EMCrit FOAM Feed

If you are not using the bougie for your intubations then you are leaving first pass success on the table. Today, George Kovacs on how to use the bougie, aka the tracheal tube introducer. This is a remix of two lectures from Georges amazing AIME Airway Project. If you want to hear the full version, click on over to George's Youtube (Part 1 & Part 2).

George discusses when to use the bougie, how to use the bougie, and the part that I liked best, advanced bougie techniques.

More Bougie on EMCrit

* EMCrit Guest Post – Bougie Lessons from the Literature and Experience by George Kovacs

* EMCrit Guest Post – Drawing Circles for Bougie Hangup by Neil Dasgupta

* EMCrit Podcast 226 - Airway Update - Bougie and Positioning

Now on to the Vodcast...

Something I have been preaching for a decade has finally gotten the attention and research it deserves. On this episode, I get two of the authors from the Lethal Diamond Paper to discuss hypocalcemia in the bleeding patient.

Ricky Ditzel

Prior Special Operations Combat Medic and current Premed Postbacc Student at Columbia trying to go to medical school

Jeffrey Siegler

EM Doc & EMS Physician at Wash U in St. Louis

Read the Lethal Diamond Paper

* Official JTACS Lethal Diamond

Here is a powerpoint from Ricky

The Lethal Triad Should be the Lethal Diamond

Calcium is an independent part of the death spiral, but it is also intertwined with the other three factors as this diagram demonstrates:

Calcium in Clotting

 

from @MikeEMPharmD  data from: Giancarelli A, Birrer K, Alban R, Hobbs B, Liu-DeRyke X. Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res. 2016;202(1):182-187. [PubMed]

What to Do

* Give calcium with your first unit of blood in trauma (and TXA)

* Consider giving 1g for every 2-4 products you administer during large transfusion

* Send and Respond to Icals

Read these Papers

* MilMed

* Citrate in Cirrhotics

* Hypocalcemia during MTP

* mass trans

* Ionised-calcium-levels-in-major-trauma-patients-who-received-blood-in-the-emergency-department

* Howland WS, Schweizer O, Carlon GC, Goldiner PL. The cardiovascular effects of low levels of ionized calcium during massive transfusion. Surg Gynecol Obstet 1977; 145:581.

* Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res. 2016;202(1):182-187.

* Retrospective Study

Related EMCrit Stuff

* Hypocalcemia

* EMCrit 278 – Labors of Trauma – Blunt Edition (Part 1)

* EMCrit Podcast 13 – Trauma Resus II: Massive Transfusion

* Massive Transfusion Protocol (MTP)

Now on to the Podcast...

EndoVascular Aortic Repairs are a game changer in patients with AAAs. Add a T and you get a TEVAR for the treatment of aortic dissections. Despite the amazing advances that these devices represent, they are not without problems.

Ani Aydin, MD

Dr. Aydin is an assistant professor of emergency medicine at Yale EM. She received her medical degree from Stony Brook Medicine, did EM residency at Bellevue/NYU, and then completed a fellowship in surgical critical care at the Shock Trauma Center (we bleed pink, yay!!). She is the medical director of the Yale critical care transport service. Her academic work includes projects ranging from mechanical ventilation to endovascular emergencies.

Recently Done Operation

Look at the Access Site in the groin. These devices require enormous access in the femoral vessels. Search for pseudoaneurysms, dissection, thrombosis, or bleeding.

Kidney injury both from operation and all of the imaging that goes along with it

Endoleaks

Leaks through or around the graft into the original aneurysm.

Get imaging. Don't get ad hoc imaging. They need specialized CT angiography of the chest and abdomen with both arterial phase and delayed venous phase. You really want to work the scan parameters out ahead of time with your radiologists.

* Type 1: Failure of complete apposition to vessel wall (1a is proximal, 1b is distal)

* Type 2: Retroleak - Back flow through a vessel

* Type 3: Graft torn or ruptured

* Type 4: Porosity of the graft

* Type 5: Unclassified/Who Knows?

from UW Emerg Radiology

Type 1 and Type 3 needs immediate surgical intervention

for the others, Aortic dp/dt control just like a dissection until you get in touch with Vascular

Thrombosis and Embolus

These pts can through clots to their distal vessels

Look for arterial clots and for mesenteric ischemia

Reach out to the Patient's Vascular Surgeon

anytime someone has any issue with their EVAR, call early!!!!

Review Article

* Aortic graft emergencies

Other Great FOAM

* EM Docs on EVAR Complications

Now on to the Podcast...

After my recent Resus Room Readiness post, my buddy James got in touch with me wanting to do this episode. I said frack that, we can't do an episode, there is too much goodness in the French brain, we need a series. This is the first episode in a new series with an amazing Emergency Medicine Doc and Innovator, James French.

James French, MD

Dr. James French was born to a father that was an incredible engineer and tenacious inventor. James’ earliest memories were working with his dad restoring vintage motorcycles which sparked his fascination with fixing things. When James was 5 years old he went to watch the film “Superman” with his dad. It turned out they knew Christopher Reeves from the flying club that they went to, so they actually knew superman while he was learning to fly. James attended many Emergency Departments in the years after as it turns out that no matter how hard he believe you can fly or whatever machine he invented, gravity always won.

Whilst studying for a science degree he realised that training in martial arts was a partial antidote to not being able to sit still or focus on one task and has trained in martial arts throughout the majority of his life.

In 1995 James started medical school in Southampton, England. In 1997 at a local kung-fu club he met a guy called Dr. Cliff Reid who was a resident or registrar in Emergency Medicine. They immediately became friends. Whilst at medical school James would shadow Dr. Reid when he worked in the ED, particularly at weekends . They constantly exchanged ideas about resuscitation, psychology, meditation and of course martial arts. Cliff later stated openly on social media that James saved him from a residency system that was breaking him.  To outsiders it was obvious that the “saving” was a two way street. James’ passion for resuscitation and education comes from Cliff.

James graduated medical school in 1999. Whilst driving to work as an intern in 2000 he was first on scene at a fatal road traffic collision. Trying to render aid to multiple trapped and dying casualties, with no formal training in prehospital care was a formative experience. He started working with the Magpas Air Ambulance System (www.magpas.org.uk)  as a volunteer in 2003. The training course featured multiple days of simulation based medical education, a competency based curriculum and was probably a decade ahead of its time and was lead by the legend that is Dr. Rod Mackenzie. Influenced heavily by the aviation industry and the military Rod and James invented the first RSI kit dump and RSI checklist in about 2006. James continued to work with Magpas in PHEM until 2012.

In 2009 James started working as an attending in Addenbrookes Hospital, Cambridge and was given the task of selecting and purchasing all of the clinical equipment and for a new Trauma Center. Influenced heavily by a very strong department of clinical engineers lead by Prof Paul White, James realised the necessity of applying principles of from EMS, ergonomics, lean and clinical engineering to resuscitation practice.

In 2012 James moved to Canada to work in Saint John, New Brunswick. Whilst in New Brunswick he chaired the trauma research subcommittee and lead an interprofessional team to establish a province wide simulation system for trauma education. In 2017 James met Dr. David Elias, who is an Emergency Physician and highly successful medical entrepreneur,

We need to be able to respond instantly to the sickest patients rolling into the resus bay--sometimes with no warning at all.

Philosophy

Instantly Ready

but no need to put things away

EM Docs are good at prep bad at breaking down

Reliability

BVM

from Precision Medical

Airway Cart

Flex Tip Bougie, Intubation Stylet for Hyperangulated Blade

Airway Supplies

Orange Tackle Boxes

Igel 4, Scalpel, Bougie, DuCanto Suction

SCRAM Resus Bag

Coming Soon...

Suction

Needs to be Set-Up

Intubation Meds

Maryland Boxes

SCRAM Rx Lite

Vascular Access

I/O

Crash Big-Bore

 

Defib with Pads

 

Epi

 

Art Line Set-Up

 

Trauma

Scalpel

Hemostats

Mayo

Blood

PCC

Two Great Virtual Conferences

Essentials of EM

Go Here for early bird discount before April 5th: Register for EEM

Bring Me Back to Life: Le Show

go to

www.Bringmebacktolife.ca and use the password "Le show" for a $100 discount

Now on to the Podcast...

Anyone who reads EMCrit knows PulmCrit and therefore its creator, Josh Farkas. We had him for virtual grand rounds at Stony Brook EM recently. This is the 1 hr GR--and it was fantastic!!!

See the Video Version

Here is the Audio-Only Version

 

 

What is a Heuristic?

A short cut to extended, analytical thinking that when functional provides a solution that may not be optimal but will be sufficient. When based on cognitive biases, heuristics may be dysfunctional. Wikipedia has a fairly good discussion of heuristics.

Thinking Fast and Slow

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System 1 vs. System 2

Our interview with Gary Klein

ERADs are the Action Version of Functional Heuristics

Emergency Reflex Action Drills from Lauria

Jerk & Check

Never immediately act on a heuristic. Have your kneejerk response and then use System 2 to Check

Functional Heuristics in Resuscitation

Flank Pain in Elderly is AAA until the Ultrasound

 

Severe Bradycardia/Heart Block = Hyperkalemia until you see the K

 

Slow Afib=Digoxin, Hyperkalemia, or Nodal Blockers until proven otherwise

 

Slovis' Hypokalemia = Hypomagnesemia (Hypok=HypoMAG)

 

Unexplained Hypotension gets antibiotics

 

Hypotension and Abdominal Pain in Child-Bearing Age Female is Ectopic

 

Chest Pain Plus

 

Tamponade is dissection until it is not

 

Old stay, young go

Err towards Young D/C and Old Stay and then check

Think LP/do LP

 

The diagnoses of costochondritis and gastroenteritis do not exist

 

What is going to kill this patient? (Pre-Mortem)

a adaption of Gary Klein's idea

Ad Spot: Butterfly IQ+

Read about and watch Mike Stone demonstrate BiPlane

EMCrit listeners get a free case worth $99 with the purchase of a Butterfly iQ+ probe and membership. Simply use the referral code "EMCRIT" at checkout

Note: Butterfly provided a probe for testing to Metasin LLC

Now on to the Podcast...

So we recently did a Myxedema Episode with Arti Bhan. On the show, we were supposed to have a 2nd endocrinologist, but due to scheduling issues, it didn't work out. For a different take on IV T3, today we have that endocrinologist on the show.

Eve Bloomgarden, MD

Dr. Eve Bloomgarden, MD is an endocrinologist at Northwestern Memorial Hospital and an assistant professor in the Division of Endocrinology, Metabolism and Molecular Medicine at Northwestern University Feinberg School of Medicine. Dr. Bloomgarden received her medical degree from New York University and completed residency and fellowship training at the Hospital of the University of Pennsylvania. Dr. Bloomgarden’s clinical expertise is in the diagnosis and management of thyroid disorders and thyroid cancer as well as general endocrinology. She is a clinician educator and contributes to the medical education of students, residents, and fellows. She loves spending time with her husband, also a physician, and their two young children. The COVID crisis has brought out her social media voice and her strength as an advocate for her fellow healthcare workers.

If the Patient Looks Crappy...

This is when to consider combined therapy in Dr. Bloomgarden's practice

Always Give Steroids First

I think this is even more critical if you are using LT3

Combined LT4/LT3 Dosing Strategy

LT4 200-300 mcg

&

LT3 5-10 mcg IV then 2.5-5 mcg q8 hrs (until pt stabilizes and then switch to just LT4)

American Thyroid Association Guidelines

* Guidelines from American Thyroid Assoc.

21c. In patients with myxedema coma being treated with levothyroxine, should liothyronine therapy also be initiated?

■  Recommendation

Given the possibility that thyroxine conversion to triiodothyronine may be decreased in patients with myxedema coma, intravenous liothyronine may be given in addition to levothyroxine. High doses should be avoided given the association of high serum triiodothyronine during treatment with mortality. A loading dose of 5–20 μg can be given, followed by a maintenance dose of 2.5–10 μg every 8 hours, with lower doses chosen for smaller or older patients and those with a history of coronary artery disease or arrhythmia. Therapy can continue until the patient is clearly recovering (e.g., until the patient regains consciousness and clinical parameters have improved).

Weak recommendation. Low-quality evidence.

Not Many Patients Treated with LT3 in this Review

Japanese Review of Treatment Options for Myxedema

Want More Eve?

* Check her out on the Curbsiders

More Myxedema and Thyroid on EMCrit

* IBCC chapter & cast - Myxedema coma (decompensated hypothyroidism)

* Decompensated Hypothyroidism ("Myxedema Coma")(Opens in a new browser tab)

* Thyroid Storm(Opens in a new browser tab)

* Podcast 149 – Thyroid Storm

Terren Trott, MD

Emergency Medicine + Ultrasound + Critical Care Physician + Airway Enthusiast. Editor for 5minuteairway and critical care now.

The Original Crit Care Now Blog Post

Terren's Post on Critical Care Now

The Two NEAR Database Papers on Ketamine Hemodynamics

* Mohr et al.

* April et al.

Jabre RCT on Ketamine vs. Etomidate

* KetaSED - Jabre Lancet RCT

* Bottom Line KetaSED Summary

* Reanalysis of Jabre demonstrating that all intubations were done by EM in ED or EMS Environment

 

Now on to the Podcast...

 

Thyroid storm is tumultuous and exciting; Myxedema is somewhat enervating and markedly less exciting--but it is also life threatening. We need to know about this disease! Today, I interview Arti Bhan, MD on the topic:

Arti Bhan, MD

Division Head, Endocrinology @HenryFord Health System

"I strive to provide the highest quality health care services to all my patients efficiently, effectively and compassionately. I believe in partnering with my patient in order to achieve our goals."

Dr. Bhan received her medical degree from India. She completed an Internal Medicine Residency at St. John Hospital and Medical Center and then went on to a fellowship in Endocrinology at Henry Ford Health System.

She has been a senior staff physician at Henry Ford since 2003 and is currently serving as the Division Head of Endocrinology. She is active in clinical research and is an investigator in numerous trials, including NIH funded studies. She is published in peer reviewed literature and is the Associate Editor for Clinical Diabetes.

Dr. Bhan's main area of interest is in thyroid disorders, and she trains fellows in thyroid ultrasonography and thyroid biopsies.

What We Cover on Myxedema

* What is the look of myxedema

* What TSH should get you worried

* How to treat Myxedema

* Should we use T3 (LT3)

* What do resus docs screw up when treating myxedema

Related & More

* IBCC Myxedema

* EMCrit Thyroid Storm

Now on to the Podcast...