EMCrit FOAM Feed

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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.

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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

I brought the DantasticTox guys back to discuss how toxidrome really present, you know in real life.

If you missed their first EMCrit episode, go listen:

* EMCrit Podcast 215 - A Disagreement of Toxicologists

and then check out the Dantastic Tox Podcast

by Nick Manzari

Anticholinergic

Altered, but will give you 3 seconds of attention

Big, non-reactive pupils (constrictors knocked out); Pupils may not even be enormous until you stimulate and then they get wide

Dry-everywhere. Put a gloved hand in the axilla if you are brave like Howard

Voice--Worst cottonmouth ever

Picking behaviors (this is the big one) - they will be plucking at EVERYTHING. Taking off gown.

Stimulus evoked tachycardia

Bowel Sounds-screw bowel sounds, because DEMONS

 

Cholinergic

Like Spongebob when you squeeze-water comes from everywhere

“SLUDGE”: Salivation, Lacrimation, Urination, Defecation, GI cramping, Emesis + “Killer B’s”: Bronchorrhea, Bradycardia, Bronchospasm

Pinpoint pupils

Pooping on themselves

Lacrimation

So remember cardiogenic shock with crying and diarrhea and pinpoint pupils.

 

Sympathomimetic

Mydriasis, but briskly reactive (i.e. they will constrict when you shine light)

Sweaty

Psychomotor agitation, Paranoia, Psychotic, but they will respond to questions (but you won't like the answers)

Tachycardia, htn,

BODY TEMPERATURE

Blunts fatigue, pain response, and exhaustion

Sedative/ETOH Withdrawal can only really be differentiated by history

 

Opioid

bradypnea first then look at the pupils

 

Sedative/Hypnotics

Sleepy

Ventilations preserved

Benzo plus is where the problem comes

Now on to the Podcast...

This is Part II of a 2-part lecture on TTP, DIC, and thrombocytopenia in the critically ill patient. It was given by Tom Deloughery at the EEMCrit Conference. The Essentials folks have a video package of the whole day at their site.

See Part I for Diagnosis

TTP

Never Give Platelets Never Give Platelets Never Give Platelets

Plasma Exchange is the treatment of Choice

Temporize with 2 units of Plasma, then 1 unit q6 hrs until plasma exchange

These patients will not bleed regardless of PLTs when you place the HD Cath--just do it (but not the intern)

Give Steroids (i.e. 125 mg solumedrol or similar)

 

Send ADAMSTS13 find out how long it takes and make sure it is sent before plasma exchange

 

Goals

* PLT target >150,000 on 2 draws

* normalizing LDH

* neuro sx fixed

after this, 2 more days; then cold turkey or wean

 

DIC

Treat underlying cause (duh_

Transfuse to

* Fibrinogen > 150 (200 in OB disasters) -- Give 10-pack of cryo and recheck (even in places that have fibrinogen conc.)

* PLT > 50

* HCT > 21

* PTT < 1.5 x control

* INR < 2-3

Heparin and AT III have not panned out. Only use heparin if there is macro-thrombosis (i.e. PE)

Now on to the Vodcast...

Please, please read the guidelines, listen to the wee, and then if you agree--sign the petition below

Literature Mentioned

* 2018 SSC Guidelines 1-hour Bundle

* Prehospital Antibiotics didn't result in benefit

* Kumar Editorial

Additional Resources

* Merv Singer on Early Antibiotics for Sepsis

* PulmCrit Take

* EMNerd Take

* PulmCCM Take

* Must Read: Evidence Underpinning the US Government-Mandated Hemodynamic Interventions for Sepsis

* IDSA's rationale for not endorsing

The Petition

*

Please sign here if you agree with this wee

This is Part I of a 2-part lecture on TTP, DIC, and thrombocytopenia in the critically ill patient. It was given by Tom Deloughery at the EEMCrit Conference. The Essentials folks have a video package of the whole day at their site.

See Part II for Diagnosis

Tom DeLoughery MD, MACP, FAWM

Professor of Medicine, Pathology and Pediatrics, Divisions of Hematology/Oncology and Laboratory Medicine at Oregon Health & Science University

Tom DeLoughery is a native Hoosier who graduated from Indiana State University in 1981 (one year after Larry Bird) and the Indiana University School of Medicine in 1985. He did his internship at the University of California, Irvine before traveling to Oregon where he finished his internal medicine residency and hematology/oncology fellowship.

His clinical interests are in blood diseases, hemostasis, and thrombosis, subjects on which he has written extensively. He has won numerous teaching awards and has given education sessions to national meetings of many professional societies. He is a master at the American College of Physicians and Fellows of the Academy of Wilderness Medicine. Recently the 3rd edition of his popular handbook Hemostasis and Thrombosis was published. His one odd fact is that he has been to 40 Bob Dylan concerts in 5 countries.

Thrombotic Thrombocytopenic Purpura (TTP)

* Primary Disease

* Decreased ADAM-TS-13

* A Disease of Excess Platelet Aggregation

* Terrible Triad

* No schistocytes = no TTP

* Symptoms wax and wane

Disseminated Intravascular Coagulation (DIC)

* aka Disease-Induced Coagulopathy

* Secondary Disease

* Too much thrombin

* Thrombosis and Bleeding

* Platelet Activation

* Markedly increased D-Dimer

* Decreased Fibrinogen

* Normal Coags = No DIC

Amazing Image Above by Dr. Hanson

Now On to the Vodcast...

 

You are getting this podcast 1 week early.

We do an EDECMO ECPR course each year called REANIMATE. REANIMATE5 blew away all previous iterations. One of the main reasons was our guest of honor, Demetris Yannopoulos from the University of Minnesota. Demetris has organized Minneapolis into arguably the most impressive ECPR city in the world. We were lucky enough to be able to film his Sharp Hospital Grand Rounds. This lecture was mind-blowing and made me so jealous. We think you will love it.

Tickets are on Sale for REANIMATE6

* REANIMATEconference.com

Slides from the Talk

* Dr. Yannopoulos' Slides (Minus In Review Data)

Additional Info/Resources

* EDECMO 36 - Zack interviews Demetris

* EDECMO Crash Episode - Microdissection of Demetris' ECPR Techniques

* JAHA Publication on ECPR Results

Now on to the Vodcast...