EMCrit FOAM Feed

Today on the podcast, we discuss Midlines. This is the first of two parts. In a week, I will interview Rory Spiegel on the topic, so send me your thoughts and questions in anticipation of that episode.

Our Article

* Utility of Midlines in Ann Emerg Med 2020

What the Heck is a Midline?

a 8-25 cm catheter that is placed in the arm and doesn't extend past the shoulder

Why Ultrasound-Guided IVs Suck?

* They aren't long enough [30021833]

* Nearly 1/2 of them are dislodged in 24 hrs [Ann Emerg Med 1999;34(6):711]

* Another study demonstrating they do not last [AJEM 2010;28:1]

* Vessel Depth and Catheter Depth are the key to longevity [AJEM 2011 Fields et al.]

* Need 2.75 cm in the vessel for good reliability [https://doi.org/10.1016/j.annemergmed.2019.11.013]

* Midlines are better for avoidance of infections

Which Midlines Do We Use?

10 cm Midline

Bard Powerglide ST

20 cm Midline

Medcomp 20 cm 5F CT Midline

 

 

I take no money from any of these folks

Video of the Dual-Lumen Midline Placement

Start at 7:10

Other Lit

Safety of Midlines for

Send Me ?s below or on Twitter

Now on to the Podcast...

[featimage]

Do you administer thrombolytics during cardiac arrest? Or maybe you don't believe in thrombolytics, but are totally down with fibrinolytics during arrest. Who do you administer them to and which one do you use? I give you my own circuitous ramblings on the topic in this episode.

Who Should Get Lysed?

SR/MA

* Wang et al.

RCT Mentioned

* TROICA (19092151)

Studies not Included in that SR/MA

* PEAPETT (27422214) (RebelM Review)

* French Registry Trial (31381884)

What Lytic?

Full Dose Tenecteplase via Manufacturer Recs or 50 mg of Alteplase by IV Push over ~60 seconds (29880524)

How Long Should You Keep Going?

* 30-60 minutes after lytic administration

===Ad from Friends===

EZDrips APP

“EZDrips is a non-profit application that facilitates the administration of medications in adult and pediatric resuscitation and critical care. You enter the patient’s weight and the app does the rest for you. We are not on the App Store so visit us at www.ezdrips.com. The first 200 subscribers at www.ezdrips.com/emcrit get the app for free, for life!”

Thanks again!Fred and JF

Update

Evidence on the lack of utility of the RV during arrest to dx PE

Now on to the Podcast...

[featimage]

NEJM recently published an interesting review article on upper airway obstruction. This podcast was spurred by a rantorial on twitter by Farkas regarding the article:

https://twitter.com/PulmCrit/status/1195103809745440768?s=20

I took a look--and it was indeed bad...

Here is the Article:

Eskander et al. Acute Upper Airway Obstruction

Some Additional References

Here is the review article on which some of the flawed messages of the NEJM piece are based:

* Cricothyrotomy versus Trachetomy: An Otolaryngologist's Perspective. Laryngoscope. 1988 Feb;98(2):131-5.

These two pieces from the ENT and OMFS literature correct these errors:

* Cricothyrotomy: When, Why and Why Not: Am J Otolaryng 2000;21(3):195

* Elective Surgical Cricothyroidotomy in Oral and Maxillofacial Surgery Br J Oral Max Surg 2013;51:779

Updates:

Best Practices for Emerg Surg Airway (Laryng Invest Otolaryng 2019;4:602)

Now on to the Podcast...

 

Taking Cardiogenic Shock Management to the next level...

The question of the use of Andexxa, a reversal agent for Factor Xa Inhibitors, has been batting around my brain for a few months now. We are in the unfortunate position of having a drug with very questionable evidentiary support but with an FDA labelled indication. I received an email from the lead author of paper just published in Neurocritical Care.

* Peled et al. Key Points to Consider When Evaluating Andexxa for Formulary Addition. Neurocrit Care 10.1007/s12028-019-00866-6

Dr. Harry Peled is the medical director of Cardiology and Critical Care at St Jude Medical Center in California. Relevantly, he is also chair of the Pharmacy an Therapeutics Committee.

I would love to hear your thoughts on this issue--place them in the comments below.

See Also

* I Have Issues with Andexanet by K. Kipp, PharmD

Update:

* In-Vivo Trial of 4-Factor PCC for Reversal of Xas

Now on to the Podcast...

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...