Coda Change

Poisons and novel agents are a moving target in the clinical arena. This talk begins with a historical look at decontamination and pitfalls that have been discovered along the way. The advent of intubation and critical care was a major boon in the improvement in mortality from poisoning. The Scandinavian Method is described and is an important lesion to this day. The rise of antidotes is mentioned.

Emerging drugs are highlighted in the context of where we have come from. The phenylethylamine compound structure and corresponding variants are described. The importance of the principles of supportive care as learned in the Scandinavian method is emphasized. Other emerging topics including synthetic cannabinoids, and anti-NMDA receptor antagonists are discussed. Emerging interventions of prescription naloxone, and ED ECMO are outlined. High vigilance for new agents, and innovative treatments will enable clinicians deal with these evolving trends.

Summary by: Joe Lex

How Common Are In-Flight Emergencies?• Occur on one in every 600 flights• 44,000 of 2.75B airline passengers / year

What Are Most Common Emergencies• Lightheadedness or fainting ~37%• Respiratory problems ~12%• Nausea or vomiting ~10%• Cardiac symptoms ~8%• Seizures ~6%• Other Emergencies• Laceration ~0.3%• Cardiac arrest ~0.3%• Ear pain ~0.4%• Obstetrical or gynecological symptoms ~0.5%• Headache ~1%

Who Responds to the Call?• Physician passenger responds in ~48%• Nurse passenger responds in ~20%• EMT passenger responds in ~5%

Minimum first aid kits on commercial airliners16 Adhesive bandage compressors, 1 in20 Antiseptic Swabs10 Ammonia Inhalants8 Bandage compressors, 4 in5 Triangular bandage compressors, 40 in1 Arm splint, non inflatable1 Leg splint, non inflatable4 Roller bandage, 4 in2 Adhesive tape, 1 in standard roll1 Bandage Scissors2 Protective latex gloves pair2 Insect sting relief pad2 Triple antibiotic ointment2 First Aid/burn cream, 9 gm.2 Povidone iodine infection control wipes2 Alcohol cleansing pads2 Gauze dressing pad 2" x 2" in2 Motion Sickness Tab4 Ibuprofen tablets4 Non Aspirin Tablets2 Sunscreen lotion towelette2 Trauma pads 5 x 9 in (12,7 x 22,8 cm)1 Survival rescue blanket1 Pelican case 1170 waterproof1 Emergency first aid guide (American Red Cross)

Required medications on flights• Antihistamine – tablets and injectable• Atropine 0.5 mg injectable• Aspirin tablets 325mg• Bronchodilator MDI• Dextrose 50% injectable• Epinephrine 1:1000 and 1:10,000• Nitroglycerin tablets• Lidocaine injectable• IV needle• 500ml Saline injectable

All crewmembers are trained for common emergencies. For each flight attendant¥ Instruction to include performance drills in the proper use of automated external defibrillators¥ Instruction to include performance drills in cardiopulmonary resuscitation¥ Recurrent training … at least once eve

Don't Forget A & B!

Over 500,000 patients per year suffer sudden cardiac arrest. Despite advances in our understanding and management of cardiac arrest, less than 15% of patients survive to hospital discharge with meaningful neurologic survival. In recent years, the focus of cardiac arrest resuscitation has been the delivery of high-quality chest compressions and early defibrillation for those with a shockable rhythm. As a result, airway interventions and ventilation now follow attempts to optimize circulation in cardiac arrest patients. Though high-quality CPR and early defibrillation are essential in the initial stages of resuscitation, advanced airway placement and appropriate ventilation are critical to overall patient survival.

Dr. Winters' discusses the current literature on the timing of advanced airway placement, oxygenation, and ventilation for the cardiac arrest patient. In addition, he discusses optimal targets for oxygenation and ventilation in the patient with return of spontaneous circulation from sudden cardiac arrest.

Summary by: Lisa McQueen

I’ve long been a fan of David Newman’s “Pseudoaxioms,” those medical proclamations handed down from generation to generation despite growing evidence that they are false. In this talk, I turn a critical eye toward common pseudoaxioms in pediatrics. Does aspirin really cause Reye syndrome? Should you routinely use atropine in preparation for neonatal intubation? Join me in an exploration of these and other pseudoaxioms. I may even debunk the notion that “children are not just little adults.”

ECMO or extracorporeal membrane oxygenation has shown promise in the use of cardiac arrest patients. Zack Shinar and his crew from San Diego have lead the way in emergency physician initiated ECMO for patients in cardiac arrest.

In this lecture he explains briefly how ECMO works, what their outcomes have been and where ECMO is moving. Initially 5 of their first 8 patients were neurologically intact survivors. Their first patient had over an hour of downtime when cardiac bypass was initiated. He walked out of the hospital completely neurologically intact nine days later and now has been featured on the film “Code Black”. Physicians from their hospital, Sharp Memorial, were also recently featured on the television show “Untold Stories in the ER” for a save of a 21 year old female arresting from hyperkalemia. Dr. Shinar also discusses some of the latest physiologic questions as the Australians have pushed for smaller diameter catheters that allow for smaller flow volumes.

He also discusses how in Paris pre-hospital ECMO is being done by physicians in various places like the subway, apartment buildings and even the Louvre.

In the end, Dr. Shinar discusses the biggest question in any novel resuscitation technique: cost. Prolongation of life and particularly after a cardiac arrest is expensive and many people do not survive.

Dr. Shinar uses various pioneers in the world of technology to tell how true genius is not in technologic advancements but in making those advancements available to the masses. He ends with a story about Linus Torvalds. Dr. Shinar shows how this man through the use of the collective minds of computer programmers worldwide created one of the best operating systems ever created: Linux. He asks the medical community to endorse this idea and introduces the concept of “free open access medical innovation”.

Summary by: Mark Wilson

Consciousness comprises “wakefulness” (that’s the brain stem, opening your eyes component) and “content” (that’s the supratentorial, thinking, “someone’s home” component). You can have wakefulness without content (e.g. persistent vegetative state) but not content without wakefulness.

Describing a “level” of consciousness, converting this multifaceted human brain ability into a linear scale was possibly the biggest neuroscience break through of the 20th Century. The 1974 Lancet paper in which Brian Jennet and Sir Graham Teasdale proposed the Glasgow Coma Scale (GCS) is certainly the most cited neuroscience paper. We had even put a man on the moon before this had been created. It’s relative simplicity and repeatability meant GCS was rapidly taken up across the world. Now 40 years on, is it out of date?

There are problems with the GCS – it doesn’t include pupil response, it doesn’t look at ventilation or other autonomic functions hence other systems such as the 4 score system have been proposed. But these take longer, and are poorly known so cannot be used like GCS to rapidly convey in a meaningful way the level of consciousness of a patient between clinicians.

In this talk Mark Wilson goes through the history of the GCS and other conscious measures… is it time to say Goodbye to GCS?

One of the many things that we, as intensivists or emergency physicians, do better than anyone in the business is obtain the emergent airway. We are usually introduced to our patients on the worst days of their lives and even though we may sometimes wish for it, we do not have the option to reschedule our intubations. Smashed, bloody, distorted, edematous airways secondary to trauma, anaphylaxis, and GI bleeds are the commonality not the exception. We manage those airways routinely with nary a complaint or even a hither for a better look at the glottis than what we can obtain. We often feel lucky to even get a glimpse of the arytenoids much less something that actually resembles normal laryngeal anatomy.

Personally, if I knew that I would need to be intubated today, that my airway would be a bloody, edematous, traumatic mess and there was only chance for one person to take a shot at placing the tube, then I would pray to God that the last face I saw before the Roc and Ketamine pushed me asunder was the familiar grill of one of my EM/critical care colleagues. Who better to bet all my chips on then someone who deals with the most difficult airways on the face of the planet as part of their daily routine?

The EM doc or critical care provider can not only get that airway, but is so relaxed about it that they will often casually check on the patient in the next bed before and after the intubation. That’s the confidence I’m looking for when it comes to the fast-paced life and death world of emergency airway. Now put a child’s life on the line. Are you ready to intubate what was a perfectly healthy three year old two hours before trauma threatened their life and placed their airway in your hands? You will be...

Andrew Sloas DO, RDMS, FACEP, FAAEM, FAAP Editor-in-Chief: The PEM ED Podcast www.pemed.org

This talk will cover what we should do for patients who are considered too sick to have emergency surgery. These patients provide major management challenges in Critical Care. Do we admit them to intensive care to optimise them prior to emergency surgery or should we get on with surgery and resuscitate them intraoperatively? Should the surgery, if undertaken, be limited to damgae control surgery or operative resuscitation, or should more definitive surgical procedures be undertaken.

There often isn't good evidence to mandate a course of action either way so the decision will mostly be based on the treating clinicians opinions. In these complex cases, who should decide? These factors and others will be examined

Error is almost inevitable in our clinical practice so we should be prepared to help and prepare those individuals involved for the benefit of them, our systems and our patients. Do you remember that patient you saw last night?': A phrase the strikes terror into the hearts of all physicians. The prospect of a patient coming to harm as a result of a mistake is terrifying but it can and does happen. The consequences for the patient and their family are often tragic but what of the clinicians who made the error? For many the result of making a terrible error is life changing. Those permanently harmed by error are often referred to as second victims with the consequences of terrible events being life-long.

This talk explores the predictable course for clinicians who are involved in error and asks whether we can prepare and support such individuals through a difficult time.

In 2013, ~500,000 children in sub-Saharan Africa died as a direct result of Plasmodium falciparum malaria, accounting for 90% of global malaria mortality. The scale-up of control efforts has led to some reductions in malaria incidence in parts of Africa, but countries where transmission is high malaria continues to be a major public health problem. Early optimism that the most promising malaria vaccine candidate (RTS,S) would reduce the burden of malaria proved premature since following (3-dose) vaccination since immunity rapidly wanes >20 months post-vaccination. Severe malaria remains a major cause of hospital admission and paediatric death across sSA. Nevertheless, clinical research has been fragmented, resulting in only two large Phase III clinical trials - both with landmark results. The AQUAMAT trial, enrolling 5425 children demonstrated significantly lower in-hospital mortality in those receiving artesunate (8.5%) versus quinine (10.9%) (relative risk reduction 22.5%). Second, FEAST a pragmatic trial of fluid resuscitation as a supportive treatment in 3141 African children with shock, of whom 57% had severe malaria; this trial was stopped early due to higher 48-hour mortality in bolus arms (RR increase 45%) than no bolus (control) across all sub-groups. Even with artesunate as standard antimalarial treatment, overall mortality remains ~10%, but includes large sub-groups with substantially higher case fatalities (15-20%) with 3 key prognostic markers (coma, metabolic acidosis or a high blood urea nitrogen) and/or bacterial co-infection (CF ~24%). There seems little prospect for further reducing the substantial mortality of severe malaria within the foreseeable future without a concerted and strategic effort from funders and researchers. SMAART (a nascent consortium for research and trials) aims to catalyse and accelerate the severe malaria research agenda. SMAART will formulate and coordinate seamless Phase I/II to large multi-centre Phase III trials using efficient trial designs to inform treatment guidelines and ultimately the outcome amongst African children