Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation
Here's the Latest Episode from EMCrit Podcast – Critical Care and Resuscitation:
Dexmedetomidine (Precedex) - You'd have to be Delirious Not to Use It -
Chris Hicks and I discussing the Labors of Trauma (Blunt edition), everything a trauma team leader needs on their radar screen.
Where do the fights come from?
When should you pull the trigger on Angiotensin II for vasodilatory shock?
Ultrasound signs of pericardial tamponade with my buddy, Jacob Avila
I frequently see both residents and attendings inappropriately using ketamine for agitated patients. Inappropriately both by giving it when it is unecessary and giving it in poor fashion when it is indicated.
The complete (hopefully) menu of cognitive and operational tasks for the Trauma Team Leader for sick trauma patients.
COVID Pulmonary Physiology
Rapid Code Status Conversations are essential to render proper and compassionate care...
A Q&A format discussion of neurological emergencies
Cliff Reid on Team Leadership
Today on the podcast, my guest lays out a theoretical framework for the pathophysiology of the lung effects of COVID-19.
Inhaled Pulmonary Vasodilators
RV Failure and how not to kill patients when they have it...
Including the Intubation-Monkey Checklist
cutting edge info on COVID19 management
A zentensivist discussion of ventilator management
A Primer on APRV - TCAV, perhaps the mode of choice for COVID19
as of 3 APR 2020
You need a plan right now for the allocation of scarce resources
not NC at 6lpm then tube
Will be updated as new info comes in...
additional COVID airway management thoughts
Patients can become neurologically injured or code with no overt signs
High Sensitivity Troponins are coming
Our ECPR is different...
Midlines part 2 with @emnerd
A case as a means of discussing severe CCB and BB OD
The VEXUS Score - A way to quantitate how badly you overloaded your patient...
Midlines can change your vascular access practice
Who should we thrombolyse during cardiac arrest?
Thoughts on a recent NEJM review on upper airway obstruction
Taking Cardiogenic Shock Management to the next level...
Should hospitals stock Andexxa?
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 ROSCPOCUS PulseCarotid POCUS PulseBadra et al. on POCUS PulseNarrow / Wide doesn't WorkRory 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 BPProsen on Vasopressin for PEACritical Care and Neurocritical Care Boards Review BookMayo Clinic Board ReviewJust fantastic! (Note: i received a reviewers' copy of this book)UpdatesMore on PEA on the EM Cases Blog - I speak with Anton Helman on the topicThe Right Heart being Big doesn't mean PE during Arrest (from Ultrasound Podcast)Now on to the Podcast...
A polite discussion about a controversial post
Some dozen years ago, a couple of my buddies and I created the RUSH exam. Today, I give you an update:
Pigtails are just plain nicer
Central Line Tips and Tricks
dedicated to my friend, George Kovacs
Are you a people-oriented or care-oriented resus doc?
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 ResponseThe website is www.global-response.org Instagram global.response Facebook Twitter @GRM_GlobalVolunteer 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...
More Philosophical Ramblings...
A video version of the rebellion's attempts to overthrow the STEMI Empire
How to make your M&M conference important and useful
Lessons learned from teaching hundreds of people to cric
All the dope on Dissociated Awake Intubation using Ketamine
A swerve from typical content
Tension pneumothorax is actually 2 diseases
We've been doing it all wrong--mysteries solved thanks to PO Berve
New evidence on who needs to go to lab after cardiac arrest
ED Nephrology with the Kidney Boy, Joel Topf
New stuff on sepsis resuscitation for 2019
Renal Compartment Syndrome, Venous Congestion, CHF, and POCUS.
All things Vent Alarms
GTD Update for 2019
EMCrit 238 - Medical Error Epidemic Craziness with G. Gianoli. Medical Error is the 3rd leading cause of death in the US--or is it?
More on Vents
Approach to steps of laryngoscopy/intubation
Cardiac Arrest Science
Are you saying?...
Remixed and Better for 2018
Stay or Go with Cardiac Arrest in the Field?
How to use the cric models and optimal surgical airway technique.
Precise Resuscitation Communication is crucial for patient safety
drum roll please...
The verdict is in...
Is it safe to use beta-blockers in cocaine toxicity and is that even the questions...
Physiology-Guided Cardiac Arrest Management in 2018 with Dr. Robert Sutton
A refractory anaphylaxis case presented as a mock trial
Bicar-ICU changes my practice with bicarb infusions and let's end the great lactate debate on EMCrit 227:
A discussion of bougie-first, bougie best and hopefully a summary of proper positioning
The real scoop on toxidromes
Part 2 of DIC vs TTP - Treatment
please read this post--if you care about your practice and your patients
Low platelets in the Critically Ill Patient--TTP, DIC, MAHA
Yannopoulos on ECPR
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. SchtuffThe EM Cases Podcast that partially sparked the debateJustin Wrote an Additional Post after our DiscussionOn Parachutes and SuchOn to the Wee...
Part II on Airway and Breathing in Burns
Beat The Stress Fool!
Burns Part I - Fluid Management
Physostigmine for Anticholinergic toxicity
what's going on with the EMCrit Project
So in prior posts, I have discussed the jerry-rigged "ultimate" BVM. But there is a better way--the creation of a manufactured BVM that helps us not kill patients.It would have the following characteristics: Facets of the Ultimate BVM Now on to the Vodcast...
Even better than Hemodynamic Kills
Get ready for ADRENAL
Dantastic Mr. Tox/&Howard discuss some Tox stuff and Santa Beards
Advanced uses of ultrasound to assess volume status
Issues with pts in the ED without an inpatient team yet
Intubation is failure!
My thoughts on the recent interview with Anders Ericcson
Why can't we all just get along
Expertise & Deliberate Practice with Anders Ericsson and @resuspadawan
Part 2 on Art Lines
All things Arterial Lines-Part 1
I need help...
More on GTD
You are doing CPR wrong
Acid Test your Resus
The next in the microskill series
ApOx & PreOx Update
An update on push-dose pressors
The new amazing cric trainer
Nurses should be leading cardiac arrest management
New agents for Reversal of NOACS
blood bank stuff: The basics of crit care transfusion medicine
A new vasopressor is out there--angio II
My friend Rob Orman Interviews Me for Ep. 200
Management of Massive Hemoptysis
Scared of insulin pumps--not anymore
More on rocketamine...
The hands-on of orchestrating a massive transfusion protocol
The sick and the dead from SMACCdub
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 SruTtS PostEsophageal Diversion Maneuver (Intentional Esophageal Intubation) deliberately insert the ETT down the esophagus and gently inflate the balloonThere 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 TechniquesMeconium 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)Large Bore Suction Surrogate Wanted to run something by you. I'm an EM-3 in Cleveland at University Hospitals rotating up in the CT-ICU at my institution with a CA-2. We were just fooling around with mechanisms to make large bore suction improvisation kits, and stumbled upon a VERY good one I didn't see on your site. 7.0 ETT with the adapter pulled off. Hook that up to suction EXTENSION tubing with the little white plastic adapter that comes with the extension tubing. Connect that tubing adapter directly to the 7.0 ETT on one end, and the tubing it is meant for on the other. Should have a small gap of that adapter bridging between the tubing end (traditionally a blue end I believe) and the ETT. Doesn't work with larger bores we found out. Easy as that. Drained 750cc of fluid in less than 3 seconds on repeat testing with continuous suction. No meconium aspirator needed (for those working in the community), and because it is an ETT, there is the built in hole at the end of the tube to prevent suck down events onto tissue in the oropharynx.-Chris Peluso ( firstname.lastname@example.org ) SALAD ComicMore StuffSALAD 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 JimMore from Jim DuCanto on EMCritPodcast 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 ILAimage at the top from J Downham Now on to the Podcast...
Edited interview with Paul Marik
Podcast 194 - The Definitive Emergent Awake Intubation Lecture by @kovacsgj
Yep, EM is indeed a failed paradigm
Ashley crushes stigma and leaves us acutely aware of how our words and actions affect our colleagues and those that we love
The slides are not the problem...
if you still want to listen after reading the title
Cardiac Arrest Update & the Syndromes of Arrest
SSC 2016 Guidelines
Hypertensive emergencies look like emergencies!
A brain dump at the end of 2016
Brindley Session 2 - continuing the rudeness discussion
Hypernatremia -- not sexy, but we gotta get 'im done
How to Diagnose and Manage Coma
Danger, Disruption, and Reub Strayer
The first Brindley Session is on Rudeness
Response to letters to the editor on mechanical ventilation article
The needle vs. knife debate rages on, but it looks like the knife may be winning
Driving Pressure with Dr. Roy Brower
Pulmonary Hypertension and Acute on Chronic RV Failure
A slight diversion to discuss how to argue better
Today, I am joined by my friend, Mike Lauria, to interview Gary Klein, PhD. Dr. Klein is a masterful cognitive psychologist. He is known for many groundbreaking works, including: the Recognition-Primed Decision (RPD) model to describe how people actually make decisions in natural settings; a Data/Frame model of sensemaking; a Management by Discovery model of planning to handle wicked problems; and a Triple-Path model of insight. He has also developed several research and application methods: The Critical Decision method and Knowledge Audit for doing cognitive task analysis; the PreMortem method of risk assessment; the ShadowBox method for training cognitive skills. He was instrumental in founding the field of Naturalistic Decision Making. The Books Sources of PowerThis is the one that got Mike and I started as Klein Fanboys Streetlights and ShadowsThe absolute best compilation of Dr. Klein's decision-making concepts that are directly applicable to medicine Seeing What Others Don'tNext up on my reading list Recognition Primed DecisionmakingWikipedia Link for RPD Sites and LinksDr. Klein's Company Shadowbox TrainingArticles Mentioned in the ShowKahneman D, Klein G. Conditions for intuitive expertise: a failure to disagree. Am Psychol. 2009 Sep;64(6):515-26. Can We Trust Best Practices? Six Cognitive Challenges of Evidence-Based Approaches. Journal of Cognitive Engineering and Decision MakingAdditional Related StuffEffect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. Effects of reflective practice on the accuracy of medical diagnoses. Going fast might not induce more error, it's about experience and if you have the patterns to recognize: Disrupting diagnostic reasoning: do interruptions, instructions, and experience affect the diagnostic accuracy and response time of residents and emergency physicians? Slowing down doesn't help. Slow is just slow. Smooth is FAST, and smooth is about economy of cognitive resources and movements The relationship between response time and diagnostic accuracy. The etiology of diagnostic errors: a controlled trial of system 1 versus system 2 reasoning. The Checklist Manifesto: How to Get Things Right Descartes' Error: Emotion, Reason, and the Human BrainNow on to the Podcast:
No more bougie hold-up for scalpel-finger-bougie cric
Rapid Sequencing of Awake Intubation
What to actually do (besides nothing) for severe hyponatremia
NC: yea or nay
Team Performance from Chris Hicks
The seven folks that ruin your day...
The new improved version of the EMCrit RSI checklist
My opening talk at SMACCdub was on meditation: vipassana and stoic negative contemplation. It will be available in the next few months. Hopefully this wee will tide you over.
Fluids in Sepsis
Banging -- My -- Head -- Against -- Wall -- Repeatedly...
Laryngoscope as a Murder Weapon - Oxygenation Kills Part II
Laryngoscope as a Murder Weapon - Oxygenation Kills, Part I
G+ is dead, long live reddit
Yes, you can trust medical podcasters
the BVM is the most dangerous device in medicine--let's do better
Slow is Smooth, Smooth is Fast. Now, get faster
I want the perfect external mind palace...
Resuscitation is a System I Game...
Resuscitative REBOA is interesting, but was probably too complex for Resus Doctors--well not anymore!
More on Sepsis 3.0
Hear from the lead author of the new Sepsis 3.0 definitions
The USA's first stand-alone EDICU, the EC3
Sara Gray is amazing--hear her talk about ED Critical Care from @smaccteam:
Endocarditis in Acutely Ill Patients
How to have an end of life conversation in the ED
An amazing story from Mike Mallin
ART Program and FEMinEM Hangout
A response to some DSI questions in the Annals
You saved a life or blew an airway--Now What? Handling the post-resuscitation on EMCrit # 163:
yep, more on fluid responsiveness
Fluids, Sepsis, Ultrasound, French-Canadian: what more do you want?
An all-star panel of world sepsis experts discuss the controversial areas
Rounding on critically ill patients in the ED
Matt Semler, MD and colleagues performed an RCT on Apneic Oxygenation in Medical ICU patients
Part II of the Central Line Series discusses placement tips
A break down of the skills needed for Seldinger technique
Stop Effing Up Your Central Lines
It seems simple, but not treating this situation with respect can lead to disaster.
Tom Bleck on Status Epilepticus
A preemptive smaccback on the SMACC Chicago Sepsis Panel
In Memory of Our Friend, John Hinds
HFNC--the new hot thing or just blowin' hot air?
Jim Miner discusses the fine points of ED/ICU procedural sedation
Can't believe we made it this far...and it's all thanks to the emcritters!
When hyperthyroidism goes really wrong...
A whole bunch of stuff
More on the recent cric case from the perspective of airway decision making
An amazing surgical airway case
Finally in one place, all of the STEMI equivalents with Steve Smith--Part II
Finally in one place, all of the STEMI equivalents with Steve Smith
How to cool the too hot tox patient
Awake Intubation from SMACC 2015
The RLA and Resus Graphs
The biggest news in the management of traumatic hemorrhage is the PROPPR Trial. Want to hear from the lead author?
Hemodynamic Management of Massive PE
In this 3rd post for JanuAirway, I am joined by airway educator extraordinaire: George Kovacs.
It's Janu-Airway: Here's a little update on preox (you know the topic I think about 20 hours a day)
A case of anatomically and physiologically difficult airway presented live at #EMCritConf 2015.
Welcome to our annual rehash of the goodness of the past year.
Can we manage pain more effectively without Opioids?
There is a ton to speak about regarding vasopressors, but before we get to the edge cases, we need to set-up a foundation.
Not quite ED Critical Care, but I hope this discussion of EM/Resus Productivity may be helpful to some of you out there.
John Hinds on Blunt Traumatic Arrest
Smells like some confirmation bias here
the Arise Study (Australasian Resuscitation In Sepsis Evaluation) and Severe Sepsis Care in 2014
London HEMS docs peform REBOA and save a life
Need access--this may be a way
Today, I interview Mike Lauria on the concepts of toughness and resilience.
Should we be extending ACLS in patients we really want to save?
Today on the podcast, I address the last little bit from my SMACC lecture on the new management of the intra-arrest: hemodynamic, individualized dosing of epinephrine.
You'll be hearing more from Mike
This is the another of the Laryngoscope as a Murder Weapon lectures; though in this case it is really more of an aggravated assault.
We now have way too many treatment options for sub-massive and massive pulmonary embolism (PE) patients who aren't coding in front of you. How do you decide which one is right for your patient? To help answer this question, I am joined today by Oren Friedman, pulmonary critical care doc and one of the members of the Cornell PEAC team. Cornell Pulmonary Embolism (PE) Advanced Care Team (PEAC), aka the CLOT Team Oren Friedman MD, Pulm Crit Care; James Horowitz MD, Cardiology; Arash Salemi MD, Cardiac Surgery; Akhilesh Sista MD, Interventional RadiologyYou can shoot the team an email: peadvancedcare at gmail dot com Who Should We Treat? Wood 2002 PE Mortality Curve30% normotensive patients have RVD; 10% progressed to shock; 5% in hospital mortality[cite]10859287[/cite] The Better Risk Categories for Pulmonary EmbolismWell and Stable Sub-Massive High-Risk Sub-Massive MassivePEITHO Trial NEJM 2014;370(15):1402Full dose tenecteplase with concurrent heparinDeath or hemodynamic decompensation occurred in 2.6% of the tenecteplase group as compared with 5.6% of the placebo group Extracranial bleeding occurred in 32 patients (6.3%) in the tenecteplase group and 6 patients (1.2%) in the placebo group (P0.06 ?g/L or troponin T >0.01 ?g/L. These may be relatively inclusive thresholds. Not all placebo patients developing hemodynamic collapse received subsequent thrombolysis; likewise, almost half of those who received open-label thrombolysis had no hemodynamic collapse. Half the deaths in the placebo arm were “sudden unexplained” or “other”, compared with bleeding or stroke complications in the thromboysis arm.TOPCOAT Trial Jeff Kline's trial was stopped midway through due to an institution change. Complicated primary endpoint with promising, but unusable results [cite]24484241[/cite]For the scoop on this one see the Bottom Line Review post on TOPCOAT MOPETT Trial Half-dose alteplase led to a marked reduction in pulmonary hypertension without sig. complicationsSharifi M et al. Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT trial). (J Cardiol 2013; 111: 273)See this prior EMCrit Wee as well on MOPPETTUpdate: This meta-analysis states that the half-dose may be appropriate, effective, and safe [cite source='pubmed']24412030[/cite] Meta-Analysis Chatterjee et al. have the most current meta-analysis on this topic (JAMA. 2014;311(23):2414-2421)See the Bottom Line Review post on this studyNakamura just published another MA this week; see Rory Spiegel's take on the two here Is it just in the Oldies? Markedly lower risk in
BVMs are ridiculously crappy and downright dangerous. The solution? the Oxylator
The First SMACC-Back from SMACCgold
In this episode, I speak with Niklas Nielsen on his thoughts on the TTM trial.
I told you today we would have a bit of discussion on Rob Mac Sweeney's FOAM. Well here it is...
Rob Mac Sweeny on the Intra-Arrest Talk
Should we err towards errors of commission or omission?
Enough with cook book medicine and courses for dermatologists--let's provide cutting edge intra-arrest care
My favorite part of SMACCgold; buy some Cricolol
Proning is one of the only evidence-based techniques to affect the mortality of ARDS patients. I've been wanting to do an episode on proning for a while.
I talk with a member of the surviving sepsis campaign steering committee re: ProCESS
What if you had a REBOA catheter through which you could give blood and drugs?
Rob Bryant presents a case
What is the proper care for a patient in cardiac arrest or shock after smoke inhalation if they don't have severe burns?
This episode, we discuss REBOA (resuscitative endovascular balloon occlusion of the aorta).
I speak to the lead author of the ProCESS trial, Dr. Derek Angus
There is a really smart anesthesiologist out there called Nicholas Chrimes. He along with his mate Peter Fritz invented the Vortex Approach to Airway Management. He also runs a blog called Clinical CrEd.He did a post advocating the Mapleson B Circuit as the Ultimate Preox DeviceWhat is the Mapleson B? The Mapleson circuits were used for anesthetics in the good old days. At least in the US, we have move to bigger, and arguably better designs for our operative patients. Many would have thought this device would have been consigned to the trash heap, but seemingly not.from anesthesia 2000My Recommended Approaches I recommend two approaches to preox: standard and shunt physiology strategies. I outlines these strategies in the paper Rich Levitan and I wrote.Standard: NRB @ >=15 lpm and NC @ 10-15 lpm for 3 minutesShunt Physio: Choose 1BVM with PEEP Valve & NC @ 10-15 lpm NIPPV Ventilator with NIPPV Mask or BVM Mask & NC @ 10-15 lpmNick makes a number of arguments as to the superiority of the Mapleson circuit over these standard techniques. His points are excellent, but I disagree with pretty much all of them--I think it becomes a question of perspective. Automatic Checking Yes, using the same device for reox and preox makes sure the reox device is there and hooked up, but this for me is an inadequate argument to dispense with NRB/NC set-up. Multiple BVM Masks We don't have these readily available in any ED or ICU I've worked in. We have neonate, peds, and adult. Our masks also are not inflatable. PEEP PEEP is good, Mapleson may or may not be a good way to provide this for the reasons I've mentioned in the wee, but a BVM with a PEEP valve or a vent are at least as good. ApOx Mapleson may provide this better than BVM, but not as well as a NC, which should be on during any intubation. ETCO2 No advantage of Mapleson Low resistance Maybe this matters, as soon as you put on the PEEP, I can't imagine this difference persisting Room Air Entrainment Release your seal for even one breath and you have blown denitrogenation. Always, always use a strapped system if possible=NRB/NC, NIV mask, or BVM mask with OR straps. Troubleshooting Leaks This is the real area in which Nick and I differ. Nick makes the point that a good seal in preox guarantees a good seal in reox--this may be true, but it is unimportant. What I care about is does a bad, one-handed seal in preox mean I won't be able to reox with the BVM--this is entirely untrue. If I did to an awake patient what I will do to them when asleep and desaturating, they would, quite rightfully, punch me in the face.Anesthesiologists should use Mapleson B/C; ED/ICU should only use BVM +/- PEEP Valve with two hands and oral airway and a rocking triple maneuver (that no pt should experience if they are conscious) otherwise they should be NIV mask with straps or (BVM mask with straps).This is the same reason I tell my residents to just train with Macintosh blades.Primary and secondary leaks are the main thrust of Nick's love for the old-timey circuits. But all of us have appreciated this easily by squeezing the bag-valve-mask: Easy-squeezy or Hard SqueezyETCO2 with a monitor you can see Is he holding or squeezing? I can feel compliance with a BVM if I squeezed it, but I don't unless the pt needs it during reox. But are they squeezing the Mapleson? If they are, they may be doing damage. This study (Anesthesiology 2014;120:326) talks about the myths of Gentle Facemask Ventilation:>15 cmH20 may be entraining gas into the stomach via the LES (in some patients, even 10 cmH20 may be a problem)UES will withstand at least 20 cmH20 until NMB at which point again 15 seems to be the number (The latter is why we don't bag during apnea unless we have to) Two hands ALWAYS on the mask Recently, I spent 2 weeks intubating 10-15 patients per day. One hand mask skills got better and better--all for naught.
Rich Levitan on Surgical Airway from EMCrit/ISMMS 2014 Conference
Cliff Reid joins me for the 1st EMCrit book club on the book, On Combat by Dave Grossman
This one is really good!
If you are an EM:RAP listener, you have probably heard Mel Herbert's story of 2 cars crashing right outside of his house. Mel realized he did not stock a medical kit in his house with the necessary crucial supplies for an emergency scene. I realized I don't either (there is one in my car). So, I reached out to the master of preparedness, Dr. Keith Conover.
Dr. Andy Jagoda debates my friend Dr. Anand Swaminathan on the use of tPA for Ischemic Stroke in the Emergency Department
What you do in the ED for post-intubation sedation will determine whether your patient lives or dies
Best of 2013
Part 2 of an interview with Stephen Bernard on the Care of the Post-Arrest Patient in 2013
Dr. Stephen Bernard on the topic of post-arrest care
Last week I posted a lecture by Paul Marik on Fluid Management in severe sepsis. The lecture is the equivalaent of a bucket of ice water poured over your head. Now let's give you a towel and discuss.
More on TTM Trial
Cold, but not all that cold may be the way
Our favorite critical care skeptic, Dr. Paul Marik, on fluids in severe sepsis
A SMACC back on Simon Carley's talk on Educational Leadership
Management of Severe Hemorrhage from Mid-Face Blunt Trauma
Management of asymptomatic markedly elevated blood pressure
Mind of the Resuscitationist Lecture from SMACC 2013 and Blakemore Placement
How to place a Blakemore tube for esophageal varices with massive bleeding.
This was my favorite lecture from SMACC 2013. If you are not moved and inspired then your heart is made of stone.
Can we give vasopressors peripherally? And if we do, what if they leak?
SMACC Gold is March 18-21st on the Gold Coast of Australia--best ED conference you will ever attend
Cliff Reid runs the amazing Resus.me site and any listener of EMCrit knows that I have an enduring (and purely platonic) love for Cliff and all of his teachings.
This was my favorite lecture assigned to me at SMACC 2013. It discusses the search for excellence in our profession. I hope you enjoy!
A lecture from SMACC2013 on how not to kill the shocked patient when intubating
New medication therapy for cardiac arrest
A SMACC Back on Justin Bowra's IVC Ultrasound bashing.
I am joined by Bryan Hayes for Part II of our discussion on the avoidance of critical medication errors during resuscitations.
I've wanted to discuss tips and pitfalls for the FAST exam for a while now, but I needed a master to talk with. Luckily at Castlefest, I met Laleh Gharahbaghian, MD.
SMACC Back 1 on Catecholamines
I am joined by Bryan Hayes to discuss the avoidance of critical medication errors during resuscitations.
Keynote from SMACC 2013
Is lactate clearance a flawed paradigm? I don't think it is.
Aviation is to anesthesia as Combat Aviation is to Resuscitation
Tricyclic overdoses are not uncommon and these patients can be incredibly ill.
Learn about Janus General
So last podcast, I bashed on sodium bicarbonate or as John Kellum and David Story call it: chloride-free sodium. This episode I talk about all the good reasons to use NaBicarb.
More on Bicarb in the Critically Ill and a discussion with John Kellum, MD
New Trauma Guidelines: ATLS and Spine
Thomas Scalea discusses new frontiers in the management of ICP and TBI
The vortex approach is a new paradigm for airway management in all areas of the hospital
Chad Meyers' lecture on fluid resus in severe sepsis
SMACC - The best Critical Care Conference...EVER!!
2013 Ischemic Stroke Guidelines from AHA/ASA and ACEP
I debate Paul Mayo on whether standard laryngoscopy still has a role in emergency and critical care intubation
One of the best palliative care lectures I have ever heard.
I received a distressed email from a fan who was dismayed that other residents in her program were bashing medical podcasting; this is my response.
A place for your Clinical Cases and Questions that are not podcast specific
Since Peter Pronovost's landmark study on how a simple checklist can nearly abolish central line infections, checklists have been the darling of the medical literature
2012 Surviving Sepsis Campaign Guidelines from my Practical Evidence Podcast
You can't pick a more critical diagnosis than acute aortic dissection. Mess it up and the patient dies.
SSC Guidelines 2012
Cliff Reid on owning the resuscitation room
The rundown of things I liked from 2012
We have hit the 10,0000 patient mark in the NYC STOP Sepsis collaborative. Here are some of the lessons learned...
A new trial on half-dose thrombolysis for PE for sub-massive PE
One of the last few airway topics for a little while: Pulse Ox Lag and an Understanding of the Oxyhemoglobin Dissociation Curve
EAST Trauma Guidelines on Blunt Cardiac Injury
SMACC Conference and SIMWars
In this Mind of the Resuscitationist Episode, I discuss stop points: one for when you are using multiple vasopressors and especially about a cognitive stop point whenever things are going south.
Can the Inferior Vena Cava Ultrasound guide our fluid administration in the ED? Of course it can!
ACEP 2012 Opioid Prescription Policy
In this Hurricane Sandy episode of the EMCrit podcast, I talk about the confirmation of two of my clinical prejudices.
There is a ton of stuff to do post-intubation besides confirming the tube and giving the team high-fives. What we do in the ED has ramifications on the patient's course in the hospital.
Crack to cure; in the right circumstances you may save a life. ER thoracotomy--do it improperly and you put you and your team at risk.
The difference between screening, rule-out, and risk prediction criteria.
Today, I put on my head-shrinker cap (it is a fez) and get Cliff Reid on the coach
Antithrombotic Therapy and Prevention of Thrombosis, 9th ed Guidelines from the American College of Chest Physicians
Let's talk trauma. I interview Karim Brohi on traumatic arrest, massive transfusion and hypotensive resuscitation.
When I read a recent meta-analysis by Paul Marik on femoral central lines, the first thing I did was bang my head against the wall 10 or 20 times.
Reducing door to tPA time in Ischemic Stroke. Strategies and tips to optimize patient care.
Today we are going to discuss increased intracranial pressure (ICP) and herniation
Further discussion of prepassing the bougie and why fiberoptic laryngoscopy may obviate all of the classic teaching on bimanual laryngoscopy.
LVADs are complicated especially when the patient starts going downhill. Zack Shinar is going to attempt to make it a bit easier.
National Institute for Health and Clinical Excellence: Acute upper GI bleeding: NICE guideline
So my friend, Darren Braude and a colleague had a horrible airway case, which they presented on EM:RAP. I wanted to comment on the case.
I got to speak with Michael McGonigal, MD of the Trauma Professional's Blog about severe pediatric trauma in the ED.
Are we creating a blockage of blood flow to the brain with EGAs in cardiac arrest?
The 2nd EMCrit Live Show
The New AHA/ASA SAH Guidelines
Today we are joined by Benjamin Abella, MD to discuss who to cool after cardiac arrest.
Psychic Terror as an Effective Pressor
James DuCanto on fiberoptics and airway management in general.
ACEP's Policy on the Management of Early Pregnancy Presenting to the ED
How to Post a Case or Question to EMCrit Google Plus
Hemodynamically unstable pelvic fractures are a talk-and-die situation. These folks require aggressive, rapid treatment if they are going to survive the injury. Inspired by my mentor, Thomas Scalea, I discuss the management of the unstable pelvic trauma patient.
Can we monitor ETCO2 with extraglottic airways? The answer is definitively: I don't know.
Today, I got to interview Kenji Inaba; an incredibly prolific trauma surgeon from LA County, California.
Welcome to the second episode of Practical Evidence, a podcast about the evidence you NEED to know but may not have time to read.
Should we stop using Epi in the field for cardiac arrest
Rich Levitan is one of the best teachers on the skills of airway management and laryngoscopy--or as he would probably put it, epiglottoscopy. Here is an hour long lecture he delivered last month at Mount Sinai School of Medicine.
On the editorial policy of EMCrit
Drs. Keith Lurie and Demetris Yannopoulos elaborate on the future of CPR
Prehospital Doc Cliff Reid's tips for intubation
Welcome to the first episode of Practical Evidence, a podcast about the evidence you NEED to know but may not have time to read.
The first ever live EMCrit Podcast
One of the most exciting and underutilized therapies for trauma is tranexamic acid (txa).
A response to a question on c-spine imaging
The Lewis Lead (S5) allows you detect atrial activity that cannot be discerned on the standard 12-lead
It is winter and that means cardiac arrests coming in with extremely low body temperatures after environmental exposure. How do you treat these patients? How do you rewarm if you don't have bypass?
Today I want to talk about proper ventilation with a Bag-Valve-Mask, aka the BVM. I am joined by my friend Reuben Strayer, MD of EM Updates. You'll see Reub's talk from this year's EMCrit ED Critical Care Conference and hear some of my thoughts as well.
Today I had the pleasure to interview Dr. Paul Marik, Professor and Division Chief of Pulmonary Critical Care at Eastern Virginia Medical Center. We got to speak on the topic of fluid responsiveness--one of the toughest questions in critical care.
Podcast 63 set off some expected controversy given my take that plain films are a dead imaging modality for c-spine injuries. I wanted to briefly outline my impression of the existing evidence:
In this episode, I discuss the diagnosis of c-spine injuries. I argue that we should not send patients to imaging unless we have used the NEXUS rule and then added the Canadian C-spine Rule to the sequence. If we are imaging, it should be with a 3-view reconstructed CT scan. And even after that is done, you still need a clearance exam before removing the collar.
My favorite discoveries in the medical blogosphere and podcast land
Replay of the incredible Wall Motion Abnormality Talk from the Emergency Ultrasound Podcast
In this podcast, I explain why I don't think needle compression is such a clever idea. Main points are: most people can't find anterior target, most angiocaths won't reach, and if used diagnostically you may not be in the pleura leading to an unidentified pneumo or hemothorax. Also, when used diagnostically, if the chest was negative you just caused a pneumothorax.
I recently spoke at a symposium at the Greater NY Hospital Assoc's with the title: Controversies in Critical Care. I debated Paul Mayo, MD on the topic of whether paralytics should be used for ICU emergent intubations. Of course, I took the pro side of the debate. Dr. Mayo based his con side on an amazing study that came out of his ICU at LIJ hospital in NY.
How to make your crappy BVM into a powerful preoxygenation device--on the cheap.
Today I am joined by toxicology master, Leon Gussow to discuss a new quasi-legal class of drugs: Bath Salts. I saw my first OD of this a month ago; despite the drug's name, this patient was neither clean nor pleasantly refreshed. He was violent, agitated, and overheated.
Part II of an interview with EMS Physician Cliff Reid of the amazing blog, resus.me.
Joe Bellezzo, MD along with his partner-in-crime, Zack Shinar, MD have started an ED ECMO service at Sharp Memorial Hospital in San Diego. I am so jealous! In this episode of the podcast, I get to talk to Joe about how it works.
Part III of an amazing talk by Dr. Emanuel Rivers on Severe Sepsis, Septic Shock, and early goal directed therapy.
Part II of an amazing talk by Dr. Emanuel Rivers on Severe Sepsis.
Part I of an amazing talk by Dr. Emanuel Rivers on Severe Sepsis.
In this podcast short, Minh Le Cong discusses three airway disasters.
What technique should we use in the can't intubate/can't oxygenate (CICO) situation: Needle Cricothyrotomy vs. Bougie Cricothyrotomy.
Organ Donation in the Emergency Department Though it may not seem as important as some of the things we do in ED Critical Care, managing the potential organ donor can lead to many lives saved. In this episode I interview Isaac Tawil, an Emergency Intensivist of University of New Mexico Health Sciences and associate medical director of New Mexico Organ Donor Services. Here are the current standards for determining brain death Wijdicks et al. Evidence-based guideline update: Determining Brain Death in Adults Brain Death Checklist brain death statement What to Exclude J Crit Care 2019;53:212 Here is a video of Dr. Tawil demonstrating the brain death examEMCrit Site LinksBrain Death(Opens in a new browser tab)Now on to the Podcast...
Jeff Kline is the master of all things pulmonary embolism in emergency medicine. This is a lecture he gave on fibrinolysis for pulmonary embolism. He discusses both massive and sub-massive PE.
This is Part 4 of the Acid Base saga. In this episode, I discuss the acid base effects of fluids and when and how to use sodium bicarbonate.
Richard Dutton is a trauma anesthesiologist who was one of the primary formulators of the concept of 1:1:1 resuscitation. Here he is speaking on hemostatic resuscitation.
This Part I of the Mind of a Resus Doc Series, in which we delve into the philosophies that make a good resuscitationist.
A few months ago, we had Dr. Stephen Smith on the podcast to discuss a variety of EKG issues. Dr. Smith has an EKG blog that is required reading for every ED and ICU doc. This is Part II and I think it discusses an incredibly important issue: right now major medical societies including the AHA and ACEP are asking us to fibrinolyse or PCI patients with new or presumed new LBBB. However, your interventionalists will tell you that this strategy is a ridiculous waste given how few acute occlusions will actually be found. Why this discrepancy?
Cliff Reid of Resus.Me fame put out an incredible post on NAP4, the audit done on all of the airway complications in Great Britain. It was such a phenomenal post that I got in touch with Cliff and asked if he wanted to come on the podcast to speak about it. He did me one better and got an interview with one of the authors of the Emergency and Critical Care Section.
In part III, we go through 2 cases of acid base abnormalities step by step.
It can be a b*tch to pass the esophageal temperature probe for hypothermia. Here's how to get er done.
This second lecture discusses a quantitative approach to acid base management. I lay out the formula I use to approach an acid-base problem.
This lecture discusses a quantitative approach to acid base management. This is also known as the Fencl-Stewart approach, the strong-ion approach or the physicochemical approach. It provides explanations for why acid base disorders occur in human pathophysiology.
Since we had the Kayexalate episode, I did not want to do a full podcast, so I thought I would just air some listener questions:
Dr. Siamak (Mak) Moayedi, MD found nothing to indicate that kayexalate is effective for the acute management of hyperkalemia.
Here is a video to go along with podcast 43 on the insertion and use of the Air-Q intubating laryngeal airway
My favorite supraglottic airway is the Cookgas Air-Q; it was created by an anesthesiologist, Dr. Daniel Cook. He just created a new device that allows the placement of an esophageal blocker through the laryngeal airway. I gave him a call to hear about the new product and in the course of that conversation, he gave me a ton of tips on the placement of laryngeal airways. Part II will specifically discuss the new device.
Electrocardiograms can be subtle; but you can't miss them or patients die. Today, I interview, Dr. Stephen Smith of the incredible blog: Dr. Smith's EKG Blog.
I was lucky to cajole Cliff Reid of the amazing blog, resus.me on to the EMCrit program. Cliff is truly a doc after my own heart as you will hear from the cast.
Delayed Sequence Intubation (DSI) is a procedural sedation, the procedure in this case being effective preoxygenation. Give ketamine, put them on the mask, and in 3 minutes paralyze and intubate.
Hmm… he’s tasty, but he just needs a little salt! In this podcast, I discuss the management of hyponatremia in the ED.
My favorite ED things for 2010...the EMCrit dirty dozen.
When an ED starts providing advanced care for severe sepsis, lactate testing is an absolute requirement. Lactate use brings up a lot of questions, especially if it is not commonly ordered in your department. In this podcast, I discuss all of the lactate questions that have come up in the course of the NYC Sepsis Collaborative.
Management of traumatic arrest. Many things to do in these patients, but two things you definitely should not be doing are closed-chest CPR or giving ACLS medications. We discuss who gets a thoracotomy, what to do if a thoracotomy is not indicated, and when to stop.
In this podcast, I discuss extubating patients in the ED. Specifically, I deal with patients who have only been intubated for a few hours in distinction to extubation of the patient who has been lingering in your ED for 2-3 days. The best patients for this short-term extubation are those intox folks with a low GCS and signs of trauma, overdoses, or endoscopy cases.
The brand new ACLS & BCLS guidelines were published last week. Not huge changes, but some good stuff! The free full text is available at the Circulation website. It takes hours to make your way through all of it. I boiled it down to just the facts and posted a summary on the EMCrit site. In this EMCrit Podcast I discuss some of the highlights that I think are particularly important.
This is the video for cerebellar stroke diagnosis. Listen to the podcast first.
What if I told you that I think that patient you just sent home with vertigo may have been a missed cerebellar stroke? Would you be dialing risk management or could you tell me all of the reasons why I'm wrong? Isolated vertigo without other neurological findings can't be a stroke, right? That is true, if you are doing the right exam, but if you are just doing your standard ED neuro screening exam then you might be missing serious pathology. In this episode of the EMCrit podcast, I discuss how to perform the tests that will differentiate a peripheral cause of continuous vertigo from a cerebellar stroke.
Hey folks. As I get ready for ACEP, I just wanted to get a quick podcast put up. One of the listeners requested an episode on the treatment of hyperkalemia in the ED.
This week we talk about managing the intra-arrest period of cardiac arrest. My paradigm has changed dramatically over the past few years. In the past, I viewed the arrest as a period to teach my residents how to place a subclavian central line, how to intubate when the patient is moving, and how to cram as many drugs as possible into a patient in a short period of time. Looking at how I manage an arrest today, so much has changed.
I'm lecturing at ACEP in Las Vegas this year. This is one of two lectures I'm giving there. If you are going to the conference and plan on coming to my lecture, don't listen to this lecture; I'd rather you here the real one in person.
This week we discuss the resuscitation of the hemorrhagic shock patient with Dr. Richard Dutton, MD.
It seems the government and other specialties are trying hard to make sedation as difficult as possible in the ED. We must persevere to provide the best procedural sedation to allow maximal comfort and safety for our patients. This continues the discussion started in Part I.
Here is a piece I wrote for EMPGU
This is the audio only version of the previous post (Part I of the Sedation Talk).
It seems the government and other specialties are trying hard to make sedation as difficult as possible in the ED. We must persevere to provide the best procedural sedation to allow maximal comfort and safety for our patients. This brief lecture was originally posted on the defunct EMCrit Lecture Site on 8/7/2009.
Severe CNS Infections are time dependent diagnoses! You must have a high index of suspicion, a good plan for your work-up, and rapid provision of treatment. After seeing a severely ill meningitis patient, I figured I would do a podcast on some tips and pearls on this topic.
This week, I am joined by Leon Gussow, MD of the excellent blog: The Poison Review (TPR). TPR is my source for new toxicology articles; I highly recommend it as an incredible read. I got to meet Leon for a few beers a month ago; he is just a great guy. My Canadian pal, Ram, suggested calcium channel blocker OD as a podcast episode. Ram, here you go.
At this stage of the game, if your hospital is not offering hypothermia to out-of-hospital cardiac arrests, you are probably lagging behind optimal care. For shockable rhythms, you essentially double your patient's chances of leaving the hospital with good neurological outcome. However hypothermia can be tough, unless you have done a bunch. Learn from my mistakes in this lecture.
When I was a resident, every vent lecture either put me to sleep or left me dazed and bewildered. I gave a lecture of that ilk when I started working after fellowship--I had become part of the problem. I decided there must be a way to make vent management more understandable and if not interesting, at least bearable.
When I was a resident, every vent lecture either put me to sleep or left me dazed and bewildered. I gave a lecture of that ilk when I started working after fellowship--I had become part of the problem. I decided there must be a way to make vent management more understandable and if not interesting, at least bearable.
This post is just to place the vent handout into itunes.
Even when we can't cure a patient, we can relieve suffering. On average, we kind of stink at pain control in the ED. One physician, Dr. Ed Gentile, has created a simple path to optimal acute pain control in the ED. I heard this lecture on the EM:RAP podcast and got permission from Drs. Gentile and Herbert to repost it here. This is not a critical care topic per se, but it is applicable to the critically ill, the non-critically ill--basically any patient who is in pain in the ED.
I received a bunch of emails asking how to get the old episodes into itunes. I expanded the RSS feed to include them, now you just need to bring them into itunes, this 40 second video shows you how.
We're still working on the Greater NY Sepsis Initiative. The next step towards making a non-invasive protocol possible is to teach folks how to use ultrasound of the IVC to assess fluid responsiveness. I developed this video to get ED & ICU docs up to speed. If you can do ANY ultrasound exam, you can do this one.
Aggressive palliative care is just as important as aggressive critical care in the ED. Sometimes we will be the first physicians to talk to a family about end of life issues, even if their loved one is terminally ill. Now that is not how it should be, but it just means that we must be just as skilled at family palliative care discussions as we are at floating a transvenous pacer. In this podcast, I discuss my vision of how to handle palliative care issues in the ED.
Two listener questions answered in 5 minutes. One on awake intubation in trauma and the other on intubating the patient with severe RESP acidosis.
Darren Braude, Aiway and EMS master from New Mexico demonstrates the use of a bougie to make the cric procedure MUCH easier. For more great Braude magic, see his site at airway911.com.
This video demonstrates the fiberoptic styler-aided cric. In this case he is using a Levitan Scope, but an adult bonfils or any other rigid fiberoptic should work fine.
Here is my video on performing open cricothyrotomy in 3 situations: with a trach set and an assistant, with a trach set when alone, and when you only have a scalpel.
Ok, Ok, I promise this is the last airway episode for at least a little while. I am perhaps a bit obsessed. Had this show in the works for a while. The cric is the last barrier between a failed airway and death. EM docs need to be able to perform this procedure without hesitation. This requires training and practice until you can perform the procedure in
So after the intubation video went up on emrap tv, I got a flurry of emails telling me how cool the concept is, but questioning who this would actually be usable on.To answer that question, we first must discuss who actually requires intubation. If you wait until the patient is apneic, then of course you can't use awake intubation. The idea is to intubate before the patient stops breathing.
Dr. David Schriger gave a fantastic lecture on risk in emergency medicine at the ALL LA Conference. If you have not heard it, go and listen now; it is vitally important to our specialty. This is a brief EMCrit rant on some of my thoughts on the lecture.
Young patient, lactate of 5.2, pneumonia... You know what you're supposed to do--put in the central line and start early goal directed therapy. Problem is, most people can't see sticking a central line in a patient that does not need pressors and otherwise looks well. Yet these patient have an annoying habit of going on to decompensate and perish. Well now there may be another way. Thanks to an article just published in JAMA, we may have a path to non-invasive treatment of severe sepsis. In this EMCrit Podcast, I interview Dr. Alan E. Jones, author of the article, Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. Then I discuss how this article changes the game when it comes to caring for severe sepsis patients.
Pushing some ativan followed by vecuronium is no longer an acceptable strategy to manage post-intubation sedation. A good analgesia and sedation package is essential if you care about your patient's comfort and well-being. We need to move to PAIN-FIRST paradigm. Optimize analgesia and then add in sedative agents as a bonus. In this episode of the EMCrit Podcast, I expand on a previous rant to discuss the optimal way to handle routine post-intubation patients and some special scenarios you may encounter.
Your patient is pale and diaphoretic. Blood pressure is 70/50. Heart rate is 178. EKG shows atrial fibrillation... What are you going to do???Yeah, yeah the Pavlovian ACLS response--You cardiovert. Wonderful, except it didn't change a thing. Now what?In this episode, I discuss the crashing atrial fibrillation patient.
Intubation is a sexy procedure, there is no doubt about it.NIV does not have the glamour; it's not nearly as cinematic. But for the patient, to spend 30 minutes on a NIV mask is preferable to a couple of days on the ventilator. In this episode, I discuss some of the basic ideas and methods of NIV.
So you have a patient with intracranial bleeding or you have a high pre-ct suspicion of intracranial bleeding and they are taking coumadin, aspirin, or clopidogrel. Should you reverse them? If so, how?
Hi folks,Sorry about the voice--got a cold off those damn ED keyboardsThanks to my friend Reuben, this week we'll talk about the asthmatic patient that codes while on the ventThe DOPE mnemonic gives you a path to figure out why a patient is desaturating(If anyone knows who created the DOPE mnemonic, please add a comment or send me an email. An EMCrit listener solved the mystery)If the pt is asthmatic, add an "S" to make DOPESThe "S" stands for Stacked Breaths--and it's the first thing to address.Address it by disconnecting the vent circuit. Don't think about it, don't dither, just disconnect the vent."E" is for equipment. Attach a BVM hooked up to O2 and you'll eliminate ventilator equipment failures."D" is for tube displacement. Verify the tube with ETCO2, either qualitative or quantitative."O" reminds you to check for obstruction of the tube. See if you can put a suction cath all the way down.If all of these don't fix the problem, then consider "P" for pneumothorax.Lung sounds are not always definitive. Throw on the UTS if you have the time.Otherwise perform bilateral finger thoracostomies. What the hell is that, you say?Listen to the podcast.Then you can read more about it in this articleC.D. Deakin, G. Davies and A. Wilson, Simple thoracostomy avoids chest drain insertion in prehospital trauma, J Trauma 39 (2) (1995), pp. 373–374.Update: Is the tube mainstem, is there a ball-valve obstruction? Consider reintubation Consider BronchoscopyFinger Thoracostomy BET Emerg Med J 2017;34:417-418.
To PEEP or not to PEEP, that is the question...in the management of the severe asthmatic
Chris Nickson is an Aussie, oops Kiwi, who is a lead author of a great blog: lifeinthefastlane.com and tweets under the moniker @precordialthump; check him out, he's doing really good stuff. He wrote a comment about the last podcast-- Hey Scott, Great to hear your views and approach to EGDT. I agree with the need for aggressive resuscitation of the septic patient – with fluid, antibiotics, vasopressors (we’re a ‘norad/ norepi shop’ too) and adequate oxygen delivery being the mainstays – and, if nothing else, the Rivers paper deserves credit for bringing this into the spotlight. However, the Rivers study itself is still a cause of concern for me – a single center study that has never been repeated as an RCT, with a very high mortality in the control arm (mid-40s%), and more recently the WSJ allegations about about methodological ‘dodginess’ behind the scenes and concerns about conflicting financial interests (of which I’m not sure what to make). Most ICUs in Australia don’t use CV02 monitoring, yet our mortality rates are substantially better than the Rivers study (ICU sepsis mortality around 20% these days, down from 34% in 1997) – different populations or something else? I’m also uneasy about the blood transfusion phase of the Rivers protocol. Hopefully trials like ARISE and ProCESS will help clear up what actually works. In the mean time, I heed your call to resuscitate! Cheers, Chris Nickson ED/ICU Registrar, Perth So in this brief aside, I respond to Chris' comments and tell you a bit about the EMCrit Podcast EBM philosophy.Here are the links mentioned:Henry Ford Hospital Reply to WSJ - 10.27.2008 New MSSM ED Crit Care Sepsis ProtocolMR of Early Quantitative Therapies for Sepsis
In this episode I rant and rave about why for the most part Emergency Medicine has disappointed me by not doing something about our sick septic patients. If you are offering aggressive (Early Goal Directed) therapy in the ED, then good on you.
On this podcast,I recap from last show, especially the concept of bare minimum normotension (called erroneously permissive hypotension by just about everyone else) and why we should keep the MAP higher if there is suspected elevations in intracranial pressureI then talk about massive transfusion. This is probably the best strategy for a patient that will require greater than 8-10 units of PRBCs.What may be the best review of the topic is by Spinella and Holcomb: (Blood Reviews 2009;23:231-240) I talk about1:1:1 transfusion PCC, Factor VIIa, Cryo Calcium IV Accesscoming up in the next few podcasts: Sedatives for Intubation, Trauma Airway Management, The Crashing A-fib patient For updated thoughts See this Mass Trans Post Now on to the Podcast...
Thought we'd talk about some trauma stuff, specifically the resuscitation of the critically ill hemorrhagic shock patient.There is much to discuss, so this will be a multi-episode affair.Today, we'll concentrate on the Lethal Triad and BP Goals. Lethal TriadThe picture says it all.Bleeding causes acidosis, hypothermia, and coagulopathy. Then the cycle begins as they all beget each other. If this continues for too long, it is irreversible.We can iatrogenically make things worse by keeping our patients exposed and infusing ice cold fluids and products. By diluting their existing clotting factors and platelets with too much fluid and red cells. And by not ensuring adeqaute perfusion to counter acidosis. BP Goals Your goal is a MAP of 65. This is not hypotensive resus, which is still not proven. It is normotensive resuscitation; beyond 65, no additional benefts will be seen, but you do risk increased bleeding and dilutional coagulopathy.If MAP 65 - check perfusionthere are monitors for this such as NIRS measurement of thenar eminence, but at this stage, I recommend using the presence of a nice strong pulse and warm hands.MAP > 65 & Good Perfusion-stand tightMAP > 65 & Bad Perfusion-give fentanyl 20-25 mcgwhy fentanyl? b/c taking away pain and fear will limit endogenous catecholamines and the pt's bp will drop slightly from vasodilation. Now give fluids/products to take the MAP to > 65.Here are the articlesresus of crit ill trauma patientsdamage_control_anesthesiaNext Time: Massive Transfusion Protocols
The management of severe ETOH withdrawal and Delirium Tremens
Mohamed, a listener from Sudan, emailed asking about the treatment of acute pulmonary edema in patients with low blood pressure. This is in distinction to SCAPE patients (see podcast 1).If the patients have pulmonary edema and low BP from a cardiac cause, then they are in Cardiogenic shock. First, consider the etiology:Rate-related Valve Disorder Ischemic (Right sided infarct, STEMI, NSTEMI) Cardiomyopathy ToxicologicAt the same time, you are treating the patient with:Inotropes (dobutamine, milrinone, calcium) Pressors to achieve a MAP > 65 (allows coronary perfusion) (Meta-Analysis demonstrates norepi superior to dopamine Medicine. 96(43):e8402, OCT 2017) Oxygenation support, most likely with intubation Optimize O2 carrying capacity (Hb>10)Here is a fantastic set of guidelines to manage these patients Update:Contemporary Management of Cardiogenic Shock Circulation 2017;136:e232 Journal Feed Summary
Does the EM ban on letting sick patients go to CT scan make sense? Listen to the podcast and then register your opinion.
This week's podcast is on the management of a the patient with SAH. It's not a complete review, just some tips and reminders.Best article for EM that I've found, comes out of ColumbiaFor more reviews on mostly ICU issues see here and here.Update: Critical Care Management of Patients Following Aneurysmal SAH Guidelines from NCC 1. Get a neuro exam before you intubate 2. Intubation Give pretreatment, now just lidocaine and fentanylEtomidate or propofol; plus sux.Most experienced intubater should perform laryngoscopy 3. Treat Pain and if intubated, give sedation 4. Treat Vasospasm give nimodipine 60 mg PO or NGT 5. BP Control place a-linetreat pain firstGive Labetalol or Nicardipine to achieve the patient's baseline BP if the patient has good mental statusif they are obtunded, be a bit more conservative until ICP monitoring is in placeIf MAP is below 80, give fluids, pressors, and inotropes 6. Anti-seizure prophylaxis Load with phenytoin or fosphenytoin 7. Anti-fibrinolytics Amicar is the main one these days; ask your neurosurgeon/neurointensivist on a case-by-case basissee ehced.org for drip sheets 8. Reverse Coagulopathy 9. Think Heart these patients can get EKG changes, dysrhythmias, LV stunning, and frank infarcts from their SAH 10. ICP ASAP get the neurosurgeons to get the EVD (external ventricular drain) aka IVC (intraventricular catheter) in place as soon as possiblekeep ICP 55-60 Please Subscribe and Please Comment! .
Hi folks,this podcast is really brief--I gave a lecture at Jacobi last week (thanks for having me Jacobites!), and in response to a question I gave this rant on my vision of sedation after intubation.
Note: Please listen to the PDP update episode either before or immediately after listening to this one Finally a non-intubation topic!Bolus dose pressors and inotropes have been used by the anesthesiologists for decades, but they have not penetrated into standard emergency medicine practice. I don’t know why. They are the perfect solution to short-lived hypotension, e.g. post-intubation or during sedation.They also can act as a bridge to drip pressors while they are being mixed or while a central line is being placed.Click Here for printable sheet with mixing instructions Epinephrine Do not give cardiac arrest doses (1 mg) to patients with a pulseHas alpha and beta-1/2 effects so it is an inopressorOnset-1 minuteDuration-5-10 minutesMixing Instructions:Take a 10 ml syringe with 9 ml of normal salineInto this syringe, draw up 1 ml of epinephrine from the cardiac amp (amp contains Epinephrine 100 mcg/ml)Now you have 10 mls of Epinephrine 10 mcg/mlDose:0.5-2 ml every 1-5 minutes (5-20 mcg)No extravasation worries!Mixing Video:Phenylephrine Phenyl as a bolus dose is clean, quick, and never causes trouble. But...It is pure alpha, so no intrinsic inotropy; it may increase coronary perfusion which can improve cardiac output. I only use this in tachycardic patients (and even then, only sometimes)Onset-1 minuteDuration- 5-10 minutes (usually 5)Mixing Instructions:Take a syringe and draw up 1 ml of phenylephrine from the vial (vial concentration must be 10 mg/ml)Inject this into a 100 ml bag of NSNow you have 100 mls of phenylephrine 100 mcg/mlDraw up some into a syringe; each ml in the syringe is 100 mcgDose:0.5-2 ml every 1-5 minutes (50-200 mcg)No extravasation worries!Mixing Video:Ephedrine I don’t use this one, listen to the podcast to hear why. I put it here solely for the anesthesiologists on the blog.Onset-Near InstantDuration-1 hourMixing Instructions:Take a 10 ml syringe with 9 ml of normal salineInto this syringe, draw up 1 ml of ephedrine from the vial (vial contains Ephedrine 50 mg/ml)Now you have 10 mls of Ephedrine 5 mg/mlDose:1-2 ml every 2-5 minutes (5-10 mg)No extravasation worries! Additional Video of a Real Patient By Larry Mellick's Crew Update: 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 (The Journal of Emergency Medicine Volume 49, Issue 4, October 2015, Pages 488–494) Here is a review article from the nursing literatureNow on to the Podcast...
We've had a few gruesome airways in patients with GI bleeds and bellies full of coffee ground emesis.This is a top 10 list encompassing my approach to this difficult situation: 1. Empty the Stomach Place a salem sump and suck out all of the stomach contents. Varices are not a contraindication (see: Digest Dis 1973;18(12):1032, Gastrointest Endosc. 2004 Feb;59(2):172-8, and Anesth Analg 1988;67:283)Administer Metoclopramide 10 mg IVSS 2. Intubate the Patient with HOB at 45° Semi-Fowler's position will keep the gastric contents from moving up the esophagus 3. Preoxygenate like mad You do not want to bag these patients, give yourself a preox cushion 4. Intubation Meds Use a sedative that is BP stable, use reduced doses.These patients NEED paralytics. You need to optimize first pass success. Paralytic agents actually increase the lower esophageal sphincter tone (Br J Anaesth 1984;56:37). 5. Gather your equipment to optimize first pass Use fiberoptic laryngoscopy if you have it (e.g. Glidescope)At the bedside, have a bougie, an LMA, a meconium aspirator (more below), and 2 suction set-upsWear eye protection! 6. If you need to bag after a failed attempt... Bag gently and slowly (10 times a minute) Consider placing an LMA if you need to bag. 7. If the patient vomits: Trendelenberg This potentially keeps the emesis out of the lungs 8. Meconium Aspirator If the normal suction is too slow, attach the meconium aspirator to your ET tube. See this post on a novel ETT suction set-up for the full description.9. No ABX for Aspiration Aspiration in the initial phases is a chemical pneumonitis, not a bacterial pneumoniaSee Marik's article (NEJM 2001;344(9):665) 10. SIRS Expect a sepsis-like syndrome from the aspiration. This folks may need pressors and tons of additional fluid
This lecture is part of the Laryngoscope as a Murder Weapon Series:Hemodynamic Kills Oxygenation Kills Ventilatory KillsSorry about the voice--blame the swine flu. Case Thanks to Joe ChiangSevere DKA; Obtunded with pH 6.65, PaCO2 18, Bicarb 5 Pt’s mental status is worsening The decision is made to intubate Should you give NaBicarb? Probably won’t help as patient is already breathing at their maximum. Unless they blow off the Bicarb-generated CO2, they won’t increase their pH significantly. What you need Properly fitted NIV mask Ventilator, not a NIV machine Someone who knows how to work the vent Normal intubation stuff If available, Quantitative ETCO2 ProcedurePlace pt on pseudo-NIVSettings are Mode Volume SIMV Vt 550 ml FiO2 100% Flow Rate 30 lpm PSV 5-15 PEEP 5 RR 0Attach ETCO2 and observe value Push the RSI MedsTurn the Resp Rate to 12 Perform jaw thrust Wait 45 secondsThis violates the tenets of RSI, but keeping the pt alive is probably more crucial right now. Most experienced operator should intubate the patientAttach the ventilator Confirm tube placement by observing ETCO2 Immediately increase Respiratory Rate to 30 Change Vt to 8 cc/kg predicted IBW Change Flow Rate to 60 lpm, this si the normal setting for intubated patients (forgot to mention this in the audio)Why 30 BPM? Listen to the podcast.Make sure ETCO2 is at least as low as it was when you started Check ABG Pat yourself on the backPreVent to prevent Death (coined by Sara Crager) Now on to the Podcast...
I did a spot on ETCO2 for Amal Mattu's podcast a couple of weeks ago. I try to clear up some of the myths on the use of ETCO2.Of course the most pervasive and potentially dangerous myth is that ETCO2=PaCO2. Long story short, in our patients, it doesn't.Listen to the podcast for more...
Here it is, the 1st EMCrit podcast.It's on the topic of Sympathetic Crashing Acute Pulmonary Edema (SCAPE). This condition is on a very different part of the disease spectrum from FOPE (Fluid-Overload Pulmonary Edema, an acronum I first saw used by by @Cameronks)To boil it down to 10 seconds:Start patient on Non-invasive ventilation with a PEEP of 6-8; quickly titrate to a PEEP of 10-12. Start the patient on a nitroglycerin drip. Administer a loading dose of 4oo mcg/min for 2 minutes (120 ml/hour on the pump for 2 minutes with the standard nitro concentration of 200 mcg/ml.) Then drop the dose to 100 mcg/min and titrate it up from there as needed.By 10 minutes, your patient should be out of the water.See crashingpatient.com for the references.Here is some info from a handout from a lecture I gave on the topic: High Dose Nitroglycerin Homeopathic nitroglycerin does not work so well Start at 50-100 mcg/min, you can rapidly titrate to 200-400 mcg/min.You must stand at the bedside to use these doses. Need >120 mcg/min to get sig decreased Pulm Cap Wedge Pressure (Am J Cardio 2004;93:237) But even this strategy is not as effective as the … Nitro Bolus First Can give 400-800 mcg over 1-2 minutes = 400 mcg/min for 1-2 minutes. (Annals EM 1997, 30:382) How to do it Standard nitro mix is 200 mcg/ml. VERIFY YOUR HOSPITAL’S MIX BEFORE USING THESE RECS In order to give the 400 mcg/min for 2 minutes, set the pump to Rate: 120 cc/hr Volume to be Infused: 4 ml (This will deliver 400 mcg/min for 2 minutes and then stop)OrDraw up 4 ml of the nitro and 6 ml of NS and give over 2 minutesAfter the bolus, I drop the drip to 100 mcg/min and titrate up from there to effect When the patient gets better, you need to sharply decrease this drip rate Some folks have gone even further High dose nitroglycerin for severe decompensated heart failure—2 mg at a time (Ann Emerg Med 2007;50:144) Cotter gave isosorbide 3 mg q 5 minutes with good results in his study. This is equivalent to nitro 600 mcg/min. (Lancet 1998 351:9100, 389-393)Bolus intravenous nitroglycerin predominantly reduces afterload in patients with excessive arterial elastance (Journal of the American College of Cardiology Volume 22, Issue 1, July 1993, Pages 251–257) UpdatePiyush Mallick did an amazing study on nitro-bolus to avert intubation Someone finally put the term into the literature (Agrawal N, Kumar A, Aggarwal P, Jamshed N. Sympathetic crashing acute pulmonary edema. Indian J Crit Care Med 2016;20:719-23) 1-2 mg bolus doses are safe and effective (American Journal of Emergency Medicine 2017, 35 (1): 126-131) How you set-up the drip sig. affects time to med (Douma MJ, O'Dochartaigh D, Corry A, et al How intravenous nitroglycerine transit time from bag-to-bloodstream can be affected by infusion technique: a simulation study Emerg Med J 2015;32:498-500.)