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Brian Driver, MD

Dr. Brian Driver is the Director of Clinical Research in the Department of Emergency Medicine at Hennepin County Medical and an Assistant​ ​Professor​ ​of​ ​Emergency​ ​Medicine at the University of Minnesota Medical School. In 2016, his research was selected for Airway World’s Airway Article of the Year.

Dr. Driver loves teaching, as it keeps his knowledge and skill-set fresh, and challenges him to think in new ways. He sees it as a good way to learn something new every day. His favorite moments are with students who are particularly curious, and eager to solve new problems. “It’s fun to work with them and break it down, and work through their knowledge gaps and figure out the best way to approach new scenarios.”

In his free time, Dr. Driver likes to mountain bike, run, and during some parts of the year, can be found biking over a frozen lake on the way to work.

The Two NEAR Database Papers on Ketamine Hemodynamics

* Mohr et al.

* April et al.

A Flawed Analysis of the Papers

EMCrit Podcast on the topic

The Driver Ketamine Paper

* Driver Ketamine Only

My Podcast on Ketamine Dissociated Intubation

 

Now on to the Podcast...

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Neurogenic Shock

Neurogenic shock is on our differential for hypotension and hemodynamic instability in trauma patients. Today, we discuss this condition as well as the use of vasopressors for hemorrhagic shock.

Neurogenic Shock is not Spinal Shock

Spinal Shock is a loss of reflexes below the level of the injury

What Level?

Preganglionic sympathetic neurons originating in the hypothalamus, pons and medulla are located in the intermediolateral cell column of the spinal cord between the first thoracic (T1) and second lumbar (L2) vertebrae. Theoretically, any SCI within or above this could cause sympathetic disruption. Since sympathetic innervation of the heart only occurs from T1 to T5, it is often said that neurogenic shock can only occur when the lesion is above the mid-thoracic (T6) level. [ 27697845]

Presentation

* Doesn't necessarily happen instantly

* Won't always have bradycardia

* Move arms and legs during primary survey

Fluids

InoPressors

* dopamine is bad--diuresis

MAP Push

* 85 for 7 days???

* UPDATE: Recently published cohort trial supports this practice (but not great evidence here) [Journal of Trauma and Acute Care Surgery Issue: Volume 90(1), January 2021, p 97-106]

More Reading

* Deb Stein's ENLS on Spinal Cord Injury

* Descriptive Reporting of Neurogenic Shock

Should we be using Vasopressors in Hemorrhagic Shock?

I listened to a thought-provoking episode of Traumacast today. It was an interview with Dr. Carrie Sims on the use of Vasopressin after Hemorrhagic Shock.

The contention is that Vasopressin at the 0.03-0.04 unit/minute dose will not affect blood pressure unless the patient is actually vasopressin deficient.

5th-10th Unit of blood, vasopressin levels begin to drop

Are we diluting out our stress hormones?

RCT by Carrie Sims et al. (PMID: 31461138)

vasopressin (bolus 4 IU) and i.v. infusion of 200 mL/h (vasopressin 2.4 IU/h) for 5 h after pts who received 6 units of product

 

Vasopressors are associated with worse otucome after blunt trauma shock (PMID: 18188092), but little can be taken from this study

Spahn, D.R., Bouillon, B., Cerny, V. et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 23, 98 (2019). https://doi.org/10.1186/s13054-019-2347-3

If they are warm, give them vasoconstriction

 

 

Today, we turn back to a topic near and dear to my heart (pun always intended), resuscitative thoracotomy. I covered the basics of this in my:

Crack to Cure Lecture

If you have not seen that one, you should watch it first. Then come back here to listen to the conversation I had with Dennis Kim.

Dennis Kim, MD

Dennis is a trauma surgeon and intensivist at Harbor-UCLA. He was born and raised in Toronto, Canada & attended medical school at McMaster University. Following his general surgery residency, he completed a critical care medicine fellowship at the University of Ottawa. He then completed a fellowship in trauma & surgical critical care at UC San Diego. His passion for surgical education led me to complete a Masters in Medical Education at the University of Dundee. I’ve been a trauma surgeon at Harbor-UCLA Medical Center in Torrance, CA, since 2012.

He also runs the wonderful Trauma ICU Rounds podcast which you should check out ASAP if you are interested in Trauma and Surgical Critical Care.

Today we run through the entire thoracotomy procedure with tips, tricks and pitfalls.

Additional EMCrit Thoracotomy Stuff

* Podcast 83 – Crack to Cure – ED Thoracotomy

* The Abbreviated ED Thoracotomy Tray

* John Hinds on Crack the Chest–Get Crucified

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

* EMCrit Podcast 36 - Traumatic Arrest(Opens in a new browser tab)

Now on to the Podcast...

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We've spoken about the concepts of venous congestion being problematic beyond just pulmonary edema. I've had Phil Rola on in the past to discuss Venous-side issues such as Renal Compartment Syndrome, the Vexus score, and other issues of the under-respected side of the circulation.

Prior Episodes

* EMCrit Podcast 240 - Renal Compartment Syndrome - It's all about the Venous Side and We've Been Fracking it up for Years

* EMCrit Podcast 263 - The Venous Side Part 1 - VEXUS Score with Phillipe Rola

Today we go further into these concepts, with some concentration on the micro-circulation. There may be quite deleterious effects from iatrogenic volume overload--especially when we are compelled by government regulation to go against our clinical gestalt.

 

Journal Articles

* Blood pressure deficits in acute kidney injury: not all about the mean arterial pressure?

* Renal Perfusion Pressure < 60 predisposes to kidney injury

* There is individual variation on micro-circ from NorEpi

* CVP affects Microcirc Flow (Editorial)

* Physiology of the Microcirculation

* Perioperative Blood Pressure

* Sublingual Microcirculatory Microscopy

* Hot off the Press: Relative Hypotension and Adverse Kidney-related Outcomes among Critically Ill Patients with Shock. A Multicenter, Prospective Cohort Study. Am J Respir Crit Care Med. 2020 Nov 15;202(10):1407-1418. doi: 10.1164/rccm.201912-2316OC.

Special Mention to Ince on Microcirculatory Hemodynamic Coherence

* Ince hemodynamic coherence

Now on to the Podcast...

 

Rob Orman steers a conversation on skillful ways to discuss code status, comfort care, intubation, and whether or not dying debilitated patients should go to the ICU.

For more of the amazing Rob Orman, check out the Stimulus Podcast.

Pearls:

* When family members have to make decisions for their loved ones, you can minimize their guilt by being clear what you think is medically inappropriate.

* In an ideal world, a DNR order would only affect what you do when a patient’s heart stops.

* When having a comfort care conversation, Scott uses the dichotomy of two goals:  curative care vs. dignity.

___________________________________________________________________________

Tips and tricks for having a conversation with a patient and/or their family about plan of care:

* If you don’t have time for the conversation, then reconsider having it.

* You still must make the initial foray to find out if they have preexisting wishes and if the pt's condition is dire, then you have no choice.

* Deferring the conversation to the ICU is an option.

* A slapdash conversation is worse than no conversation at all.

* Create a space where everyone feels comfortable.

* Provide chairs so people can be seated.

* Reassure the family that this is a discussion you have with EVERYBODY who enters the hospital system.

* Feel out the situation and try to understand one another. 

* Your job is to translate the medical realities in a way the family can understand.

* The family’s job is to translate their wishes, desires, and belief structure to us in a way we can understand.

* 5-10% of people are “vitalists”. They want anything done to bring back whatever form of life possible, no matter the predicted quality of that life. You’re not going to get what you feel is medically appropriate in those cases.

* Pick your own philosophy that fits with your strategy and psyche in medicine.

* Weingart has learned to be medically paternalistic and socially completely open.

* Inquire:  has the family had prior end-of-life conversations with their loved one?

* It makes everything easier if they have.

* If they haven’t, ask them to put themselves in the mindset of their loved one. By asking the family to be a channeler of what their loved one would want, you minimize their guilt.

* If you feel something is medically inappropriate, state it clearly.

* This transfers guilt to yourself.

* In many countries (ie. Canada, Australia, New Zealand), CPR is not offered if it’s felt to be medically unacceptable.

* Avoid being manipulative when describing CPR.

* Don’t tell them chest compressions might break ribs or cause organ damage.

* Instead, concentrate on the end game and what you could get out of CPR.

There are 3 tiers of care:  DNR (do not resuscitate), DNI (do not intubate), and comfort care.

* DNR

* In an ideal world, DNR would only apply when a patient’s heart is about to stop.

* While DNR is not supposed to affect the rest of the care we provide, it often does.

* Being DNR may have significant effects on the willingness of physicians to provide aggressive care,

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Algorithmic social media is stealing your joy and may be making your life dramatically worse. If you haven't watched The Social Dilemma, you probably should sit down and give it a view, especially if you have kids.

Advertising + Algorithm

Misalignment of incentives

Business model in which incentive is to find customers ready to pay to modify someone else's behavior

 

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The Algorithm

Get you to the app and keep you there

Movie Social Dilemma gets it Wrong

Negative trumps positive

Dopamine hit

Addictive, but mostly shallow or perhaps b/c of shallowness

Tribalism & Mob Behavior

Magnification of Fringe Views

Makes assholes more assholey

Attention is the reward on social media, and assholery gets the most attention

Loss of Objective Reality

 

Individual Apps

Facebook

The Worst!!!

A bunch of you are there so EMCrit has to announce new episodes there

Instagram

Just as evil

Reddit

 

Twitter

Sponsored Tweets

Built to inflict misery and turn people into assholes

Reub--bring it to Reddit

Twitter happiness feed

Youtube

Turn off "Up Next"

TikTok

Insanely addictive

Netflix

Algorithm with the right incentives

The News

Algorithm

If you can't change it, don't regard it as important

Google

not just creating an echo chamber

but actually sculpting Truth based on a political agenda

* Switching over to Hey Email

* DuckDuckGo

RSS

The way to have social media goodness come to you

Turn off Notifications

for any social media and for anything else possible

Go Deep instead of Shallow

 

If you have kids, avoid social media until ~16

Jonathan Haidt

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More Stuff to Check Out

* How to go from being an Ass-hole to an AYS-hole on Twitter

* 7 Ways to be Insufferable on Facebook

* How to Use RSS and Itunes to Maximize FOAM Podcasts

* The Online Hierarchy of Needs - Social Media and FOAM

Please ReRead 1984

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Now on to the Podcast...

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So this episode addresses a big gap in the EMCrit content, namely a discussion of the myriad uses of dexmedetomine. This is one of the primary agents I use for post-intubation sedation (PAD), but also for things like NIPPV sedation and procedural sedation.

Upsides of Dexmedetomine (Precedex)

* No respiratory depression

* Opioid sparing/analgesic effect

* Preserves Sleep Architecture

* Sympatholysis

* May be delirium-protective

* May be more hemodynamically stable than propofol

* Good for neurocritical care

Downsides of Dexmedetomidine

* Bradycardia

* Hypotension (especially when the pt is volume depleted)

* Cost (much less of an issue now that it is generic)

* Diuretic effect

* Slow onset

* Constipation

Useful for...

* Post-intubation sedation

* NIPPV sedation

* Procedural sedation

* Add-on to propofol

Other Stuff on EMCrit

* Podcast 115 – A New Paradigm for Post-Intubation Pain, Agitation, and Delirium (PAD)

* PulmCrit Wee- Extubating the agitated patient: dexmedetomidine vs. cowboy-style?

* Dexmedetomidine to facilitate noninvasive ventilation

 

Studies

The Effect of Propofol and Dexmedetomidine Sedation on Norepinephrine Requirements in Septic Shock Patients (Critical Care Medicine: February 2019 - Volume 47 - Issue 2 - p e89–e95)

https://www.ncbi.nlm.nih.gov/pubmed/21812509

https://www.ncbi.nlm.nih.gov/pubmed/27035758

Now on to the Podcast...

Labors of Trauma (Blunt Ed.)

So a few weeks ago, I podcasted the Labors of Trauma, a comprehensive list of the responsibilities of a Trauma Team Leader.

EMCrit 278 - Labors of Trauma - Blunt Edition

I promised that I was going to do a part II with my co-conspirator, Chris Hicks.

Hick's Pre-Brief and Leave the Room Checklist

 

St. Mike's New Trauma Bays

Calcium

Ditzel RM Jr, Anderson JL, Eisenhart WJ, et al. A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond?. J Trauma Acute Care Surg. 2020;88(3):434-439

New Hemostatic Resus Ratios

* Should we add calcium and fibrinogen to our ratios

New Name for the Pelvic Binder

* We should be calling these Trochanteric Binders

Now on to the Podcast...

 

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Why Can't Emergency Medicine and Trauma Surgery Just Get Along? This is a question we often ask in the USA given our unique Trauma system. It seems custom built to create conflict in the trauma bay. To explore this issue, I got to talk with Joe DuBose and Bill Teeter. This discussion originally was recorded for Joe's new podcast on Trauma Surgery, Tiger Country. Tiger Country has a bunch of episodes that are worth a listen for ED and ICU folks as well.

Joe DuBose

Trauma and Vascular Surgeon at the Shock Trauma Center. Professor of Surgery. Research leader on all things REBOA.

William Teeter

Started as a surgery resident, switched over to EM residency and then Crit Care Fellowship. Now an EM Intensivist down South.

More from DuBose

* Podcast 170 - the ER REBOA Catheter with Joe DuBose

Now on to the Podcast...

I did an initial EMCrit episode on Angiotensin II when the Athos 3 trial was fist published. Today, now that the drug has been available for a while, I wanted to hear from someone smart, with no financial conflicts of interest, on when to actually use this medication.

Rinaldo Bellomo MD PhD

Dr. Bellomo's Bio is too extensive to place here, please check out his Monash Page. Suffice it to say that he is a total badass as a clinical intensivist and a critical care researcher.

 

Renin Angiotensin Aldosterone System (RAAS)

Who Should Get Angio II

* Renin > 175 (or round up to 200)

* Septic Pts on RRT or about to need it

* Patients on pre-illness ACE-I

Rinaldo's Paper in AJRCCM

* Renin and Survival in Patients Given Angiotensin II for Catecholamine-Resistant Vasodilatory Shock

More on this Topic

* PulmCrit- Angiotensin II: five cautions & three comparisons

* Review Article from EMJ

Now on to the Podcast...