Coda Change

Bouncing Back from the Beach – Cutting to Air to secure an Emergency Surgical Airway

Summary by: Thomas Dolven

To handle airways means being prepared to handle them all the way. You need to be prepared for a cannot intubate cannot oxygenate CICO scenario. The common, final end point of airway management in a is the emergency surgical airway, the cricothyroidotomy.

So how to prepare?Often, it is not being taught right. This is a rare procedure under high stress and time sensitive. And most importantly, it is a bloody procedure that will be blind. You cannot use your eyes. So it needs a simple technique without fine motor skills, and it must be tactile. Your finger is the perfect tool for this task, and will guide you through it. The video of my personal real world experience is backed by available empirical evidence and lab training. There will never be an RCT, this is the best evidence we will have. So read NAPP4 and the case series article on the scalpel-finger-tube technique.

Read these available articles, train, and remember these two key points:1) There will be blood. But that’s OK, because.2) Your finger can see.

Tox-Dogmalysis is a talk about evidence in Toxicology. It's been said that 50% of what we learn is incorrect; we just don't know which 50%. As the complexity of medicine increases, it is of the utmost importance for clinicians to be skeptical of old data and new data alike.

Many in the FOAM community have made huge strides in busting myths that have persisted over time.

However, sometimes we may declare myths busted too prematurely based on incomplete or misunderstood data. This talk will explore three topics in toxicology for which the perceived myths may actually be true, or at least not completely busted.

Fluids in Critical Care: Time to SPLIT With Normal Saline?

Summary by: Paul Young

Intravenous fluid therapy is a ubiquitous treatment for critically ill patients and has been used in clinical practice for over 175 years. Despite this long history, the majority of intravenous fluids have not been subjected to the same level of scrutiny as other drugs. That said, large-scale fluid trials evaluating albumin and starch solutions compared to 0.9% saline have been conducted and their results have changed clinical practice around the world so that crystalloid fluid therapy is now predominant in many parts of the world.

While 0.9% saline is the world’s most commonly prescribed crystalloid fluid, increasingly clinicians are turning to buffered or balanced crystalloid solutions as an alternative to 0.9% saline. This practice change from 0.9% saline towards balanced crystalloids is not based on high quality evidence but is supported by observational data suggesting that saline may be associated with an increased risk of renal toxicity and mortality compared to buffered crystalloids.

This talk gives an overview of the data comparing the comparative effectiveness of 0.9% saline and buffered crystalloids, provides an overview of the historical context of intravenous fluid therapy (and proctoclysis), and describes the design of the Saline vs. Plasma-Lyte 148® for Intravenous fluid Therapy (SPLIT) trial which has now been completed and was recently published in the Journal of the American Medical Association.

External Links• [The Bottom line] SPLIT trial reviewed• [article] Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit The SPLIT Randomized Clinical Trial• [editorial] Editorial accompanying paper• [videocast] Presentation of SPLIT trial at ESICM by Dr Paul Young• [Further reading] Association Between a Chloride-Liberal vs Chloride-Restrictive Intravenous Fluid Administration Strategy and Kidney Injury in Critically Ill Adults• [St Emlyn's] SPLIT trial published. Saline or Plasmalyte on the ICU?

Mark Wilson hosts an all-star cast!Summary By: Mark Wilson

Traumatic brain injury (TBI) is a hugely important topic in critical care. It is a major cause of morbidity and mortality throughout the world with hospital presentations totaling over 2million in the US, 1 million in the UK and 700,000 in Australia each year. Not only do they represent a huge proportion of injuries, but they are a unique in their potential to fundamentally change “who a person is”. As critical care and trauma practitioners there are many aspects of management that can change outcomes for patients in the short and long term.

Dr Mark Wilson (@MarkHWilson) is a neurosurgeon and doctor for the Air Ambulance in the UK. In this session from SMACC Chicago entitled “It’s a Knockout”, he expertly leads a discussion which holds a magnifying glass to the current practice guidelines for managing TBI as taught in ATLS. On the discussion panel is a star-studded international cast including: Pierre Janin, Andrew Dixon (@DrAndrewDixon), Karim Brohi (@karimbrohi), Karel Harbig (@karelharbig), Deb Stein, Michael McGonigal, Bill Knight, John Hinds and Ralph the Janitor (who looks remarkably like Cliff Reid @cliffreid).

In this discussion forum, international specialists from the fields of neurosurgery, intensive care, trauma surgery, emergency medicine and radiology engage in a discussion of the step-by-step management of a real case of a patient with a head injury. This discussion highlights the many management controversies including how to manage the c-spine, whether or not to oxygenate, whether or not to intubate, when to extubate, if and how to sedate the patient, when to CT and how to monitor the head injured patient. In typical SMACC style this discussion demonstrates the approach to the management of a patient from different vantage points and demonstrates why it is so difficult to come to a consensus of the approach to this type of injury.

Panelists delve into the features of TBI that you won’t find in textbooks including impact brain apnoea, multi-compartment syndrome and more. Watch out for the a segue into the Good Sam App, a smartphone app which alerts registered medically trained personnel to nearby emergencies to minimize downtime when medical emergencies occur.

This forum has everything you have come to love and expect from SMACC including international experts, heated debates, controversial #hashtags, guest speakers and more!

Summary by: Paul Young

The febrile response to infection occurs in most animals and is regulated by a common biochemical mechanism involving prostaglandin E2. This common mechanism suggests that the response may have evolved in a common ancestor more than 350 million years ago. As the febrile response comes at a significant metabolic cost, its persistence across a broad range of species provides circumstantial evidence that the response has some evolutionary advantage. Furthermore, it logically follows that the components of the immune system would have evolved to function optimally in the physiological febrile range.

There are a number of historical examples of dramatic responses to treatment with therapeutic hyperthermia in some infectious diseases, including neurosyphilis and malaria. The relevance of these historical examples to the modern era is unclear. Furthermore, arguments based on the evolutionary importance of the febrile response do not necessarily apply to critically ill patients who are, by definition, supported beyond the limits of normal physiological homeostasis. Humans are not adapted to critical illness. In the absence of modern medicine and Intensive Care, most critically ill patients with fever and infection would presumably die. Among critically ill patients, it seems likely that there is a balance to be struck between the potential benefits of reducing metabolic rate that come with fever control and the potential risks of a deleterious effect on host defence mechanisms. Where this balance lies is very unclear as there are very few interventional studies of fever management in critically patients.

Remarkably, although paracetamol is very widely used in ICU patients with fever and infection, only one RCT, the HEAT trial, has investigated the safety and efficacy of administering paracetamol to critically ill patients with fever and infection. This talk gives the background to the HEAT trial which has now been published in the New England Journal of Medicine.

Links

• [The Bottom line] HEAT trial reviewed• [NEJM article] Acetaminophen for Fever in Critically Ill Patients with Suspected Infection• [NEJM supplement] Supplementary reading • [podcast] Paracetamol improves recovery in critically ill patients. Radio interview with Paul Young• [other studies] Paracetamol therapy and outcome of critically ill patients: a multicenter retrospective observational study

What is it that enables some physicians to step into a high pressure situation with poise, presence, and consistently perform to their capabilities?

What else is there beyond technical knowledge and clinical skill that can be developed to help immunize the person that is a physician from some of the more human challenges that can present?

In a field so ripe with immense performance pressures, demands, and expectations what are those people doing who seem to thrive amidst it all?

In this session you will be introduced to a variety of strategies rooted in the principles of performance psychology, and their application in high-pressure performance environments such as medicine. Learn how the top performers I have observed through my extensive collaborations with physicians, and others in high-pressure fields (e.g. elite athletes, business leaders and military/tactical officers) have come to gain efficiencies in how they focus, stay perceptive, maintain equanimity, process their experiences, create and sustain an optimal “feel” in their work and ultimately, perform to their potential when it matters most.

Kevin Fong is an astrophysicist, astronaut and anaesthetist with an interest in medical error and safety. In this talk he focuses on lessons learnt from his time at NASA which can be applied to medical practice. Fong believes that key to safer practice is in the collection of accurate data. He outlines some aspects of the famous communications between Sully Sullenberger (pilot) and the Le Gardia air-traffic control tower as Sullenberger miraculously lands a commercial airline on New York's Hudson River - Fong's point is not in the words said or in the calmness of the communications, but that we can go back and analyse every word spoken because the data is collected so accurately.

He goes on to discuss some of the failures surrounding both the Space Shuttle Challenger and Columbia accident's. More importantly he stresses not so much the lessons learnt but the lessons forgotten and the need to ensure organisational memory. We only protect ourselves and our patients through technology and the systems of operation we create.

Is the care you deliver to critically ill patients in your ED the same as the care delivered in your ICU? And if not, why not?Consider the challenges facing the delivery of excellent care in the ED, and be inspired to make changes at your hospital to improve your system. Learn ten strategies for optimizing the care of critically ill patients in your ED. References:1. Learn more about ED-ICU’s at Scott Weingart’s excellent site http://www.emcrit.org2. Consider a resuscitation fellowship like this one: http://www.resuscitationinstitute.org/index.cfm/education/resuscitation-fellowship1/3. There are zillions of articles about the benefits of simulation and training, here is a link to just one, if you only want to dip your toe in the water: http://qualitysafety.bmj.com/content/19/Suppl_2/i34.full4. Audit and feedback around quality outcomes are a potential strategy. Read more about the pros and cons from the World Health Organization here: http://www.euro.who.int/en/data-and-evidence/evidence-informed-policy-making/publications/2010/using-audit-and-feedback-to-health-professionals-to-improve-the-quality-and-safety-of-health-care

When settings outside the hospital are taken into account (ED, primary care), the overall number must be considerably higher. While many factors contribute to diagnostic failure, a variety of sources suggest that physician’s thinking has a lot to do with it.

Dual Process Theory describes how the brain makes decisions in one of two modes: through fast, unconscious, intuitive processes (System 1) or through slower, conscious, analytical processes (System 2). Mental short-cuts (heuristics) and biases are predominantly located in the intuitive mode where we spend most of our conscious time, and this is where the majority of decision failures occur. Thinking straight essentially means achieving a good balance between System 1 and System 2 decision making, and much of our cognitive effort needs to go into monitoring what our unconscious brains are doing in System 1. This is referred to by a variety of terms: metacognition, reflection, mindfulness, and others. They all involve cognitive de-coupling from System 1 and characterize the process of cognitive de-biasing. This is not easily accomplished in the ED or any environment where decision density is often high, throughput pressure exists, resources may be limited, and where decision makers may be fatigued and/or sleep deprived.

While medicine has acquired a variety of strategies over the years for de-biasing clinicians, added benefits can be obtained by developing specific mindware to tackle particular biases. Clinicians need to be aware of the operating characteristics of the dual process model of decision making, of the prevalence and nature of biases, and of how to apply and sustain de-biasing mindware in their decision making.

The human circulation is a complex system that has evolved over millenia, primarily designed to promptly respond to conditions of stress - the fight and flight response. The traditional physiological approach focuses on the heart as a pump, adapting to changes in volume and metabolic states.

These principles are underpinned by the Starling equation and incorporated into an adaptation of Ohm\'s law. These principles have been maladapted, punctuated by an increasing reliance on surrogate and derived variables that have little to do with teleological haemodyanamic responses.Insights into the central role of the autonomic nervous system are provided by Guytonian theory that in part explain the physiological fallacy germane to many clinical protocols and practices.

These fallacies have been amplified by commercial studies directed at short-term physiological improvements that have little to do with patient-centred outcomes in the medium and longer term.Such effects have been demonstrated in recent high-quality RCTs that force a re-appraisal of seductive short-term physiologically-based gratification.