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A brief summary of this episode

A brief summary of this episode

A brief summary of this episode

Trial Publication on the JAMA

BaSICS Trial (Fluid Rate)

BaSICS Trial (Fluid Choice)

Zampieri et al.

~11,000 patient trial

90 Day Mortality was the primary

The mean (SD) volume infused as boluses on day 1 was 1162 mL (916 mL) for slower infusion vs 1252 mL (1009 mL) for control infusion rate.

did not randomize fluid received before ICU

 

Take Home Message

There was no statistically significant difference between the 2 groups with respect to fluid choice (NS vs. Plyte 148) or infusion rate (333 mL/h vs. 999 mL/h). Patients were also randomized to receive balanced solution or 0.9% saline using a factorial design.

Now on to the Wee...

A brief summary of this episode

You are going to see it referred to by many names: Cerebral Venous Thrombosis (CVT), Venous Sinus Thrombosis (VST), Cavernous Sinus Venous Thrombosis (CSVT)--all a little bit different but within a spectrum of disease we will talk about today. This is a rare cause of headache, but if you do not have a disease script for this diagnosis, you will miss it! Without the right treatment the patient will get much worse, but if you do think about it and diagnose it, these patients can do very well.

To talk about CVT, I have brought on new EMCrit Team Member, Casey Albin.

Casey Albin MD

I first discovered Casey on Twitter where she does insanely good neuro-critical care tweetoriols. She is an Assistant Professor of Neurology and Neurosurgery in the Division of Neurocritical Care at Emory University School of Medicine.

 

Casey Wrote Up Her Own Shownotes (b/c she is Amazing!)

When should I think about Venous Sinus Thrombus?

* Understanding the presenting signs requires knowing a little bit about the pathophysiology

* Remember that the anatomy of the brain is quite different in that the arteries and veins do not run in parallel proximity or supply and drain the same territories.

* When we talk about Cerebral Venous Thrombosis we are talking about to subtypes that often coexist

* Cerebral Vein Thrombosis

* Venous Sinus Thrombosis

* Often the patient has both and colloquially these get interchanged to mean the same thing, but

* Cerebral veins drain the brain parenchymal and there are two systems – superficial and deep

* These are draining the brain parenchyma and are beneath the meninges

* These ultimately drain to venous sinuses which are venous channels that are between the layers of dura.

* The most important of these are the sagittal sinus, transverse sinuses, straight sinus and cavernous sinus.

The reason the distinction matters is the downstream consequence of a vein being occluded is going to be a little different than if a sinus is occluded.

* When a vein is occluded you get a downstream blockage to flow within the parenchymal (remember, that’s where the vein are!)

* this causes a build=up of pressure which leads vasogenic edema

* If the pressure is great enough that you don’t get forward flow à cytotoxic edema and cell death, a so-called “Venous Infarct”

* And if there is still pressure into the dying tissue you can get an intraparenchymal hemorrhage

This can also occur when a Sinus is occluded, but it may not, but if enough of the venous sinuses are occluded you can see a dramatic rise in intracranial pressure.  Because not only are you impeding VENOUS drainage but also CSF is ultimately reabsorbed back into the sinuses through the arachnoid granulations.

So, the reason all of the pathophysiology matters is that the patient can have different symptoms depending on what is physiologically happening.

That’s what makes diagnosing this so tricky, because in many ways VST is a mimicker of other pathology and it’s a very rare etiology stroke (<1%)

There is a really broad spectrum of the way this can present.

* International Study on Cerebral Vein and Dural Sinus Thrombosis group found that almost 90% of patients had a headache and about a 1/3 had papilledema

* Headache was most commonly subacute and crescendo type, not sudden onset WHOL although that may happen especially with associated IPH

* Localizing signs like paresis, aphasia,

Mike Weinstock comes on the show to discuss a case from a chapter of his brand new book: [easyazon_link identifier="189001883X" locale="US" tag="emcrit-20"]Bouncebacks Critical Care[/easyazon_link]. We go through the case and the key decision points. I think you will love it!

 

Read the Full Chapter from the Book

Bouncebacks Crit Care_CHAPTER 11 - 63 yo man fall SOB

Things Mentioned During the Ep.

* Avila on "Is it a Tamponade?"

* RUSH Exam

Get the Book

[easyazon_image align="none" height="500" identifier="189001883X" locale="US" src="https://m.media-amazon.com/images/I/41z5DGzP4fL._SL500_.jpg" tag="emcrit-20" width="389"]

Now on to the Podcast...

Today an update on pain management in the ED. Sergey is a great friend and a previous guest on the show when he discussed the Opioid-Free ED.

Sergey Motov, MD

Sergey is an Emergency Medicine Physician practicing in the Department of Emergency Medicine at Maimonides Medical Center, Brooklyn, New York. He graduated from Medical Academy of Latvia and completed his EM residency at Maimonides Medical Center. Dr. Motov is a Research Director who is passionate about safe and effective pain management in the ED. He has numerous publications on the subject of opioid alternatives in pain management, and is actively involved in growing this body of work both nationally and globally.

The Pain-Free ED

Sergey has an amazing site, with resources and lectures: The Pain-Free ED

A Brief Discussion of the Advantages of Morphine over Hydromorphone and Fentanyl from a Euphoria Perspective in Patients with Intact Organs

This is far more an issue for what you send these patients home on.

Sergey recommends MSIR tablets 7.5-10 mg Q 6 hrs for 3 days for most acute pain indications in patients without organ failure. There is also liquid 10 mg/5 ml, so 1/2 tsp gets you 5 mg.

Consider diclofenac gel in the appropriate patient. Now available over the counter. Apply twice/day.

Giving Fentanyl For Longer Duration Pain Means the Patient will be in Pain Again Soon

* Consider a regimen that matches the duration of pain

Kidney Failure

* Do Not Use Morphine

* Hydromorphone--avoid in ESRD, If you feel the need to use it in more mild renal failure, Drop Dose by 75%  (e.g. from 1mg to 0.25 mg per dose)and extend dosing regimen (from q4-6 hrs extended to q8-12hrs)

* In the ED, you should probably use Fentanyl. Still reduce dose by 75% of standard and extend dosing intervals

* When you need to send the patient home, do not use tramadol. Mild to moderate, use oxycodone with sig. dose reduction. In the future, buprenorphine may be the agent of choice.

Liver Failure

* Very low dose morphine, but probably the better idea is:

* Fentanyl with a dose reduction and interval extension

* For sending a patient home, Oxycodone consider half dose with extension of intervals

Ketamine

* Recent trial compared 0.15 mg/kg to 0.3 mg/kg with no difference

* Breath-Actuated Nebulized Ketamine

Sergey does not Like IM Pain Meds

* Causing pain to relieve pain doesn't make a ton of sense

More from Sergey

* More on Kidney and Liver Failure Pain Management

* Pain Pearls on Opioids

* Handout on Analgesics for Hepatic and Renal Failure

Do a Virtual Resus Fellowship

Resus Leadership Academy

Now on to the Podcast...

“Fear is beneficial. It happens for a reason. Everything we have in our heads is evolutionarily beneficial for the most part. The benefit of fear is it allows you to predict the evil sh*t that's going to happen and avoid it.”

This is another episode from Rob Orman's Stimulus Podcast. Rob is my best buddy and the best interviewer in the business. In this episode, we discuss:

The distinction between carrying fear and being afraid

Good doctors carry fear with them. Those who don’t carry a healthy dose of respect for the risks of their actions can be dangerous.

Fear should be your friend. It should be one of many internal voices that you listen to and to which you decide whether you want to regard or ignore.

Fear should not be your limiter. “If fear is your primary internal theme, then you're afraid. And that's a problem.”

The importance of embracing the idea that sick patients don’t take a joke

The sicker the patient, the less room you have for error. Be very careful.

The Five Fears

1. Scott’s fear number one: lawyers

This is a healthy fear as long as you use it the right way. Shared decision-making and good documentation help to keep this fear positive.

It’s a bad fear if it prompts you to practice defensive medicine and do things that patients don’t need or want (such as order unnecessary tests or procedures).

When you document, be sure to show that you thought of the life-threatening diagnosis and why you did not think it was the cause of the patient’s complaint.

2. A common fear that Scott does not personally experience: being an imposter 

This is the inner voice that says negative things about your performance and capability of getting the job done.

Scott’s mindset has always been to assume that his baseline skill level at anything is zero until there is external calibration. With this cognitive assumption, he has never had an inner voice speaking negatively to him.

In emergency medicine there are plenty of opportunities to externally calibrate your skill set (eg. following up on patients to see if your diagnosis was correct or keeping a log of your first-pass intubation success rate).

3. Fear of Monday morning quarterbacking 

This is a useful fear to have because it allows you to foreshadow what you're going to experience tomorrow and the chance to fix the situation today.

While Monday morning quarterbacking can yield strategies for improvement when done in a positive fashion, it can also be done badly and be an opportunity to serve insults.

“The fear of Monday morning quarterbacking should drive your documentation more than it drives your practice.” And if you can anticipate what the Monday morning quarterback is going to harp upon, it should drive you to take actions to have the appearance of due diligence.

4. Fear of procedural complications

Procedural complications can be prevented by breaking them down into distinct micro skills that can be individually mastered.

No matter how adroit one is at procedures, having a certain level of fear of the potential complications is healthy. That fear makes you question whether the procedure is truly necessary, or whether it would be safer done in another setting such as the OR.

Create a Goal

Safe First Pass Success (sFPS)

DASH-1A

An Airway Quality Assurance Program Improves First Pass Success without Desaturation

* What is good FPS

* Emerg Med Australas 2017;29:40

* Research published in the last 16 years shows a mean ED FPS rate of 84.1%. This represents the best available published data that can be used to benchmark emergency airway performance.

* 60% of ED Intubations deemed difficult Acad Emerg Med 2013;20:71

Creation of an Airway Lead

One attending was assigned to oversee airway management quality and empowered to enact changes to maximize success. (2020 DOI: 10.1016/j.bja.2020.04.053)

* Watches every intubation

* Conducts CQI / Reviews every Intubation that went Awry

* Training

* Lit Watch

 

Development of a Debrief Form

This form allowed a review and quality improvement process for every intubation.

Development of an Airway Database

If you are not measuring, I promise you, you are not doing well

Checklist

A call-and-response checklist was used for all non-crashing intubations. The nurse-leader of the resuscitation would read through each item of the checklist (see on-line materials) and a member of the intubating team would affirm or stop to remedy the missed item.

Use of a Validated Failed Airway Algorithm

A three pass maximum airway algorithm was adopted as standard practice (2009 DOI: 10.1213/ane.0b013e3181ad87b0; 2011 DOI: 10.1097/ALN.0b013e318201c42e)

Development of an Airway Note

Key aspects of management: CL, story behind the airway

Standard Operating Procedure

No everyone cannot have their own way of doing things

Perfect Preox and Preintubation Optimization

We changed the allowable preoxygenation techniques to allow full denitrogenations. ETO2 monitoring was added to allow monitoring of success. Positioning of the patient for intubation was standardized

Midline Approach

Some attendings were teaching a right-sided mouth entry with aggressive tongue sweep. Video review demonstrated that often with this approach, key structures were missed and the esophagus was entered. A switch to mandatory midline approach with progressive visualization of uvula and epiglottis avoided this issue.

VL for all First Passes

At the beginning of the intervention, there was wide variance on techniques and choice of intubating equipment between the attending staff of our department. This was viewed as a primary source of poor first-pass performance and decreased the teaching potential for residents. Video laryngoscopy allows for real-time teaching during airway management and allows salvage of poor performance during the first pass.

* Maximize FPS

* Maximize Learning

* Maximize Teamwork

* Maximize Reflection

Standard Geometry Video Laryngoscopy as Standard

Unless intubating a patient with cervical spinal precautions, a CMAC macintosh standard geometry blade was made the standard for all first-pass intubation attempts. Based on the impediments noted on the first laryngoscopy, in some cases a switch to a hyper-angulated blade was indicated for subsequent passes.

Recordings and Videographic Review of All Intubations