Pulseless Electrical Activity ( PEA ) is confusing! The diagnosis and treatment of PEA is bogged down by terminology and misunderstandings. Spurred by a recent interview I did with Anton Helman of EM Cases, I lay down some of my thoughts on PEA here.

The last time I discussed these issues was 5 years ago with Zack and Joe on EDECMO 13.

PEA Progression to ROSC

POCUS Pulse

* Carotid POCUS Pulse* Badra et al. on POCUS Pulse

Narrow / Wide doesn't Work

Rory breaks it down on the CCnerd in a post about QRS size in PEA.

What to Do if You Have Compressions/POCUS Pulse but No BP

Prosen on Vasopressin for PEA

Updates

More on PEA on the EM Cases Blog - I speak with Anton Helman on the topic

The Right Heart being Big doesn't mean PE during Arrest (from Ultrasound Podcast)

Now on to the Podcast...

So, Josh recently published a guest post on PulmCrit discussing some interesting ideas on the treatment of asthma. This post nearly gave me a stroke. Luckily I had some tPA sitting in my medicine cabinet and just took some empirically, b/c as the stroke neuro folks that respond to Swami's posts tell me, "It can't hurt."

As soon as I read Josh's post, I knew we must discuss this on the podcast to flesh out some of the issues raised.

You should read the post first:

* PulmCrit The Crashing Asthmatic with Leo Stemp

If you are interested in my Crashing Asthma Cast it is here:

* EMCrit 15 Asthma

* My response to Lew Rubinson's Comment

Then you can listen to this EMCrit wee....

Some dozen years ago, a couple of my buddies and I created the RUSH exam. Today, I give you an update:

[featimage]

On Podcast 168, I discussed Michigan's EC3 stand-alone EDICU. The folks from the EC3 recently published on their first 2.5 years of operation in a before and after trial.

Gunnerson et al. EC3 Study

I gathered a bunch of my EC3 buddies to discuss the article.

 

On the call, you will hear:

* Bob Neumar, Chair of EM

* Kyle Gunnerson, Division Chief of Emergency Critical Care and Director of the EC3

* Ben Bassin, Operations Director for the EC3

* Renee Havey, CNS for the EC3

* Nate Haas, EC3 Faculty

Other Folks' Takes:

* First10EM

* RebelEM

Tell us what you think below

Now on to the Wee...

Pigtails should replace chest tubes for most pneumothoraces and pleural effusions requiring drainage. In this episode, I discuss points on use and placement. The next post will be a video on an actual placement. Please put your comments and thoughts below.

For a video of the procedure,

come on over here:

EMCrit -  The Pigtail Video

Updates:

* See a real-time ultrasound placement from ThinkingCC

* ThinkingCC's thoughts on Pigtails

* GRAVITAS RCT

* Safe even in coagulopathy and anti-plt

Now on to the Podcast...

[featimage]

I always have a great time at the Essentials of Emergency Medicine conference, not just because it is an amazing conference, but because I get to hang out with my buddy, Rob Orman. This year, we did a on-stage demo of central line tips and tricks. Hope you enjoy:

Here's the Vid:

 

[featimage]

You do perfect patient positioning.

You open the mouth.

A beautiful, gentle, stepwise insertion of the laryngoscope allows you to get the tip of your video Mac into the valeculla.

And you see...

Nothing!

What now?

Abandon the attempt--nope!

Use the Kovacs Kata

The Kovacs Kata is dedicated to my friend and airway Guru, George Kovacs.

George had described his EVLI approach to laryngoscopy as a kata (see EMCrit 236). That struck me more as mental rehearsal however. A kata in my martial arts experience was always a fight against multiple imaginary opponents. The way I taught the kata for rescuing a failed laryngoscopy is a fight against 5 opponents of success using 5 techniques:

1. Neck

Neck refers to external laryngeal manipulation (ELM).

* Bimanual Laryngoscopy on LitFL

* Levitan Study on BiManual/ELM

2. Head

If you do not have a good view with your pre-intubation positioning, keep lifting and if necessary, flex the head.

* Kovacs Head Lift Video

* Keith Greenland on Why this Works

* Head and neck elevation beyond the sniffing position improves laryngeal view in cases of difficult direct laryngoscopy

3. Hands

If you are not strong enough to lift the patient's head off of the bed with one hand, use two. Then maintain the lift with one hand, aided by locking the left elbow against your body.

4. Scoop

If you have an epiglottis that you can't see past, despite the optimizations above, then just lift it with the Mac, i.e. use the Mac as a Miller.

* Levitan Article on Managing an Omega Epiglottis including the Scoop Maneuver

5. Pull Back

This one is for the hyperangulated blade. You have a great view--you just can't get the tube to go into the glottis.

* Why too close is too bad

* George on Hyperangulated Problem-Solving

* Levitan on HyperAngulated Blade Use and the Kovacs Sign

Additional Attributions

* Full Kata Video

Now on to the Vodcast...

Today, I present an excerpt from an interview with Andrew Davies, host of the mastering intensive care podcast. The full interview was over an hour long, but this is a polarizing excerpt.

The Full Mastering Intensive Care Interview

* Scott Weingart being interviewed by Andrew Davies

REANIMATE 7 Conference

* reanimateconference.com

Now on to the Podcast...

There is a group of clinicians operating on the front line of war zones with no other purpose than to save lives. Global Response Management's Helen Perry comes on the show to discuss their work.

Helen Perry ACNP-BC, MSN, RN, CCRN, CEN

Their motto is semper vitae--always life. Their mission is to provide life saving emergency and prehospital care to those impacted by war and conflict.

Find Global Response

* The website is www.global-response.org

* Instagram global.response

* Facebook

* Twitter @GRM_Global

Volunteer

We are always looking for qualified volunteers and we use Paramedics and above. EMTs are welcome to apply, but they may not be working in a clinical capacity due to World Health Organization minimum operating standards. We even need non-medical folks (social media marketing, finance, smart computer people, grant writers, etc.)

Donate

They are a registered not-for-profit (501c3) and their admin budget is super low. Please consider helping these folks.

Note

I have had to close this post to comments b/c there have been a number of comments made by folks with false names and/or false contact information. The policy of this site is that all commenters must use their real identity linked to a real email address. There seems to be a group of folks out there that doubts the veracity of the GRM. If you have verifiable information on that, please get in touch by the contact link above.

Now on to the Wee...

 

 

In Part I of the philosophical diversions series, we discussed free will. Today, let's bring up some other thoughts:

Conscious Decisions

Consciousness by Annaka Harris

Podcast Episode

Naïve Realism

Perception isn't Reality

* Ross, L., & Ward, A. (1996). Naive realism in everyday life: Implications for social conflict and misunderstanding. In T. Brown, E. S. Reed & E. Turiel (Eds.), Values and Knowledge (pp. 103–135).

Fundamental Attribution Error

Synopsis

Umvelt

The RCM is Back in Stock

resuscrisismanual.com

Now on to the Podcast...