EMS Nation Podcast

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~Faizan H. Arshad, MD @emscritcare

Ep #60 Rapid Sequence Intubation - Overview for the NY State Collaborative Protocols @87MD1 Oct 12, 2017

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Continue along for the New York State Collaborative Protocol series with Dr. Chris Fullagar @87MD1 as he reviews the indications, ideal pre-oxygenation strategies, laryngoscopy techniques, confirmation of tube placement as well as guidelines for post-intubation sedation for prehospital providers operating in New York State.

Christopher J. Fullagar, MD, EMT-P, FACEP @87MD1

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https://www.smacc.net.au/

Ep #59 Modern Disaster Responce in Unpredictable Times #smaccFORCE #dasSMACC Jun 29, 2017

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Anne Creaton – An Emergency Physician & retrievalist HQ’d in Melbourne Australia. She spent the last 4 years in Fiji establishing emergency medicine training in a low resource environment while building capacity in pre-hospital care and disaster response. While living in Fiji she experienced Cyclone Winston first hand and was part of the in-country response. She is an educator in mass gathering medicine and the MIMMS system and was part of the instructor team for a multiagency tabletop simulation of a multi-site terrorist attack in Melbourne.

Lionel Lamhaut – An anesthetist with critical care and emergency training and an associate professor of the SAMU de Paris (excuse my French - Service d'Aide Médicale Urgente), Dr. Lamhaut is not only a disaster response physician but an academician of the highest caliber with recent publications on the prospective deployment of ECPR for refractory cardiac arrest in the Paris area with a multicenter study well underway. He responded directly to the deadly terror attack of Charlie Hebdo and was instrumental in the after action analysis in the coordinated multi-site terror attack that struck Paris on Friday the 13th of 2015.

Raed Arafat – Put a warm round of applause together for the Secretary of State and Minister of Internal Affairs of Romania! Tasked with development of emergency medical care in the country, he is the founder of SMURD – the Mobile Emergency Service for Resuscitation and Extrication. In his current position he leads the Department for Emergency Situations including fire and rescue, civil protection, prehospital emergency medical services, air rescue as well as emergency departments. Ladies and gentleman… a Knight and Grand Officer of the National Order of Merit in Romania, he has overcome both politics and prejudice in his sterling career as a champion of the highest quality prehospital care.

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~Faizan H. Arshad, MD @emscritcare

Ep #58 Push Dose Pressors & Push Dose Nitroglycerin @emscritcare #EMSWeek2017 Jun 01, 2017

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Happy Friday of #EMSWeek2017!

https://emcrit.org/wp-content/uploads/push-dose-pressors.pdf

Resuscitation - beginning from initial patient contact to the emergency department to the intensive care unit is a continuun of care - though the first few minutes of patient contact with a critically ill patient can have tremendous repercussions on the patient's ultimate outcome. Whether in critical care transport or in 911 emergency response, patient's may require a medication in small aliquots immediately that would be either unfeasible or cumbersome to administer via infusion on a dedicated pump.

While circumstances in which a patient needs a push dose medication may be uncommon, the administration of these drugs can be potentially lifesaving. There are two prehospital scenarios in which the paramedic carries the necessary medication in their armamentariam and with appropriate instruction and training can safely reconstitute into an appropriate dose for use in out-of-hospital resuscitation for the critically ill patient.

Push dose pressors are often employed in profoundly hypotensive patients that will require endotracheal intubation. Rapid Sequence Intubation and Positive Pressure Ventilation are both associated with hypotension, thus in the patient that requires advanced airway and is hypotensive upon EMS arrival, push dose pressors may be employed to effectively "resuscitate before you intubate". Typically Epinephrine is diluted to an appropriate dose and adminstered in small aliquots (10mcg/ml) for inotropoic support to optimize hemodynamics prior to RSI or intubation. There is also anaesthesia literature supporting the use of neosynephrine as well as phenylephrine for this purpose, though these medications are less readily available prehospitally. Even brief episodes of relative hypotension can cause effects seen days later; in critically hypotensive patients these may be even more pronounced. By using push dose pressors, a field provider can safely and effectively resuscitate their patient in order to mitigate the risks associated with endotracheal intubation prior to securing an advance airway.

Conversely, a separate and distinct class of patients who suffer from decompensated heart failure may present with respiratory distress due to volume overload with pathophysiology associated with marked systemic hypertension. While CPAP is the mainstay of therapy for these patients prehospitally and has significantly reduced intubation of the CHF patient over the past several years, IV Lasix and topical Nitroglycerin play little role in the EMS management of the decompensated heart failure patient. Nevertheless, these patients often require preload and afterload reduction to manage their symptomatology; it is common to initiate nitroglycerin infusions in critical care transport as well as in the emergency department for management of this hypertension.

Nitroglycerin lowers preload via venous vasodilation at low doses and lowers after load via arterial vasodilation at higher doses, making the patient's vascular container larger lowering the systemic pressure. Aggressive, high dose NTG paired with the recruitment of the alveoli using CPAP & PEEP make up the mainstay of pre-hospital treatment of APE and decompensated heart failure. Bolus doses as high as 2 mg (2000 mcg) of nitroglycerin have been given safely and effectively in previous studies.

In emergent resuscitations we need to focus on bolus dose medications in the acute phase versus starting and titrating critical care infusions while a patient is in extremis. The goal is to achieve clinical end points of treatment faster with bolus dosing at the bedside and then begin maintenance infusions once resuscitation goals are met and the hemodynamics are stable. Similar to push dose pressors in the acutely hypotensive EMS patient requiring resuscitation, patients with decompensated heart failure may benefit acutely with push dose nitroglycerin, a potent vasodilator.

@AmpaDocs #CCTMC17

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April 9-11th 2018

Wyndham Riverwalk - San Antonio Texas

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~Faizan H. Arshad, MD @emscritcare

Ep #57 Human Factors in Advanced Airway Management Outcomes @DaveOlvera1 #EMSWeek2017 May 31, 2017

Show notes

www.who.int/patientsafety/activities/technical/who_mc_topic-2.ppt

Happy Thursday of #EMSWeek2017!

David Olvera, AAS, FP-C, EMT-P

LinkedIn: https://www.linkedin.com/in/david-olvera-36048a1b

World Health Organization Human Factors PowerPoint-

Glucometer that monitors blood sugar via phone-

https://www.dexcom.com/

Checklist Articles:

Development of a standard operating procedure and checklist for RSI in the critically ill.( Scandinavian journal of trauma, resuscitation, and emergency medicine, Sept 11th 2014)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4172951/

A pre-procedural checklist improves the safety of emergency department intubation of trauma patients. (Academic Emergency MedicineAug, 2015)

https://www.ncbi.nlm.nih.gov/pubmed/

Greater Sydney Area HEMS Checklist-

https://nswhems.files.wordpress.com/2013/01/prehospital-emergency-anaesthesia-checklist-3-1-final.pdf

Failed Attempts at Intubation Associated With More Adverse Events

http://www.anesthesiologynews.com/Clinical-Anesthesiology/Article/02-17/Failed-Attempts-at-Intubation-Associated-With-More-Adverse-Events/40210/ses=ogst?enl=true

@AmpaDocs #CCTMC17

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April 9-11th 2018

Wyndham Riverwalk - San Antonio Texas

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~Faizan H. Arshad, MD @emscritcare

Ep #56 Demystifying the Surgical Airway @ktcollopy #EMSWeek2017 May 25, 2017

Show notes

Happy Wednesday of #EMSWeek2017! Definitive airway management in the prehospital sphere for critically ill patients is often forced upon EMS providers especially when encountering failure of traditional challenging airway algorithms. Failure to ventilate and intubate a patient can results in immediate sphincter tightening for providers. Being facile with a surgical airway based on one's specific kit and armamentarium is paramount for providers in whom the surgical airway falls within their scope of practice. Adequate training and skills maintenance are perpetual challenges in this HALO (high acuity low occurrence) procedure.

His Bio & Credentials:

Kevin T. Collopy, BA, FP-C, CCEMT-P, NR-P, CMTE, WEMT, is an educator, e-learning content developer and author of numerous articles and textbook chapters. He is also the clinical education coordinator for AirLink/VitaLink in Wilmington, NC. Contact him at ktcollopy@gmail.com.

LinkedIn: https://www.linkedin.com/in/ktcollopy

Kevin's #CCTMC16 Podcast: Taking a "Time Out" before Initiating RSI Improves Patient Safety and First Pass Success

http://emsnation.libsyn.com/ep-30-taking-a-time-out-before-initiating-rsi-improves-patient-safety-1st-attempt-success-with-kevin-collopy-ktcollopy

NYS Collaborative Training Video for Surgical Airway:

http://emsnation.libsyn.com/ep-48-surgical-cricothyroidotomy

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April 9-11th 2018

Wyndham Riverwalk - San Antonio Texas

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~Faizan H. Arshad, MD @emscritcare

http://www.emstoday.com/index.html

Ep #55 Using DSI To Prevent Rapid Sequence Death #EMSWeek2017 May 24, 2017

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Checkout EMS Today 2018!

Happy Tuesday of #EMSWeek2017! You've asked and you shall receive... Optimizing your patient's airway prior to pulling the trigger for RSI. Delayed Sequence Intubation in the prehospital realm to prevent Rapid Sequence Death. Dr. Jeff Jarvis, a paramedic from Williamson County Texas turned EMS Medical Director of Williamson County Texas challenges traditional thought processes to bring the best possible medical care to 911 patients. "It's medical decision making that saves lives... not a plastic tube through the trachea!!!!" Here is story from conception of the idea, to education and roll out, to challenges experienced interfacing with local emergency departments as well as preliminary results for prospectively collected data.

His Bio & Credentials:

https://www.wilco.org/Departments/EMS/Leadership/Jeff-Jarvis (Williamson County)

http://www.sw.org/Dr-Jeffrey-L-Jarvis (Baylor Scott & White)

@EMSToday #EMSToday2017

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February 21-23, 2018

Charlotte, NC Convention Center

Registration Link: http://www.emstoday.com/register.html

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Wishing Everyone a safe tour!

~Faizan H. Arshad, MD @emscritcare

Ep #54 What's Wrong with American Prehospital Care & How Do we Fix it! #EMSWeek2017 May 23, 2017

Show notes

http://www.atacc.co.uk/

Happy Monday of #EMSWeek2017! Roll up your sleeves and mentally prepare for getting your hands dirty. Chief Flight Physician of University of Wisconsin MedFlight, Dr. Mike Abernethy @FLTDOC1, gives an honest assessment of the current state of discongruity in EMS in America. An honest assessment of the intricacies of American Prehospital Care and efforts we can take to improve outcomes for all our patients.

His Bio & Credentials:

http://www.emed.wisc.edu/content/mike-abernethy-md

@AmpaDocs #CCTMC17

Mark your calendars for #CCTMC18

April 9-11th 2018

Wyndham Riverwalk - San Antonio Texas

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