We've spoken about the concepts of venous congestion being problematic beyond just pulmonary edema. I've had Phil Rola on in the past to discuss Venous-side issues such as Renal Compartment Syndrome, the Vexus score, and other issues of the under-respected side of the circulation. Prior Episodes * EMCrit Podcast 240 - Renal Compartment Syndrome - It's all about the Venous Side and We've Been Fracking it up for Years * EMCrit Podcast 263 - The Venous Side Part 1 - VEXUS Score with Phillipe Rola Today we go further into these concepts, with some concentration on the micro-circulation. There may be quite deleterious effects from iatrogenic volume overload--especially when we are compelled by government regulation to go against our clinical gestalt. Journal Articles * Blood pressure deficits in acute kidney injury: not all about the mean arterial pressure? * Renal Perfusion Pressure < 60 predisposes to kidney injury * There is individual variation on micro-circ from NorEpi * CVP affects Microcirc Flow (Editorial) * Physiology of the Microcirculation * Perioperative Blood Pressure * Sublingual Microcirculatory Microscopy Special Mention to Ince on Microcirculatory Hemodynamic Coherence * Ince hemodynamic coherence Now on to the Podcast...
Rob Orman steers a conversation on skillful ways to discuss code status, comfort care, intubation, and whether or not dying debilitated patients should go to the ICU. For more of the amazing Rob Orman, check out the Stimulus Podcast. Pearls: * When family members have to make decisions for their loved ones, you can minimize their guilt by being clear what you think is medically inappropriate. * In an ideal world, a DNR order would only affect what you do when a patient’s heart stops. * When having a comfort care conversation, Scott uses the dichotomy of two goals: curative care vs. dignity. ___________________________________________________________________________ Tips and tricks for having a conversation with a patient and/or their family about plan of care: * If you don’t have time for the conversation, then reconsider having it. * You still must make the initial foray to find out if they have preexisting wishes and if the pt's condition is dire, then you have no choice. * Deferring the conversation to the ICU is an option. * A slapdash conversation is worse than no conversation at all. * Create a space where everyone feels comfortable. * Provide chairs so people can be seated. * Reassure the family that this is a discussion you have with EVERYBODY who enters the hospital system. * Feel out the situation and try to understand one another. * Your job is to translate the medical realities in a way the family can understand. * The family’s job is to translate their wishes, desires, and belief structure to us in a way we can understand. * 5-10% of people are “vitalists”. They want anything done to bring back whatever form of life possible, no matter the predicted quality of that life. You’re not going to get what you feel is medically appropriate in those cases. * Pick your own philosophy that fits with your strategy and psyche in medicine. * Weingart has learned to be medically paternalistic and socially completely open. * Inquire: has the family had prior end-of-life conversations with their loved one? * It makes everything easier if they have. * If they haven’t, ask them to put themselves in the mindset of their loved one. By asking the family to be a channeler of what their loved one would want, you minimize their guilt. * If you feel something is medically inappropriate, state it clearly. * This transfers guilt to yourself. * In many countries (ie. Canada, Australia, New Zealand), CPR is not offered if it’s felt to be medically unacceptable. * Avoid being manipulative when describing CPR. * Don’t tell them chest compressions might break ribs or cause organ damage. * Instead, concentrate on the end game and what you could get out of CPR. There are 3 tiers of care: DNR (do not resuscitate), DNI (do not intubate), and comfort care. * DNR * In an ideal world, DNR would only apply when a patient’s heart is about to stop. * While DNR is not supposed to affect the rest of the care we provide, it often does. * Being DNR may have significant effects on the willingness of physicians to provide aggressive care,
Algorithmic social media is stealing your joy and may be making your life dramatically worse. If you haven't watched The Social Dilemma, you probably should sit down and give it a view, especially if you have kids. Advertising + Algorithm Misalignment of incentives Business model in which incentive is to find customers ready to pay to modify someone else's behavior The Algorithm Get you to the app and keep you there Movie Social Dilemma gets it Wrong Negative trumps positive Dopamine hit Addictive, but mostly shallow or perhaps b/c of shallowness Tribalism & Mob Behavior Magnification of Fringe Views Makes assholes more assholey Attention is the reward on social media, and assholery gets the most attention Loss of Objective Reality Individual Apps Facebook The Worst!!! A bunch of you are there so EMCrit has to announce new episodes there Instagram Just as evil Reddit Twitter Sponsored Tweets Built to inflict misery and turn people into assholes Reub--bring it to Reddit Twitter happiness feed Youtube Turn off "Up Next" TikTok Insanely addictive Netflix Algorithm with the right incentives The News Algorithm If you can't change it, don't regard it as important Google not just creating an echo chamber but actually sculpting Truth based on a political agenda * Switching over to Hey Email * DuckDuckGo RSS The way to have social media goodness come to you Turn off Notifications for any social media and for anything else possible Go Deep instead of Shallow If you have kids, avoid social media until ~16 Jonathan Haidt More Stuff to Check Out * How to go from being an Ass-hole to an AYS-hole on Twitter * 7 Ways to be Insufferable on Facebook * How to Use RSS and Itunes to Maximize FOAM Podcasts * The Online Hierarchy of Needs - Social Media and FOAM Please ReRead 1984 Now on to the Podcast...
So this episode addresses a big gap in the EMCrit content, namely a discussion of the myriad uses of dexmedetomine. This is one of the primary agents I use for post-intubation sedation (PAD), but also for things like NIPPV sedation and procedural sedation. Upsides of Dexmedetomine (Precedex) * No respiratory depression * Opioid sparing/analgesic effect * Preserves Sleep Architecture * Sympatholysis * May be delirium-protective * May be more hemodynamically stable than propofol * Good for neurocritical care Downsides of Dexmedetomidine * Bradycardia * Hypotension (especially when the pt is volume depleted) * Cost (much less of an issue now that it is generic) * Diuretic effect * Slow onset * Constipation Useful for... * Post-intubation sedation * NIPPV sedation * Procedural sedation * Add-on to propofol Other Stuff on EMCrit * Podcast 115 &#8211; A New Paradigm for Post-Intubation Pain, Agitation, and Delirium (PAD) * PulmCrit Wee- Extubating the agitated patient: dexmedetomidine vs. cowboy-style? * Dexmedetomidine to facilitate noninvasive ventilation Studies The Effect of Propofol and Dexmedetomidine Sedation on Norepinephrine Requirements in Septic Shock Patients (Critical Care Medicine: February 2019 - Volume 47 - Issue 2 - p e89–e95) https://www.ncbi.nlm.nih.gov/pubmed/21812509 https://www.ncbi.nlm.nih.gov/pubmed/27035758 Now on to the Podcast...
Labors of Trauma (Blunt Ed.) So a few weeks ago, I podcasted the Labors of Trauma, a comprehensive list of the responsibilities of a Trauma Team Leader. EMCrit 278 - Labors of Trauma - Blunt Edition I promised that I was going to do a part II with my co-conspirator, Chris Hicks. Hick's Pre-Brief and Leave the Room Checklist St. Mike's New Trauma Bays Calcium Ditzel RM Jr, Anderson JL, Eisenhart WJ, et al. A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond?. J Trauma Acute Care Surg. 2020;88(3):434-439 New Hemostatic Resus Ratios * Should we add calcium and fibrinogen to our ratios New Name for the Pelvic Binder * We should be calling these Trochanteric Binders Now on to the Podcast...
Why Can't Emergency Medicine and Trauma Surgery Just Get Along? This is a question we often ask in the USA given our unique Trauma system. It seems custom built to create conflict in the trauma bay. To explore this issue, I got to talk with Joe DuBose and Bill Teeter. This discussion originally was recorded for Joe's new podcast on Trauma Surgery, Tiger Country. Tiger Country has a bunch of episodes that are worth a listen for ED and ICU folks as well. Joe DuBose Trauma and Vascular Surgeon at the Shock Trauma Center. Professor of Surgery. Research leader on all things REBOA. William Teeter Started as a surgery resident, switched over to EM residency and then Crit Care Fellowship. Now an EM Intensivist down South. More from DuBose * Podcast 170 - the ER REBOA Catheter with Joe DuBose Now on to the Podcast...
I did an initial EMCrit episode on Angiotensin II when the Athos 3 trial was fist published. Today, now that the drug has been available for a while, I wanted to hear from someone smart, with no financial conflicts of interest, on when to actually use this medication. Rinaldo Bellomo MD PhD Dr. Bellomo's Bio is too extensive to place here, please check out his Monash Page. Suffice it to say that he is a total badass as a clinical intensivist and a critical care researcher. Renin Angiotensin Aldosterone System (RAAS) Who Should Get Angio II * Renin > 175 (or round up to 200) * Septic Pts on RRT or about to need it * Patients on pre-illness ACE-I Rinaldo's Paper in AJRCCM * Renin and Survival in Patients Given Angiotensin II for Catecholamine-Resistant Vasodilatory Shock More on this Topic * PulmCrit- Angiotensin II: five cautions &#038; three comparisons * Review Article from EMJ Now on to the Podcast...
Ultrasound signs of pericardial tamponade with my buddy, Jacob Avila. This episode is simulacasted with Core Ultrasound. Right Atrial Collapse greater than 1/3 of the cycle is probably the most specific Right Ventricular Collapse If the RV is collapsing when the mitral valve is open, then that is specific for tamponade IVC Lead pipe is specific, flat doesn't rule it out (if pt is volume depleted, etc.) Check Out my Prior Episode with Jacob * EMCrit 256 - RUSH Redux with Jacob Avila Steve Alerhand has written a great review article in AJEM Alerhand-Is it Tamponade? Now on to the Wee...
I frequently see both residents and attendings inappropriately using ketamine for agitated patients. Inappropriately both by giving it when it is unecessary and giving it in poor fashion when it is indicated. Our guest today is Reub Strayer (@emupdates). He is the author of EMUpdates.com. His research and clinical interests include checklists and standardization, airway, legislative work on the treatment of opioid dependence, and an approach to opioid misuse in the ED. Reub breaks agitated patients down in to 3 groups: 1. Agitated, but Cooperative Not a problem in the ED. Oral medications or non-pharm techniques. 2. Disruptive without Danger Use standard anti-psychotics and sedatives, with the understanding that Haldol 5mg and Lorazepam 2 mg given IM will take a long time for full effect and even then, may not provide adequate sedation. There are better choices for this group: * Droperidol monotherapy 5-10 mg IM or 5 mg IV * Droperidol 5 mg + Midazolam 2mg IM or IV in the same syringe * Olanzapine 10 mg IM (Needs Resp Monitoring) * Olanzapine 5 mg + Midazolam 2 mg IM or IV (Needs Resp Monitoring) * Haldol 5 mg + Midazolam 2 mg IM or IV (will be slower than the other choices) If using standard 5/2 (haldol and lorazepam IM), too much time for effect and impatience leads to the wrong subsequent choice, i.e. giving ketamine to this group. 3. Disruptive and Dangerous * dangerous to staff, dangerous to self * danger is relative to the resources of the location Danger could be due to * The agitation itself or * An underlying condition that the agitation is preventing from being treated (and may be the cause of the agitation, e.g. tension pneumothorax) Dividing Line Question: Would you consider intubation to control the situation if ketamine was not available? Reub calls this the Ketamine Litmus Test. Ketamine takedown must be treated as Procedural Sedation (1:1 nursing observation) Intramuscular Medication Administration * Can go through clothes if you need to [Fleming et al.] * Reub states maximum volume of up to 20 mls per injection * Harrington 2005 Administer Single Site 30mL Injection Fosphenytoin - Medsurg Nursing * Hopkins 2013 Large Volume IM Injections Review of Best Practices (Oncology) - Onc Nurse Advisor * Ramsay 1997 IM Fosphenytoin Loading High Volumes - Epilepsy Research Ketamine Brain Continuum <a href="https://emcrit.org/wp-content/uploads/2020/08/ketamine-brain.
After reviewing many recordings of major trauma resuscitations, I have come to the conclusion that we are not training our learners on how to perform as a Trauma Team Leader (TTL). They are forced to extrapolate from ATLS, a course never designed for a team at a Level I trauma center. Trauma resuscitations as opposed to medical are a bounded reality. Both the time in the bay and the menu of options are limited--the complete list could be delineated and therefore available for novice TTLs. For a few weeks, I set out to do exactly that. I then sent it out to Chris Hicks (@humanfact0rz) for peer review. His feedback was so good, that I asked him to co-author this project with me. If the response to this project is positive, we will work on the penetrating edition as well. Blue=cognitive tasks for the TTL Red=TTL must assign to a subteam (operational) Solid=always happens in every trauma Dotted=May happen based on patient injuries or severity * Zero Point Survey * Team Leadership with Cliff Reid * EMCrit #230 - Resuscitation Communication * COMM CHECK: More On Resuscitation Communication * Rapid Infusion Catheter Revised Assessment of Bleeding and Transfusion (RABT) * Penetrating Trauma * Shock Index > 1.0 * Pelvic Fracture * Positive Abdominal FAST >=2 had sensitivity of 84% and a specificity of 77% World J Surg 2018;42:3560 5 Sites of Bleeding * Chest * Intra-Peritoneal * Retro-Peritoneal/Pelvis * Thigh * Street * Hemostatic Resuscitation by Richard Dutton, MD * EMCrit Podcast 30 Hemorrhagic Shock Resuscitation <a href="https://emcrit.