[featimage]

A few tweets sparked a debate (big surprise there) and suddenly there was a storm of opinions on whether OOH cardiac arrests should be transported or terminated in the field. Well, since I do not debate on twitter anymore, I needed a person to speak with on the topic--and there is no better than Howie Mell.

Howie Mell, MD, MPH, FACEP

Chair - ACEP Subcommittee on EMS Education

Reservist Emergency Physician - Vituity

Host of the So What 2.0 podcast

SMACCforcer

(@DrHowieMell)

Steel-Man Rules for this Debate

* Any time you want to contradict the other discussant, you must first restate the views they have just stated and confirm with them that you are understanding correctly. If you can bolster their point even more strongly before contradicting, this is even better.

* No ad-hominem attacks (i.e. attacks on the person, not their views. Feel free to politely destroy the views)

* Logical fallacies should be pointed out

* Try to state whether a viewpoint is based on evidence, and what quality or based on your clinical practice

Accepted as Given?

* We are dealing with Adults

* Asytole without signs of life should be run and terminated in the field

* There are EMS services and EDs where EMS does a better job running the arrest than the ED, in those venues EMS should run almost all codes to field termination

* There are some venues where nothing (nothing!) additional gets done in the ED beyond what EMS can do, in those venues EMS should run almost all codes to field termination

The Questions

* What is a public health view of EMS vs. a medical view?

* What is the best approach to <75 y/o vfib/vtach/PEA patient without end-stage comorbidity?

* Can we safely get these patients to the ED?

Cardiocerebral Resuscitation (CCR)

* Watch Ben Bobrow's vid

* Search for Pit Crew CPR to see amazing coordination and perfect, continuous hand cpr

Beam Me Up Scotty?

if we had teleporters…

Can We Safely Transport?

Take Out 1-2 Shocks from the Field Success Rates

and everything changes!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

why is this cheaper?

Things I Can Do in the ED

* Ultrasound

* TEE

* Arterial Lines

* Esmolol

* DSD

* Multiple Antidysrhythmics for Electrical Storm

* Cath Lab

* ECMO

* Blood

* Pericardial Drainage

* Thrombolytics

 

3 Scenarios for when a Resus Center can make a difference

Vfib shocks to Sinus and then Regresses

these patients almost always have a coronary lesion and there is NOTHING the field management can offer these patients. Even if they don’t you don’t have the monitoring to keep these patients in sinus. multiple pressors/varied pressors

Electrical Storm

there is nothing the field is going to accomplish in these patients

PEA

* what you can fix—hypoxemia

* what you can’t accurately diagnose

* tension pneumo

* what you can’t

* bleeding

* pericardial tamponade

* PE

* SAH

* what you sort of can

* hyperk

* toxicology in most protocols

Please tell us what you think in the comments section below

[featimage]

Call it cric, call it surgical airway, call it FONA. Whatever you call it, you need to have the skills and mindset to make it happen at the ready every time you intubate. Every month make an appointment for yourself to practice cric (just like my buddy Sara Gray does).

First, you Need the Model

Head over here and print out a 3D model to have for the rest of your career

Next, Buy Some Gaffer Tape

[easyazon_image align="none" height="160" identifier="B00GZE3UJ8" locale="US" src="http://emcrit.org/wp-content/uploads/2018/08/51ZG6tchJxL.SL160.jpg" tag="emcrit-20" width="160"]

[easyazon_link identifier="B00GZE3UJ8" locale="US" tag="emcrit-20"]Gaffer Tape By GafferPower [/easyazon_link]

One roll will last a LONG time. And trust me, buy the gaffer power brand, some of the knockoff brands really suck.

Then Acquire Some 4x4s and Plastic Bags

I think you know where to find some...

Then, Watch the Video

For More on All Things Cric

Come on over to the EMCrit Cric Page

They made a bleeding model using Laura's Model

 

[featimage]

What we have here is a failure to Resus Communicate...

Inspired by Reid, Brindley, Hicks, & Novak

My Favorite Paper on Resus Communication

* by the Brindley

Lecture You Must Watch

* Novak on Combat Aviation Lessons

Resus By Voice

* from flying by voice

* Shared Mental Model

* Resuscitate - Differentiate - Communicate

Tactical Pause (Hick's term)

* Step-Back or SitRep

* aka The Cross-Check- Keep coming back to the global patient picture before diving into any minutiae

* "What am I missing" - team realignment

* Ten-for-Ten1

Close the Loop

from Hargestam et al.

* Set a notification -"Put in an art line and tell me when it is done"

Podium Nurse

* 360 awareness

* Assignment of Tasks (3 Cs: Clear Instructions, Cite Names, Close the Loop)

Sterile Cockpit

* 10,000 feet

* Train the team to acknowledge that phrase

* Central Line Kits / Shock Trauma Hallways

Resuscitese

* from Cliff

* Combat Mitigating Language-Efficient and Unambiguous Communication - Directive, Descriptive, Informative

* Belay that

* Acknowledge or Close-the-Loop

* Say Again

* Read Back

* Tally Ho

* Nato Phonetic and [easyazon_link identifier="076367852X" locale="US" tag="emcrit-20"]read this book[/easyazon_link]

Briefings

PreBrief

* Planning: Mission, Defined Roles, and Set the tone

* Zero Point Survey Self-Team-Environment

Debrief

* Learning happens in the debrief

* Hot Debrief - INFO Model

Additional Info

* Communication Under Pressure

* More Critical Strategies

* LitFL Article

Sai De Silva

What are your thoughts on resuscitation communication? Tell me in the comments section below.

Now on to the Podcast...

[featimage]

In an amazing lecture; Joe Novak, ED doc and former combat aviator; spoke about the need for memorized boldface actions and then the availability of a quick reference handbook (QRH) for the next steps. But where are either of those things for resuscitation? That lack was the inspiration for the past 4 years of my life and the life of my guest this week, Dave Borshoff. Dave is an anesthesiologist in Perth, AU and a former pilot. He is author of the Anesthesia Crisis Manual and co-editor of the just-released Resus Crisis Manual.

A QRH from a Cockpit

The Bold Face for Emergency Ejection

The Rest of the QRH for Controlled Ejection

Combat Aviation with Joe Novak

EMcrit # 99

Ready to Check Out the RCM?

See the Resus Crisis Manual

Now on to the Podcast...

Music by Caged Dreams (CC)

[featimage]

We recently put up an amazing mock trial of an anaphylaxis case put together by my friend Mike Weinstock. If you have not watched that, then this wee is pretty much useless to you. In this discussion, we reveal the verdict and talk a little bit of the philosophy of malpractice and how to stay safe in the ED. I think you'll like it!

[featimage]

The Participants (alphabetically)

Jeff Lapoint (@lapizity)

Emergency Physician and Medical Toxicologist

Director, Division of Medical Toxicology

Kaiser San Diego

California, USA

John Richards (@JR_Code3)

Emergency Physician

Professor of EM

UC Davis Emergency Medicine

California, USA

The Posts that Got us Here

* John on LitFL

* Jeff on the Tox and the Hound

Steel-Man Rules for this Debate

* Any time you want to contradict the other discussant, you must first restate the views they have just stated and confirm with them that you are understanding correctly. If you can bolster their point even more strongly before contradicting, this is even better. The moderator may prompt you if you forget.

* No ad-hominem attacks (i.e. attacks on the person, not their views. Feel free to politely destroy the views)

* Logical fallacies will be pointed out by the moderator if they have not been by the other discussant

* Try to state whether a viewpoint is based on evidence, and what quality or based on your clinical practice

The Questions

* Should beta-blockers be used in patients with cocaine toxicity?

* How are we defining cocaine toxicity?

* Does Unopposed Alpha phenomena actually exist?

* Are beta-blockers safe in cocaine toxicity?

* Even if they are safe, is there any compelling reason we should use them over other treatments?

* What about the non-floridly toxic patient, for instance: a case of hypertensive, tachycardic, sweaty patient with chest pain. Already received 2 rounds of Ativan and nitro with continuing symptoms, see how each manage

* Do your thoughts on beta-blockers in cocaine toxicity apply to the other stimulants?

* What about patients who admit to taking cocaine in the recent past, but show no signs of toxicity--Is it safe to use beta-blockers in these patients?

* A case: 48 y/o with type I DM, HTN, High Chol. Presents with substernal CP, first trop negative. For some reason nurses obtained a urine drug screen positive for cocaine. When asked, pt states he is an occ. User and last use was 2 days ago. Denies any use today. Pt has been totally forthcoming about all of his drug use and you believe him. Your hospital uses CTCA for this risk category of chest pain to allow immediate discharge for f/u if negative. You order the test, but radiology refuses to do the scan b/c of the requirement for beta-blockers and a drug screen positive for cocaine. Is this justified or not?

Additional Info

* John's extensive publications on cocaine and beta-blockers

* If you don't trust my editing and want an unabridged version, it is here.

[featimage]

The slide above is from an SCCM talk by Robert Sutton. Dr. Sutton is a pediatric intensivist at CHOP in Philadelphia. His research interests include pediatric CPR quality research with a focus on evaluating novel interventions, both educational and technological, with the overall goal to improve care delivered to children during resuscitation attempts.

What We Spoke About...

We went box by box through the algorithm above. Note, very little of this is supported by high level evidence. However, neither is anything we are doing now--so be wary of staus quo bias.

Additional Info

* An article by Dr. Sutton on Hemodynamic Guided CPR

* Physio-Guided CPR1

* Article: Ahn, S et al. Sodium bicarbonate on severe metabolic acidosis during prolonged cardiopulmonary resuscitation: a double-blind, randomized, placebo-controlled pilot study. J Thorac Dis 2018; 104(4): 2295-2302

from rebelem

* Comp. of DBP and ETCO2 for CT quality (hint DBP is better)

* Brain Ox

Note: To do this technique properly, it is imperative you read this post (choosing the correct DBP); you should also probably listen to that podcast.

Prior Posts on EMCrit

* Podcast 125 - The New Intra-Arrest (Cardiac Arrest Management)

* Podcast 191 - Cardiac Arrest Update

Now on to the Podcast...

1.

Morgan RW, Sutton RM, Berg RA. The Future of Resuscitation. Pediatric Critical Care Medicine. 2017;18(11):1084-1086. doi:10.1097/pcc.0000000000001316

The Case (Refractory Anaphylaxis and Difficult Airway)

* Mock Trial - The Case

 

Please place your vote on the verdict below!

Photo by Melinda Gimpel

Video Version

Audio Version

The Acid Base Series

EMCrit Podcast – Acid Base Ep. 7 – Bicarb Updates, Quantitative Approach, and Prof. David StoryPodcast 97 – Acid-Base VI – Chloride-Free SodiumPodcast 96 – Acid Base in the Critically Ill – Part V – Enough with the Bicarb AlreadyEMCrit Podcast 50 – Acid Base Part IV – Choose the Solution Based on the ProblemEMCrit Podcast 46 – Acid Base: Part IIIEMCrit Podcast 45 – Acid Base: Part IIEMCrit Podcast 44 – Acid Base: Part I

Time for more discussion of acid-base, a subject you know i obsess about.

Bicar-ICU Trial

* Read the amazing trial by Jaber et al.

* PulmCrit's take

* The Bottom Line

* CCNerd

Keith Corl's Email

Hi Scott,

By now I'm sure you've seen the work from Jaber's group on using bicarb in critically ill academic patients. Obviously there are limitations to the trial, not the least of them a negative primary outcome. And while the study wasn't powered to look a 28 day mortality or 7 day organ failure in those with a AKIN score of 2-3 I am sure many will take this positive secondary finding and run with it.

My biggest criticism was that they didn't break the study down into patients with anion gap metabolic acidosis (AGMA) vs. non-anion gap metabolic acidosis (NAGMA). I'm a big fan of your acid base pods and tend to agree with your take and the Forsythe paper and don't give bicarb to patients with an AGMA. So I went ahead and emailed Jaber and he got back to me. He told me that "90% of the patients enrolled were hyperlactatemic." Moreover, most GI and renal patients with base loss were excluded b.c. bicarb was considered standard care, therefore the "large majority" had an AGMA. Interesting, now I'm second guessing myself and wondering if I should consider bicarb in AKIN patients with a AGMA.

I'm interested to hear your thoughts. I think it would make a great pod or a topic for Josh or Rory.

I hope all is well,

Keith

 

then I bring on Dr. David Story to discuss acid base and a set of posts by Jon-Emile Kenny.

Professor David Story

Head of Anaesthesia, Perioperative and Pain Medicine Unit (APPMU), Melbourne Medical School, University of Melbourne; Director, Melbourne Clinical and Translational Sciences (MCATS) research platform

Jon-Emile Kenny Lactate Debate Posts

* Part 1

* Part 2

Gamblegram

go to acidbase.

Bougie First?

A recent RCT from Hennepin1 by Driver et al. evaluated the effect of bougie use on first pass success. This adds to a prior retrospective study by the same group.2 These studies lend support to a practice that many of us have already adapted--bougie first intubation.

Few things on the bougie stuff

Some bougies are too short & this leads to A LOT of their downsides (RCT used a 70 cm bougie, as opposed to the 60cm bougie that I have)

Most bougies don't retain their shape, which is a shame b/c the airways where you most need the bend to stay are the ones that are least likely to tolerate multiple removals to reshape. Levitan bougie should solve this

We cannot conflate the Hennepin article with preloading the bougie

Technique

* A discussion is in the episode and 2-person vs. 1 person

Can You Advance an ETT over a bougie without having someone grab the proximal end first?​

* Listen to the episode and let me know what you think

How to know the bougie is in when used in a C/L 3 view

* Clicks - I find this unreliable

* Hold-Up - as long as this is done gently, it is fantastic

* Laura Duggan recommends: A trained assistant with gentle thumb on one side, two fingers on the other of trachea at the sternal notch is priceless to confirm placement without the need for the 'hang up test'

What about the Pre-Load Techniques?

See this poster for one bench eval

VBM S-Guide

* Video for S-Guide

I'd also like to see their METTS stylet. Go to VBM Medical to see these.

Snail Trail for Bougie Bending

from3 though I actually put the circle closer to the tip

Also See

* Bougie Vids

* EMNerd on the Bougie RCT

* Kovacs on why he doesn't like the D-Grip

* ETT vs. Railroad Bougie vs. Preload Bougie

* Sal on Driver's first study

Update

* This is the highest FPS I have seen using CMAC and Frova on all intubations4

Positioning

stand behind the patient

lift their head

and push their head towards their feet (causing base of neck flexion)

until their ear holes (ext auditory meatus) are at or higher than the level of their sternal line (sternal notch to xiphoid process)

while constraining the face plane to stay parallel to the ceiling

then padding under head & shoulders until this position is maintained

Semler et al.5 showed Ramping is worse, however you'll need to listen to the podcast to understand what that means.

Flextension by Chrimes

 

Chrimes on Positioning

 

 

 

Greenland on Positioning