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October 9, 2019
Pulseless Electrical Activity ( PEA ) is confusing! The diagnosis and treatment of PEA is bogged down by terminology and misunderstandings. Spurred by a recent interview I did with Anton Helman of EM Cases, I lay down some of my thoughts on PEA here. The last time I discussed these issues was 5 years ago with Zack and Joe on EDECMO 13. PEA Progression to ROSC POCUS Pulse * Carotid POCUS Pulse* Badry et al. on POCUS Pulse Narrow / Wide doesn't Work Rory breaks it down on the CCnerd in a post about QRS size in PEA. What to Do if You Have Compressions/POCUS Pulse but No BP Prosen on Vasopressin for PEA Critical Care and Neurocritical Care Boards Review Book Mayo Clinic Board Review Just fantastic! (Note: i received a reviewers' copy of this book) Now on to the Podcast...
September 27, 2019
So, Josh recently published a guest post on PulmCrit discussing some interesting ideas on the treatment of asthma. This post nearly gave me a stroke. Luckily I had some tPA sitting in my medicine cabinet and just took some empirically, b/c as the stroke neuro folks that respond to Swami's posts tell me, "It can't hurt." As soon as I read Josh's post, I knew we must discuss this on the podcast to flesh out some of the issues raised. You should read the post first: * PulmCrit The Crashing Asthmatic with Leo Stemp If you are interested in my Crashing Asthma Cast it is here: * EMCrit 15 Asthma * My response to Lew Rubinson's Comment Then you can listen to this EMCrit wee....
September 18, 2019
Some dozen years ago, a couple of my buddies and I created the RUSH exam. Today, I give you an update: To keep me from saying something stupid regarding ultrasound, I wanted to get a master of all things ED POCUS to act as chaperone. There is no better person to fill this role than... Jacob Avila Host of the 5minutesono podcast and cohost of the ultrasound podcast, Jacob is an incredible ultrasound educator. He is soon to be taking over as the director of ultrasound in the ED at the University of Kentucky. We also recorded a second episode that will air soon on EMCrit. RUSH Updates since we sent this exam into the wild, there have been many misconceptions and alterations of the vision of the exam. Some of these have led to beneficial evolution and some of them are messing s&*t up. Hopefully, this episode clears up some of the latter. Now on to the podcast...
September 10, 2019
On Podcast 168, I discussed Michigan's EC3 stand-alone EDICU. The folks from the EC3 recently published on their first 2.5 years of operation in a before and after trial. Gunnerson et al. EC3 Study I gathered a bunch of my EC3 buddies to discuss the article. On the call, you will hear: * Bob Neumar, Chair of EM * Kyle Gunnerson, Division Chief of Emergency Critical Care and Director of the EC3 * Ben Bassin, Operations Director for the EC3 * Renee Havey, CNS for the EC3 * Nate Haas, EC3 Faculty Tell us what you think below Now on to the Wee...
September 4, 2019
Pigtails should replace chest tubes for most pneumothoraces and pleural effusions requiring drainage. In this episode, I discuss points on use and placement. The next post will be a video on an actual placement. Please put your comments and thoughts below. Now on to the Podcast...
August 22, 2019
I always have a great time at the Essentials of Emergency Medicine conference, not just because it is an amazing conference, but because I get to hang out with my buddy, Rob Orman. This year, we did a on-stage demo of central line tips and tricks. Hope you enjoy: Here's the Vid:
August 9, 2019
You do perfect patient positioning. You open the mouth. A beautiful, gentle, stepwise insertion of the laryngoscope allows you to get the tip of your video Mac into the valeculla. And you see... Nothing! What now? Abandon the attempt--nope! Use the Kovacs Kata The Kovacs Kata is dedicated to my friend and airway Guru, George Kovacs. George had described his EVLI approach to laryngoscopy as a kata (see EMCrit 236). That struck me more as mental rehearsal however. A kata in my martial arts experience was always a fight against multiple imaginary opponents. The way I taught the kata for rescuing a failed laryngoscopy is a fight against 5 opponents of success using 5 techniques: 1. Neck Neck refers to external laryngeal manipulation (ELM). * Bimanual Laryngoscopy on LitFL * Levitan Study on BiManual/ELM 2. Head If you do not have a good view with your pre-intubation positioning, keep lifting and if necessary, flex the head. * Kovacs Head Lift Video * Keith Greenland on Why this Works * 3. Hands If you are not strong enough to lift the patient's head off of the bed with one hand, use two. Then maintain the lift with one hand, aided by locking the left elbow against your body. 4. Scoop If you have an epiglottis that you can't see past, despite the optimizations above, then just lift it with the Mac, i.e. use the Mac as a Miller. Levitan Article on Managing an Omega Epiglottis including the Scoop Maneuver   5. Pull Back This one is for the hyperangulated blade. You have a great view--you just can't get the tube to go into the glottis. * Why too close is too bad * George on Hyperangulated Problem-Solving * Levitan on HyperAngulated Blade Use and the Kovacs Sign Additional Attributions * Full Kata Video Now on to the Vodcast...
July 28, 2019
Today, I present an excerpt from an interview with Andrew Davies, host of the mastering intensive care podcast. The full interview was over an hour long, but this is a polarizing excerpt. The Full Mastering Intensive Care Interview * Scott Weingart being interviewed by Andrew Davies REANIMATE 7 Conference * reanimateconference.com Now on to the Podcast...
July 20, 2019
There is a group of clinicians operating on the front line of war zones with no other purpose than to save lives. Global Response Management's Helen Perry comes on the show to discuss their work. Helen Perry ACNP-BC, MSN, RN, CCRN, CEN Their motto is semper vitae--always life. Their mission is to provide life saving emergency and prehospital care to those impacted by war and conflict. Find Global Response * The website is www.global-response.org * Instagram global.response * Facebook * Twitter @GRM_Global Volunteer We are always looking for qualified volunteers and we use Paramedics and above. EMTs are welcome to apply, but they may not be working in a clinical capacity due to World Health Organization minimum operating standards. We even need non-medical folks (social media marketing, finance, smart computer people, grant writers, etc.) Donate They are a registered not-for-profit (501c3) and their admin budget is super low. Please consider helping these folks. Note I have had to close this post to comments b/c there have been a number of comments made by folks with false names and/or false contact information. The policy of this site is that all commenters must use their real identity linked to a real email address. There seems to be a group of folks out there that doubts the veracity of the GRM. If you have verifiable information on that, please get in touch by the contact link above. Now on to the Wee...    
July 16, 2019
In Part I of the philosophical diversions series, we discussed free will. Today, let's bring up some other thoughts: Conscious Decisions Consciousness by Annaka Harris Podcast Episode Naïve Realism Perception isn't Reality * Ross, L., & Ward, A. (1996). Naive realism in everyday life: Implications for social conflict and misunderstanding. In T. Brown, E. S. Reed & E. Turiel (Eds.), Values and Knowledge (pp. 103–135). Fundamental Attribution Error Synopsis Umvelt The RCM is Back in Stock resuscrisismanual.com Now on to the Podcast...
June 27, 2019
Pendell Meyers is attempting to change the paradigm of classifying MIs as STEMI vs. NSTEMI. An important first step in this attempt was his publishing the OMI Manifesto However, many folks just don't read, so here is a video version. Ideas to Think About... * False Negative Paradox * Why did the term stemi equivalents not catch on? * Why is there not currently a retrospective coding of missed occlusive MIs? Please, please put your thoughts and comments below
June 13, 2019
You Can Either Learn or You Can Blame, You Can't Do Both --Sydney Dekker Steps Prior to the M&M Find a Case The standard referral paths (hospital reporting, pissed off administrators, mortalities) will happen automatically. But you also want to establish yourself as a Master of Whisperers. The way to get people to report cases is to inspire trust. You need to offer protection, establish clear patterns of non-putative motives, and show that you actually do something with the information reported. Build a Thin Timeline Comb the chart to build an initial time-line. This will only reflect events, but will offer little actual understanding of what took place. Interview Primary Decision-Makers * Dr. Douros asks lets them know he wants to meet over coffee and asks them to write up a 1 paragraph description of events. * He sends out a Pre-Reading Sheet of what to expect. * The goal is to find the inflection point where things diverted from optimal care * Then to get to the point where the actions that occurred make sense * Seek to Understand Local Rationality * Knowledge at the time * Focus at the time * Goals at the time * Goals of this interview overlap greatly with the skillset of a simulation debriefer. As such, check out Simulcast for amazing resources. Build a Thick Timeline Incorporate the results of the interview(s) into the timeline Analyze for Systemic Problems and Brainstorm Solutions Behavior must be judged as if the outcome is not known. If it was ok when things go right, it is ok when things go wrong.   Presenting the M&M Dr. Douros does 2 cases in a one-hour block, 1 of them an M&M and the other a Safety & Success case (similar to the Amazing & Awesome Rounds). PreBrief Remind the group that this is about learning and identifying systemic problems, not about blame & shame. Present the Thin and Thick Timelines * Should take about 10 minutes. * Exclude extraneous information * The case can be presented by a Junior, but there needs to be a master facilitator at all sessions Discuss the Case ~10-15 minutes Probe for Systemic Problems and Solutions ~10-15 minutes Send F/U Email with Lessons To reinforce for those who attended and fill in those who did not Recommended Resources The Field Guide to Understanding 'Human Error' This is the first go-to, a must read. It will change your vision of error. Next, you can move on to another Dekker book:
June 4, 2019
At the last SMACC, I yet again taught the surgical airway station of the airway workshop. I was joined with amazing faculty and together we taught 160 people our method of performing cricothyrotomy. We've been doing this for 4 years, but this past session was the first time it really felt just right. In this podcast, I want to go over some of the lessons learned and how they may contribute to your own self-training on surgical airway. Models Each participant had their own 3-d printed model. This was absolutely crucial and a big difference from prior sessions. We have found models to offer a more realistic experience than animal parts​1​ Who Gets a Cric & Mental Prep including a discussion of CricCon2 see this prior episode for more on CricCon Finding the Membrane/Cut Site Start Low, feel high Laryngeal Handshake We teach Rich's choke hold as a backup method​2–4​ * Practice_of_Ultrasound_Guided_Palpation_of_Neck Build the Model We used the same steps as in my how to practice crics video Teaching the participants to build their own was hopefully encouragement to get their own model and practice each month. All they need is: * the 3D-printed model* Good gaffers tape* 4x4s* Plastic Bags We had a few of the frova cric trainer holders, which would have been nice to use, but we didn't have enough for everybody, so we left them in the box. Rapid Cycle Deliberate Practice (RCDP) I learned about this teaching method from Alia Dharamsi at the amazing ResusTO conference. I also used the a modified version of her delphi-derived steps as a handout taped to each station. Hear more from Alia * Alia Dharamsi on Delphi-Study and RCDP Alia Dharamsi Steps of RCDP​5​ * Splitting Cases/Procedures into small segments* Micro-Debrief after each one* Add progressive challengesfrom Taras & Everett * EMCrit-Modified Cric Steps* The Original Delphi Article Iterations * Step-by-Step through the Procedure * Dominant Side Palpable Anatomy* Look-Up* Non-Dominant Side* Non-Palpable Anatomy / Cut and then spread to air* Under Stress I was demonstrating up front with a video camera--this was huge as it allowed real-time correction with a much lower instructor to participant ratio.
May 16, 2019
Today, we talk about the theory and practice of the Dissociated Awake Intubation. This technique allows the rapid provision of an intubatable patient while preserving spontaneous respirations. A few days ago I posted George Kovacs' thoughts on the matter. * George Kovacs on KFI This was in response to a blog post by frenemy of the show and brilliant airway tactician, Reub Strayer. * Ketamine-Only Breathing Intubation (KOBI) What is Dissociated Awake Intubation? I coined this term to describe the administration of a dissociating dose of ketamine to allow a patient to be intubated for many of the same circumstances as the traditional topical awake approach. This is theoretically distinct from the idea of using ketamine in a sedative-only intubation. The two ideas are separated by the intent, with the former subbing for a topical awake and the latter for a RSI, in systems where for whatever reason, paralytic can be used. In practice, they look the same--it is often the users that look different. Kovacs has used the term ketamine facilitated intubation to encompass both uses. This post and podcast only deal with dissociated awake. Awake Intubation Posts * Emergency Awake Topicalized (EAT) Intubation – An Awake Intubation Update * Podcast 194 – Definitive Emergent Awake Intubation with George Kovacs  Why Awake Intubation? If an airway is predicted to be difficult, consider an awake approach. This predicted difficulty could be an anatomic. It could also be physiological: namely Hemodynamics Kills, Oxygenation Kills, or pH Kills. When there is a combination of two or three of these elements, awake becomes almost a must. Awake vs. RSI RSI and awake are tradeoffs * RSI gives you the easiest laryngoscopy/tube delivery at the expense of safe time for intubation * Awake gives you a markedly harder laryngoscopy/tube delivery rewarded by a markedly extended safe intubation time You must be a much better intubator to perform an awake laryngoscopy and tube delivery. Topicalized vs. Dissociated Awake In some cases you will try topical first, and then when the pt won't cooperate or you can't adequately topicalize, that will push you to dissociation. However, there are definitely a group of patients who I will choose primary dissociated awake. It comes down to cognitive bandwidth. Nuts and Bolts of the Technique * Give small aliquots of ketamine every 15 sec. or so until dissociation (25 mg at a time * Have everything ready for RSI and failed airway, including paralytics prepared and ready before first dose of ketamine * I still topicalize Awake Intubation from George's Online Textbook Kovacs AIME Airway Textbook (Infinity Edition) - Awake Intubation Chapter) Now on to the Podcast...
May 2, 2019
This Article is a Must Read if you Found this Episode on Free Will Interesting The Lucretian Swerve Attributions While 1% of this episode may be independent thinking, the rest was surely based on influences too countless to cite. Some that clearly remain foremost as inspiration are the article above, Dan Dennett's work, Sam Harris' book, the book, Four Views on Free Will, and all by poor undergrad professors that had to put up with the utter annoyance of my stubbornness. Image by Narcournus        
April 24, 2019
Today, a topic about which you may already believe you know all you need to know--chances are you don't. What we were taught about tension pneumo by textbooks and trauma courses may not be right. To discuss tension pneumothorax, there is no better guest than... Dr. Simon Leigh-Smith Consultant in Emergency Medicine, Defence Medical Services & NHS Lothian, Surgeon Commander Royal Navy, Clinical Lead for Pre-Hospital Care and Medic 1 Simon graduated from Liverpool in 1990 and had a varied training / experience including Commando, Para, GP, Emergency Medicine and Pre-Hospital/Retrieval before Consultant appointment in 2006. He has worked in Liverpool, Plymouth, Edinburgh, Portsmouth, London, Sydney, Kuwait, Iraq, Belize, Norway, Antarctic, South Atlantic, Iraq and Afghanistan. He has a strong interest in Tension Pneumothorax, Human Factors in team working and the delivery of excellent pre-hospital care to major trauma and critical illness. He loves all the usual ‘adventure sports’ but after he sailed around Cape Horn his wife and 2 daughters were glad to hear that he no longer wanted to sail around the world! He tries to exercise his Hungarian Vizsla (dog) whilst mountain biking but often feels guilty leaving her behind to go for long road rides….. Tension Pneumothorax is 2 Diseases rather than 1 Awake/Spontaneously Breathing Patients * Purely hypoxemic * No hypotension until just before collapse * May have long periods of compensation (though can also progress in minutes) Ventilated Patients * Sudden, both resp and cardiovascular disease * Will be hypoxemic and hypotensive Classic Signs are Rubbish * Tracheal deviation is unreliable * Breath Sounds are unreliable * Chest wall observation signs are variable * Need to go with clinical suspicion or ultrasound, radiograph, or empiric decompression More on the Perils of Needle Decompression * EMCrit Needle vs. Knife II A Countervailing View Simon's Publications * Clinical Presentation of Patients With Tension Pneumothorax: A Systematic Review1 * Tension pneumothorax - time for a re-think. * Slides from Full Lecture Additional Reading and Info * Pulmonary Artery Pressures with Tension * Decreased cardiac index as an indicator of tension pneumothorax in the ventilated patient 1. Roberts D, Leigh-Smith S, Faris P, et al. Clinical Presentation of Patients With Tension Pneumothorax: A Systematic Review. Ann Surg. 2015;261(6):1068-1078. https://www.ncbi.nlm.nih.gov/pubmed/25563887.
April 15, 2019
In episode 130 of the podcast and in many subsequent discussions, I have advocated for femoral-artery-monitoring during cardiac arrest to allow titrated use of vasopressors. Many of my colleagues in the advanced resuscitation community have a similar practice. In 2013, the AHA has released an advanced practice guideline recommending the same practice.1 But... What if the diastolic blood pressure number shown on the monitor is the WRONG PRESSURE. That is the contention of our guest today: Today's GuestPer-Olav Berve is a Norwegian anaesthesiologist who works for the Oslo air ambulance and in-hospital at the Oslo University Hospital. He is currently wrapping up a PhD on CPR physiology, focusing on multimodal monitoring. His main project is a OHCA study on mechanical active compression-decompression CPR. (Bio from scanFOAM). It seems the machine picks the DBP that is the lowest point between systoles. This works well with waveforms generated by the normal cardiac compression. During CPR, however the lowest point (decompression phase nadir) actually represents the reformation of the aortic outflow tract after it has been compressed. This generates a brief negative pressure which can give extremely low pressures. If you use this as your DBP you will be steered in exactly the wrong direction--the better the cpr and the more pronounced the vascular tone, the lower this number will be. Image from PO Berve In the arterial wave form image above, Point A is a DBP of zero. This is the number that will appear on the monitor; this number can actually be negative. In the past, I would be rezeroing the transducer thinking it must be in error. And when I spoke about refractory vasoplegia, it was because of this number. What we need to be looking at is Point B, the point just before the systolic upstroke--this is the true DBP to titrate your vasopressors according to PO. The better the CPR and the higher the vasomotor tone, the lower Point A and the higher Point B will be. So as we are doing better, we will see lower and lower DBPs if we go by the displayed numbers. Here is a normal waveform from an actual beating heart as contrast: Solutions You must visualize the waveform rather than looking at the computer-generated DBP * Change displayed waveforms to 10 sec. if possible * Auto-Wave (match the top and bottom of the scale to the actual waveform parameters) to make the waveforms as big as possible * If your machine has a line that can be set to a pressure, put it at 40 mm Hg and then just look to see if the beginning of the systolic upstroke is above this line The Full Lecture from the Big Sick ScanFOAM has an amazing post with PO's full lecture, slides, and all the references from the lecture. * PO Berve on Waveforms during Cardiac Arrest from scanFOAM The Paradis et al. Papers * 1989 Paper2 * 1990 Paper3 Superimposed Aortic and Right Atrial Waveforms from Paradis et al. 1989 Note that the CVP and arterial waveforms look almost iden...
March 31, 2019
Hot off the press is the COACT trial randomizing patients to immediate vs. delayed cardiac catheterization after cardiac arrest. I had this on my list to do a 'cast on, but EMCrit Team Member Felipe Teran beat me to it. He interviews past show guest and the lead author of the editorial on the paper, Ben Abella. The trial only included patients with an initial shockable rhythm and they were still unconscious. STEMIs went right to the lab. COACT Trial * Actual Paper1 * Editorial2 This comes right at the heels of the AHA statement by Yannopoulos et al. recommending a more aggressive stance on immediate cath.3 ResusTEE Course Easily the best resuscitative TEE/TOE course I have ever seen. Just pure goodness. Use the Code: EMCRIT#RESUSTEE to get an EMCrit Discount London Course (April 27) Montreal Course (May 21) Now on to the Podcast... 1. Lemkes JS, Janssens GN, van der Hoeven NW, et al. Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. N Engl J Med. March 2019. doi:10.1056/nejmoa1816897 2. Abella BS, Gaieski DF. Coronary Angiography after Cardiac Arrest — The Right Timing or the Right Patients? N Engl J Med. March 2019. doi:10.1056/nejme1901651 3. Yannopoulos D, Bartos JA, Aufderheide TP, et al. The Evolving Role of the Cardiac Catheterization Laboratory in the Management of Patients With Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation. 2019;139(12). doi:10.1161/cir.0000000000000630
March 9, 2019
Joel Topf is a nephrologist in Detroit working for St Clair Specialty Physicians. He is faculty for the Nephrology Fellowship at St John Providence. Blog: PBFluids.com Twitter: @Kidney_Boy Co-creator: NephMadness, Co-creator: NephJC, Co-creator: DreamRCT The Case * Tweetorial on the Case * Slides for the Case Hyponatremia * Topf thoughts on DDAVP in hypoNa * DDAVP clamp in hyponatremia * EMCrit Intro to Hyponatremia * Curbsiders Hyponatremia Episode * IBCC Hyponatremia * Taking control of severe hyponatremia with DDAVP Joel admits elderly with Na < 130 Hypernatremia * Make sure they are not DI and then replete their free water deficit * Acetazolamide for Nephrogenic DI1 * Hypernatremia is a marker of poor quality ICU Care2 * EMCrit Hypernatremia Episode * IBCC Hypernatremia Hyperkalemia Joel's Furosemide dose is Cr x 20 * Curbsiders on HyperK with Joel * EMCrit HyperK * IBCC HyperK * Recent RCT on Kayexalate3 * The odds ratio for death was 10 at a potassium of 5.5 to 6 mEq/L. It rose to 31 for potassium above 6!4 Who Needs RRT? * Is A,E,I,O,U still the answer? More * Get Joel's Free Electrolyte and Acid Base Book Now on to the Podcast... 1. Gordon CE, Vantzelfde S, Francis JM. Acetazolamide in Lithium-Induced Nephrogenic Diabetes Insipidus. N Engl J Med. 2016;375(20):2008-2009. doi:10.1056/nejmc1609483 2. Polderman K, Schreuder W, Strack van, Thijs L. Hypernatremia in the intensive care unit: an indicator of quality of care? Crit Care Med. 1999;27(6):1105-1108. [PubMed] 3. Lepage L, Dufour A-C, Doiron J, et al. Randomized Clinical Trial of Sodium Polystyrene Sulfonate for the Treatment of Mild Hyperkalemia in CKD. Clinical Journal of the American Society of Nephrology.
February 21, 2019
A bunch of fun new ideas re: sepsis for 2019 Fluids 30 ml/kg may be based on IBW if you write in the chart that that was what you were using Andromeda-Shock Trial A fascinating study by Hernandez et al.1 * See Rory's take on it * The Bottom Line Censer Trial Early fixed-dose norepi use was examined in this trial.2 https://www.thebottomline.org.uk/summaries/icm/censer/ Procalcitonin HiTemp Study3 Procalcitonin was poor for differentiating bacterial infections and other causes of fever in the ED. Now on to the Podcast... 1. Hernández G, Ospina-Tascón G, Damiani L, et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019;321(7):654-664. [PubMed] 2. Permpikul C, Tongyoo S, Viarasilpa T, Trainarongsakul T, Chakorn T, Udompanturak S. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER) : A Randomized Trial. Am J Respir Crit Care Med. February 2019. [PubMed] 3. van der, Limper M, Jie K, et al. Procalcitonin-guided antibiotic therapy in patients with fever in a general emergency department population: a multicentre non-inferiority randomized clinical trial (HiTEMP study). Clin Microbiol Infect. 2018;24(12):1282-1289. [PubMed]
February 10, 2019
Newest Member of the EMCrit Team: Phillippe Rola ThinkingCC Internist-Intensivist in Montreal, Canada, Mad Sonographer, Proud Daddy and Husband, and sometimes jiujitero. Editor-in-Chief of ThinkingCriticalCare.com POCUS Portal Vein from the Case More on the Discussion in the Podcast on Thinking Critical Care * Physiological Resuscitation POCUS, Mythology and Hemodynamic Awesomeness H&R 2019 Conference * All info
January 26, 2019
Vent Alarms should be Regarded as Code Blue If you cannot instill this into your culture, patients will die If they are crashing, do DOPES ETCO2 on any Vented Pt This is what the real alarm should be High (Peak) Pressure from the Resus Crisis Manual Dyssynchrony Peak Only * Check the circuit * fluid pooling in circuit * fluid pooling in filter * kinking of circuit * Tube too small or biofilmed * Bronchospasm * Biting on ETT * Peak & Plat High * Tube in Mainstem * Pneumothorax * Bad Lungs >> Turn down the Vt * Abd Compartment Low Peak Pressure * Disconnect * ETT Cuff Deflated * Pt effort Low Ve/Vt * Cuff Issues (See EMCrit Wee ) * Bronchopleural Fistula Low O2 Alarm * Not hooked Up * Gases Messed Up * Sensor Messed up What to Do with Continued Alarms Despite Sedation, Equipment Check, Suctioning * Consider Bronchoscopic Assessment * If Patient begins to crash, consider tube exchange if bronch not available Breakdown on Alarm Types Article on Vent Alarm Stats 1 See More High-Peek on ALIEM 1. Cvach M, Stokes J, Manzoor S, et al. Ventilator Alarms in Intensive Care Units: Frequency, Duration, Priority, and Relationship to Ventilator Parameters. Anesth Analg. September 2018. [PubMed]
January 16, 2019
Original GTD (Gettin' Sh*t Done) Posts * EMCrit Podcast 136 - Getting Shit Done * EMCrit Podcast 209 - GTD Redux - Opportunities, Time, & Future Selves Switched to Todoist * Todoist Summary * Integration with Gcal * IFTTT and Zapier Massive Action Planning by Tony Robbins * Write down the results you want to achieve. (be specific, quantitate if possible) * Write down your purpose (compelling reasons why you want to accomplish this goal--use trigger words, emotion) * Develop a sequence of priority actions. or as Carl Pullein discusses, OPA: Outcome, Purpose, Actions Inboxes are Deadly Prune, prune, prune Use email inbox for everything (shortcut/workflow on ios & boomerang on firefox) Inbox Zero Boomerang Subconscious Cognitive Bandwidth It is not the time, it is the weight Checklists If anything you do is: 1. Fiddly & 2. Infrequent Make a checklist Directly Responsible Person (DRI) Who is the the DRI directly responsible individual from Jobs/Apple Problem for Future Homer Why we don't care about our future selves Now on to the Wee...
December 12, 2018
You and your brethren are the 3rd leading cause of death in the United States. Medical error is rampant, why are you not doing anything about this problem? How many times have you heard these statistics and others like them? How many times have you been berated by patient safety experts using these very statistics as their foundation and their whip. Have you ever wondered how these statistics could possibly be true when it doesn't jibe at all with your day-to-day experience. I know I have wondered... Today, we get to the bottom of this craziness. Gerard Gianoli, MD He did an internship in General Surgery and an internship in Pediatrics. Following a residency in Otolaryngology- Head and Neck Surgery, he completed a fellowship in Otology, Neurotology and Skull Base Surgery at the Michigan Ear Institute. He was a full-time Associate Professor at Tulane Medical School until July 2000 when he joined Ear and Balance Institute. He still maintains a Clinical Associate Professor appointment at Tulane in both the Department of Otolaryngology-Head and Neck Surgery and the Department of Pediatrics. He has published and lectured extensively in the field of Neurotology and serves on multiple Editorial Review Boards for the fields of Neurotology and Otolaryngology. Dr. Gianoli's Two Pieces on the Medical Error Studies * Medical Error Hysteria1 * Unreliable Research on Error-Related Hospital Deaths in America - Gianoli and Dunn2 The Makary and Daniel article * From the BMJ More... * Additional reanalysis from Shojania Now on to the Podcast... 1. Gianoli G. Medical Error Epidemic Hysteria. Am J Med. 2016;129(12):1239-1240. [PubMed] 2. Gianoli G. Unreliable Research on Error-Related Hospital Deaths in America. JPANDS. 2016;21(4):104-108. http://jpands.org/vol21no4/gianoli.pdf.
November 28, 2018
PreVENT Trial * PreVENT Trial * The Bottom Line on the PreVENT Study Dominating the Vent Series * EMCrit Lecture &#8211; Dominating the Vent: Part I * EMCrit Lecture &#8211; Dominating the Vent: Part II * Response to Letters on my Mechanical Ventilation Article in the Ann Emerg Med PRVC Refs * A rabbit study1 * PC vs. PRVC in Brain Injury Patients2 * Work of Breathing Analysis * Small Study demonstrating that you are not getting the Vt you think you are3 * Small Crossover Trial4 Now on to the Podcast References 1. Porra L, Bayat S, Malaspinas I, et al. Pressure-regulated volume control vs. volume control ventilation in healthy and injured rabbit lung: An experimental study. Eur J Anaesthesiol. 2016;33(10):767-775. [PubMed] 2. Schirmer-Mikalsen K, Vik A, Skogvoll E, Moen K, Solheim O, Klepstad P. Intracranial Pressure During Pressure Control and Pressure-Regulated Volume Control Ventilation in Patients with Traumatic Brain Injury: A Randomized Crossover trial. Neurocrit Care. 2016;24(3):332-341. [PubMed] 3. Kallet R, Campbell A, Dicker R, Katz J, Mackersie R. Work of breathing during lung-protective ventilation in patients with acute lung injury and acute respiratory distress syndrome: a comparison between volume and pressure-regulated breathing modes. Respir Care. 2005;50(12):1623-1631. [PubMed] 4. Guldager H, Nielsen S, Carl P, Soerensen M. A comparison of volume control and pressure-regulated volume control ventilation in acute respiratory failure. Crit Care. 1997;1(2):75-77. [PubMed]
November 11, 2018
Another iteration of the Brindley Sessions: The Article Followership by Leung, Lucas, Brindley et al. The Table Figure 1: Robert Kelley’s Followership dimensions and styles, adapted from Kellerman (2008)1 in the podcast, the passive followers are described as yes-people from: https://www.medicalprotection.org More Sparks for Ideas * Kelley's followership model with discussion * A related discussion we published in BMJ * A discussion on culture (including nations) by Geert Hofstede * And a darn good book about cultivating "eulogy virtues" rather than "resume virtues" * NOLS 4 leadership roles Listen to the Rest of the Brindley Sessions More from Peter Now on to the Session...
October 31, 2018
A video lecture from my friend and airway guru,  Prof. George Kovacs. He has been obsessed with airway for decades. This lecture discusses breaking down the steps of airway management into chunks. George's Site * AIME Airway More from George on EMCrit * The Psychologically Difficult Airway by George Kovacs * Definitive Emergent Awake Intubation with George Kovacs * Airway Things I Learned from George Kovacs at the NYC Airway Course * Antifragile in EM by George Kovacs Now on to the Vodcast...
October 17, 2018
Today, I get to speak with my buddy Zack Shinar about soem cardiac arrest science. Questions Discussed Is there a no-flow time past which there is no hope for survival? If there is, how do we know the pt was actually fully no-flow--are we are conflating no-cpr for no flow? What is the survival limit on low flow time? VF survival is not linear across time. What happens to that number if you strip out all the 1-2 shock v-fib (real comparator for ecmo right? Who are the few (5%) of non-ecpr patients who survive after 30 minutes of CC? Effect of Transient ROSC on outcome data Current Cardiac Arrest Assumptions – mantras needs changing * Cardiac arrest rhythms have overlap but are very different disease * Termination of Resuscitation (TOR) is outdated * Pre-hospital prognostication needs an increase in sophistication Some Literature on the Stuff Spoken About * Asystole in patients with wearable ICDs are much better than historical1 * Shockable rhythm patients can have neurologically intact survival with CPR out to 47 minutes (mRS 0-3)2 * When Should EMS Transfer-Transport for ECPR should be considered between 8 to 24 minutes of professional on-scene resuscitation, with 16 minutes balancing the risks and benefits of early and later transport. Earlier transport within this window may be preferred if high quality CPR can be maintained during transport and for those with initial non-shockable rhythms.3 50%of ROSC would be captured at 8 minutes and 90% by 16 minutes. * Reynolds et al. found similar data with 21 minutes being the 90% capture mark.4 * PEA should prob. not be an exclusion for ECMO, they can have a 23% neuro intact survival in this paper.5 * Wake County Data Packet * Rate of Brain Death and organ donation, possibly another reason field termination in the field is a bad strategy in viable cohorts * Adnet et al. on No-Flow and Low-Flow Durations Other EMCrit Links of Interest * Cardiac Arrest Update * EMS Field Decisions in Cardiac Arrest with Howie Mell Sign up for REANIMATE6 before tickets sell out REANIMATEconference.com Now on to the Podcast... References 1. Liang J, Bianco N, Muser D, Enriquez A, Santangeli P, D’Souza B. Outcomes after asystole events occurring during wearable defibrillator-cardioverter use. World J Cardiol. 2018;10(4):21-25. [PubMed] 2. Reynolds J, Grunau B, Rittenberger J, Sawyer K, Kurz M, Callaway C. Association Between Duration of Resuscitation and Favorable Outcome After Out-of-Hospital Cardiac Arrest: Implications for Prolonging or Terminating Resuscitation. Circulation. 2016;134(25):2084-2094. [PubMed] 3. Grunau B, Reynolds J, Scheuermeyer F, et al. Relationship between Time-to-ROSC and Survival in Out-of-hospit...
October 3, 2018
* Jenny Rudolph on WTF * Pew Center Article * Types of People to Hate on Facebook Now on to the Podcast...
September 19, 2018
Why First Pass Success? Best review article - first-shot-is-the-best-shot Each Attempt Makes Things Worse Hasegawa et al. showed at 3 attempts, things got bad (Ann Emerg Med 2012;60:749) Sackles JC et al. showed that >1 attempt radically increased complications (ACADEMIC EMERGENCY MEDICINE 2013; 20:71–78) Mort demonstrated this in the ICU, after two attempts risk of crit desat (70%) is huge and assoc. with cardiopulm arrest (Anesth Analg 2004;99:607) Mort has further elaboration re: the dangers of intubation in the critically ill (J Inten Care Med 2007;22(4):208) Heffner et al. showed a 4% cardiac arrest rate in ED intubations (Incidence and factors associated with cardiac arrest complicating emergency airway management. Resus 2013) Duggan showed >1 attempt = badness Learning Curve for Laryngoscopy Best review of lit is at Openairway VL Teaches DL This letter has a discussion and pertinent references (BJA 2017;119(4):842–843) EMCrit Failed Airway Algo V2.0 click for pdf Bug the ResusTO Folks to Do the Course Again ResusTO Blade Views by Nick Chrimes Now on to the Vodcast...
September 5, 2018
A few tweets sparked a debate (big surprise there) and suddenly there was a storm of opinions on whether OOH cardiac arrests should be transported or terminated in the field. Well, since I do not debate on twitter anymore, I needed a person to speak with on the topic--and there is no better than Howie Mell. Howie Mell, MD, MPH, FACEP Chair - ACEP Subcommittee on EMS Education Reservist Emergency Physician - Vituity Host of the So What 2.0 podcast SMACCforcer (@DrHowieMell) Steel-Man Rules for this Debate * Any time you want to contradict the other discussant, you must first restate the views they have just stated and confirm with them that you are understanding correctly. If you can bolster their point even more strongly before contradicting, this is even better. * No ad-hominem attacks (i.e. attacks on the person, not their views. Feel free to politely destroy the views) * Logical fallacies should be pointed out * Try to state whether a viewpoint is based on evidence, and what quality or based on your clinical practice Accepted as Given? * We are dealing with Adults * Asytole without signs of life should be run and terminated in the field * There are EMS services and EDs where EMS does a better job running the arrest than the ED, in those venues EMS should run almost all codes to field termination * There are some venues where nothing (nothing!) additional gets done in the ED beyond what EMS can do, in those venues EMS should run almost all codes to field termination The Questions * What is a public health view of EMS vs. a medical view? * What is the best approach to
August 25, 2018
Call it cric, call it surgical airway, call it FONA. Whatever you call it, you need to have the skills and mindset to make it happen at the ready every time you intubate. Every month make an appointment for yourself to practice cric (just like my buddy Sara Gray does). First, you Need the Model Head over here and print out a 3D model to have for the rest of your career Next, Buy Some Gaffer Tape Gaffer Tape By GafferPower One roll will last a LONG time. And trust me, buy the gaffer power brand, some of the knockoff brands really suck. Then Acquire Some 4x4s and Plastic Bags I think you know where to find some... Then, Watch the Video For More on All Things Cric Come on over to the EMCrit Cric Page They made a bleeding model using Laura's Model
August 8, 2018
What we have here is a failure to Resus Communicate... Inspired by Reid, Brindley, Hicks, & Novak My Favorite Paper on Resus Communication * by the Brindley Lecture You Must Watch * Novak on Combat Aviation Lessons Resus By Voice * from flying by voice * Shared Mental Model * Resuscitate - Differentiate - Communicate Tactical Pause (Hick's term) * Step-Back or SitRep * aka The Cross-Check- Keep coming back to the global patient picture before diving into any minutiae * "What am I missing" - team realignment * Ten-for-Ten1 Close the Loop from Hargestam et al. * Set a notification -"Put in an art line and tell me when it is done" Podium Nurse * 360 awareness * Assignment of Tasks (3 Cs: Clear Instructions, Cite Names, Close the Loop) Sterile Cockpit * 10,000 feet * Train the team to acknowledge that phrase * Central Line Kits / Shock Trauma Hallways Resuscitese * from Cliff * Combat Mitigating Language-Efficient and Unambiguous Communication - Directive, Descriptive, Informative * Belay that * Acknowledge or Close-the-Loop * Say Again * Read Back * Tally Ho * Nato Phonetic and read this book Briefings PreBrief * Planning: Mission, Defined Roles, and Set the tone * Zero Point Survey Self-Team-Environment Debrief * Learning happens in the debrief * Hot Debrief - INFO Model Additional Info * Communication Under Pressure * More Critical Strategies * LitFL Article Sai De Silva
July 25, 2018
In an amazing lecture; Joe Novak, ED doc and former combat aviator; spoke about the need for memorized boldface actions and then the availability of a quick reference handbook (QRH) for the next steps. But where are either of those things for resuscitation? That lack was the inspiration for the past 4 years of my life and the life of my guest this week, Dave Borshoff. Dave is an anesthesiologist in Perth, AU and a former pilot. He is author of the Anesthesia Crisis Manual and co-editor of the just-released Resus Crisis Manual. A QRH from a Cockpit The Bold Face for Emergency Ejection The Rest of the QRH for Controlled Ejection Combat Aviation with Joe Novak EMcrit # 99 Ready to Check Out the RCM? See the Resus Crisis Manual Now on to the Podcast... Music by Caged Dreams (CC)
July 23, 2018
We recently put up an amazing mock trial of an anaphylaxis case put together by my friend Mike Weinstock. If you have not watched that, then this wee is pretty much useless to you. In this discussion, we reveal the verdict and talk a little bit of the philosophy of malpractice and how to stay safe in the ED. I think you'll like it!
July 22, 2018
The Participants (alphabetically) Jeff Lapoint (@lapizity) Emergency Physician and Medical Toxicologist Director, Division of Medical Toxicology Kaiser San Diego California, USA John Richards (@JR_Code3) Emergency Physician Professor of EM UC Davis Emergency Medicine California, USA The Posts that Got us Here * John on LitFL * Jeff on the Tox and the Hound Steel-Man Rules for this Debate * Any time you want to contradict the other discussant, you must first restate the views they have just stated and confirm with them that you are understanding correctly. If you can bolster their point even more strongly before contradicting, this is even better. The moderator may prompt you if you forget. * No ad-hominem attacks (i.e. attacks on the person, not their views. Feel free to politely destroy the views) * Logical fallacies will be pointed out by the moderator if they have not been by the other discussant * Try to state whether a viewpoint is based on evidence, and what quality or based on your clinical practice The Questions * Should beta-blockers be used in patients with cocaine toxicity? * How are we defining cocaine toxicity? * Does Unopposed Alpha phenomena actually exist? * Are beta-blockers safe in cocaine toxicity? * Even if they are safe, is there any compelling reason we should use them over other treatments? * What about the non-floridly toxic patient, for instance: a case of hypertensive, tachycardic, sweaty patient with chest pain. Already received 2 rounds of Ativan and nitro with continuing symptoms, see how each manage * Do your thoughts on beta-blockers in cocaine toxicity apply to the other stimulants? * What about patients who admit to taking cocaine in the recent past, but show no signs of toxicity--Is it safe to use beta-blockers in these patients? * A case: 48 y/o with type I DM, HTN, High Chol. Presents with substernal CP, first trop negative. For some reason nurses obtained a urine drug screen positive for cocaine. When asked, pt states he is an occ. User and last use was 2 days ago. Denies any use today. Pt has been totally forthcoming about all of his drug use and you believe him. Your hospital uses CTCA for this risk category of chest pain to allow immediate discharge for f/u if negative. You order the test, but radiology refuses to do the scan b/c of the requirement for beta-blockers and a drug screen positive for cocaine. Is this justified or not? Additional Info * John's extensive publications on cocaine and beta-blockers * If you don't trust my editing and want an unabridged version, it is here.
July 11, 2018
The slide above is from an SCCM talk by Robert Sutton. Dr. Sutton is a pediatric intensivist at CHOP in Philadelphia. His research interests include pediatric CPR quality research with a focus on evaluating novel interventions, both educational and technological, with the overall goal to improve care delivered to children during resuscitation attempts. What We Spoke About... We went box by box through the algorithm above. Note, very little of this is supported by high level evidence. However, neither is anything we are doing now--so be wary of staus quo bias. Additional Info * An article by Dr. Sutton on Hemodynamic Guided CPR * Physio-Guided CPR1 * Article: Ahn, S et al. Sodium bicarbonate on severe metabolic acidosis during prolonged cardiopulmonary resuscitation: a double-blind, randomized, placebo-controlled pilot study. J Thorac Dis 2018; 104(4): 2295-2302 from rebelem * Comp. of DBP and ETCO2 for CT quality (hint DBP is better) * Brain Ox Note: To do this technique properly, it is imperative you read this post (choosing the correct DBP); you should also probably listen to that podcast. Prior Posts on EMCrit * Podcast 125 - The New Intra-Arrest (Cardiac Arrest Management) * Podcast 191 - Cardiac Arrest Update Now on to the Podcast... 1. Morgan RW, Sutton RM, Berg RA. The Future of Resuscitation. Pediatric Critical Care Medicine. 2017;18(11):1084-1086. doi:10.1097/pcc.0000000000001316
July 5, 2018
The Case (Refractory Anaphylaxis and Difficult Airway) * Mock Trial - The Case Please place your vote on the verdict below! Photo by Melinda Gimpel Video Version Audio Version
June 28, 2018
The Acid Base Series EMCrit Podcast &#8211; Acid Base Ep. 7 &#8211; Bicarb Updates, Quantitative Approach, and Prof. David StoryPodcast 97 &#8211; Acid-Base VI &#8211; Chloride-Free SodiumPodcast 96 &#8211; Acid Base in the Critically Ill &#8211; Part V &#8211; Enough with the Bicarb AlreadyEMCrit Podcast 50 &#8211; Acid Base Part IV &#8211; Choose the Solution Based on the ProblemEMCrit Podcast 46 &#8211; Acid Base: Part IIIEMCrit Podcast 45 &#8211; Acid Base: Part IIEMCrit Podcast 44 &#8211; Acid Base: Part I Time for more discussion of acid-base, a subject you know i obsess about. Bicar-ICU Trial * Read the amazing trial by Jaber et al. * PulmCrit's take * The Bottom Line * CCNerd Keith Corl's Email Hi Scott, By now I'm sure you've seen the work from Jaber's group on using bicarb in critically ill academic patients. Obviously there are limitations to the trial, not the least of them a negative primary outcome. And while the study wasn't powered to look a 28 day mortality or 7 day organ failure in those with a AKIN score of 2-3 I am sure many will take this positive secondary finding and run with it. My biggest criticism was that they didn't break the study down into patients with anion gap metabolic acidosis (AGMA) vs. non-anion gap metabolic acidosis (NAGMA). I'm a big fan of your acid base pods and tend to agree with your take and the Forsythe paper and don't give bicarb to patients with an AGMA. So I went ahead and emailed Jaber and he got back to me. He told me that "90% of the patients enrolled were hyperlactatemic." Moreover, most GI and renal patients with base loss were excluded b.c. bicarb was considered standard care, therefore the "large majority" had an AGMA. Interesting, now I'm second guessing myself and wondering if I should consider bicarb in AKIN patients with a AGMA. I'm interested to hear your thoughts. I think it would make a great pod or a topic for Josh or Rory. I hope all is well, Keith then I bring on Dr. David Story to discuss acid base and a set of posts by Jon-Emile Kenny. Professor David Story Head of Anaesthesia, Perioperative and Pain Medicine Unit (APPMU), Melbourne Medical School, University of Melbourne; Director, Melbourne Clinical and Translational Sciences (MCATS) research platform Jon-Emile Kenny Lactate Debate Posts * Part 1 * Part 2 Gamblegram go to acidbase.
June 13, 2018
Bougie First? A recent RCT from Hennepin1 by Driver et al. evaluated the effect of bougie use on first pass success. This adds to a prior retrospective study by the same group.2 These studies lend support to a practice that many of us have already adapted--bougie first intubation. Few things on the bougie stuff Some bougies are too short & this leads to A LOT of their downsides (RCT used a 70 cm bougie, as opposed to the 60cm bougie that I have) Most bougies don't retain their shape, which is a shame b/c the airways where you most need the bend to stay are the ones that are least likely to tolerate multiple removals to reshape. Levitan bougie should solve this We cannot conflate the Hennepin article with preloading the bougie Technique * A discussion is in the episode and 2-person vs. 1 person Can You Advance an ETT over a bougie without having someone grab the proximal end first?​ * Listen to the episode and let me know what you think How to know the bougie is in when used in a C/L 3 view * Clicks - I find this unreliable * Hold-Up - as long as this is done gently, it is fantastic * Laura Duggan recommends: A trained assistant with gentle thumb on one side, two fingers on the other of trachea at the sternal notch is priceless to confirm placement without the need for the 'hang up test' What about the Pre-Load Techniques? See this poster for one bench eval VBM S-Guide * Video for S-Guide I'd also like to see their METTS stylet. Go to VBM Medical to see these. Snail Trail for Bougie Bending from3 though I actually put the circle closer to the tip Also See * Bougie Vids * EMNerd on the Bougie RCT * Kovacs on why he doesn't like the D-Grip * ETT vs. Railroad Bougie vs. Preload Bougie * Sal on Driver's first study Update * This is the highest FPS I have seen using CMAC and Frova on all intubations4 Positioning stand behind the patient lift their head and push their head towards their feet (causing base of neck flexion) until their ear holes (ext auditory meatus) are at or higher than the level of their sternal line (sternal notch to xiphoid process) while constraining the face plane to stay parallel to the ceiling then padding under head & shoulders until this position is maintained Semler et al.5 showed Ramping is worse, however you'll need to listen to the podcast to understand what that means. Flextension by Chrimes Chrimes on Positioning &nbsp; &nbsp; &nbsp; Greenland on Positioning
May 28, 2018
I brought the DantasticTox guys back to discuss how toxidrome really present, you know in real life. If you missed their first EMCrit episode, go listen: * EMCrit Podcast 215 - A Disagreement of Toxicologists and then check out the Dantastic Tox Podcast by Nick Manzari Anticholinergic Altered, but will give you 3 seconds of attention Big, non-reactive pupils (constrictors knocked out); Pupils may not even be enormous until you stimulate and then they get wide Dry-everywhere. Put a gloved hand in the axilla if you are brave like Howard Voice--Worst cottonmouth ever Picking behaviors (this is the big one) - they will be plucking at EVERYTHING. Taking off gown. Stimulus evoked tachycardia Bowel Sounds-screw bowel sounds, because DEMONS Cholinergic Like Spongebob when you squeeze-water comes from everywhere “SLUDGE”: Salivation, Lacrimation, Urination, Defecation, GI cramping, Emesis + “Killer B’s”: Bronchorrhea, Bradycardia, Bronchospasm Pinpoint pupils Pooping on themselves Lacrimation So remember cardiogenic shock with crying and diarrhea and pinpoint pupils. &nbsp; Sympathomimetic Mydriasis, but briskly reactive (i.e. they will constrict when you shine light) Sweaty Psychomotor agitation, Paranoia, Psychotic, but they will respond to questions (but you won't like the answers) Tachycardia, htn, BODY TEMPERATURE Blunts fatigue, pain response, and exhaustion Sedative/ETOH Withdrawal can only really be differentiated by history &nbsp; Opioid bradypnea first then look at the pupils &nbsp; Sedative/Hypnotics Sleepy Ventilations preserved Benzo plus is where the problem comes Now on to the Podcast...
May 14, 2018
This is Part II of a 2-part lecture on TTP, DIC, and thrombocytopenia in the critically ill patient. It was given by Tom Deloughery at the EEMCrit Conference. The Essentials folks have a video package of the whole day at their site. See Part I for Diagnosis TTP Never Give Platelets Never Give Platelets Never Give Platelets Plasma Exchange is the treatment of Choice Temporize with 2 units of Plasma, then 1 unit q6 hrs until plasma exchange These patients will not bleed regardless of PLTs when you place the HD Cath--just do it (but not the intern) Give Steroids (i.e. 125 mg solumedrol or similar) Send ADAMSTS13 find out how long it takes and make sure it is sent before plasma exchange &nbsp; Goals * PLT target >150,000 on 2 draws * normalizing LDH * neuro sx fixed after this, 2 more days; then cold turkey or wean &nbsp; DIC Treat underlying cause (duh_ Transfuse to * Fibrinogen > 150 (200 in OB disasters) -- Give 10-pack of cryo and recheck (even in places that have fibrinogen conc.) * PLT > 50 * HCT > 21 * PTT < 1.5 x control * INR < 2-3 Heparin and AT III have not panned out. Only use heparin if there is macro-thrombosis (i.e. PE) Now on to the Vodcast...
May 8, 2018
Please, please read the guidelines, listen to the wee, and then if you agree--sign the petition below Literature Mentioned * 2018 SSC Guidelines 1-hour Bundle * Prehospital Antibiotics didn't result in benefit * Kumar Editorial Additional Resources * Merv Singer on Early Antibiotics for Sepsis * PulmCrit Take * EMNerd Take * PulmCCM Take * Must Read: Evidence Underpinning the US Government-Mandated Hemodynamic Interventions for Sepsis * IDSA's rationale for not endorsing The Petition * Please sign here if you agree with this wee
April 30, 2018
This is Part I of a 2-part lecture on TTP, DIC, and thrombocytopenia in the critically ill patient. It was given by Tom Deloughery at the EEMCrit Conference. The Essentials folks have a video package of the whole day at their site. See Part II for Diagnosis Tom DeLoughery MD, MACP, FAWM Professor of Medicine, Pathology and Pediatrics, Divisions of Hematology/Oncology and Laboratory Medicine at Oregon Health & Science University Tom DeLoughery is a native Hoosier who graduated from Indiana State University in 1981 (one year after Larry Bird) and the Indiana University School of Medicine in 1985. He did his internship at the University of California, Irvine before traveling to Oregon where he finished his internal medicine residency and hematology/oncology fellowship. His clinical interests are in blood diseases, hemostasis, and thrombosis, subjects on which he has written extensively. He has won numerous teaching awards and has given education sessions to national meetings of many professional societies. He is a master at the American College of Physicians and Fellows of the Academy of Wilderness Medicine. Recently the 3rd edition of his popular handbook Hemostasis and Thrombosis was published. His one odd fact is that he has been to 40 Bob Dylan concerts in 5 countries. Thrombotic Thrombocytopenic Purpura (TTP) * Primary Disease * Decreased ADAM-TS-13 * A Disease of Excess Platelet Aggregation * Terrible Triad * No schistocytes = no TTP * Symptoms wax and wane Disseminated Intravascular Coagulation (DIC) * aka Disease-Induced Coagulopathy * Secondary Disease * Too much thrombin * Thrombosis and Bleeding * Platelet Activation * Markedly increased D-Dimer * Decreased Fibrinogen * Normal Coags = No DIC Amazing Image Above by Dr. Hanson Now On to the Vodcast...
April 8, 2018
You are getting this podcast 1 week early. We do an EDECMO ECPR course each year called REANIMATE. REANIMATE5 blew away all previous iterations. One of the main reasons was our guest of honor, Demetris Yannopoulos from the University of Minnesota. Demetris has organized Minneapolis into arguably the most impressive ECPR city in the world. We were lucky enough to be able to film his Sharp Hospital Grand Rounds. This lecture was mind-blowing and made me so jealous. We think you will love it. Tickets are on Sale for REANIMATE6 * REANIMATEconference.com Slides from the Talk * Dr. Yannopoulos' Slides (Minus In Review Data) Additional Info/Resources * EDECMO 36 - Zack interviews Demetris * EDECMO Crash Episode - Microdissection of Demetris' ECPR Techniques * JAHA Publication on ECPR Results Now on to the Vodcast...
April 5, 2018
So my friend, Justin Morgenstern recently put up a post on Idarucizumab, aka Praxbind. He seemed pretty fired up on the issue, so I got him on the line to talk about it. What follows is a conversation on evidence and what to do when there is not a good amount of it. Schtuff * The EM Cases Podcast that partially sparked the debate Justin Wrote an Additional Post after our Discussion * On Parachutes and Such On to the Wee...
April 2, 2018
Today we are joined by Dennis Djogovic to do Part II on severe burns. * See Part I on Fluid Therapy Dennis Djogovic Dr. Djogovic completed training in Emergency Medicine and Critical Care Medicine from 1999-2005, and is currently employed at the University of Alberta Hospital as an Emergency Physician, and as an Intensivist in the General Systems Intensive Care Unit and in the Firefighters Burn Treatment Unit. Inhalation Injuries and Airway Management Read These * Tracheal intubation difficulties in the setting of face and neck burns: myth or reality? (Am J Emerg Med. 2014 Oct;32(10):1174-8) * Diagnosis and Management of Inhalation Injury Securing Tubes and Catheters More Info * PulmCrit on Flash Cigarette Burns * Maryland CC Project Severe Burns Episode * EM Practice Smoke Inhalation Issue Now on to the Podcast...
March 19, 2018
The Article PEP under Stress Breathe Conscious control of the autonomic system Xhaler https://twitter.com/nathanwpyle/status/1071860695371825155 Talk Positive self-talk See Mental Rehearsal/Visualization Focus Development and Use of a focus/trigger word Additional Resources * Brindley's CRM for Team Performance Guide * Hicks and Petrosoniak on Human Factors in Trauma Resus (Show on this Soon) * Anything by Jason Brooks Now on to the Podcast...
March 5, 2018
Today we are joined by Dennis Djogovic to do Part I on severe burns. Dennis Djogovic Dr. Djogovic completed training in Emergency Medicine and Critical Care Medicine from 1999-2005, and is currently employed at the University of Alberta Hospital as an Emergency Physician, and as an Intensivist in the General Systems Intensive Care Unit and in the Firefighters Burn Treatment Unit. Fluid Management in Burn Patients Additional Resources * Victorian Burn Unit Resources Now on to the Podcast...
February 20, 2018
That diphenhydramine OD that is driving you up a wall, the seroquel OD that can't give you any history and is sucking up all of your benzos--there is a solution! Physostigmine used to be standard care, but then after a scare with TCA ODS, its use by non-tox folks markedly diminished. Bryan Hayes Today I am lucky to have Bryan Hayes, the Pharm ER Tox Guy, back on the show to discuss Physostigmine for anti-cholinergic toxicity. Bryan is a ED pharmacist with a fellowship in toxicology. He tweets as PharmERToxGuy and blogs at Academic Life in EM and on his own site, pharmertoxguy.com. Use in Anticholinergic Poisoning Physostigmine controlled agitation and reversed delirium in in 96% and 87% of patients, respectively (Ann Emerg Med 2000;35(4):374-81.). Benzodiazepines controlled agitation in only 24% of patients but were ineffective in reversing delirium. Indications Presence of peripheral or central antimuscarinic effects without significant QRS or QT prolongation * Peripheral: dry mucosa, dry skin, flushed face, mydriasis, hyperthermia, decreased bowel sounds, urinary retention, and tachycardia * Central: agitation, delirium, hallucinations, seizures, and coma Hayes' Algorithm * Physostigmine 1 mg IV over 5 minutes (mixed in 50 mL NS), can be repeated x 1, ~10-15 minutes after the 1st dose. Continuous cardiac monitoring and atropine at the bedside. Contraindications (from package insert) * Reactive airway disease, peripheral vascular disease, intestinal or bladder obstruction, intraventricular conduction defects, and AV block and in patients receiving therapeutic doses of choline esters and succinycholine. * Known or suspected TCA OD The Post on Bryan's Site * Don’t be Afraid of Physostigmine Nice Review Article * Dawson et al. Some Literature * 1980's cases of asystole in TCA poisoning: https://www.ncbi.nlm.nih.gov/pubmed/7001962 * 1998 case of 15 year old with asystole in TCA poisoning: https://www.ncbi.nlm.nih.gov/pubmed/9655671 * Physo clearly beneficial over benzos: https://www.ncbi.nlm.nih.gov/pubmed/10736125 * Physo associated with less ICU admissions: 
February 17, 2018
Want to be a Section-Editor for EMCrit? You need to be a current 2nd year EM Resident or a 1st year Crit Care Fellow Express interest here: Interest Form and we'll be in touch Now on to the State of the Crit...
February 5, 2018
So in prior posts, I have discussed the jerry-rigged "ultimate" BVM. But there is a better way--the creation of a manufactured BVM that helps us not kill patients. It would have the following characteristics: Facets of the Ultimate BVM &nbsp; Now on to the Vodcast...
January 22, 2018
&nbsp; &nbsp; &nbsp; In Podcast 104, we discussed how to avoid killing hemodynamically unstable patients while intubating. Today's podcast takes that concept a step further to allow you achieve a hemodynamically neutral intubation. The Pieces Rapid Sequence Awake Discussed in this podcast or Dissociated "Awake" Intubation or A Combination then you can consider a DSI for Hemodynamics, but only in non-tenuous patients then place the patients on CPAP/PSV mode with both set to zero if the patient requires mechanical ventilatory support because they continue to decline, consider Higher Vt/Lower Rate as per Davis et al. and Sedate with small hits of ketamine or fentanyl Further Reading * Pulmonary Hypertension Awake Intubation from CCM Now on to the Podcast...
January 8, 2018
Bottom Line * Fantastic look at the history of this issue Farkas on Steroids in Septic Shock * PulmCrit European & SCCM CIRCI Guidelines * Guidelines Crit Care Reviews Meeting * A Few Tickets are Left Find the Livestream and then the Edited Version of the Session at this Link: emcrit.org/adrenal Now on to the Wee...
December 25, 2017
Happy Solstice! A delightful and hilarious toxicology podcast started up a few months ago, the Dantastic Mr. Tox & Howard Show. I managed to get the hosts on the line to talk some tox. Howard Greller (@heshiegreshie) Dr. Greller is EM and toxicology out of St. Barnabas in NYC Howard Greller Dan Rusyniak (@drusyniak) Dr. Rusyniak  is EM and toxicology at Indiana University Dan Rusyniak Opioids * New York State Opioid Statistics * DantasticTox Opioid Show Intralipids * The DantasticTox Lipids Show * LipidRescue Site Calcium Channel Blocker Overdose * EMCrit CCB Episode The Santa Beard EEMCrit Conference REANIMATE ECMO Conference Now on to the Podcast...
December 15, 2017
My buddies, Rory Spiegel and Phillipe Rola taped an amazing conversation about the advanced uses of ultrasound to assess volume/fluid status. I think you will find it as interesting as I did. Links of Interest * Portal Veins & Pocus * A physiologist/intensivist responds * And more from Phillipe * Marik has a whole bunch of recent posts on the evils of fluid overload Now on to the Wee...
December 11, 2017
You Need to Round on Them Pulm Toilet Cuff Pressure Vent Adjustments Analgesia and Sedation Eye Care FEN Urine Output Maintenance Fluids Repeat Labs Repletions &nbsp; Meds The 2nd Dose of Antibiotics * Crit Care Med 2017;45:956 Insulin for IDDM Medication Reconciliation anti-coagulants, anti-platelets, rejection meds, endocrine meds, statins, Update--Venous Thromboembolism Prophylaxis Glaring omission in the audio. Thanks for reminding me, Maarten! Alarms Ventilator Alarms Pump Alarms &nbsp; &nbsp;
November 27, 2017
This post is part of the bleeding edge series--you have been warned! What you'll hear.... Two Phenotypes of Critical COPDers * Severe Bronchospastic Crisis * Hypercapneic Encephalopathy This episode primarily talks about #2 The New Reflex Actions for Coma/AMS * Check Fingerstick * Look at the Pupils/Resp Rate * Look for Stigmata of Seizure/Recently Completed Seizure * Get a VBG The Controlled Burn for Hypercapneic Encephalopathy in COPD This is the bleeding edge part. I am super-curious to hear what you think. Place your comments below. Articles to Read * Resp Med 2011;105:1109 Now on to the Podcast...
November 12, 2017
After Podcast 211 with Anders Ericsson, I promised my thoughts on deliberate practice and expertise... But first, something sad: Bob Wears has died Read a wonderful obituary Reality behind 10,000 let's think about that... Innate non-physical talent doesn't really matter that much.  Can't alter your height, but can alter your brain Driving a car for 10000 hours doesn't make you an expert driver. We do exactly zero hours of deliberate practice. We have no coach. Procedures My fellows filming themselves Microskill breakdown Why Purposeful much less deliberate practice is tough in Emergency Medicine Experts vs. Experts @ Teaching EM & Crit Care Lacks Feedback Mental Representations/Mental Models OODA Loops experts have very good memory of what has happened verbalize thinking sob low sat tachypenic pt looks bad, start thinking airway SCAPE, mental status good, pt will respond to BIPAP CHF Surgical Scripts Book Abernathy & Hamm Mental Models Article from Michael Simmons Shadowboxing watch stimuli commit to a course listen to the expert Thought Experiment on Computer Based Ratings Are Experts Actually Experts? Name Badge Believers How to Create Purposeful/Deliberate right time of day plenty of sleep deliberate practice is deep work patience 15-20 minutes, not 4-5 hours at least at first need a coach or if you can't find an expert performer and ask them how they got good good teacher builds representations Mental practice cric training given videos smacc airway workshop no place your hands here The Diamond Age a book by Neil Stephenson We need a primer Now on to the Podcast...
October 31, 2017
So I recently did an interview with the Curbsiders, an IM podcast, on why EM and IM sometimes have conflicts. It was a ton of fun and may be worth a listen. Here is the episode: The Curbsiders with Guest, EMCrit Find Out What this Diagram Means EEMCrit Conference Resident Competition Speak at the EEMCrit Conference and win a spot at the EEM Conference in May EEMCrit Blast Competition Now on to the Wee...
October 29, 2017
Mike Lauria set up an interview with Dr. K. Anders Ericsson, first author of Peak: Secrets from the New Science of Expertise. Dr. Ericsson is a brilliant cognitive psychologist, currently at the Florida State. He has dedicated his career to studying the science of expertise and performance. He was incredibly generous with his time, to the tune of a 2-hour interview. In the podcast below, I excerpted some of the most interesting pieces, but it was all great. If you want to listen to the unedited, full interview I have placed a link below. 10,000 Hour Rule Debunked * from Salon How to Deliberately Practice in Diagnostic Medicine * Get recordings of patient presentations, get people to commit, listen to what an expert would do, and then show what happened. Full Unedited Interview * ~ 2 hours of Dr. Ericsson Want More? * Art of Charm Interview with Dr. Ericsson was Amazing! * Brian Johnson's Summary * The Seductive Path of Good Enough * Deliberate Practice from Farnam Street * The Academic Paper on Deliberate_Practice_and_the Acquisition of Expertise by Dr. Ericsson * Pondering EM did a Two-Parter on Deliberate Practice (Part 1 & Part 2) * The Path to Insanity Now on to the Interview...
October 20, 2017
For Show Notes and To Leave Comments, Got to EMCrit.org/210 Now here is Part 2
October 16, 2017
Today, we talk about arterial lines. I love arterial lines: monitoring, true MAPs, easy blood draw, easy blood gases, fluid status--what's not to love. This turned into a 2-parter. Part 1 covers radial art lines Here is Arterial Lines - Part 2 covers everything else below The (Essentials of EM)Crit Conference go to EMCritConference.com use the promo code "emcrit" when you sign up Part 1 Covers: Radial Arterial Lines Peripheral vs. Central Arterial Lines Sterility Here is a systematic review of most of the literature [cite]24413576[/cite] My take on it is, use sterile gloves, mask, chlorhexidine prep, and if you can grab a fenestrated drape or some OR towels. Technique * Kit (The one I use is Arrow RA-04020) * Ultrasound * Threading * How to Save it * Allen Test Securing Tegaderm alone is not enough. I suture, but I really wish we had arterial line stat-locks I always loop around the thumb and secure with tape outside of the tegaderm--I hate replacing pulled out art lines Central vs. Peripheral Arterial Pressures [cite]28523028[/cite] Part 2 Covers: Femoral Sterility-Full Sterile unless you are going for speed or the Dirty Double Technique Use Ultrasound Find the Common Femoral Artery Use of a central line kit?--No! Back of wire? Check, but yes! Axillary Need Ultrasound Brachial Is it safe? Dorsalis Pedis https://www.ncbi.nlm.nih.gov/pubmed/28523028 The Arterial Line Set-Up How to set up an art line pressure transducer You do not need to wait for crash arterial lines Heparin Flush Pimping Ammunition - Where is that Catheter sent by Intensivist, Mark Dunn Now on to the podcast (and Remember: Here is Part 2)...
October 11, 2017
Please Send me your ideas on how to... Artificiality of Dissemination * Is email the best forum? * Get people to actually read the emails you send re: departmental protocols, changes, ideas, etc. * Do you track? Referencing Reference * How do you create a reference site? * What nitty-gritty details? * Is it password protected? Does everyone have a unique login? * How do you sort/create search--what pages, tags, categories, long tables of contents, etc. * How do you handle orientation into your new unit/department Old Dogs, New Skills How do you teach new skills * Meetings * Videos * Screencasts Post thoughts on Reddit here: REDDIT Post for this Wee Now on to the Wee...
October 2, 2017
A few years ago, I put out a podcast on Getting Things Done--people seemed to really like discussing this topic. I am giving a lecture on this subject this week. It has gotten me thinking about some of the higher level aspects of GTD and I thought I would share some of them with you. Deciding on Opportunities Present you vs. future you Petrie Triangle Time Tracking/Forecasting Opportunity Cost Deciding on Goals Deep Work Time Blocking Pomodoro technique creator's website Getting Tactical re: Email * Put the call to action up top * Preempt the back-and-forths * doodle.com * Close the loop beforehand * Ask one ?, make it easy, and make sure it is not web-searchable/already answered Resus Fellowship Click Here for More Info on the Stony Brook Resus Fellowship Now on to the Podcast...
September 18, 2017
You are doing CPR wrong, or so says Felipe Teran, an ED resuscitation sonographer. Felipe has just started as a Resus/ED attending at University of Pennsylvania. The Vodcast Let us know what you think in the comments section below &nbsp;
September 5, 2017
This week a case to test your Resus chops. The care is not hard, the logistics definitely are. Items of Interest * Dirty Double * Push-Dose Pressor Update * RUSH Exam * Hyperkalemia * HOP Killers * Peripheral Vasopressors * SLED Now on to the Podcast...
August 29, 2017
This is the next installation in the central line (and really any Seldinger procedure) microskills. You should have already watched the videos with the following microskills: * Syringe Suction while Manipulating * Needle Stabilization during Syringe Removal & Wire Insertion * Wire Manipulation * Dilation (this video) * Bonus Skills (Wire Straightening without Cheater) This microskill video discusses dilation. I see this being done improperly with incredible frequency, but people get away with their bad technique because they are using small dilators for small catheters. When you go big, you will do damage unless you know what you are doing. Dilation Mantras * Push & Rack * Twist & Rip * Pinch & Pull Additional Tips * Keep wire and dilator wet with saline (thanks for the reminder, Matt) * Clots are your nemesis--if there are clots on the wire, clear them off before continuing to upsize your dilators
August 21, 2017
We've spoken a ton on EMCrit on Apneic Oxygenation and Preoxygenation, well here is some more. Nick Caputo and his Lincoln Airway Group did an amazing trial of ApOx in the ED. Rory recently wrote about it and there have been some amazing posts around the FOAM world as well (see Rory's post). Now I weigh in with my take and a discussion of my new thoughts on PreOx. Three Items to Read * The ENDAO Trial * Sakles' Editorial * The EMNerd Post Also See * Fellow Trial Post * EMCrit Preox Should we use Nasal Cannula? I think yes, because: * ApOx will still probably benefit some patients (probably those without sig. physiological shunt or those whom you have recruited) * Makes BVM mask leaks better * Allows apneic CPAP with the devices below Why Doesn't It Work in this RCT? * Great Preox * Not Enough Potential for Sig. Desat due to rapidity and ease of intubation * THRIVE NC is Different than Standard * Physiologic Shunt-Shunt Fraction would be a great thing to know to interpret these studies What Should be on the Patient's Face just prior to Induction choose one: * Vent as Bag with BVM Mask * Oxylator with BVM Mask * BiPAP Machine with BVM Mask * Ultimate BVM with PEEP Valve, Pressure Gauge All of the above should have a NC @ >15 lpm and ETCO2 capnography Why not the Mapleson C (or similar)? I'd like a pressure gauge on that badboy to track each breath Update Ivan Pavlov updated the tables from our MA (Am J Emerg Med. 2017 Aug;35(8):1184-1189) to include the Caputo trial: Clinically Sig. Hypoxemia SpO2
August 7, 2017
Today, an update on Push-Dose Pressors. I coined the name Push-Dose Pressors (PDPs) way back on episode 6. The idea was not new, anesthesiologists and resus docs have been using bolus-dose vasopressors for decades. I just thought the name was dumb, these are not boluses in the way I have always thought of them (a brief iv drip). I also thought it was crazy that the concept had not really penetrated very far into emergency medicine and the ICU--at least in the States. My prehospital doc friends told me it was common in their world. Since the podcast, I have received 100s of emails describing the use of PDPs to lifesaving effect (or at least code-preventing), but there has been scant published literature on this technique in EM. Recently that has all changed. Can We Wait for the Drip? Resus-Ready EDs should be able to get a vasopressor drip up within 8 minutes (completely made-up number, just like most hospital certification standards) Dead Space in the Lines What should you do when you can't wait that long? How do you treat critically low perfusion to the heart & brain? Push-Dose Pressors Fill the Gap Especially in the Peri-Intubation, when patients have an annoying habit of popping into cardiac arrest ED Pharmacists Discussion of Medication Safety for Push-Dose Pressors Safety Guidelines for Push Dose Pressors While there seems to be a slightly negative bias against docs' capability to mix drugs and a pro-pharmD bias (understandable), the messages from this article as a whole were fantastic. Here are some alterations/things to be aware of that I discuss in the podcast: * The Prohibition against Pre-Filled Saline Syringes * The Phenylephrine Chart An Editorial on the Above Article Cole Editorial on Push-Dose Pressors Why EPI has won my Heart Sorry Phenyl you were but a brief fling Push-Dose Epi Labels Inspired by the Danny the Medic Cardiac Arrest EPI Syringe 0.5 mls of the cardiac arrest epi is an ok stopgap Dirty Epi Drip I do not recommend the dirty epi drip. Please, please understand how this makes our specialty look For the love of all this is Resus, Label the frackin bag! This is not the time to have something going on in the background that you are paying no attention to Push-Dose Norepi if you Just Never Want to Deal with Mixing Check your premixed concentration: If you have the 4mg in 250 ml (16 mcg/ml) you can give 0.5 to 1 ml per minute Pick One Way to Go in your ED Otherwise errors are more likely ED Pharmacists in General Love having ED PharmDs as part of the team! Are there downsides? Premixed Push-Dose Epi Other Lit Mentioned * The impact of push-dose phenylephrine use on subsequent preload expansion in the ED setting. The American Journal of Emergency Medicine Volume 34, Issue 12, December 2016, Pages 2419–2422 * This study compares push-dose phenylephrine to continuous infusion–no difference between the two (Anesthesia Analgesia 21012;115(6):1343) First article in the ED demonstrates efficacy on blood pressure (
July 31, 2017
George Kovacs left a great comment on the hemoptysis post: Great discussion.  Unfortunately with these cases getting the tube is THE major problem before we consider any bronchoscopic intervention. Here are my pearls based on experience and cadaveric simulations: * Call for help: Patients with massive pulmonary hemorrhage die. Respect hemoptysis especially related to tumors or scenarios where there is an erosion into a vessel. They're ok until they're not and then its often too late, * Send someone to the chart/x-ray to get info as to which side the pathology is on * Raising the bed will help allow you to lift the epiglottis out of the pool of blood and see it more easily. * Do the Ducanto thing... SALAD * Hope that the disease is on the left. If you know this use a bougie and 1/4 turn to the right once (if) you feel clicks and place gently until holdup then go ahead with a BFT. As per the study quoted in this piece we have been able to consistently cannulate the bronchus of choice using a bougie in cadavers. * If you are not sure of the side they are bleeding from then we would suggest a poor man's isolation technique using a 7.0 ETT and intubating the RM bronchus either with or without a bougie. The left side can then be accessed with a bougie again by a 1/4 turn to the left once in the trachea and advancing until gentle hold up at ~30 cm and placing a second 7.0 ETT. Yes I know that a bronch won't like these tubes but otherwise there is no opportunity for subsequent therapy as the patient drowns. It's an awful death. You can block the offending side with a foley. * If bleeding is too much and SALAD etc approach fails... these patients die. One device that will be returning to the market developed here in Halifax is the lightwand and its the only device out there that will consistently be successful in a soiled airway.... IF YOU HAVE IT AND IF YOU HAVE EXPERIENCE WITH IT which most don't. It has saved my ass numerous times. * If you can't see from above then FONA is indicated use a small ETT 5.0 and push it too hilt will usually go to RM bronchus. You will either be able to oxygenate or divert blood so now you can put a second tube in if necessary from above. Used a 5.0 ETT because takes up less real estate for second tube to pass from above. * When your consultant comes down and complains about the size of tubes that are in place resist telling them to fuck off. Now on to the Wee...
July 25, 2017
So my friend Laura Duggan has been engaged in a multi-prong project to save lives through the dissemination of surgical airway information. We've previously discussed the airway app to collect data on front-of-neck-access. Now she is releasing a cric model that blows the old ones I used to recommend out of the water. You want one of these models... You want one to practice the moves of surgical airway at least once a month. Laura is not charging for this model, she is releasing it into the wild as FOAM. You'll have to get it 3d printed yourself--we'll tell you how Instructions for Printing 3D Cric Trainer Instructions Where to Print 3Dsmith in Canada 3Dsmith.ca Chris and Steve are brothers who own their small company They are awesome info@3Dsmith.ca get  formlabs standard resin as the material and it will resist scalpels beautifully! Shapeways for the USA shapeways.com Got my model Went with the strong & flexible plastic for $21.78 feel is rough but function is great Buy Kevlar if you plan on wearing this cric trainer CRL Cut Protection Kevlar® Neck Protector 99995 The Model (Send this to your 3D Printer) * Full Resolution Plans * Slightly Lower Resolution for Places with Upload Limits Go to Airway Collaboration Site * www.airwaycollaboration.org/ Matt Mac Partlin Has a Cardboard Model See the ETM/Vortex Version by Andy Buck (with a cool printable neck) Disclaimer If you decide to wear or have colleagues wear this, it is at your own risk. It is inherently dangerous to come at anyone with a scalpel Now on to the Wee...
July 24, 2017
I am joined again by my good friend, Joe Bellezzo, to discuss the nurse-led code. I've been doing this at my two shops for about a decade. Joe, along with his partners-in-crime Zack Shinar & Chris Ho, have set up a beautiful process for nurse led code management at their hospital, Sharp Memorial in San Diego. Stuff Mentioned in the Podcast * Here is the tactical-approach podcast from EDECMO.org * EMCrit Intra-Arrest Management Lecture * Podcast 191 - Cardiac Arrest Update The SBM Nurse Leader Responsibilities * Call forEpi q 5 minutes. Once a-line is in, decide on epi based on art line DBP
July 10, 2017
This stuff is not sexy and frankly, it hurts my head. That is all the more reason to do a show on the new landscape of NOAC reversal. We must pursue rather than avoid the subjects we are weak on. But I needed someone far smarter than myself--I needed a EM PharmD. Nobody better to speak about this topic than Nadia Awad. Nadia is associate editor of the Emergency Medicine PharmD Blog. She is an Emergency Medicine Pharmacist at the Robert Wood Johnson University Hospital in New Jersey. Laboratory Parameters for Monitoring Target-Specific Oral Anticoagulants * Hawes EM et al. J Thromb Haemost 2013; 11:1493-1502. * Cuker A et al. J Am Coll Cardiol 2014; 64:1128-1139. * Favaloro EJ et al. Semin Thromb Hemost 2015; 41:208-227. * Samuelson BT et al. Blood Reviews 2017; 31:77-84. Interim Analysis of Idarucizumab: REVERSE-AD * Pollack CV et al. N Engl J Med 2015; 373:511-20. Clinical Experiences Reported in Literature with Idarucizumab Following Approval by FDA * Reviewed on Emergency Medicine PharmD Fantastic Review on Idarucizumab * Miller et al. Use of Extracorporeal Measures to Expedite Elimination of Dabigatran in the Setting of Life-Threatening Bleeding * Awad NI et al. J Med Toxicol 2015; 11:85-95. Andexanet Alfa * Siegal DM et al. N Engl J Med 2015; 373:2413-2424. * Connolly SJ et al. N Engl J Med 2016; 375:1131-1141. Low-Dose FEIBA for ICH Induced by Factor Xa Inhibitors Mao G et al. JEM 2016 [Epub ahead of print]. Aripazine (PER977) AKA Ciraparantag * Ansell JE et al. N Engl J Med 2014; 22:2141-2142. * Ansell JE et al. Thromb Haemost 2017; 117:238-245. Recommendations for Reversal of ICH Induced by Antithrombotics from Neurocritical Care Society * Frontera JA et al. Neurocrit Care 2016; 24:6-46. Excellent reviews on Idarucizumab * Ann Emerg Med 2017;69(5):554 * EM Lit of Note Dosing Monoclonal antibody works within minutes Thrombin time and ECT are best monitoring, aPTT if stone-cold normal prob. rules out Dabi Package comes with 2 vials 2.5 gm each 5 gms is the initial dose Give each over 5 minutes Spike and hang vial give 2nd vial with 15 minutes of first (no reason not to give immediately) $4200 for both vials at Janus General Dabi lasts 12 hours in normal patients, and antidote lasts same ostensibly Kcentra Studies * RCT of Kcentra (Circulation 2013;128:1234)
June 25, 2017
I wanted to do a show on the basics of the blood bank and there was no better guest than Joe Chaffin, MD. He is the CMO of the Lifestream Blood Center and a pathologist with expertise in transfusion medicine. I first came across Dr. Chaffin due to his extraordinary blog and podcast at bbguy.org. He started BBGuy.org in 1998 primarily to teach pathology residents. Today, the site exists to help anyone who wants to learn the essentials of blood banking and transfusion medicine. His teaching includes humor, occasional irreverence, and clear communication to highlight your path to understanding complex topics. I've been an avid listener since its inception, so it was a great honor to get him on the show. At the same time we recorded this episode, I was interviewed for an episode of Joe's show. If you like what you heard here, check out that one as well: Ep. 33 of the Blood Bank Guy Essentials Podcast Topics of Discussion * What actually is a type + screen * What are you actually accomplishing with a crossmatch * What type of FFP is acceptable for massive/emergent transfusion (PMID:28452877) * Do we need to be type-specific with platelets * What INR is acceptable for procedures Episodes to Listen to Immediately on the BBGE Podcast * When to Transfuse Plasma * Intro to Apheresis * Treatment of TTP EMCrit Episodes Mentioned * Podcast 197 - The Logistics of the Administration of Massive Transfusion * Podcast 144 - The PROPPR trial with John Holcomb * Podcast 71 - Critical Questions on Massive Transfusion Protocols with Kenji Inaba Now on to the Podcast...
June 12, 2017
In Ep. 138, we discussed the basics of vasopressor and inotrope use. During that podcast, I promised we would go more in-depth in subsequent episodes--this is one of those that will fulfill that promise. Angiotensin II is a new (old) player on the field. To discuss this topic and more on vasopressors, I asked Dr. Mink Chawla to join me on the podcast. Conflict of Interest Disclaimer Dr. Chawla is the CMO of La Jolla Pharmaceuticals, the manufacturer of Angiotensin II Bio for Dr. Chawla Dr. Chawla is Chief Medical Officer of La Jolla Pharmaceuticals. Dr. Chawla was an Professor of Medicine at the George Washington University, where he had dual appointments in the Department of Anesthesiology and Critical Care Medicine and in the Department of Medicine, Division of Renal Diseases and Hypertension. Dr. Chawla was also the Chief of the Division of Intensive Care Medicine at the Washington D.C. Veterans Affairs Medical Center. During his tenure at George Washington, Dr. Chawla was the designer and lead investigator of a pilot study called the ATHOS (Angiotensin II for the Treatment of High Output Shock) trial.  Dr. Chawla was an active investigator in shock, inflammation and extracorporeal therapies, including: continuous renal replacement therapy, dialysis and albumin dialysis. Dr. Chawla is also the author of over 100 peer-reviewed publications and an Associate Editor for the Clinical Journal of the American Society of Nephrology. Dr. Chawla's Maryland CC Project Lecture * Link to the Maryland CC Project Video * Link to the Maryland CC Project Shownotes Article Mentioned Regarding IntraOp Hypotension * Walsh & Sessler et al. * Also Check out: (Intens Care Med 2018;44:811) Now on to the Podcast... Angio II Papers * The use of angiotensin II in distributive shock- * Angiotensin II for the Treatment of Vasodilatory Shock - NEJM - 2017-(Athos 3) * Angiotensin-II- More Than Just Another Vasoconstrictor to Treat Septic Shock–Induced Hypotension * ATHOS-3 protocol & editorial, CCR_Mar_17_text[1] * ATHOS-3_appendix * Chawla-ATHOS-Crit Care-2014-(Athos 1) * Clinical_Experience_With_Angiotensin_II Links of Interest * Vasopressor Basics Show * PulmCrit's Voodoo *
May 29, 2017
Hey Folks For episode 200 of EMCrit, my friend Rob Orman of ERCast interviews me on some non-clinical topics--you've been warned.
May 14, 2017
Today, I am joined by my buddy and pulmonary-critical care stud, Oren Friedman, to discuss the management of Massive Hemoptysis See More from Oren * Clot Management of Massive and SubMassive PE * Hemodynamic Management of PE Some Basics on Massive Hemoptysis * LitFL * First10 EM * Review by Sakkour on Massive Hemoptysis Intubate Big Localize C-XR, chart review, and initial bronch. Remember Oren's tip: if you get in there and can't find any bleeding, temporarily disconnect the vent Is it Amenable to Bronch Treatment? If not, Block; preferably at the segmental level Use a bronchial blocker, not a double lumen tube Uni Blocker EZ Blocker A poor 2nd choice is mainstem intubation Bougie for selective lung Then Get a CTA of the Chest Then go to IR for Bronchial Artery Embolization 95% of the lesions will arrise from the bronchial circulation. The ones that don't are PE, Pulmonary Art Catheter mishaps, and AVMs of the Pulmonary arterial circulation. If that fails, Surgery or ECMO Updates * Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018 Oct 12. pii: S0012-3692(18)32572-8. doi: 10.1016/j.chest.2018.09.026. Now, On to the Podcast...
May 1, 2017
Today, we discuss the topic of insulin pumps. Heralded as a huge advance in the management of insulin-dependent diabetes mellitus (IDDM), they also bring a bit more complexity to the mix. To sort through this confusion, I brought my friend Josh Miller (@glucosedoc) on to the show to discuss. Josh Miller, MD Dr. Joshua D. Miller is the Medical Director of Diabetes Care for Stony Brook Medicine and an Assistant Professor of Endocrinology & Metabolism in the Department of Medicine. He is dual board-certified in Internal Medicine and Endocrinology, Diabetes & Metabolism.  Dr. Miller has vast experience helping people with diabetes to conquer the challenges of living with the disease; he has been living with type 1 diabetes for over twenty years. He is an expert in insulin pump and glucose sensor management as well as the transition of care to adult endocrinology for young adults with diabetes. What we Covered Tell Us About Insulin Pumps * Settings (Basal, Bolus) * What can go wrong * How do we know if it is functioning * How to turn it Off * Site Infection--is this even an issue? * More on Insulin Pumps What do We do If Pt with PUMP has DKA? * Leave It on or * Supplement or * Adjust Settings or * Turn it off--if so how to take pt settings into account Basal Insulin in the Critically Ill * How much and how * Insulin Drip * Is Lantus Safe-how much and when Euglycemic DKA * what agents (SGLT2) * how to manage * See also RebelEM Hypoglycemia with a Pump from Josh: Hypoglycemia in a patient with diabetes on pump is multifactorial. If the hypoglycemia is so severe as to warrant admission, I would suspend or remove the pump. The patient should undoubtedly be assessed for insulin pump competency and diabetes self management skills. Acutely, patients should know how to temp basal or suspend the pump. Rarely would we treat through the insulin with dextrose and continue 100% basal delivery. If the patient is altered in any way, the pump should be suspended (by someone knowledgeable about pump function) or removed and an alternative SQ insulin regimen should immediately be pursued. The risk of course is forgetting the depot regimen and, once hypoglycemia resolves, causing ketosis. Take home point: hypoglycemia on pump = call endocrine immediately. Additional Info Br. J. Anaesth.-2016-Partridge-18-26 Now on to the Show...
April 25, 2017
So Josh's post yesterday (Rocketamine vs. keturonium for rapid sequence intubation) sparked much controversy and comment. I wanted to wade into the conflict, hence this wee. Rocuronium Administration-Prior to Sedative Administering roc as first drug is a variation of the timing principle demonstrated in a bunch of studies RCTs, here are 4 of them: * http://www.ncbi.nlm.nih.gov/pubmed/9195356 * http://www.ncbi.nlm.nih.gov/pubmed/9585312 * http://www.ncbi.nlm.nih.gov/pubmed/7923516 * https://www.ncbi.nlm.nih.gov/pubmed/21547177 The most effective way to administer the med is actually to administer the sedative 15 sec after the roc, but most do not go that far. An easier to justify method is: * Roc * Induction agent * Flush This is my method for etomidate or propofol. For ketamine, I prefer DSI-type administration. Listen to the Wee to Hear my Thoughts...
April 17, 2017
We've talked about the rationale of massive transfusion a bunch on the EMCrit show: * EMCrit Podcast 13: Trauma Resus II: Massive Transfusion * Podcast 71: Critical Questions on Massive Transfusion Protocols with Kenji Inaba * Podcast 144: The PROPPR trial with John Holcomb * Podcast 081 - An Interview on Severe Trauma with Karim Brohi * Hemorrhagic Shock Resus with Rick Dutton Let's talk about the logistics of the actual administration of a massive transfusion protocol in an exsanguinating patient. Some of the Stuff Mentioned in the Show * The Level-1 Rapid Infusion System * The Belmont Rapid Infuser Update Removal of needle free valves had dramatic effect on flow rates1 Now on to the 'Cast: 1. Khoyratty S, Gajendragadkar P, Polisetty K, Ward S, Skinner T, Gajendragadkar P. Flow rates through intravenous access devices: an in vitro study. J Clin Anesth. 2016;31:101-105. [PubMed]
April 4, 2017
Trauma Year in Review 2016 from SMACCdub by Chris Hicks and Andrew Petrosoniak The science of trauma resuscitation has undergone a fairly massive evolution in the past decade.  This talk was our attempt to summarize the best-of-the-best in trauma literature from the past several years, and package it into a series of clinically useful recommendations (i.e., our evidence-based opinions).  This talk was live peer reviewed by trauma surgery deity Karim Brohi, who gave us a thumb’s up (although you kind of had to be there). Here’s a run-down of our take-home points: Use the Clamshell Unless you’re a thoracic surgeon, consider the bi-thoracotomy as your initial approach to resuscitative thoracotomy. Don't operate in a hole – give yourself the best exposure, and the best shot at fixing the problem. * Ref: WJS 2013, 37: 1277-1285 * How-to guide: http://emj.bmj.com/content/22/1/22 Prognosticate with POCUS Point-of-care ultrasound (POCUS) has an ever-expanding role in trauma resuscitation, including prognosticating in cardiac arrest. In this study, patients with no cardiac activity and no pericardial effusion had no survival. * Ref: Ann Surgery 2015, 262(3): 512-518 Get with the Guidelines The EAST thoracotomy guidelines might be the most useful and evidence-based set of recommendations for the management of traumatic cardiac arrest yet. Bottom line: VSA trauma patients with penetrating thoracic injuries and an arrest time of < 10 minutes deserve a resuscitative thoracotomy – these are salvageable patients, and deserve an aggressive approach. * Ref: Critical Care 2013, 17:308, J Trauma 2015, 79(1): 159-173 * Compare and contrast – WEST guidelines (2012): http://bit.ly/2mFemtM Skip the Films Stable patients with a plan for CT imaging don’t need a chest x-ray or pelvis x-ray. Not all patients undergoing CT need the full “pan-scan”. In the middle are assessable patients with reassuring vital signs, POCUS +/- x-ray imaging: they can be admitted for observation, or discharged. * Ref: http://bit.ly/292tAUm * In the same spirit – local wound exploration for anterior abdo stab wounds can eliminate the need for CT imaging, admission: https://www.ncbi.nlm.nih.gov/pubmed/22182859 Crystalloids kill The paradigm of 1-2L of crystalloid boluses in hypotensive trauma patients is harmful and should be abandoned. If PRBCs aren’t immediately available, give small boluses (250 cc at a time) for patients with sBP < 70, altered mental status or loss of peripheral pulses. NICE guidelines restrict crystalloids to pre-hospital only. * Ref: BJM 2012; 345: 38-42, http://bit.ly/292tAUm Be Propper PROPPR PROPPR in a nutshell: A balanced ratio of blood products (approximating 1:1:1) is probably the optimal approach for patients who are bleeding to death; also, platelets are pretty important early in trauma resus. * Ref: JAMA 2015, 313(5): 471-482 Who Needs Mass Trans? Predicting the need for massive transfusion in trauma is tricky. Relying on gestalt alone is associated with under-resuscitation in about one third of patients, even when trauma experts are making the call. In tricky situations, use the ABC score or shock index to improve situation awareness. * Ref: Injury 2015, 46: 807-813, J Trauma 2009, 66: 346-352 Drop the dose Trauma patients in profound shock don’t need the Full Monty when it comes to induction agents for RSI. Even the all-mighty ketamine can have negative hemody...
April 3, 2017
Friend to the show, Jim DuCanto has been obsessed with SALAD. Not the leafy greens delicately touched with a tart emulsion, but with Suction Assisted Laryngoscopy and Airway Decontamination (SALAD). Jim DuCanto, MD  is an anesthesiologist extraordinaire with a constant drive to perfect new airway techniques and document them on video along the way. COI Statement Dr. DuCanto invented and receives royalties on the DuCanto Catheter from SSCOR and the Nasco SALAD mannequin Read More about SALAD from Taming the Sru * TtS Post Esophageal Diversion Maneuver (Intentional Esophageal Intubation) deliberately insert the ETT down the esophagus and gently inflate the balloon There is lit for this [cite source='pubmed']25943615[/cite] SALAD Park Maneuver Keep tip of suction catheter in the esophagus on the left side of the mouth SALAD Techniques Meconium Suction Set-Up Here was our original letter (J Clin Anesth, 23 (2011), pp. 518–519) (fulltext) It was recently validated (The Journal of Emergency Medicine Volume 52, Issue 4, April 2017, Pages 433–437) More Stuff * SALAD Facebook Page * SSCOR Site * Taming the SRU write-up of SALAD * DuCanto Suction Catheter * General Description of system and demonstration by Jeff Hill of the University of Cincinnati’s EM Program * Product page of SALAD Mannequin * University of Wisconsin HEMS Fellow with the “Static” Excercise * University of Wisconsin HEMS Fellow with the “Dynamic” Excercise * University of Wisconsin HEMS Attending takes on the SALAD Simulator * Check out the next level of SALAD—SALAD 2.0 * Listen to the JellyBean with Jim More from Jim DuCanto on EMCrit * Podcast 73 – Airway Tips and Tricks * A New Bougie for your Pocket by Jim DuCanto * A Guide to Intubating through the Intubating Laryngeal Airway * Two New Videos from Jim DuCanto * The Oxylator * More DuCanto and Pocket Bougie Videos * Two OR Intubation Videos * How to Custom Bend a Video Stylet for use with the Cookgas AirQ ILA
March 28, 2017
Read Josh's Post on the Metabolic Resuscitation of Sepsis first, then listen to this interview with Paul Marik: Note to Listeners: I took down the original version and put up this edited version. The only difference from the original is some additional comments added at 13:03 to give a more accurate perception of the current level of evidence of this therapy. Please, please read the Pulmcrit post listed above before listening. On to the Wee...
March 20, 2017
The Best Paper and the most amazing site Guidelines for Tracheostomy and Laryngectomy Emergencies (Anaesthesia 2012;67:1025) from the National Tracheostomy Safety Project (NTSP), the ultimate site for trach emergency management Bedside Signs Get the Tracheostomy Sign as double-sided sign for the bedside Get the Laryngectomy Sign as double-sided sign for the bedside Here is the version to edit your own signs Now on to the Podcast...
March 6, 2017
Not enough people are doing awake intubation in the ED or doing it as quickly as possible in the ICU. I have spoken about the technique many times on EMCrit. This lecture was specifically crafted for the EMCrit audience by my friend and airway guru, George Kovacs. I consider it to be the definitive discussion on emergent awake intubation. For the equipment links, go to the Rapid Sequence Awake Post Previous Podcasts on Awake Intubation * The original method (I've moved away from the teachings here with the availability of better equipment) * The Rapid Sequence Awake Intubation Awake in Halifax, Part I - An interview with Ian Morris, Anesthesiologist More Great Stuff from George Kovacs * Lights Camera Action: Redirecting Videolaryngoscopy (Guest Post) * Antifragile in EM by George Kovacs * George's Self-Intubation Sign up for REANIMATE4 REANIMATE Site Now on to the Vodcast...
February 20, 2017
At SmaccDUB, I got to debate my friend and head wizard of St. Emlyns, Simon Carley. Our topic was, Emergency Medicine (EM) is a Failed Paradigm. I took the pro side--it was a ton of fun. Take a watch and then tell me what you think in the comments section below. The St. Emlyn's Post Simon wrote a wonderful blogpost about the debate. The Slides Additional Links of Interest Graham Walker on "Emergentology: Don't Worry; We'll Handle It" Transcript (note-it is computer generated so many errors) EM_is_a_Failed_Paradigm The Video
February 16, 2017
I have a friend named, Ash. She is a nurse, a veteran, a prehospital/retrieval provider, and a... badass. She gave this talk at SmaccDUB. I loved it so much; I hope you do as well: Blurb Time tested rules and myths explored in a real life adventure, meant to honor and display the courage, commitment and sacrifice made by emergency medicine and critical care professionals around the globe. In a painfully honest reflection, Ashley crushes stigma and leaves us acutely aware of how our words and actions affect our colleagues and those that we love. The Talk
February 6, 2017
People have a tendency to blame powerpoint (or keynote) for the horrible presentations they are forced to sit through. But the slides are merely an external manifestation of a deeper problem, just like the teeth of a meth addict. For the past two years, I have been speaking at The Teaching Course in NYC. Two years ago, I gave a 60-minute talk on presentation creation (you can see that original talk below). This year, the course directors reduced my time to 30-minutes...resulting in a tighter and much better talk. That is what I am posting today. The Twelve Steps 1. Admit you have a problem 2. Choose your Topic and your Purpose 3. Create Brainstorming Spaces * Template for folders * Mindmap reference book 4. Choose a Structure 5. Add the flesh 6. Work the Transitions 7. Visualize the Visuals * Where to get Images from First10EM 8. Edit to Time 9. Mark the Stage 10. Create a "Handout" 11. Give it for Real 12. Do it Again Other Things mentioned in the Talk * Beyond Bullet points template * Recorder recommendations * Rich Borden Reference * How to Sequence a Talk * Ira Glass Quote * 10 ways to end your talk * Cicero rules for good talk * Lawrence Lessing talk * Multimedia Learning book * Slideument reference * Feedback form (see slides) * Brief Feedback form (see slides) * Using space information * Nancy Duarte Reference and this one * Presentation Zen * Scriptwriting: Story by McKee * Ed Tufte on Data Presentation * Posture Reference * Up resolution to PPT link * Screencast on how to save as jpg (pending) * Iskysoft Imedia Converter for Mac or Windows * Share your checklist (pending) * Good remote * Test slide The Rehearsals as elaborated in the Public Words Blog See the posts here: Rehearsals, Rehearsals * Rehearsal 1 is for content (I would recommend doing this one twice, once before powerpoint and once after) *
February 1, 2017
Politics not even going to bother writing anything here, my country has gotten so ridiculous. Why I'm Divorcing Twitter * The Hey Girl Meme * Feminist Ryan Gosling * I was going to post he twitter threads from the EMCritConf discussing the meme here, but looking back at them today, I see a ton of them have been deleted. It prob. would have been poor form to call any particular person out by name anyway as I am sure there were innocents amongst the guilty. The Intro to the EMCritConf 2017 - Full lectures will be posted on EMCrit soon Now on to the Useless Wee...
January 23, 2017
The team has done a bunch of stuff on cardiac arrest here on the EMCrit site: * Podcast 125 - The New Intra-Arrest (Cardiac Arrest Management) * EMNerd: The Tell-Tale Heart * Hemodynamic-Directed Dosing of Epinephrine for Arrest * The Future of CPR There has been a lot of interesting stuff that has come out since my SMACCgold talk. This podcast will bring you up to date on the crap running though my mind. Beware: very little evidence lies here. The Syndromes of Cardiac Arrest Refractory Vfib/Vtach (Electrical Storm) * Anti-Dysrhythmics See EMNERD's ALPS Post * Dual-Sequential Defib Amazing session on EMRAP by Zack Shinar (membership required) Study of Dual-Sequential shows early double better than single (Resuscitation. 2019 Jun;139:275-281) * Esmolol Driver et al. (Resuscitation. 2014 Oct;85(10):1337-41 PMID 25033747) 500 mcg/kg IVP, can add a drip starting at 50 mcg/kg/min See this great EMPharmD Post * Take them to the Lab * ECMO anyone? Vasoplegia Note:  I (we) have probably been misunderstanding this Vasoplegia, it is imperative you read this post (choosing the correct DBP); you should also probably listen to that podcast. * High-Dose Epi * Methylene Blue What's the dose? Who knows? I give 2 mg/kg (but not in pts on SSRIs) * REBOA * Junctional Tourniquet PREM/PRES We did an episode on this topic on the EDECMO podcast (ignore the ECG stratification stuff--since been debunked). Monitoring * ETCO2 * Cerebral ox * Ultrasound (preferably TEE) Time Zero Prognostication * What can we use?? * This retrospective study from France indicates that if the pt has the following 3: 1. OHCA not witnessed by emergency medical services personnel, 2. nonshockable initial cardiac rhythm, and 3. no return of spontaneous circulation before receipt of a third 1-mg dose of epinephrine then there was no RONF and the pts should be put on the donation path. (Ann Intern Med. 2016 Dec 6;165(11):770-778. doi: 10.7326/M16-0402. Epub 2016 Sep 13.  Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation) Blood Gases during Cardiac Arrest * From the book Cardiac Arrest * Study on Blood Gases during Arrest Nurse-Run Codes
January 22, 2017
Image Taken from the FOAMCast Episode We've discussed SEPSIS a ton on EMCrit. * Podcast 154 - Preemptive Sepsis Panel SmaccBack * Wee - Cliff Deutschman with Additional Thoughts on Sepsis 3.0 * Renoresuscitation: Sepsis resuscitation designed to avoid long-term complications * Podcast 112 - A Response to the Marik Sepsis Fluids Lecture * Podcast 169 - Sepsis 3.0 with Merv Singer * Podcast 89 - Lessons from the STOP Sepsis Collaborative Recently, the Surviving Sepsis Campaign released their 2016 guideline update. Overall, I think this iteration moves the guidelines closer to the best evidence out there. Of course, when you travel that path it forces a divergence from the distinctly non-evidence-based CMS guidelines. In this Practical Evidence Podcast, we will discuss the SSC guidelines, the aforementioned divergence, and various alcohol recommendations. I brought on my buddy, Jeremy Faust, to discuss the changes. Jeremy is 1/2 of the FOAMcast podcast which just discussed the new guidelines in a recent episode. Guideline Stuff * The SSC 2016 Guidelines * PDF Version of the SSC 2016 * Users' Guide to the Guidelines * Our Emergency Medicine Clinics Article The Guideline Recommendations The Definition of Sepsis They basically ratified SEPSIS 3.0 (Jeremy found where he saw the remnants of the old definition; it was in the Users' guide figure 2--super contradictory) Fluids 30 ml/kg in the first 3 hours Crystalloid first, then maybe albumin Use dynamic markers and/or fluid challenges Goal MAP>65 EGDT is no longer recommended Lactate attempt to normalize lactate Blood Cultures get them before antibiotics, if obtaining them will not delay the provision of antibiotics Antibiotics Within 1 hour of sepsis or septic shock Vasopressors Norepi is the first choice, add in epi or vaso Do not use dopamine Steroids 200 mg Hydrocortisone for patients who are still unstable after fluids and vasopressors Blood In most circumstances, use a trigger of
January 10, 2017
The first thing to understand about Hypertensive Emergencies is that they look like emergencies The second thing is in the short term, the only way to really fuck up non-emergent hypertension is by acutely lowering it too much Hypertensive emergencies, hypertensive urgencies, markedly elevated blood pressure--ugggh! Hypertension is a real annoyance in emergency medicine. Folks get scared of numbers and encourage dangerous behavior because of them. It's a bit better in the ICU, where there is a filter to keep out non-emergent hypertension cases. "Hypertensive Emergencies" are a whole different bag. In these conditions, the hypertension is usually secondary to the actual emergency. So I prefer to call these emergencies with a side of hypertension. Treatment Priorities 25% in the first hour * Pain * Inotropy/Chronotropy * Arterial Vasodilation The Meds * Labetalol * Esmolol * Nitroglycerin * Nitroprusside * Nicardipine * Clevidipine * Fenoldopam * Hydralazine Sucks The Emergencies ACS SCAPE * SCAPE Podcast Aortic Dissection/AAA *  Treatment of Aortic Dissection Ischemic Stroke * Stroke Podcast ICH or TBI aSAH * Management of SAH PreEclampsia/Eclampsia Hypertensive Encephalopathy/Malignant Hypertension a headache is not a hypertensive emergency unless the patient looks so bad that you are rushing her to CT Usually (but not always) will have papilledema Visual Changes, AMS, Confusion, Severe Headache, Coma Tox Sympathomimetic OD MAO Inhibitors Pheo Acute Glomerulonephritis Thyroid Storm * Thyroid Storm Podcast Want More Info? * Great Htn Review Article from Paul Marik * Fantastic post from the Strayer Now on to the Podcast...
December 28, 2016
Some topics that have been batting around my head over the past few months: The Secret Sixth Cause of Arterial Hypoxemia You should know the standard five: * V/Q Mismatch (Deadspace) * Low FiO2 * Hypoventilation * Diffusion Abnormality * Shunt (Usually Physiologic) but the sixth cause can be particularly dangerous with cause #5, the physiologic shunt. The sixth cause is Low Mixed Venous Saturation (SvO2). &nbsp; Pure Vasoactives It ain't phenlephrine anymore Dissociated Awake for Critical AS/Pulmonary Hypertension just keep loving this more and more. See the hemodynamically neutral intubation podcast for the final version of this idea. Now on the the Podcast and Happy New Year...
December 12, 2016
This is part II of the Brindley Sessions on Rudeness. If you haven't yet, you should listen to Part I: Brindley Session I - On Rudeness In this podcast, we discuss some more concrete approaches to dealing with rudeness. I also had a chat with Paul Jhun on these issues with the ALiEM wellness thinktank. Some Things We Mentioned Vic Brazil's Tribalism Talk Timing, Tribes, and STEMI from SMACC Gold and the book she mentions: Very Rough Sketch of the EM Culture Requests for Folks Visiting our Department * Be Polite * Be Kind * Be Open Minded * Be Communicative * Be Non-Accustory - errors should be looked at as an opportunity to discuss, learn, and make things better in the future Links of Interest * Seems these issues are going on in the UK as well Buy a Ticket to the EMCrit Conference * EMCritConference Site Now on to the Podcast...
November 28, 2016
So we've discussed hyponatremia a ton on the blog site. That's because hyponatremia has become a little bit sexy. Not so with sodium that is too high. But I've seen a bunch of less than ideal management of hypernatremia, so I figured it is time to put out a podcast about it. This is mostly so I have a place to go to look all of this up. Join us at the EMCrit Conference Jan 11 2017 EMCrit Conference Site Articles * Androgue-Madias from NEJM * Hypo and Hypernatremia in the Crit Ill * Hypernatremia in the Critically Ill Read this Book * Joel Topf is of PBF is 2nd author of an excellent fluids and electrolyte text. He has released it for free on the Precious Body Fluids Blog How do you become Hypernatremic Loss of free water and/or Loss of hypotonic fluid and/or Increased Solute and thirst or access to water must be thwarted Hypernatremia Results in... * Impaired glucose metabolism * Rhabdo * AMS * Seizures Avoid Iatrogenic Complications Cerebral Shrinkage is Bad Causes of  Hypernatremia Extrarenal water loss * Dehydration by exposure * Burns * Gastric losses * Diarrhea (Lactulose) * Fever Salt gain * Infusion of sodium-rich fluids of some sort (eg. hypertonic saline) * Ingestion of sea water * Salt pica Nephrogenic DI * Hypercalcemia * hypokalemia * Lithium * Pyelonephritis * Medullary sponge kidney * Multiple myeloma * Amyloid * Sarcoid Central DI * Traumatic brain injury * Pituitary tumour * Meningitis * Encephalitis * Tuberculosis * Sarcoidosis * Idiopathic * ICH Renal losses * Glucosuria * Mannitol * Urea therapy * Loop diuretics * Post obstructive diuresis * Hyperaldosteronism * Cushings This table stolen directly from Deranged Physiology (primarily b/c I hate making html tables) Chart of Figuring Out What the Hell is Going On from Lindner et al article linked above Treatment Stop or Correct the Underlying Cause Correct Quickly if Na got high superrapid-style (Idiots drinking a quart of soy sauce) Correct < 10 meq/day (< 0.5 mmol/L/hr) if the Na went up gradually (2-3 mmol/L/hr if rapid rise in sodium) Oral/Gastric Tube is the safest way to correct Administer Hypotonic Fluids (D5W, 1/4 NS, 1/2 NS, sterile water (central line)) Do not administer NS unless pt is HYPOVOLEMIC (NS doesn't work!!!; see Androgue-Madias for mathematical demonstration of this)
November 13, 2016
So you have an unresponsive patient. The CT is negative. What now? Coma is tough! The differential is long and filled with many life threats. Today, I talk to Eelco Wijdicks about some specific questions regarding the evaluation of the comatose patient in the first few hours in the ED or ICU. Eelco Wijdicks MD PhD is Professor of Neurology and Chair of the Division of Critical Care Neurology and currently practicing in the Neurosciences Intensive Care Unit at Saint Marys Hospital (Mayo Clinic Rochester). He is the founding editor of the journal Neurocritical care, the official journal of the Neurocritical Care Society.He has over 650 research papers,book chapters,topic reviews and editorials to his credit. Join the RLA Resus Leadership Academy Eelco's Book The Comatose Patient Coma Differential from Eelco's review article below Legend: Initial thoughts on coma in the ICU. This algorithm is a simplification of clinical practice. Localization and withdrawal motor responses are most probably not associated with brainstem involvement, and therefore the dichotomy is made. Once abnormal brainstem reflexes are found, two options are likely—acute hemispheric mass or acute brainstem lesion. Bihemispheric injury is structural or physiological and further differentiated into specific locations and suggestions for tests. ABG arterial blood gas, CSF cerebrospinal fluid, CT computed tomography, CTA computed tomography angiography, EEG electroencephalogram, SAH Subarachnoid hemorrhage The Coma Neuro Exam * Carefully examine the eyes (Vertical Skew, Anisocoria, Eye Movements) * Check Brainstem Reflexes * Check Tone * Assess the FOUR Score Full Outline of UnResponsiveness (FOUR) Score FOUR Score Handout from the Mayo Coma Review Articles * Eelco's Amazing Article on Coma Basics * Traub-Diagnosis and Management of Coma * Why you may need a Neurologist to see a Comatose Patient in the ICU Now on to the Podcast...
October 31, 2016
Way back in episode 60, I discussed the chemical takedown. My buddy Reub Strayer blew that podcast away with his lecture at SmaccDUB. This lecture was note-perfect and enhanced by Reub's inimitable presentation style. I know you'll enjoy it. For more Strayer goodness, head on over to the EMUpdates Site. Slides Now on to the Vodcast...
October 26, 2016
The Brindley sessions brings the brilliance of Peter Brindley to the EMCrit Podcast. Our first topic of conversation is rudeness and its ill effects on the medical team. Peter gave a great lecture on this topic at SmaccDUB, but I wanted to hear more. Part II on Rudness is now up as well Dr. Peter Brindley Peter Brindley MD, FRCPC, FRCP (Lond), FRCP (Edin), Full-time Critical Care Doc from the University of Alberta Hospital. To the surprise of many (himself included) he is a Professor of Critical Care Medicine, Anaesthesiology, and Medical Ethics. He has authored 90 peer-reviewed manuscripts, 25 book chapters, 50 lesser manuscripts, and has two textbooks pending. He has given over 300 invited presentations in 10 countries, and over 30 plenaries. He was a founding member of the Canadian Resuscitation Institute; and was perviously Medical-Lead for Simulation, Residency Program Director, and Education Lead at the UofA. He has advised the Canadian Patient Safety Institute, and the Royal Colleges of Canada and of Edinburgh. There are many better speakers, but none happier to be here. He welcomes questions; comments and especially disagreements: after all he doesn’t wish to be wrong a moment longer than absolutely necessary. Some Studies & Papers * RCT of the effects of rudeness on team performance (CoreEM discussion of this paper) * Improving Verbal Communication in Critical Care * Improving Teamwork * Questionnaire Study on Rudeness * More Rudeness * McLuhan on the Medium is the Message Verbal AiKiDo aka Dealing with Assholes Psychologist Albert Bernstein recommends these three tips: * Say, "Please speak more slowly, I’d like to help" or some variation thereof. Doesn't matter if they are already speaking slow as molasses. * Ask, "What would you like me to do to make this better." or ANY other question. Questions short circuit the anger cycle. * Let them have the last word See more from this post Rudeness Affects Team Performance as well Pediatrics. 2017 Jan 10. pii: e20162305. doi: 10.1542/peds.2016-2305. Rudeness and Medical Team Performance. Now on to the Session...
October 21, 2016
Recently, I wrote an article for the Annals of Emerg Med on initial mechanical ventilation settings in the ED. Two letters to the editor were sent regarding the article. As usual, the number of words I was given to respond to these letters was grossly inadequate. So the replies the letters deserve are posted in this wee. The Original Annals Article * mech-vent-article The Letters to the Editor * Letter One * Letter Two Some Articles of Interest * Breath Stacking Dysynchrony (Beitler, J.R., Sands, S.A., Loring, S.H. et al. Intensive Care Med (2016) 42: 1427. doi:10.1007/s00134-016-4423-3) * Lung-Protective Ventilation With Low Tidal Volumes and the Occurrence of Pulmonary Complications in Patients Without Acute Respiratory Distress Syndrome: A Systematic Review and Individual Patient Data Analysis. (Crit Care Med. 2015 Oct;43(10):2155-63. doi: 10.1097/CCM.0000000000001189.) * Chatburn - A taxonomy for mechanical ventilation Now on to the Wee...
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