodium bicarb infused over 30 minutes.

Why use Isotonic Bicarb as an IV Fluid?

Read this article by Ed Omron (J Intensive Care Med. 2010;25(5):271-80.)

Problems with Bicarbonate Drips

• Hypokalemia
• Hypocalcemia

When not to use Bicarb

• Probably no role in Cardiac Arrest unless you feel the patient has hyperkalemia or toxicologic cause.

You just read the post: Podcast 97 – Acid-Base VI – Chloride-Free Sodium from EMCrit Blog - Emergency Department Critical Care.

MDCalc is where I go when I need to remember a clinical scoring system. I was thus quite pleased to find one of the scores I use every shift appear on the site. The LLS score is how I determine the need for many interventions, but especially to decide who needs massive transfusion.

You just read the post: The LLS Score from EMCrit Blog - Emergency Department Critical Care.

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

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.

How about this quote from a strong-ion approach to the use of buffers (Crit Care 2004;8:259):

When ventilation is fixed, however, as commonly occurs in mechanically ventilated patients, the effect of sodium bicarbonate may be to lower arterial pH, as was seen in patients ventilated with a lung protective strategy… [in this study-Am J Resp Crit Care Med 2000;161:1149].

But don’t believe me, let’s Get an Expert…

I got to interview John Kellum, MD, master of all things acid-base in the critically ill. You’ll hear more from him in upcoming episodes; this time I asked him the following questions:

• Does giving NaBicarb actually do anything to the patient’s pH if the patient can’t increase their minute ventilation to blow off the generated PaCO2? (Closed System)
• Let’s say you can actually can increase pH with NaBicarb, Is there any clinical advantage to actually doing this in an Anion-Gap Acidosis?
• How about in a patient that received a ton of NS in the ED, should we switch them to a bicarb drip to get SID back in balance?

Even when you Fix the pH with Bicarb, have you done any good in patients with SIG Acidosis?

Probably not!

Advocates of NaBicarb discuss its salutary effects on hemodynamics. However based on the available evidence, there is no reason to think there is any additional effects above those you would see giving hypertonic saline.

Small head-to-head study of NaBicarb and NS showed deleterious effects of the Bicarb (Am J Med. 1989 Jul;87(1):7-14.)

One of the best reviews is by Forsythe and Schmidt in this article (Chest 2000; 117:260–267). Table 1 demonstrating the intracellular effects is particularly relevant.

The other is by Hindman et al. (Anesthesiology 1990;72(6):1064).

If you are going to use it, use it by slow infusion while increasing minute ventilation. Boyd et al. agree and say it better than I can (Curr Opin in Crit Care 2008;14:379).

Severe Acidosis in Trauma Patients

Not fantastic evidence, but in this recent trauma paper (J Trauma 2013;74:45) giving bicarb to severely acidotic patients was associated with increased mortality.

Comments and where they Go…

• If you have a comment about a podcast, put it in the comments of that podcast–more people will see it that way
• If you have an unrelated clinical question, put on the EMCrit Google Plus Community Page.

An Amazing Conference is Coming in June 2013:

New York Symposium on Neurological Emergencies and Neurocritical Care

Here is a bibliography of the Literature Reviewed for this Episode

[1] Arieff AI, Leach, W, Park, R, et al. Systemic effects of NaHCO3 in experimental lactic acidosis in dogs. The American journal of physiology. 1982;242: F586-591.

[2] Bersin RM, Chatterjee, K, Arieff, AI. Metabolic and hemodynamic consequences of sodium bicarbonate administration in patients with heart disease. The American journal of medicine. 1989;87: 7-14.

[3] Boyd JH, Walley, KR. Is there a role for sodium bicarbonate in treating lactic acidosis from shock? Current opinion in critical care. 2008;14: 379-383.

[4] Cuhaci B, Lee, J, Ahmed, Z. Sodium bicarbonate controversy in lactic acidosis. Chest. 2000;118: 882-884.

[5] Dell RB. Acid-base effects of hypertonic sodium bicarbonate solutions: a commentary. The Journal of pediatrics. 1972;80: 681-682.

[6] Forsythe SM, Schmidt, GA. Sodium bicarbonate for the treatment of lactic acidosis. Chest. 2000;117: 260-267.

[7] Gehlbach BK, Schmidt, GA. Bench-to-bedside review: treating acid-base abnormalities in the intensive care unit – the role of buffers. Critical care. 2004;8: 259-265.

[8] Hindman BJ. Sodium bicarbonate in the treatment of subtypes of acute lactic acidosis: physiologic considerations. Anesthesiology. 1990;72: 1064-1076.

[9] Kallet RH, Jasmer, RM, Luce, JM, et al. The treatment of acidosis in acute lung injury with tris-hydroxymethyl aminomethane (THAM). American journal of respiratory and critical care medicine. 2000;161: 1149-1153.

[10] Omron EM, Omron, RM. A physicochemical model of crystalloid infusion on acid-base status. Journal of intensive care medicine. 2010;25: 271-280.

[11] Ostrea EM. The influence of bicarbonate administration on blood pH in a “closed system”: clinical implications. The Journal of pediatrics. 1972;80: 671-680.

[12] Rhee KH, Toro, LO, McDonald, GG, et al. Carbicarb, sodium bicarbonate, and sodium chloride in hypoxic lactic acidosis. Effect on arterial blood gases, lactate concentrations, hemodynamic variables, and myocardial intracellular pH. Chest. 1993;104: 913-918.

[13] Steichen JJ, Kleinman, LI. Studies in acid-base balance. I. Effect of alkali therapy in newborn dogs with mechanically fixed ventilation. The Journal of pediatrics. 1977;91: 287-291.

[14] Wilson RF, Spencer, AR, Tyburski, JG, et al. Bicarbonate therapy in severely acidotic trauma patients increases mortality. The journal of trauma and acute care surgery. 2013;74: 45-50; discussion 50.

Now on to the podcast…

You just read the post: Podcast 96 – Acid Base in the Critically Ill – Part V – Enough with the Bicarb Already from EMCrit Blog - Emergency Department Critical Care.

Thomas Scalea is a legend! He is Physician-in-chief at the Shock Trauma Center in Balitmore. He started the EM program at Kings County in 1991. He is also an excellent doctor and a wonderful person. At the 2012 EMCrit Conference, he gave an amazing lecture on the cutting edge techniques they are using at Shock Trauma for intracranial pressure (ICP) management.

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…

You just read the post: Podcast 95 – Thomas Scalea on Cutting-Edge ICP Management from EMCrit Blog - Emergency Department Critical Care.

I recently got an email from the creators of a new approach to airway management

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:

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…

You just read the post: EMCrit Wee – The Vortex Approach from EMCrit Blog - Emergency Department Critical Care.

My friend Chad Meyers is an ED Intensivist from NYC. He gave this lecture at ALLNYCEM 2012, but the video sucked. He rerecorded it for the EMCritters.

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…

You just read the post: EMCrit Wee – The Holy Grail of Fluid Resuscitation is just a Tin Cup from EMCrit Blog - Emergency Department Critical Care.

The Conference

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

You just read the post: EMCrit WEE – SMACC 2013 Summary and Learning Points from EMCrit Blog - Emergency Department Critical Care.

Paul Mayo and I seem to have established a tradition of debating each other at the annual Greater NY Hospital Association Critical Care Controversies Conference.

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…

You just read the post: Podcast 94 – Has Video Laryngoscopy Killed the Direct Laryngoscope? from EMCrit Blog - Emergency Department Critical Care.

Cliff Reid adds to the MotR lexicon with Chicken Bombs and Muppet Factors

You just read the post: Mind of the Resuscitationist – Chicken Bombs and Muppet Factors from EMCrit Blog - Emergency Department Critical Care.

As you know, my motto is maximally aggressive care, ALWAYS! Maximally aggressive curative care and maximally aggressive palliative care. I did a 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:

1.  ”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.
2. “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
3. ” 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

Need an Audio-Only version?

Right-Click here and choose save-as

Now on to the Vodcast…

You just read the post: Podcast 93 – Critical Care Palliation with Ashley Shreves from EMCrit Blog - Emergency Department Critical Care.

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?

You just read the post: EMCrit Wee – Tacit Knowledge and Medical Podcasting from EMCrit Blog - Emergency Department Critical Care.

At the 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 this insanely good post:

The post Perimortem C-section at St.Emlyn’s appeared first on St Emlyns.

And here is a simulator video:

Video on Vimeo

Now on to the Wee…

You just read the post: EMCrit Conference Blast Winner: Peri-Mortem C-Section from EMCrit Blog - Emergency Department Critical Care.

If you have a comment or question about one of the podcasts, chuck it into the comments section.

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:

1. it allows my answer to be seen by a much larger group of people
2. it allows folks smarter than me to chime in as well
3. 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:

You just read the post: Join the EMCrit G+ Community Page from EMCrit Blog - Emergency Department Critical Care.

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
• Awake Intubation Video
• 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?

from AirwayCam Site

Would the patient benefit from pre-intubation NGT?

• Intubating the GI Bleeder

Skills of Intubation

Laryngoscopy

Cricothyrotomy

Video

Bougie-Aided Cricothyrotomy

Video

Post Intubation Management

• Ventilator Lecture
• The Package

Building Checklists

The Checklist Project and their Checklist for Checklists

Other People’s Intubation Checklists for Inspiration

The EMCrit checklist drew inspiration and aid from these other checklists. Shoulders of giants and such…

Did you like this post? Then tweet the hell out of it

Finally… The EMCrit Call/Response VodCast is done. Podcast 92: emcrit.org/podcasts/emcri… Now tear it apart and make it better!

— Scott Weingart (@emcrit) February 5, 2013

Need the Audio only version

Right Click here and Choose Save-as

Now, on to the podcast…

You just read the post: Podcast 92 – EMCrit Intubation Checklist from EMCrit Blog - Emergency Department Critical Care.

A listener, Brian Katan, wrote to suggest adding ondansetron to the awake intubation procedure. Now this is interesting, because I don’t want the patient to vomit from ramming things into the back of her throat, but the mechanism is not nausea–it is the gag reflex. So, the question is: does ondansetron affect the gag reflex? Turns out it does…

Evaluation of the efficacy of oral ondansetron on gag reflex in soft palate and palatine tonsil areas

So now, ondansetron 4 mg IVP has been added to the airway checklist. Thanks Brian!

You just read the post: Ondanestron for Awake Intubation from EMCrit Blog - Emergency Department Critical Care.

My friend Chris Bond  runs a blog called SOCMOB (see below for an explanation).

Like all Canadians, Chris likes to have a nice meal, drink a glass of wine, and then go to the parking lot, break a beer bottle and stab people with it. In Canada, they call this bottling. When not bottling, Chris posts on emergency medicine topics; he put together a video on how to build a cheap and dirty cric trainer. Take a look…

Here is the original SOBMOB post.

The trainer is based on this article: (Anaesthesia 2004; 59:1012–15).

A recent letter to the editor takes the model even further: (Anaesthesia, 2009, 64, pages 687–697).

Diagnosis Wenckebach

Chris is also the creator of  the, “Diagnosis Wenckebach” video:

What is SOCMOB?

SOCMOB = Standing on the corner, minding my own business.  For any of you who work in emergency departments, you’ve likely heard this history before.  Most likely the presenting complaint was trauma

The SOCMOB Algorithm

You just read the post: How to Build the Ultimate Cricothyrotomy Trainer with Chris Bond from EMCrit Blog - Emergency Department Critical Care.

The American Society of Anesthesia just released their new difficult airway guidelines. Of course, I’ll be reviewing them on the Practical Evidence Podcast.

Those guidelines are a bit too involved for Emergency Medicine and Intensive Care. For us, I recommend the Shock Trauma Algorithm. I modified it somewhat to fit my own prejudices (as usual).

Click on the image for full-size

The approach was validated in this study:

[Stephens CT, Kahntroff S, Dutton RP. The success of emergency endotracheal intubation in trauma patients: a 10-year experience at a major adult trauma referral center. Anesth Analg. 2009 Sep;109(3):866-72.]

Couldn’t be easier to remember and use.

You just read the post: Shock Trauma Center Failed Airway Algorithm from EMCrit Blog - Emergency Department Critical Care.

This podcast was originally posted on the 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

1. 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).
2. In patients with elevated lactate levels targeting resuscitation to normalize lactate (grade 2C).

B. Screening for Sepsis and Performance Improvement

1. Routine screening of potentially infected seriously ill patients for severe sepsis to allow earlier implementation of therapy (grade 1C).
2. Hospital–based performance improvement efforts in severe sepsis (UG).

C. Diagnosis

1. 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).
2. 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.
3. Imaging studies performed promptly to confirm a potential source of infection (UG).

D. Antimicrobial Therapy

1. 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.
2. 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).
3. 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).
4. 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).
5. 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).
6. Antiviral therapy initiated as early as possible in patients with severe sepsis or septic shock of viral origin (grade 2C).
7. Antimicrobial agents should not be used in patients with severe inflammatory states determined to be of noninfectious cause (UG).

E. Source Control

1. A specific anatomical diagnosis of infection requiring consideration for emergent source control be sought and diagnosed or excluded as rapidly as possible, and intervention be undertaken for source control within the first 12 hr after the diagnosis is made, if feasible (grade 1C).
2. When infected peripancreatic necrosis is identified as a potential source of infection, definitive intervention is best delayed until adequate demarcation of viable and nonviable tissues has occurred (grade 2B).
3. When source control in a severely septic patient is required, the effective intervention associated with the least physiologic insult should be used (eg, percutaneous rather than surgical drainage of an abscess) (UG).
4. If intravascular access devices are a possible source of severe sepsis or septic shock, they should be removed promptly after other vascular access has been established (UG).

F. Infection Prevention

1. Selective oral decontamination and selective digestive decontamination should be introduced and investigated as a method to reduce the incidence of ventilator-associated pneumonia; This infection control measure can then be instituted in health care settings and regions where this methodology is found to be effective (grade 2B).
2. Oral chlorhexidine gluconate be used as a form of oropharyngeal decontamination to reduce the risk of ventilator-associated pneumonia in ICU patients with severe sepsis (grade 2B).

G. Fluid Therapy of Severe Sepsis

1. Crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock (grade 1B).
2. Against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock (grade 1B).
3. Albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids (grade 2C).
4. Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion with suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (a portion of this may be albumin equivalent). More rapid administration and greater amounts of fluid may be needed in some patients (grade 1C).
5. Fluid challenge technique be applied wherein fluid administration is continued as long as there is hemodynamic improvement either based on dynamic (eg, change in pulse pressure, stroke volume variation) or static (eg, arterial pressure, heart rate) variables (UG).

H. Vasopressors

1. Vasopressor therapy initially to target a mean arterial pressure (MAP) of 65 mm Hg (grade 1C).
2. Norepinephrine as the first choice vasopressor (grade 1B).
3. Epinephrine (added to and potentially substituted for norepinephrine) when an additional agent is needed to maintain adequate blood pressure (grade 2B).
4. Vasopressin 0.03 units/minute can be added to norepinephrine (NE) with intent of either raising MAP or decreasing NE dosage (UG).
5. Low dose vasopressin is not recommended as the single initial vasopressor for treatment of sepsis-induced hypotension and vasopressin doses higher than 0.03–0.04 units/minute should be reserved for salvage therapy (failure to achieve adequate MAP with other vasopressor agents) (UG).
6. Dopamine as an alternative vasopressor agent to norepinephrine only in highly selected patients (eg, patients with low risk of tachyarrhythmias and absolute or relative bradycardia) (grade 2C).
7. Phenylephrine is not recommended in the treatment of septic shock except in circumstances where (a) norepinephrine is associated with serious arrhythmias, (b) cardiac output is known to be high and blood pressure persistently low or (c) as salvage therapy when combined inotrope/vasopressor drugs and low dose vasopressin have failed to achieve MAP target (grade 1C).
8. Low-dose dopamine should not be used for renal protection (grade 1A).
9. All patients requiring vasopressors have an arterial catheter placed as soon as practical if resources are available (UG).

I. Inotropic Therapy

1. A trial of dobutamine infusion up to 20 micrograms/kg/min be administered or added to vasopressor (if in use) in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion, despite achieving adequate intravascular volume and adequate MAP (grade 1C).
2. Not using a strategy to increase cardiac index to predetermined supranormal levels (grade 1B).

J. Corticosteroids

1. Not using intravenous hydrocortisone to treat adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (see goals for Initial Resuscitation). In case this is not achievable, we suggest intravenous hydrocortisone alone at a dose of 200 mg per day (grade 2C).
2. Not using the ACTH stimulation test to identify adults with septic shock who should receive hydrocortisone (grade 2B).
3. In treated patients hydrocortisone tapered when vasopressors are no longer required (grade 2D).
4. Corticosteroids not be administered for the treatment of sepsis in the absence of shock (grade 1D).
5. When hydrocortisone is given, use continuous flow (grade 2D).

K. Blood Product Administration

1. Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic heart disease, we recommend that red blood cell transfusion occur only when hemoglobin concentration decreases to <7.0 g/dL to target a hemoglobin concentration of 7.0 –9.0 g/dL in adults (grade 1B).
2. Not using erythropoietin as a specific treatment of anemia associated with severe sepsis (grade 1B).
3. Fresh frozen plasma not be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures (grade 2D).
4. Not using antithrombin for the treatment of severe sepsis and septic shock (grade 1B).
5. In patients with severe sepsis, administer platelets prophylactically when counts are <10,000/mm3 (10 x 109/L) in the absence of apparent bleeding. We suggest prophylactic platelet transfusion when counts are < 20,000/mm3 (20 x 109/L) if the patient has a significant risk of bleeding. Higher platelet counts (?50,000/mm3 [50 x 109/L]) are advised for active bleeding, surgery, or invasive procedures (grade 2D).

L. Immunoglobulins

1. Not using intravenous immunoglobulins in adult patients with severe sepsis or septic shock (grade 2B).

M. Selenium

1. Not using intravenous selenium for the treatment of severe sepsis (grade 2C).

N. History of Recommendations Regarding Use of Recombinant Activated Protein C (rhAPC)

A history of the evolution of SSC recommendations as to rhAPC (no longer available) is provided.

O. Mechanical Ventilation of Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS)

1. Target a tidal volume of 6 mL/kg predicted body weight in patients with sepsis-induced ARDS (grade 1A vs. 12 mL/kg).
2. Plateau pressures be measured in patients with ARDS and initial upper limit goal for plateau pressures in a passively inflated lung be ?30 cm H2O (grade 1B).
3. Positive end-expiratory pressure (PEEP) be applied to avoid alveolar collapse at end expiration (atelectotrauma) (grade 1B).
4. Strategies based on higher rather than lower levels of PEEP be used for patients with sepsis- induced moderate or severe ARDS (grade 2C).
5. Recruitment maneuvers be used in sepsis patients with severe refractory hypoxemia (grade 2C).
6. Prone positioning be used in sepsis-induced ARDS patients with a Pao2/Fio2 ratio ? 100 mm Hg in facilities that have experience with such practices (grade 2B).
7. That mechanically ventilated sepsis patients be maintained with the head of the bed elevated to 30–45 degrees to limit aspiration risk and to prevent the development of ventilator-associated pneumonia (grade 1B).
8. That noninvasive mask ventilation (NIV) be used in that minority of sepsis-induced ARDS patients in whom the benefits of NIV have been carefully considered and are thought to outweigh the risks (grade 2B).
9. That a weaning protocol be in place and that mechanically ventilated patients with severe sepsis undergo spontaneous breathing trials regularly to evaluate the ability to discontinue mechanical ventilation when they satisfy the following criteria: a) arousable; b) hemodynamically stable (without vasopressor agents); c) no new potentially serious conditions; d) low ventilatory and end-expiratory pressure requirements; and e) low Fio2 requirements which can be met safely delivered with a face mask or nasal cannula. If the spontaneous breathing trial is successful, consideration should be given for extubation (grade 1A).
10. Against the routine use of the pulmonary artery catheter for patients with sepsis-induced ARDS (grade 1A).
11. A conservative rather than liberal fluid strategy for patients with established sepsis-induced ARDS who do not have evidence of tissue hypoperfusion (grade 1C).
12. In the absence of specific indications such as bronchospasm, not using beta 2-agonists for treatment of sepsis-induced ARDS (grade 1B).

P. Sedation, Analgesia, and Neuromuscular Blockade in Sepsis

1. Continuous or intermittent sedation be minimized in mechanically ventilated sepsis patients, targeting specific titration endpoints (grade 1B).
2. Neuromuscular blocking agents (NMBAs) be avoided if possible in the septic patient without ARDS due to the risk of prolonged neuromuscular blockade following discontinuation. If NMBAs must be maintained, either intermittent bolus as required or continuous infusion with train-of-four monitoring of the depth of blockade should be used (grade 1C).
3. A short course of NMBA of not greater than 48 hours for patients with early sepsis-induced ARDS and a Pao2/Fio2 < 150 mm Hg (grade 2C).

Q. Glucose Control

1. A protocolized approach to blood glucose management in ICU patients with severe sepsis commencing insulin dosing when 2 consecutive blood glucose levels are >180 mg/dL. This protocolized approach should target an upper blood glucose ?180 mg/dL rather than an upper target blood glucose ? 110 mg/dL (grade 1A).
2. Blood glucose values be monitored every 1–2 hrs until glucose values and insulin infusion rates are stable and then every 4 hrs thereafter (grade 1C).
3. Glucose levels obtained with point-of-care testing of capillary blood be interpreted with caution, as such measurements may not accurately estimate arterial blood or plasma glucose values (UG).

R. Renal Replacement Therapy

1. Continuous renal replacement therapies and intermittent hemodialysis are equivalent in patients with severe sepsis and acute renal failure (grade 2B).
2. Use continuous therapies to facilitate management of fluid balance in hemodynamically unstable septic patients (grade 2D).

S. Bicarbonate Therapy

1. Not using sodium bicarbonate therapy for the purpose of improving hemodynamics or reducing vasopressor requirements in patients with hypoperfusion-induced lactic acidemia with pH ?7.15 (grade 2B).

T. Deep Vein Thrombosis Prophylaxis

1. Patients with severe sepsis receive daily pharmacoprophylaxis against venous thromboembolism (VTE) (grade 1B). This should be accomplished with daily subcutaneous low-molecular weight heparin (LMWH) (grade 1B versus twice daily UFH, grade 2C versus three times daily UFH). If creatinine clearance is <30 mL/min, use dalteparin (grade 1A) or another form of LMWH that has a low degree of renal metabolism (grade 2C) or UFH (grade 1A).
2. Patients with severe sepsis be treated with a combination of pharmacologic therapy and intermittent pneumatic compression devices whenever possible (grade 2C).
3. Septic patients who have a contraindication for heparin use (eg, thrombocytopenia, severe coagulopathy, active bleeding, recent intracerebral hemorrhage) not receive pharmacoprophylaxis (grade 1B), but receive mechanical prophylactic treatment, such as graduated compression stockings or intermittent compression devices (grade 2C), unless contraindicated. When the risk decreases start pharmacoprophylaxis (grade 2C).

U. Stress Ulcer Prophylaxis

1. Stress ulcer prophylaxis using H2 blocker or proton pump inhibitor be given to patients with severe sepsis/septic shock who have bleeding risk factors (grade 1B).
2. When stress ulcer prophylaxis is used, proton pump inhibitors rather than H2RA (grade 2D)
3. Patients without risk factors do not receive prophylaxis (grade 2B).

V. Nutrition

1. Administer oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hours after a diagnosis of severe sepsis/septic shock (grade 2C).
2. Avoid mandatory full caloric feeding in the first week but rather suggest low dose feeding (eg, up to 500 calories per day), advancing only as tolerated (grade 2B).
3. Use intravenous glucose and enteral nutrition rather than total parenteral nutrition (TPN) alone or parenteral nutrition in conjunction with enteral feeding in the first 7 days after a diagnosis of severe sepsis/septic shock (grade 2B).
4. Use nutrition with no specific immunomodulating supplementation rather than nutrition providing specific immunomodulating supplementation in patients with severe sepsis (grade 2C).

W. Setting Goals of Care

1. Discuss goals of care and prognosis with patients and families (grade 1B).
2. Incorporate goals of care into treatment and end-of-life care planning, utilizing palliative care principles where appropriate (grade 1B).
3. Address goals of care as early as feasible, but no later than within 72 hours of ICU admission (grade 2C).

You just read the post: 2012 Surviving Sepsis Campaign Guidelines from EMCrit Blog - Emergency Department Critical Care.

Aortic Dissection

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)

(1) SMACC CLUB
http://lifeinthefastlane.com/2013/01/so-you-wanna-know-about-smacc-club/

(2) PK SMACC-talks (the deadline has been extended)
http://smacc.net.au/pk-smacc-talk/
entries so far: http://smacc.net.au/category/pk-talk/

You just read the post: Podcast 91 – Treatment of Aortic Dissection from EMCrit Blog - Emergency Department Critical Care.

This post used to contain a preview of the EMCrit Intubation Checklist. I have since posted the actual episode and the revised checklist. I’m leaving this post here for the 70 excellent comments. Please go to the new post to comment further.

You just read the post: Preview of the EMCrit Intubation Checklist from EMCrit Blog - Emergency Department Critical Care.

Cliff Reid is the prototypical resuscitationist; he rocks! He has discussed his philosophies on previous episodes:

•  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…

You just read the post: Podcast 90 – Mind of the Resuscitationist Series: Cliff Reid’s Own the Resus Room from EMCrit Blog - Emergency Department Critical Care.

Podcasts

• 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

2011 Hard Six

2010 Dirty Dozen

Thanks for Listening and Supporting EMCrit!

You just read the post: Natural Seven for 2012 from EMCrit Blog - Emergency Department Critical Care.

Got this email from a listener:

Hi Scott

Merry Christmas.  So here I am sitting here sipping my coffee on a quiet Christmas morning and I’m writing YOU a complete stranger, a Christmas email.  Well not a complete stranger but you can tell how obsessed I am with airway stuff when I’m writing this on Christmas morning!  Besides this is one of the few quiet moments I’ve had in many months to collects some thoughts before the troops wake up.  I started writing you this email a while back but some how erased it and haven’t gotten back to it.  In any case kudos to you for keeping up the stellar podcasts.  I really like how you have aligned yourselves with other outstanding minds in our field and created a more or less free forum to put out some incredible educational points for Crit Care and ER medicine.

One of my pet peeves is getting people to really understand the real benefits and proper technique of VL.  I’ve seen and heard some of your stuff on this but I thought I’d chime in with a few of my tips and tricks that I teach on an airway course we give here in the Middle East called AIME.  Originally designed and created by Adam Law an anaesthetist that hails from Canuck land.  Adam has shared with me some invaluable tips in using the VL which just these subtle things can make this technique so easy anyone can do it first or second try.

One of the first things people need to understand is DL is LINE OF SIGHT.  We have to have a STRAIGHT shot at the cords to be able to see and put the tube in.  That’s why we align the oral and laryngeal axes.  And that’s why we need to do the ears to sternal notch. WE CAN’t SEE AROUND CORNERS WE SEE IN STRAIGHT LINES.  This is what the standard straight bougie was designed to help us with.  So it drives me crazy when I’ve heard some people talk about using a regular bougie with VL.  Yes it’s flexible but standard bougies don’t hold a bend, they’re meant to follow along the line of sight and be able to help us with those CL grade 2 and 3 views while doing DIRECT LARYNGOSCOPY (and yes I still teach that you should use it on grade I views to get the hang of it but really it’s for the later). The other thing that people must understand that it isn’t a “blind mans cane” for grade 4 views and shouldn’t be used as such.  If all you see is tongue you don’t blindly kep shoving the bougie up and down hunting for clicks (sorry I know this is obvious to you but I’m just on a bit of a rant) .  The last point is STANDARD BOUGIES AREN’T MEANT OR DESIGNED FOR VIDEO LARYNGOSCOPY. Ok you could argue that for a King vision or Pentax AWS a bougie is great to guide down the channel but that’s not what a lot of VL’s have and so a bougie is not the tool to use.

So ultimately VL is to look AROUND the corner and therefore we don’t have to just “slightly” extend the neck in trauma; something we’re all guilty of (just getting “that little bit more extension” to get the tube in).  Alternatively someone stabilizes the neck while we do the Herculean lift to squish the tongue through the submandibular space to get our line of sight.  So I think it was either Minh or Cliff who said that they really don’t use VL in the field yet, I really think they need to begin to see the benefits of this.

Almost all video laryngoscope blades are much more curved than standard mac blades.  WHY?  AGAIN It’s because they’re designed to LOOK AROUND THE CORNER!  The only bougie that will help you with this (if you want to use a bougie) is I think the pocket bougie from Bomimed.  Now I haven’t used the pocket bougie but from what I’ve seen on Jim Ducanto’s video it can be bent or is bent to go AROUND THE CORNER.  This is the only bougie that I’ve seen that does this.  Using a STANDARD bougie may work if you’re using a VL to do Direct laryngoscopy but again the blade wasn’t designed to help you to see directly, the flatter, less curved mac blade was. But if you load an ETT with a properly formed stylet in almost all cases you really don’t need a curved bougie with VL and  especially NOT a straight bougie. I actually think we do our students a disservice by watching them do a DIRECT laryngoscopy while we watch on the Glidescope screen because the blade is so curved that the mechanics and placement of the VL blade tip in the Vallecula like you should with a regular mac blade are VERY different.  Because a VL blade is so curved if you put it in the vallecula and pull in the direction of the handle like we teach with a regular mac blade, they are not pulling in the same direction as with a standard mac blade and I think that in a difficult scenario will at best won’t make things easier and at worse might injure the perilaryngeal structures.  People should teach DL with a standard blade NOT a VL blade.  Use the right tool for the application it was designed for.

The way I teach VL is as follows.

First and foremost you must use an introducer and that introducer needs to be bent exactly in the shape of the VL blade

Because both blade and tube are so curved some times it’s difficult to slide them in straight.  I often tell the students to scissor their right index finger and thumb on upper and lower incisors respectively to open the mouth.  Then with the blade handle pointed to 9 o clock, insert the blade.  When the blade is towards the back of the tongue, rotate the handle to 12 o’clock.  Now look at the screen as you slowly advance…

I agree with your “mouth, screen, mouth, screen” reminder to prevent injuries with blade and tube insertion.

I don’t tell students to get the blade tip in the vallecula like with DL, it just makes VL harder because then end up pulling the larynx to anterior which just compounds the problems of passing the tube.  As you and I both know seeing the cords isn’t the problem, getting the tube in is.  When students in their excitement of seeing that grade I view (often for the very first time!!) love to keep this view at the expense of making getting the tube in very difficult.

What I teach is a grade II view is all you need and is actually what you want.  Once you get this, similar to inserting the blade you insert the tube with the long axis pointing to 3 o’clock and watch the tip go into the mouth and past the back of the tongue.  Now look at the screen and keep advancing slowly.  Once you can see a hint of plastic on the screen, rotate the tube to 12 o’clock and presto, the tube tip is right at the cords.

The last hold up is when they try and ram the tube and introducer in.  Invariably the tube and introducer gets rammed into the anterior larynx.  So the student needs to bring the tube tip to the cords and maybe just a little past.  Have someone hold the introducer and continue to slide the tube off and down.  If it gets hung up on the anterior larynx this is where the student can slowly twist the tube 90-180 degrees to pass the tube.  Even watching Dr. Ducanto push the pocket bougie in with it’s big bend he gets hung up on his video and has to do the multiple twists with the bougie to get it to pass down the trachea.

So that’s my Christmas rant.  I feel much better.  Have a good one.

Cheers

Harold Shim

My Comments:

Harold, Great comments/teaching tips. I would say that we need to make a clear separation between the indirect vision video blades (Glidescope, CMAC D, etc.) and the standard/displacing blade shapes (Standard CMAC). In the latter, a standard bougie works just fine; for the former the pocket bougie seems to be the best thing out there.

Your Comments…

let Harold and I know what you think

You just read the post: A Rant on Video Laryngoscopy from EMCrit Blog - Emergency Department Critical Care.

We have hit the 10,000 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

Lessons learned from 10,000 patients with severe sepsis on EMCrit Podcast 89: emcrit.org/podcasts/lesso…

— Scott Weingart (@emcrit) December 26, 2012

You just read the post: Podcast 89 – Lessons from the STOP Sepsis Collaborative from EMCrit Blog - Emergency Department Critical Care.

A premed asked what literature should one read to develop the mindset and tiger’s eye of a resuscitationist. Knowing when to consult my betters, I threw the question to @precordialthump. And Nickson responded thusly:

My advice
These days less and less is learnt from books… however there are some books mentioned in what follows.

Learn about Osler – the ultimate role model for how to succeed as human being and where all good medicine begins:

• http://lifeinthefastlane.com/2011/03/becoming-an-oslerphile/

Read “Blood of Strangers” by Frank Huyler – the best tales from the ER by a great writer

• http://www.amazon.com/Blood-Strangers-Stories-Emergency-Medicine/dp/0520218639

Check out these talks:

• http://freeemergencytalks.net/2012/10/joe-lex-an-old-fogey-speaks-45-years-on-the-front-lines/
• http://freeemergencytalks.net/2010/03/amal-mattu-finding-your-niche-in-em/
• http://freeemergencytalks.net/2010/04/peter-rosen-beginnings-of-emergency-medicine/
• http://freeemergencytalks.net/2010/04/amal-mattu-becoming-the-leader-that-others-follow/
• http://emupdates.com/2010/09/15/screencast-how-to-think-like-an-emergency-physician/
• http://emtutorials.com/2012/11/own-the-resuscitation-room-cliff-reid/

Read anything by croskerry on cognitive errors such as http://1.usa.gov/xPfmhA

Read LITFL :

• http://lifeinthefastlane.com/2011/06/memoirs-of-an-er-doctor/
• http://lifeinthefastlane.com/2012/03/new-girlfriend/
• http://lifeinthefastlane.com/2009/06/choose-medicine/
• http://lifeinthefastlane.com/2010/02/making-sense/
• http://lifeinthefastlane.com/2010/03/wrestling-with-risk/
• http://lifeinthefastlane.com/resources/aequanimitas/
• http://lifeinthefastlane.com/2009/03/the-mark-of-the-beast/

Oh, and listen to EMCrit too!

Lots of martial arts, stoic and eastern philospohy, military works, and mountaineering/ survival books have obvious parallels to what we do (at least to some of us).

C

I would add that reading Sherlock Holmes would probably serve you well as well. This BMJ article summarizes why…

White coats and fingerprints: diagnostic reasoning in medicine and investigative methods of fictional detectives

You just read the post: Literature for the Resuscitationist from EMCrit Blog - Emergency Department Critical Care.

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?

You just read the post: EMCrit Wee – MOPETT Trial from EMCrit Blog - Emergency Department Critical Care.

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:

Did you like this episode? Then tweet the hell out of it…

ON EMCrit Podcast 88, I discuss Oxygen Physiology and Pulse Ox Lag with Dan Davis emcrit.org/podcasts/oxyge…

— Scott Weingart (@emcrit) December 11, 2012

Now on to the Podcast…

You just read the post: EMCrit Podcast 88 – Oxygen Physiology with Daniel Davis from EMCrit Blog - Emergency Department Critical Care.

What is the best conference of 2013?

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

You just read the post: SMACC Conference from EMCrit Blog - Emergency Department Critical Care.

I received this message from Denis Colares:

Hi Scott, I’m an Emergency Medicine Resident from Brazil. Really love your podcast, thank you for all your help. Listen, I’ve watched your videos about central line placement and although they added a lot for my technique I still have a few questions. Having the U/S to guide the line placement is quite rare around here so the blind technique is standard. It’s very common to have to do a central line in a mechanically ventilated patient so I ask you: 1- regarding the IJV: do you increase the volume or the PEEP to enlarge the IVJ? I mean besides doing the Trendelenberg and the rest of the standard positioning? I found this paper: “Eur J Anaesthesiol. 2012 May;29(5):223-8. Effects of four different positive airway pressures on right internal jugular vein catheterisation” and I would really love to hear your opinion on this. 2- regarding the subclavian: do you disconnect the patient from the ventilator as you try to pass under the clavicle? I do exactly as you described in the video, usually don’t disconnect the patient, and have successfully done about 40 without a single complication but some people make a big deal out of this and tell me that I HAVE TO disconnect the patient otherwise the risk of a pneumothorax is greater… tell me, cause I couldn’t find anything on pubmed, is there any evidence on this? The ASA guideline simple don’t mention this issue! Sorry about the long text and really hope you can help me here. Thanks.

Denis,
Great ?s.

1. I don’t bother increasing PEEP for IJ placement, though in addition to the article you mention there are a bunch more saying the same thing in the anesthesia literature. I put my patients in Trend. and they all have at least 5 of PEEP. You can get it a bit bigger by going to 10 of PEEP, but the increase has never seemed worth it (a 15% increase is a small increase in actual vessel diameter).

2. I too have heard that stuff on subclavian patients. It seems like an old wives tale or medical myth. We routinely placed subclavians in patients on APRV with pHighs of 40 or 50 cm and never thought twice about it. Unless someone shows me GOOD evidence that this actual prevents pneumothoraces, I am not disconnecting my patients (the more PEEP they are on the more deleterious any vent disconnections).

Put any additional questions in the comments.

Scott

You just read the post: Central Line Questions from EMCrit Blog - Emergency Department Critical Care.

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.

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

Cognitive Stop Points for the Resuscitationist

Use this method whenever the situation doesn’t add up or is going bad:

1. Announce you have no idea what the f**k is going on
2. Eliminate ALL assumptions
3. 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:

Podcast 87 is a Mind of the Resuscitationist Episode on Stop Points and Engineers emcrit.org/podcasts/stop-…

— Scott Weingart (@emcrit) November 26, 2012

Now on to the Podcast…

You just read the post: Podcast 87 – Mind of the Resuscitationist: Stop Points from EMCrit Blog - Emergency Department Critical Care.

The only form of dialysis I was raised on in the ICU was Continuous Renal Replacement Therapy (CRRT). I was a CVVH man; I understood how it worked and how to order it. Lately, I’ve been hearing about slow low efficiency dialysis (SLED). Why would I want anything slow and low efficiency? Turns out I had no idea how great SLED could be until I listened to an incredible lecture by Michaela Cartner on the Intensive Care Network. While you are there, check out the other incredible posts and lectures.

You just read the post: What the hell is SLED? from EMCrit Blog - Emergency Department Critical Care.

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 do harm with additional fluid. This term was introduced to me by an amazing ED Intensivist named Chad Meyers. His lecture on this stuff from the ALLNYCEM Conference will go up very soon. IVC ultrasound is the perfect guide to fluid tolerance. CVP is fine as well, but why expose the patient to a central line.

More

Mike discussed a study he was part of that showed where you measure the IVC matters (Acad Emerg Med. 2010 Jan;17(1):96-9). Make sure you don’t measure at the diaphragm; measure distal to the hepatic veins or at least 3 cm past the diaphragm.

The Predicting Fluid Responsiveness Chapter at Crashingpatient.com has a bunch more info on all of this

Here is the video for how to perform the IVC ultrasound:

Now Mike is an amazing doc–he offhandedly mentions throughout the podcast, none of this crap matters until you have already given 6 liters of fluid or so. Amen brother. But a lot of folks are too scared to do that, hence the need for IVC ultrasound. Now there are unfortunately also references to the fluid depleted patient showing signs like cracked lips and a generally sere appearance; yeah, not so much. If we could assess volume status on vasodilated septic patients, that would be swell, but all of sepsis literature stands against our ability to do so.

Want to know why these studies may show results all over the map? It’s probably b/c the IVC is tough to measure unless you are good as demonstrated here.

Passive Leg Raise

Instead of IVC, Mike and Haney recommend using the passive leg raise with echo assessment of cardiac output before and after. You only need to do this once to realize its utility exists merely on paper. Much better is simply…

Giving a Fluid Challenge

Check cardiac index using echo, give a liter of fluid, and then recheck cardiac index.

Up until this week, I would have advocated considering using NICOM bioreactance, but a study just published makes me a bit leery until more data are in.

Did you like this episode? Then tweet the hell out of it:

EMCrit Podcast 86 is a glove slap across the cheeks of @criticalcarenow and @bedsidesono on IVC ultrasound: emcrit.org/podcasts/ivc-u…

— Scott Weingart (@emcrit) November 12, 2012

Now, on to the podcast…

You just read the post: Podcast 86 – IVC Ultrasound for Fluid Tolerance in Spontaneously Breathing Patients – EAT IT STONE from EMCrit Blog - Emergency Department Critical Care.

We’ve bent our Bonfils to fit the Cookgas ILA. Jim DuCanto has done the same with his Clarus. Here are pictures of Jim’s perfect bend as inspired by Dan Cook.

Here is one with a Ruler

You just read the post: How to Custom Bend a Video Stylet for use with the Cookgas AirQ ILA from EMCrit Blog - Emergency Department Critical Care.

Great post on PulmCCM.org on a recent JAMA Sedation Article stating these holidays may actually be a bad trip for our ICU patients.

For more on ED/ICU sedation see this prior podcast.

You just read the post: Sedation Vacations look like a Bad Trip from EMCrit Blog - Emergency Department Critical Care.

Here are some random airway videos I have been storing up

The 1-Person Bougie Technique and The Pocket Bougie Trigger Grip

Fayaz Gulamani demonstrates the 1-person bougie technique with a pocket bougie, (I have since tried this with a standard bougie and the technique is spectacular for that situation as well.) He also shows the special trigger grip for the pocket bougie.

(recommend going full-screen on this one)

Cord Previsualization for AirQ SGA Tube Exchange

Jim DuCanto has come up with a new concept for optimizing intubating through the Cookgas ILA. He recommends dropping your scope without the ETT tube on it first to optimize the SGA position. Only then, put your ETT on the scope and intubate through the ILA.

First, the Visualization:

Then, the tube placement:

Endotracheal Tube Exchange with a Pocket Bougie

Note, the techniques Jim shows are the same as when you use an airway exchange catheter

Exchange of a Laryngeal Tube Airway to ETT with Pocket Bougie and King Vision

Note: As always and forever, I have no financial relationship with these companies or any companies. I was given two pocket bougies to play around with.

You just read the post: More DuCanto and Pocket Bougie Videos from EMCrit Blog - Emergency Department Critical Care.

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!

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, please just put in me in the authorship somewhere.

Pressure Poisoning

Now I can say it: 8 ml/kg Vt by IBW for ALL ED PATIENTS should be your starting dose.

Association Between Use of Lung-Protective Ventilation With Lower Tidal Volumes and Clinical Outcomes Among Patients Without Acute Respiratory Distress Syndrome – A Meta-analysis JAMA. 2012;308(16):1651-1659

Resus.me Post: Not just in ARDS | Resus M.E!

Like this episode? Then tweet the hell out of it

Confirmation of 2 clin prejudices is the basis of EMCrit 85 with hat tips to @pbsherren, @pharmertoxguy and @cliffreid: emcrit.org/podcasts/chlor…

— Scott Weingart (@emcrit) October 29, 2012

Now on to the podcast…

You just read the post: Podcast 85 – A Confirmation of Prejudices: Chloride and Pressure Poisoning from EMCrit Blog - Emergency Department Critical Care.

The Post-Intubation Package

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, but if you want to go venous and you have a sat between 90-95% then knock yourself out.

Check Tube Depth

I start with 21 cm for women and 23 cm for men. Adjust based on size obviously. Then get an ultrasound and/or X-ray. When getting an x-ray make sure the head is in a neutral vertical position (remember the tube follows the nose, nose down-tube deep).

Bonus Meds-SUP and DVT Proph

Have an institutional plan for which meds and when

Bonus-Oral Decontamination

Chlorhexidine

Put a BVM at the Bedside ± PEEP Valve

When something goes wrong you should not need to search for this. Put the mask on the O2 tubing.

Have a Plan for Vent Alarms

Treat them like a cardiac arrest announced overhead.

Additional Reading

This amazing post from my bud Kane Guthrie from LITFL is worth a read stat: Key things to know about ventilator-associated pneumonia (VAP)

This article is geared to the ED prevention of VAP later in the patient’s course: Ventilator-associated pneumonia: the potential

A Checklist

Jeffrey Siegler, an EM PGY1, made the first foray into turning this into a checklist

I received a second one, this one index-card-sized, from Chris Huntley, PA from the University of Washington ED.

Now on to the Podcast…

You just read the post: Podcast 84 – The Post-Intubation Package from EMCrit Blog - Emergency Department Critical Care.

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

Survivor Story

Our ultrasound fellow, Dan Lakoff, sent me this survivor story from a thoracotomy

Need the audio-only version? Right click here and choose save-as

Now on to the Vodcast…

You just read the post: Podcast 83 – Crack to Cure – ED Thoracotomy from EMCrit Blog - Emergency Department Critical Care.

To all who responded to my request for help making a tough decision, thank you. You are the best audience any podcaster could ever hope for. We will back to ED Critical Care on Monday. Until then know that each of you make this so worthwhile. Thank you.

Scott

You just read the post: Thanks for your help from EMCrit Blog - Emergency Department Critical Care.

Today, I put on my head-shrinker cap (it is a fez) and get Cliff Reid on the coach. You know Cliff from his previous podcasts:

• 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…

You just read the post: Podcast 82 – Mind of the Resuscitationist with Cliff Reid from EMCrit Blog - Emergency Department Critical Care.

I got an email from the man, Joe Lex, asking me if it would be helpful if he gathered all my podcasts together in one file and disseminated it.

My answer is a resounding no for the following reasons:

• This is actually a step backwards in terms of dissemination. RSS is the way to go for device downloads. All podcasts can be downloaded in one shot as it is.
• I actually need my download stats for analysis, proof of dissemination, promotion, and proof of concept of e-learning
• When mistakes are discovered, I replace the audio in the feed and all future downloads have the corrected audio
• These changed files are less useful on current podcast devices as the meta has been removed

But the real reason I don’t recommend this is that there is a much easier way. For that, watch this video. Best watched in full screen (Click the expand arrows on the bottom of the video).

Note if you are already Itunes savvy, there is no reason to watch this video

Want More?

Here is the video I did of how to use RSS, google reader, and flipboard to read blogs

You can find another video on using iTunes on the Southampton Emergency Medicine Project Video Page

Do you have questions, then put them in the comments below:

You just read the post: How to Use RSS and Itunes to Maximize FOAM Podcasts from EMCrit Blog - Emergency Department Critical Care.

So one of my readers, Chris, wrote in to ask if neck lines are contra-indicated in digoxin toxicity. He had been told of this prohibition by one of his attendings. It seemed to me that this is one of those things that are viewed as potential harms, but there probably is no evidence. He took the initiative to do a futher lit search and here is what he came up with…

Hey Scott,

After looking it up and checking Rosen’s and Goldfrank’s, I came upon this article, which seems to be the basis for the argument of no IJs/Subclavians:

CLINICAL TOXICOLOGY 1993;31(2):261-273

I’ve attached the key excerpt from the discussion here as well:

“Safety of cardiac pacing in the treatment of digitalis intoxication was assessed in 39 pacing-treated patients from Groups 1 and 3. Fourteen adverse effects (36%) were recorded. These iatrogenic accidents were pacing-induced arrhythmias (6 cases), pacing defects (6 cases), and infectious complications (2 cases). The six pacing-induced arrhythmias occurred during or just after insertion (1 ventricular tachycardia, 3 VF) or subsequent to pacemaker adjustment (1 VA after a brief pause of pacing to study the underlying rhythm; 1 VF during reduction of ventricular rate from 80 bpm to 60 bpm). The six pacing defects occurred after ambulance transport (1 VA), external cardiac massage (1 patient), or accidental removal of the pacemaker by a confused patient, while no causes were found in three cases. The two infectious complications were staphylococcus epidermidis septicemias. One septicemia was complicated by fatal septic shock. Five out of these accidents (13 %) had a fatal outcome (2 VF, 2 VA, 1 septic shock). Thus, the overall pacing-induced mortality was 42% (5 out of 12 fatalities).”

So, they showed that pacing someone with a dig OD is bad, and that complications of pacing often occurred “shortly after insertion”, which they don’t define in the paper in terms of time. I presume this leads to the inference that it may be the guide wire of the CVC kit that irritates the myocardium and precipitates the arrythmia/death. I’m not sure I can completely make that leap, as it seems to me that repeatedly shooting electricity into the already electrically abnormal heart will be a bigger problem than tickling it with a wire.

Some other things to consider are that the pacers were put into patients receiving lower/no digibind, and that the pacers were put in ahead of time at another hospital, and patients were then transferred to the ICU center in the study. Interestingly the cardiology center put in the pacers, but had no Digibind on hand. The digibind was only available at the ICU center where the patients would be transferred after having their pacer inserted.

Alright, overall I’m feeling like a CVC is probably fine, especially in an appropriately Digibound patient. However, pacing (especially without giving Digibind) looks to be a suboptimal plan.

So this prompted me to search as well. And I found this chestnut (always intended).

Cardiology 2004;102(3);152-155

Safety of Transvenous Temporary Cardiac Pacing in Patients with Accidental Digoxin Overdose and Symptomatic Bradycardia

Ju-Yi Chena, Ping-Yen Liua,b, Jyh-Hong Chena, Li-Jen Lina

Background: Patients with digoxin intoxication may need transvenous temporary cardiac pacing (TCP) when symptomatic bradyarrhythmias are present. However, it has been reported that TCP might be associated with fatal arrhythmias in patients with acute digitalis intoxication caused by attempted suicide. The aim of this study was to assess the safety of TCP in patients with accidental digoxin-related symptomatic bradyarrhythmias. Materials and Methods: Seventy patients (30 men; age 74 ± 12 years) were enrolled in this retrospective study. Patients were divided into two groups: group 1 with TCP and group 2 without TCP. A digoxin overdose was defined as a serum digoxin level higher than 2.0 ng/ml combined with the presence of digoxin-related symptoms. Detailed clinical characteristics were reviewed on the basis of the medical records. Results: Group 1 included 24 patients (34.3%, 10 men). The rhythms prior to pacemaker insertion in group 1 included sinus arrest with junctional bradyarrhythmias (n = 9), atrial fibrillation with a slow ventricular rate (n = 11), and high-degree atrioventricular block (n = 4). The mean duration of pacemaker implantation was 5.8 ± 2.9 days (2–12 days). There was no major arrhythmic event or mortality after TCP in group 1. Two patients in group 2 (4%) died of ventricular tachyarrhythmias. Group 1 had a higher level of blood urea nitrogen (45.1 ± 26.0 vs. 33.4 ± 19.3 mg/dl), of left ventricular ejection fraction (68 vs. 56%), and of digoxin (4.4 ± 2.1 vs. 3.4 ± 1.3 ng/ml) but a lower serum calcium level (8.7 ± 0.6 vs. 9.1 ± 0.8 mg/dl). Conclusion: TCP was safe for patients with a digoxin overdose complicated by symptomatic bradycardia and should be recommended in such situations. However, this conclusion does not apply to acute digoxin intoxication as a result of attempted suicide.

So what do you folks think? With proper wire management you can ensure it goes nowhere near the heart (insert <25 cm), but is it worth it? Or should we just make Dr. Marik happy and use the groin (hate that word!) in these folks?

You just read the post: Can We Place Neck Lines in Digoxin Toxicity? from EMCrit Blog - Emergency Department Critical Care.

Yearning for some trauma aren’t you?

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

Turf wars about who should lead trauma team are sign of immature trauma system (and immature specialty) IMHO @docib @drrehn @swisstrauma

— Karim Brohi (@karimbrohi) August 12, 2012

Did you Like this Post? If so, then retweet it…

No closed-chest compressions in traumatic arrest and other pearls from @karimbrohi on EMCrit Podcast 81: emcrit.org/podcasts/sever…

— Scott Weingart (@emcrit) September 2, 2012

What do you think about ACLS and Traumatic Arrest? Comment below…

Now on to the Podcast:

You just read the post: An Interview on Severe Trauma with Karim Brohi from EMCrit Blog - Emergency Department Critical Care.

Jim DuCanto just sent two OR videos with intubations using a new bougie made to keep in your pocket or small kits: the pocket bougie by Bomimed.

In the video above, Jim is using a Glidescope with the new bougie. He also demonstrates his crankshaft maneuver.

In this second video, Jim is using a Mac blade with the bougie in a patient with high BMI (125 kg).

You just read the post: A New Bougie for your Pocket by Jim DuCanto from EMCrit Blog - Emergency Department Critical Care.

When I read a recent meta-analysis by Paul Marik, the first thing I did was bang my head against the wall 10 or 20 times. For seven years I have been trying to get people to put in neck lines because we KNOW the infection and DVT risk is lower, right? Well Dr. Marik’s review may significantly lower our certainty. You remember Paul Marik; he was on the show discussing 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???

What do you think? Leave your thoughts in the comments below.

Now on to the Podcast:

You just read the post: Podcast 80 – Uhmmmm, Maybe Groin Lines Are Not So Bad with Paul Marik from EMCrit Blog - Emergency Department Critical Care.

Another ENLS topic: Ischemic Stroke. But not the entire subject, and not even whether we should give tPA to stroke patients. Why not the latter topic–because I am not smart enough to know the answer. For that listen to 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:

Click Image for PDF

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…

You just read the post: Podcast 79 – Reducing Door to tPA Time in Ischemic Stroke from EMCrit Blog - Emergency Department Critical Care.

One of my residents did not know who ZDoggMD was; this is a travesty.

Just in case any of you have been in suspended animation for a few years, I wanted to embed the latest from this West Coast Rapper.

An important message about C. Diff from the Lord of Poo:

You just read the post: A Message of Poo by a Man on Top of his Game from EMCrit Blog - Emergency Department Critical Care.

I recently came across two articles pertaining to the peri-intubation; one made me very happy (b/c it reinforces my prejudices) and the other made me quite upset (b/c it reinforces my prejudices).

Let’s start with good tidings first:

(PMID: 22610185)

In this prospective, observational trial the use of NMBAs was associated with a lower incidence of hypoxemia and complications. NMBAs also led to better intubating conditions. Now during the debate with Dr. Paul Mayo I showed a bunch of articles that said the same thing, so why is this one so important? Because this was done in a setting that really matters to EMCrit readers: the ICU. What we have known for at least a decade is that ED/ICU intubations are an entirely different animal than OR intubations. So now we have further proof of what I have always believed–if you are a skilled airway operator, paralytics will improve your intubating conditions.

Now the not so great:

Note: I am not the author of this paper, nor am I related to him.

Thanks to Minh of the Pharm for pointing this one out to me.So here is the paper’s conclusion: Less than one-half of patients undergoing ETI in the ED receive sedative drugs while in the ED. These findings are congruent with prior smaller studies from single academic centers. Now I’m not sure if some of these patients were so deeply comatose that the team felt no sedation was necessary, but I can’t imagine it is a huge fraction of the patients that did not get sedation. This makes me so sad. The relief of pain and suffering should be our first priority as doctors. How can this still be going on?

(PMID: 22770915)

Tell me how these articles make you feel (b/c EMCrit cares) in the comments:

You just read the post: One that made me happy, One that made me sad from EMCrit Blog - Emergency Department Critical Care.

In podcast 78 on the management of elevated ICP, I discussed ocular nerve sheath ultrasound. Here are some additional resources.

Literature

• Crit Care 2008;12:150
• Acad Emeg Med 2003, Vol. 10, No. 4
• Tayal VS Ann Emerg Med 2006
• Emerg Med J 2007;24:251
• Annals of Emergency Medicine 2007;49(4):508-514
• Inten Care Med 2007;33:1704
• Academic Emergency Medicine 2008;15 (2) , 201-204
• Inten Care Med 2008;34:2062
• Neurocritical Care Dec 2009
• emerg med j 2011;28:679
• J Trauma 2011;71:779)
• Neurocrit Care 2011;15:506
• Review Article (Acta Anaesthesiol Scand 2011;55:644)

Blogposts

From Life in the Fast Lane

Media

From Ultrasound Podcast guys, a 1-minute tutorial

Link to Full Ultrasound Podcast on Ocular Nerve Sheath Exam

You just read the post: Optic Nerve Sheath Ultrasound for Detecting Increased Intracranial Pressure (ICP) from EMCrit Blog - Emergency Department Critical Care.

Today we are going to discuss increased intracranial pressure (ICP) and herniation. This is the first of 13 lectures to go with the upcoming Emergency Neurological Life Support Course that I co-chair.

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…

You just read the post: Podcast 78 – Increased Intra-Cranial Pressure (ICP) and Herniation, aka Brain Code from EMCrit Blog - Emergency Department Critical Care.

A few months ago, I got an email from Matt Hoffman asking me if I could link to his blog: pulmccm.org.

Now this is not the way I normally handle things. Every December I put out my favorite things for the past year and after looking at his site, I had already earmarked a spot for pulmccm on the 2012 list. However, the quality of the posts has been so high, it would be a shame to wait. So go to the site and I think you’ll like what you see.

Here are some of my favorite posts:

• Tobin on PEEP/PSV settings for Extubation Readiness
• Mech Vent in ARDS
• A New Definition of ARDS

You just read the post: PulmCCM.org from EMCrit Blog - Emergency Department Critical Care.

A comment by Sean Marshall (scroll all the way down) got me thinking about bimanual larygoscopy. I realized, when I am doing fiberoptic laryngoscopy, I don’t need to really perform too bimanual anymore. Big paradigm shift since I strongly espoused the virtues ever since I learned the technique from Rich Levitan.

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.

You just read the post: EMCrit Wee – Airway Outsourcing and Suction Henching from EMCrit Blog - Emergency Department Critical Care.

My former resident Seth Trueger (@mdaware) is missing having waveform capnographs at every resuscitation bedside. He is looking for a stand-alone unit for his department to purchase.

First person I suggested he reach out to is prehospital master, Christopher Watford who wrote back this,

As far as handheld goes, Nellcor makes the N-85 which has both EtCO2 (quantitative and waveform) and SpO2. I think new they’re around $4k. BCI offers the Capnocheck, which is good too, but I think has more options and is pricier. Oridion has the priciest, but a lot of prehospital and inhospital cardiac monitors use their technology.

 It also uses semi-standard adaptors, so you may get lucky with some other section of your hospital using the adaptors. EMS in your area may use it too, potential cost sharing opportunity.

We’ve got EtCO2 built into our Philips MRx’s, both our LP12′s and LP15′s, and all of our Zoll’s (E, M, and now the X-series). So we don’t really use the handheld units in EMS. You could look into upgrading inhospital monitors, usually its a $2-3k “add on” (basically a software upgrade if you’ve got the port).

Let me know if you need anything else!

Do any of you have units you use and like?

You just read the post: Stand-alone ETCO2 Monitors from EMCrit Blog - Emergency Department Critical Care.

LVAD Emergencies

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. Green Light on? Yes..ok. No? Troubleshoot for a problem with the VAD and keep working until you get the green light on the controller.

Listen: to the hum. Assuming a green light on the controller…there should be an LVAD Hum. No hum? the pump isn’t functional (duh). Find out why. Again, check all the connections and then touch the control box and check RPM, flow, etc). Pump thrombosis is your reversible problem here.

Feel: hot control box is not good and usually means thrombosis or dislodgement of the outflow cannula to the aorta…or distal obstruction like a dissection.

Compressions: here is my thought: if you’ve gone through all of the above and there is nothing to fix…then you have an LVAD patient who does not have a functional LVAD. I would treat them just as if they came to the ED the day before they got their LVAD: a patient with end stage heart failure and no blood pressure. I would begin chest compressions if their MAP was below 60 because they aren’t perfusing their vital organs and will die. I know this goes against Zack’s recommendations but that shows you that nobody really knows the best answer here. This patient will die. I say start the chest compressions and get inotropes going. Dobutamine or milrinone stat in addition to levophed. In other words…pretend they don’t have a VAD and aggressively resuscitate them. Yes, dislodging the pump is possible…but these patients are going to die anyway.

Though if I had to guess Zack and Joe would only do CPR long enough to crash the patient on to ECMO.

Algo by Dr. Higgins of MMC (Click for Full Size)

Read this PDF Now

An insanely good field guide from mylvad.com.It has device-specific recommendations. Read it NOW!

The site also has some excellent additional resources.

Additional Resources

Another great review on LVADs from Fire Engineering

the images from this post are from mylvad

Put your questions in the comments and I’ll send them on to Zack

Now on to the Podcast…

You just read the post: Left Ventricular Assist Devices (LVADS) from EMCrit Blog - Emergency Department Critical Care.

So my friend, Darren Braude and one of his co-attendings had a horrible airway case, which they presented on 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:

Click here for Full Size

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.

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…

You just read the post: EMCrit Wee – Bougie Prepass and CricCon for Difficult Airway from EMCrit Blog - Emergency Department Critical Care.

Rebecca Engelman, a critical care paramedic and soon to be PA, sent the great tips below on how to secure an IO in a peds patient. She should know because on the equipment securing hierarchy, methods that work in the filed are tops. It goes: things that work in the OR to things that work in the ICU to things that work in the ED and ends with things that work in the eight floor walk-up apartment building or a transport chopper.

How to Place an IO

I’m a critical care paramedic and up until very recently I spend 95% of my time working in pediatric critical care transport.
Tibial IO in small peds (<10kg) can be tricky if you don’t do a lot of them. When everyone learned to insert EZIOs in adults, they were probably taught to drill until they felt a ‘pop’, then stop…then promptly forgot this direction and drilled until the hub of the catheter was resting on tissue. In adults, this usually doesn’t lead to problems due to the size of the medullary space. In small pediatric patients however, sinking the IO to the hub will result in the needle passing THROUGH the tibia. If this is not recognized upon insertion or upon fluid administration it can lead to the complications mentioned by others above.

Everything that I’m about to say is purely my opinion based on my experiences:
- Let someone who knows what they are doing put the EZIO in. We used to have a lot of problems with IO (recognized) failure until we stopped letting residents put them in and made it an attending and critical care paramedic only skill. (Some of our attendings didn’t even really belong on that list, that was just a politics thing.) We rarely had any issues after that. The point is, just like airway, if you don’t do it a lot in small kids, you probably aren’t going to be great at it.
- If you don’t put (not so) EZ-IOs into small kids a lot, consider using a manual IO. I personally think they are a lot harder to screw up. When I wasn’t working primarily in peds, I would use EZ-IO for adults and manual IOs for small kids (<10kg). I really like the Jamshidis because they have an adjustable flange so you can set the maximum depth.
- Once you get the IO in, flush vigouorously, look for an signs of infiltration, then SECURE THE HECK OUT OF IT. Any movement of the catheter increases the risk of infiltration. Be vigilant about checking for infiltration and checking distal perfusion.
- As Minh suggested, an IO is only a temporary solution. As soon as the patient is stable enough or has enough intravascular volume get a peripheral or central line in them as their status warrants.
- Some people have suggested that the proximal humerus might be a prefered site both for flow rates and patient comfort. I have no experience with this, but I wonder if, in peds, it might lead to a lower infiltration rate due to the larger medullary space.

How to Secure an IO

Here’s a link to some pictures I took this morning…
http://db.tt/WnzgZkFY
If you are using a Jamshidi or another kind of IO catheter with a flange that rests on the skin, you can start with a couple pieces of tape over the flange.
If you don’t have a flange, take a piece of tape about 4-5? long and split it lengthwise about halfway down. Place the unsplit part on the skin and wrap the split ends around the hub of the IO catheter. I do this three times, spaced equally around the hub. (In case it isn’t clear, the coffee cup in the pictures represents the patient’s leg and the sharpie is the IO catheter hub.)
If you want to use tegaderm, now would be the time to apply it.
The next step is to build up a bukly dressing around the hub of the IO catheter and distal end of the IV tubing. I use roller gauze/king but anything would work. (This is represented by Epi-pen trainers in the pictures.) Tape all of this down. If you can still see the hub, you haven’t used enough bulky dressing.
The next step might be the most important for keeping the IO in place over the next few hours. Tape down, TO THE PATIENT, the next 8-12? of IV tubing. Make sure all stopcocks and ports are accessible, but also make sure that there can be ABSOLOUTLEY NO tension put on the line.

Vidacare also makes a stabilizer for EZ-IO catheters. They look nice, but I don’t have any experience with these as they are a bit pricy. I would guess that they would need a bit of stabilization in addition to this device and they definitely need the IV tubing secured.
http://www.vidacare.com/EZ-IO/Products-Accessories.aspx (scroll down)

I hope this helps and I would love to hear if anyone has any other tips or tricks.

Rebecca
NREMT-P CCP-C

‘ Click for Full Size Image

These comments were added

Minh Le Cong:

Rebecca, awesome photos thankyou and love your tips on IO care.
One other tip from one of my colleagues. If small kid and worried you might insert IO straight through tibia, consider the greater trochanter of the femur. Biggest bone in body, easier target and reasonable cavity with less chance of going through other side with current generation of manual and semiautomatic IO devices.
He had to do this on a kid with meningococcal sepsis last month after multiple failed tibial and humeral IO attempts. Still wakes up in a cold sweat about that case.

 

Don Diakow:

Rebecca…….have used the Vidacare product numerous times and it works great. Like a large OP site with a hard plastic cover for the IO hub. The IV loop threads right over the stabilizer and with a few strips of tape can also be secured to the patient.

You just read the post: How to Place and Secure an IO in a Peds Patient from EMCrit Blog - Emergency Department Critical Care.

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)

4. Eyes opening spontaneously
3. Eye opening to speech
2. Eye opening to pain
1. No eye opening or response

Best motor responses: (M)

6. Infant moves spontaneously or purposefully
5. Infant withdraws from touch
4. Infant withdraws from pain
3. Abnormal flexion to pain for an infant (decorticate response)
2. Extension to pain (decerebrate response)
1. No motor response

Best verbal response: (V)

5. Smiles, oriented to sounds, follows objects, interacts.
4. Cries but consolable, inappropriate interactions.
3. Inconsistently inconsolable, moaning.
2. Inconsolable, agitated.
1. 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…

You just read the post: Severe Pediatric Trauma with Michael McGonigal from EMCrit Blog - Emergency Department Critical Care.

On June 28th at 5pm EST, I will be appearing on AirwayWorld.com for a lecture on DSI and NIV preox. It is free to register, so come check it out.

The folks that run the site are from the Emergency Airway Course. They like difficult airway assessment acronyms, such as:

Difficult to Bag (BONES)

Beard

Obesity

No Teeth

Elderly (>55)

Snores

Difficult to Intubate   (LEMON)

Look at head and neck

Evaluate 3-3-2

Mallampati

(Using Samsoon and Young mod, which added class IV, 1987)

Obstruction=hot potato voice, can’t handle secretions, and Stridor (if audible=90% obstruction)

Neck Mobility

Difficult Extraglottic Device (RODS)

• Restricted Mouth Opening
• Obstruction: at or below the level of the larynx

• Disrupted or distorted airway. If the seat or seal of the device is disrupted

• Stiff lungs or cervical spine. Poor lung compliance or inability to extend neck may hamper seal

Difficult Cricothyrotomy (SHORT)

Surgery/Disrupted Airway

Hematoma

Obese/Access Problems (Can’t get to neck)

Radiation

Tumor

Well during next week’s lecture, I will suggest one more to be added to the list:

Difficult Physiology, aka you will box your pt during the intubation if you don’t take steps to prevent it (HOP)

Hypotension – either preintubation or the potential for intubation to cause it

Oxygenation – either already satting poorly or the patient has minimal reserve

pH -Ventilatory kills. Either the patient has a severe metabolic acidosis, or they are a brain injury patient with potential ICP issues.

You just read the post: The HOP Mnemonic and AirwayWorld.com Next Week from EMCrit Blog - Emergency Department Critical Care.

Are we creating a blockage of blood flow to the brain?

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…

You just read the post: Are Extraglottic Airways Harmful in Cardiac Arrest? from EMCrit Blog - Emergency Department Critical Care.

The 2nd EMCrit Live Show was so much fun!

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?

You just read the post: EMCrit Podcast 75 – Live Show # 2 from EMCrit Blog - Emergency Department Critical Care.

Steve Smith has an excellent post on 2 cases of post-arrest with EKG changes. Some of my ED critical care buds, Dr. Smith, and I had some back and forth on who actually needs cath post-ROSC. The evidence is mixed.

What I would recommend at this stage of the game is the following patient groups should be cathed in the immediate Post-ROSC period:

• Conventional STEMI criteria (Anatomically-Sequential ST elevations, Sgarbossa LBBB) You may want to make sure the pattern persists on a repeat EKG
• Clear Ischemic EKG that persists 20-30 minutes into resuscitation (As Dr. Smith’s post explains, immediate EKGs post-arrest may look ischemic, but resolve during the ED course)
• Electrical Storm/Persistent Ventricular Dysrhythmia
• Severe Cardiac Stunning (To look for a lesion and to place IABP)

Some would argue any patient whose rhythm was V-Fib/V-Tach without an alternate non-cardiac cause should take a trip to the lab early in their hospital course.

Love to hear your thoughts…

You just read the post: Who to Cath Post-Arrest? from EMCrit Blog - Emergency Department Critical Care.

I am across an amazing resource to bolster your understanding of emergencies involving implanted pacemakers. Art Wallace is the Chief of Anesthesia at the San Francisco VA. He has developed this handout on pacemakers that I know you will love.

Click for Handout

If you are involved in perioperative medicine, check out his site on perioperative beta-blockers as well.

You just read the post: Understanding Pacemakers from EMCrit Blog - Emergency Department Critical Care.

Rob Bryant implemented DSI at his hospital. He created a number of resources to make that possible. He was kind enough to share them. Of course he didn’t share them with me, but instead with my buddy and airway guru, Minh Le Cong. I guess Rob falls for the dulcet down-under accent. Anyway, see Minh’s post:

Rob Bryant Implementing DSI

You just read the post: Implementing Delayed Sequence Intubation (DSI) from EMCrit Blog - Emergency Department Critical Care.

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:

You just read the post: EMCrit Podcast 74 – Who the Heck to Cool after Cardiac Arrest with Ben Abella from EMCrit Blog - Emergency Department Critical Care.

Two more OR intubations from Jim DuCanto, MD

Fiberoptic Intubation through AirQ with continuous ventilation

Rapid Sequence Airway (RSA)

You just read the post: Two New Videos from Jim DuCanto from EMCrit Blog - Emergency Department Critical Care.

A couple of things on airway that may be of interest.

But Remember that Sux Sucks

Dr. Laurence Boss of Oxy’s Log produced a great slide for when sux is and isn’t safe to use. Of course I can’t leave well enough alone, so I modified a bit (with permission) and here it is:

Click for Full Size

here is a fantastic review article on the subject for those of you who just can’t get enough.

Dash-1A

Then Bill Hinckley advanced the ideal of ED/Crit Care Airway Management:

DASH-1A (Definitive Airway Sine Hypoxemia on 1st Attempt)
Note: Bill uses the word Sans, but why support the French : )

This encompasses what we really want 1st pass success, but without the sat dropping below 90%. He posted the video below on Minh’s site:

You just read the post: Airway Miscellany and Such (Sux?) from EMCrit Blog - Emergency Department Critical Care.

For Jen:

Go to Vimeo to see in Full HD Glory

You just read the post: How to Use RSS Feeds to Follow Medical Blogs on your IPAD from EMCrit Blog - Emergency Department Critical Care.

An anonymous EM Intensivist writes:

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 post on post-intubation sedation/analgesia

You just read the post: Pain and Terror as Effective Pressors from EMCrit Blog - Emergency Department Critical Care.

Recently, Minh had some questions for James DuCanto on fiberoptics and airway management in general. Here were the questions:

1. 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?
2. 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?
3. In an earlier post you mention having performed a needle cricothyrotomy and rescue jet oxygenation using a dedicated jetting device. It was successful?
4. What about ketamine assisted awake intubation?
5. 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…

You just read the post: Podcast 73 – Airway Tips and Tricks with Jim DuCanto, MD from EMCrit Blog - Emergency Department Critical Care.

Minh has taken Laryngoscope as a Murder Weapon^TM to a new level with his presentation: Doctors with Guns. See his slideset…

Minh’s doctors with guns

and even better, Minh dug up this lecture which deserves highlighting:

You just read the post: Minh’s Airway Slides from EMCrit Blog - Emergency Department Critical Care.

You just read the post: How to Post a Case or Question to EMCrit Google Plus from EMCrit Blog - Emergency Department Critical Care.

James DuCanto just emailed me with a guide to intubating through LMAs. My first question, of course, is can I share it with the listeners, so…

Here is the guide

You just read the post: A Guide to Intubating through the Intubating Laryngeal Airway by James DuCanto from EMCrit Blog - Emergency Department Critical Care.

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.

Read these Incredible Posts by Chris Nickson

Part I

Part II

Young-Burgess Shock Trauma Pelvic Fracture Classification

(J Trauma 30(7): 848-856)

from the handbook of fractures

Open Iliac Artery Clamping

Dubose and Inaba (J Trauma. 2010;69: 1507?1514)

How to Kill when Intubating

Forgot 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)

You just read the post: Severe Pelvic Trauma from EMCrit Blog - Emergency Department Critical Care.

Tim Ellender, EM Intensivist and all around cool guy just dropped his picks for the top EMCCM articles all trainees and attendings must read:

1. Hébert PC, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999 Feb 11;340(6):409-17. Erratum in: N Engl J Med 1999 Apr 1;340(13):1056.
2. The Acute Respiratory Distress Syndrome Network. Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome. N Engl J Med 2000; 342:1301-1308.
3. Michard F, et al. Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med 2000; 162:134-138.
4. Rivers M, et al. Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. N Engl J Med 2001; 345(19): 1368-77.
5. Bernard SA, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. Feb 21 2002; 346(8):557-63.
6. Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. Feb 21 2002; 346(8):549-56.
7. Annane D, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002; 288:862-871.
8. The SAFE Study Investigators. A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit. N Engl J Med 2004; 350:2247-2256.
9. Nguyen HB, et al. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med 2004; 32:1637-42.
10. Jones AE, et al. Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Crit Care Med 2004; 32:1703-8.
11. Cremer OL, et al. Effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury. Crit Care Med 2005; 33:2207–13.
12. Kumar A, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34: 1589-1596.
13. Marik PE, et al. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 2008; 134:172–178.
14. Sprung CL, et al. Hydrocortisone therapy for patients with septic shock. N Engl J Med 2008; 358:111-124.
15. Russell JA, et al. for the VASST Investigators. Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock. N Engl J Med 2008; 358:877-887.
16. De Backer D, et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med 2010; 362:779-789.
17. CRASH-2 trial collaborators. 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(9734):23-32.
18. Kilgannon JH, et al. Association Between Arterial Hyperoxia Following Resuscitation From Cardiac Arrest and In-Hospital Mortality. JAMA 2010; 303:2165-2171.
19. Jones AE, et al. Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy: A Randomized Clinical Trial. JAMA. 2010;303(8):739-746.
20. Perera P, et al. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am. 2010; 28(1):29-56.
21. Vandromme MJ, et al. Identifying risk for massive transfusion in the relatively normotensive patient: utility of the prehospital shock index. J Trauma. 2011; 70(2):384-8.

You just read the post: Top EMCCM Articles from Tim Ellender from EMCrit Blog - Emergency Department Critical Care.

You’ve got to love the twitter! Seth Trueger (@mdaware) tweeted that his EM Attending brother-in-law, Charles Maddow, has started using bougies to guide in thoracostomy tubes on morbidly obese patients with thick soft tissue around the entry site. I worried whether the bougie is long enough to allow a sig. portion to be placed in the chest cavity but still allow seldinger maneuver.

My amazing friends from (@HQMedEd) sent this photo:

Click to Enlarge

Then Graham Walker (@grahamwalker) pulled this shot from his sim lab:

Click to Enlarge

Minh (@rfdsdoc) mentioned this article where they used a similar technique with ET tubes instead of chest tubes, originally posted on Cliff’s (@cliffreid) blog.

You just read the post: Bougie-Guided Chest Tube from EMCrit Blog - Emergency Department Critical Care.

A few years ago, John McGill, of the Hennepin Crew posted an amazing video on bougie placement

Now we have a sequel to take you to next level of bougie use

You just read the post: How to Place a Bougie from John McGill from EMCrit Blog - Emergency Department Critical Care.

Can we monitor ETCO2 with extraglottic airways? The answer is definitive–I don’t know.

You just read the post: EMCrit Wee – ETCO2 with EGA? from EMCrit Blog - Emergency Department Critical Care.