EMCrit FOAM Feed

Today, a topic about which you may already believe you know all you need to know--chances are you don't. What we were taught about tension pneumo by textbooks and trauma courses may not be right. To discuss tension pneumothorax, there is no better guest than...

Dr. Simon Leigh-Smith

Consultant in Emergency Medicine, Defence Medical Services & NHS Lothian, Surgeon Commander Royal Navy, Clinical Lead for Pre-Hospital Care and Medic 1

Simon graduated from Liverpool in 1990 and had a varied training / experience including Commando, Para, GP, Emergency Medicine and Pre-Hospital/Retrieval before Consultant appointment in 2006. He has worked in Liverpool, Plymouth, Edinburgh, Portsmouth, London, Sydney, Kuwait, Iraq, Belize, Norway, Antarctic, South Atlantic, Iraq and Afghanistan. He has a strong interest in Tension Pneumothorax, Human Factors in team working and the delivery of excellent pre-hospital care to major trauma and critical illness. He loves all the usual ‘adventure sports’ but after he sailed around Cape Horn his wife and 2 daughters were glad to hear that he no longer wanted to sail around the world! He tries to exercise his Hungarian Vizsla (dog) whilst mountain biking but often feels guilty leaving her behind to go for long road rides…..

Tension Pneumothorax is 2 Diseases rather than 1

Awake/Spontaneously Breathing Patients

* Purely hypoxemic

* No hypotension until just before collapse

* May have long periods of compensation (though can also progress in minutes)

Ventilated Patients

* Sudden, both resp and cardiovascular disease

* Will be hypoxemic and hypotensive

Classic Signs are Rubbish

* Tracheal deviation is unreliable

* Breath Sounds are unreliable

* Chest wall observation signs are variable

* Need to go with clinical suspicion or ultrasound, radiograph, or empiric decompression

More on the Perils of Needle Decompression

* EMCrit Needle vs. Knife II

A Countervailing View

Simon's Publications

* Clinical Presentation of Patients With Tension Pneumothorax: A Systematic Review1

* Tension pneumothorax - time for a re-think.

* Slides from Full Lecture

Additional Reading and Info

* Pulmonary Artery Pressures with Tension

* Decreased cardiac index as an indicator of tension pneumothorax in the ventilated patient

1.

Roberts D, Leigh-Smith S, Faris P, et al. Clinical Presentation of Patients With Tension Pneumothorax: A Systematic Review. Ann Surg. 2015;261(6):1068-1078. https://www.ncbi.nlm.nih.gov/pubmed/25563887.

In episode 130 of the podcast and in many subsequent discussions, I have advocated for femoral-artery-monitoring during cardiac arrest to allow titrated use of vasopressors. Many of my colleagues in the advanced resuscitation community have a similar practice. In 2013, the AHA has released an advanced practice guideline recommending the same practice.1

But...

What if the diastolic blood pressure number shown on the monitor is the WRONG PRESSURE. That is the contention of our guest today:

[su_box title="Today's Guest"]Per-Olav Berve is a Norwegian anaesthesiologist who works for the Oslo air ambulance and in-hospital at the Oslo University Hospital. He is currently wrapping up a PhD on CPR physiology, focusing on multimodal monitoring. His main project is a OHCA study on mechanical active compression-decompression CPR. (Bio from scanFOAM).[/su_box]

It seems the machine picks the DBP that is the lowest point between systoles. This works well with waveforms generated by the normal cardiac compression. During CPR, however the lowest point (decompression phase nadir) actually represents the reformation of the aortic outflow tract after it has been compressed. This generates a brief negative pressure which can give extremely low pressures. If you use this as your DBP you will be steered in exactly the wrong direction--the better the cpr and the more pronounced the vascular tone, the lower this number will be.

Image from PO Berve

In the arterial wave form image above, Point A is a DBP of zero. This is the number that will appear on the monitor; this number can actually be negative. In the past, I would be rezeroing the transducer thinking it must be in error. And when I spoke about refractory vasoplegia, it was because of this number. What we need to be looking at is Point B, the point just before the systolic upstroke--this is the true DBP to titrate your vasopressors according to PO. The better the CPR and the higher the vasomotor tone, the lower Point A and the higher Point B will be. So as we are doing better, we will see lower and lower DBPs if we go by the displayed numbers.

Here is a normal waveform from an actual beating heart as contrast:

Solutions

You must visualize the waveform rather than looking at the computer-generated DBP

* Change displayed waveforms to 10 sec. if possible

* Auto-Wave (match the top and bottom of the scale to the actual waveform parameters) to make the waveforms as big as possible

* If your machine has a line that can be set to a pressure, put it at 40 mm Hg and then just look to see if the beginning of the systolic upstroke is above this line

The Full Lecture from the Big Sick

ScanFOAM has an amazing post with PO's full lecture, slides, and all the references from the lecture.

* PO Berve on Waveforms during Cardiac Arrest from scanFOAM

The Paradis et al. Papers

* 1989 Paper2

* 1990 Paper3

Superimposed Aortic and Right Atrial Waveforms

from Paradis et al. 1989

[featimage]

Hot off the press is the COACT trial randomizing patients to immediate vs. delayed cardiac catheterization after cardiac arrest. I had this on my list to do a 'cast on, but EMCrit Team Member Felipe Teran beat me to it. He interviews past show guest and the lead author of the editorial on the paper, Ben Abella. The trial only included patients with an initial shockable rhythm and they were still unconscious. STEMIs went right to the lab.

COACT Trial

* Actual Paper1

* Editorial2

This comes right at the heels of the AHA statement by Yannopoulos et al. recommending a more aggressive stance on immediate cath.3

More from the FOAMiverse

ECG Blog

Now on to the Podcast...

1.

Lemkes JS, Janssens GN, van der Hoeven NW, et al. Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. N Engl J Med. March 2019. doi:10.1056/nejmoa1816897

2.

Abella BS, Gaieski DF. Coronary Angiography after Cardiac Arrest — The Right Timing or the Right Patients? N Engl J Med. March 2019. doi:10.1056/nejme1901651

3.

Yannopoulos D, Bartos JA, Aufderheide TP, et al. The Evolving Role of the Cardiac Catheterization Laboratory in the Management of Patients With Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation. 2019;139(12). doi:10.1161/cir.0000000000000630

[featimage]

Joel Topf is a nephrologist in Detroit working for St Clair Specialty Physicians. He is faculty for the Nephrology Fellowship at St John Providence.

Blog: PBFluids.com

Twitter: @Kidney_Boy

Co-creator: NephMadness, Co-creator: NephJC, Co-creator: DreamRCT

The Case

* Tweetorial on the Case

* Slides for the Case

Hyponatremia

* Topf thoughts on DDAVP in hypoNa

* DDAVP clamp in hyponatremia

* EMCrit Intro to Hyponatremia

* Curbsiders Hyponatremia Episode

* IBCC Hyponatremia

* Taking control of severe hyponatremia with DDAVP

Joel admits elderly with Na < 130

Hypernatremia

* Make sure they are not DI and then replete their free water deficit

* Acetazolamide for Nephrogenic DI1

* Hypernatremia is a marker of poor quality ICU Care2

* EMCrit Hypernatremia Episode

* IBCC Hypernatremia

Hyperkalemia

Joel's Furosemide dose is Cr x 20

* Curbsiders on HyperK with Joel

* EMCrit HyperK

* IBCC HyperK

* Recent RCT on Kayexalate3

* The odds ratio for death was 10 at a potassium of 5.5 to 6 mEq/L. It rose to 31 for potassium above 6!4

Who Needs RRT?

* Is A,E,I,O,U still the answer?

*

AEIOU mnemonic for indications for emergent dialysis (from EM Cases)

Acidemia – pH<7.1 despite medical management

Electrolyte abnormalities – hyperkalemia refractory to medical management

Ingestion – nephrotoxic drug ingestion amenable to dialysis

Overload – volume overload resulting in respiratory failure

Uremia with bleeding, pericarditis or encephalopathy

More

* Get Joel's Free Electrolyte and Acid Base Book

Now on to the Podcast...

1.

Gordon CE, Vantzelfde S, Francis JM. Acetazolamide in Lithium-Induced Nephrogenic Diabetes Insipidus. N Engl J Med. 2016;375(20):2008-2009. doi:10.1056/nejmc1609483

2.

Polderman K, Schreuder W, Strack van, Thijs L.

[featimage]

A bunch of fun new ideas re: sepsis for 2019

Fluids

30 ml/kg may be based on IBW if you write in the chart that that was what you were using

Andromeda-Shock Trial

A fascinating study by Hernandez et al.1

* See Rory's take on it

* The Bottom Line

Censer Trial

Early fixed-dose norepi use was examined in this trial.2

https://www.thebottomline.org.uk/summaries/icm/censer/

Procalcitonin

HiTemp Study3

Procalcitonin was poor for differentiating bacterial infections and other causes of fever in the ED.

Now on to the Podcast...

1.

Hernández G, Ospina-Tascón G, Damiani L, et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019;321(7):654-664. [PubMed]

2.

Permpikul C, Tongyoo S, Viarasilpa T, Trainarongsakul T, Chakorn T, Udompanturak S. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER) : A Randomized Trial. Am J Respir Crit Care Med. February 2019. [PubMed]

3.

van der, Limper M, Jie K, et al. Procalcitonin-guided antibiotic therapy in patients with fever in a general emergency department population: a multicentre non-inferiority randomized clinical trial (HiTEMP study). Clin Microbiol Infect. 2018;24(12):1282-1289. [PubMed]

[featimage]

Newest Member of the EMCrit Team: Phillippe Rola

ThinkingCC

Internist-Intensivist in Montreal, Canada, Mad Sonographer, Proud Daddy and Husband, and sometimes jiujitero.

Editor-in-Chief of ThinkingCriticalCare.com

POCUS Portal Vein from the Case

More on the Discussion in the Podcast on Thinking Critical Care

* Physiological Resuscitation

POCUS, Mythology and Hemodynamic Awesomeness

H&R 2019 Conference

* All info

[featimage]

Vent Alarms should be Regarded as Code Blue

If you cannot instill this into your culture, patients will die

If they are crashing, do DOPES

ETCO2 on any Vented Pt

This is what the real alarm should be

High (Peak) Pressure

from the Resus Crisis Manual

Dyssynchrony

Peak Only

* Check the circuit

* fluid pooling in circuit

* fluid pooling in filter

* kinking of circuit

* Tube too small or biofilmed

* Bronchospasm

* Biting on ETT

*

Peak & Plat High

* Tube in Mainstem

* Pneumothorax

* Bad Lungs >> Turn down the Vt

* Abd Compartment

Low Peak Pressure

* Disconnect

* ETT Cuff Deflated

* Pt effort

Low Ve/Vt

* Cuff Issues (See EMCrit Wee )

* Bronchopleural Fistula

Low O2 Alarm

* Not hooked Up

* Gases Messed Up

* Sensor Messed up

What to Do with Continued Alarms Despite Sedation, Equipment Check, Suctioning

* Consider Bronchoscopic Assessment

* If Patient begins to crash, consider tube exchange if bronch not available

Breakdown on Alarm Types

Article on Vent Alarm Stats 1

See More

High-Peak on ALIEM

1.

Cvach M, Stokes J, Manzoor S, et al. Ventilator Alarms in Intensive Care Units: Frequency, Duration, Priority, and Relationship to Ventilator Parameters. Anesth Analg. September 2018. [PubMed]

[featimage]

Original GTD (Gettin' Sh*t Done) Posts

* EMCrit Podcast 136 - Getting Shit Done

* EMCrit Podcast 209 - GTD Redux - Opportunities, Time, & Future Selves

Switched to Todoist

* Todoist Summary

* Integration with Gcal

* IFTTT and Zapier

Massive Action Planning by Tony Robbins

* Write down the results you want to achieve. (be specific, quantitate if possible)

* Write down your purpose (compelling reasons why you want to accomplish this goal--use trigger words, emotion)

* Develop a sequence of priority actions.

or as Carl Pullein discusses, OPA:

Outcome, Purpose, Actions

Inboxes are Deadly

Prune, prune, prune

Use email inbox for everything (shortcut/workflow on ios & boomerang on firefox)

Inbox Zero

Boomerang

Subconscious Cognitive Bandwidth

It is not the time, it is the weight

Checklists

If anything you do is:

1. Fiddly &

2. Infrequent

Make a checklist

Directly Responsible Person (DRI)

Who is the the DRI directly responsible individual from Jobs/Apple

Problem for Future Homer

Why we don't care about our future selves

Now on to the Wee...

You and your brethren are the 3rd leading cause of death in the United States. Medical error is rampant, why are you not doing anything about this problem?

How many times have you heard these statistics and others like them? How many times have you been berated by patient safety experts using these very statistics as their foundation and their whip. Have you ever wondered how these statistics could possibly be true when it doesn't jibe at all with your day-to-day experience.

I know I have wondered...

Today, we get to the bottom of this craziness.

Gerard Gianoli, MD

He did an internship in General Surgery and an internship in Pediatrics. Following a residency in Otolaryngology- Head and Neck Surgery, he completed a fellowship in Otology, Neurotology and Skull Base Surgery at the Michigan Ear Institute. He was a full-time Associate Professor at Tulane Medical School until July 2000 when he joined Ear and Balance Institute. He still maintains a Clinical Associate Professor appointment at Tulane in both the Department of Otolaryngology-Head and Neck Surgery and the Department of Pediatrics. He has published and lectured extensively in the field of Neurotology and serves on multiple Editorial Review Boards for the fields of Neurotology and Otolaryngology.

Dr. Gianoli's Two Pieces on the Medical Error Studies

* Medical Error Hysteria1

* Unreliable Research on Error-Related Hospital Deaths in America - Gianoli and Dunn2

The Makary and Daniel article

* From the BMJ

More...

* Additional reanalysis from Shojania

Now on to the Podcast...

1.

Gianoli G. Medical Error Epidemic Hysteria. Am J Med. 2016;129(12):1239-1240. [PubMed]

2.

Gianoli G. Unreliable Research on Error-Related Hospital Deaths in America. JPANDS. 2016;21(4):104-108. http://jpands.org/vol21no4/gianoli.pdf.

[featimage]

PreVENT Trial

* PreVENT Trial

* The Bottom Line on the PreVENT Study

Dominating the Vent Series

* EMCrit Lecture – Dominating the Vent: Part I

* EMCrit Lecture – Dominating the Vent: Part II

* Response to Letters on my Mechanical Ventilation Article in the Ann Emerg Med

PRVC Refs

* A rabbit study1

* PC vs. PRVC in Brain Injury Patients2

* Work of Breathing Analysis

* Small Study demonstrating that you are not getting the Vt you think you are3

* Small Crossover Trial4

Now on to the Podcast

References

1.

Porra L, Bayat S, Malaspinas I, et al. Pressure-regulated volume control vs. volume control ventilation in healthy and injured rabbit lung: An experimental study. Eur J Anaesthesiol. 2016;33(10):767-775. [PubMed]

2.

Schirmer-Mikalsen K, Vik A, Skogvoll E, Moen K, Solheim O, Klepstad P. Intracranial Pressure During Pressure Control and Pressure-Regulated Volume Control Ventilation in Patients with Traumatic Brain Injury: A Randomized Crossover trial. Neurocrit Care. 2016;24(3):332-341. [PubMed]

3.

Kallet R, Campbell A, Dicker R, Katz J, Mackersie R. Work of breathing during lung-protective ventilation in patients with acute lung injury and acute respiratory distress syndrome: a comparison between volume and pressure-regulated breathing modes. Respir Care. 2005;50(12):1623-1631. [PubMed]

4.

Guldager H, Nielsen S, Carl P, Soerensen M. A comparison of volume control and pressure-regulated volume control ventilation in acute respiratory failure. Crit Care. 1997;1(2):75-77. [PubMed]