Coda Change

SMACCForce: Top 10 PHARM Papers of the last year by Conor Deasy & MJ Slabbert

Panelist participation in the "Resuscitation for the Resuscitationist" panel session.

Jordan Bonomo delivers the run down on intracranial haemorrhage and anticoagulants in critical care. Jordan freely admits – this is not a simple topic. For the simple reason that intracranial haemorrhage (ICH) sucks – and that's a problem. There are no treatments for it. Nothing seems to work. Add an anticoagulant and it is even worse. The mortality for an ICH is around 30-50%. With an anticoagulant onboard it goes up to 40-65%. So how do you manage an ICH in an anti-coagulated patient? The critical care starts in the Emergency Department. Roughly speaking 30% of intracerebral haemorrhages will increase in size by 30% in 3 hours. Time matters. In the Emergency Department there are three immediate actions that need to take place. 1) Control the blood pressure, 2) get the specific history and, 3) deliberately ascertain what medications the patient is taking. What to do about the anticoagulation? Jordan addresses three areas with his take on the best practice. The PATCH Trial compared standard care to transfusion of platelets. It showed that the platelet transfusion group had worse outcomes using a modified Rankin scale. Although this trial bothered Jordan – he was concerned about all the patients he HAD transfused with platelets in the past – it changed his practice. His hospital no longer transfuses platelets in ICH patients. With patients that are on a NOAC/DOAC there are 50% fewer ICHs. Compounding this, there seems to be less expansion of ICH in patients on a DOAC compared to on a Vitamin K antagonist (ie Warfarin). You bleed less and are less likely to expand on a DOAC. However, it is far more practical to test for VKA, and possibly easier to reverse them. Jordan takes you through your options. Finally, Jordan addresses tPA. He will discuss the rationale for use tranexamic acid to reverse tPA and why he uses it in practice. Jordan makes the complicated a little less complicated when discussing intracranial haemorrhage and anticoagulants in critical care.

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Daniel Cabrera wants you to play the game of anaphylaxis… a serious game! You are faced with a monster, with the name anaphylaxis. Daniel takes you through the resuscitation of refractory anaphylaxis. We do a terrible job managing anaphylaxis, missing 50% of the diagnoses, only giving epinephrine in 50% of the cases who need it. After the acute episode, only 40% of patient go home with an epinephrine auto-injector and only 20% get the appropriate follow up! 1-2% of the population will be affected by anaphylaxis, and 2% will die. Although this may not seem like a huge number, Daniel stresses the point - deaths from anaphylaxis are highly preventable Anaphylaxis is a sudden onset, rapid progressing multi-system organ failure due to the activation of mast cells. Anaphylactic vs anaphylactoid… it does not matter. What does matter is that it is becoming more common. Further, fatal anaphylaxis is very fast to progress highlighting the need to make the diagnosis and make it quickly. Although anaphylaxis kills through shock, hypoxia, ischemia, arrhythmia, and myocardial dysfunction, it is the lack of education and access of providers and patients that is the real issue here. Lack of education of what anaphylaxis is, and how it presents. Lack of access of patients to early care and lack of access to epinephrine. Daniel guides you through the management of a patient suffering from anaphylaxis. His advice: epinephrine (adrenaline) is the only thing that will change mortality outcomes. Use it and use it early! Remember to decontaminate the patient – be it a bee string, or food exposure, get rid of it. The patients will also need lot of crystalloids. There is weak evidence for steroids and antihistamines – they will not save your patients. Use them if you like but not at the expense of early epinephrine and fluids. In refractory cases, increasing dose of epinephrine, norepinephrine, vasopressin, glucagon, methylene blue and ECMO are considerations. Patients with airway compromise require advanced management. Finally – when patients go home they need three things: education, an epipen auto-injector and an anaphylaxis action plan! So know your enemy when dealing with anaphylaxis and you too can be the hero and save the day!

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Brandon Foreman takes you through physiological targets for traumatic brain injury in neuro-critical care. Intensivist and emergency medicine physicians already use physiology targets. They understand the complexity of these targets and the pitfalls of overreliance on any one parameter. This is also true for the use of physiology after traumatic brain injuries (TBI). TBI has never been defined by its physiology. In fact, specific targets of physiology to drive successful outcomes have all failed in the research in this patient group. It is no doubt a complex area. Physiology after traumatic brain injury is not simply defined on the pressure and volume in the skull. There are a huge variety of variables, including blood pressure, autoregulation and flow coupled functioning. Even with all these parameters, there is no Level 1 or 2A evidence for physiologic thresholding in TBI patients. As such, Brandon takes you through his approach to using physiology to manage TBI patients in neuro-critical care. He guides you through the approach, breaking up outcomes measures into three groups. First mechanics. Brandon will discuss blood pressure targets, and the real purpose of controlling them. Ultimately, he explains that thresholds are arbitrary and what is most important is blood flow. Secondly, Brendon considers metabolism. Here he guides you through the importance of glucose and ventilation with specific advice on parameters to use. Finally, he will take you through brain function, along with different clinical indicators that are useful when caring for a TBI patient in the neuro-critical care setting. This talk will encourage you to look at mechanics, metabolism, and brain function, considering each for the individual patient in front of you to guide best practice and deliver best outcomes.

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Numbers people, give me the NUMBERS! We need CONCRETE data points and percentages...! Go buy another machine to deliver the numbers and data points. We need it to be delivered by gadgets, gadgets that go ping and pong...more and more gadgets. Let's plot it on graphs and write it into a protocol to then be memorised verbatim in training and dutifully regurgitated in medical exams. That makes us excellent clinicians right? Worthy of more numbers and a couple of extra letters behind our names. Medicine is obsessed with numbers! The glorified science of modern medicine. A fictitious safety net. We are often discouraged from relying on our brains to make decisions, especially in emergency situations. Criticism of human error and the human factors which lead to error are in abundance. What if I told you, your decision-making is far more complex than that? That, how I deal with an emergency also involve guts, prayers and yes, sometimes tricks. Does that make me reckless? A cowboy (girl) or a savant? Or am I just nudged by my unconsciousness. Are you? Whether you like it or not, how you deal with emergencies, how you deal with life is far more complex and unclear and uncertain than what quantitative science would like. Our brains are amazing and we need to embrace our whole toolbox when making decisions. There is literally way more between heaven and earth than what meets the eye and your unconscious mind is filling in the gaps. So hold on and follow me down the rabbit hole... Be inspired by a talk by MJ Slabbert on processing emergency decisions in Critical care.

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Intubation is one of the most important procedures that we perform. There are many immediate and bedside methods of confirming tube placement. Ben Smith and Jacob Avila present how to confirm endotracheal tube placement with airway ultrasound. There has been a bad trauma come into the Emergency Department. The patient has suffered a head injury with an obvious laceration. They are agitated and being physically aggressive to staff. To make matters worse, they are in a neck collar, and have little to no jaw to speak of. Although you will need to protect the airway of this patient it is going to be difficult. What's more, you have no access to video laryngoscopy. How will you confirm the placement of the endotracheal tube? Physical examination to confirm endotracheal tube placement has poor evidence behind it. End tidal C02 is similarly problematic. Ben and Jacob propose adding another tool to you armamentarium. Airway ultrasound. Airway ultrasound has sound evidence supporting it. It has sensitivity and specificity in the high 90s. As such, it has been added to ACLS guidelines as the way to confirm the placement of an endotracheal tube. Join Ben and Jacob as they take you through the practical tips and tricks on how to perform this skill. As they will teach you, it is possible to use ultrasound to confirm endotracheal placement in the trachea and where it is in the trachea without having you worry about insufflating the stomach causing aspiration or vomit. You can use airway ultrasound in real time to guide the intubation, with excellent accuracy eliminating the need to bag valve mask ventilate a patient.

For more like this, head to https://codachange.org/podcasts/

A no-holds barred series of 6 provocative medical interrogations. We challenge the state of research, social media, pharmacology, social work, women in medicine, medicine in the developed work, and the health of healthcare workers. It should be novel, it may get heated, and it is not scripted. Sometimes to comfort the afflicted you also need to afflict the comfortable. This is why no prisoners will be taken, no topic is out of bounds, and no ego will be pampered. It may even offend: you have been warned.

SMACCForce: Bariatric Panel Discussion with Mark Forrest, Jason Van Der Velde, Phil Keating, Cameron O'Leary