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So my friend, Justin Morgenstern recently put up a post on Idarucizumab, aka Praxbind. He seemed pretty fired up on the issue, so I got him on the line to talk about it. What follows is a conversation on evidence and what to do when there is not a good amount of it.

Schtuff

* The EM Cases Podcast that partially sparked the debate

Justin Wrote an Additional Post after our Discussion

* On Parachutes and Such

On to the Wee...

Today we are joined by Dennis Djogovic to do Part II on severe burns.

* See Part I on Fluid Therapy

Dennis Djogovic

Dr. Djogovic completed training in Emergency Medicine and Critical Care Medicine from 1999-2005, and is currently employed at the University of Alberta Hospital as an Emergency Physician, and as an Intensivist in the General Systems Intensive Care Unit and in the Firefighters Burn Treatment Unit.

Inhalation Injuries and Airway Management

Read These

* Tracheal intubation difficulties in the setting of face and neck burns: myth or reality? (Am J Emerg Med. 2014 Oct;32(10):1174-8)

* Diagnosis and Management of Inhalation Injury

Securing Tubes and Catheters

 

More Info

* PulmCrit on Flash Cigarette Burns

* Maryland CC Project Severe Burns Episode

* EM Practice Smoke Inhalation Issue

Now on to the Podcast...

The Article

PEP under Stress

Breathe

Conscious control of the autonomic system

Xhaler

https://twitter.com/nathanwpyle/status/1071860695371825155

Talk

Positive self-talk

See

Mental Rehearsal/Visualization

Focus

Development and Use of a focus/trigger word

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Additional Resources

* Brindley's CRM for Team Performance Guide

* Hicks and Petrosoniak on Human Factors in Trauma Resus (Show on this Soon)

* Anything by Jason Brooks

Now on to the Podcast...

Today we are joined by Dennis Djogovic to do Part I on severe burns.

Dennis Djogovic

Dr. Djogovic completed training in Emergency Medicine and Critical Care Medicine from 1999-2005, and is currently employed at the University of Alberta Hospital as an Emergency Physician, and as an Intensivist in the General Systems Intensive Care Unit and in the Firefighters Burn Treatment Unit.

Fluid Management in Burn Patients

 

Additional Resources

* Victorian Burn Unit Resources

Now on to the Podcast...

That diphenhydramine OD that is driving you up a wall, the seroquel OD that can't give you any history and is sucking up all of your benzos--there is a solution! Physostigmine used to be standard care, but then after a scare with TCA ODS, its use by non-tox folks markedly diminished.

Bryan Hayes

Today I am lucky to have Bryan Hayes, the Pharm ER Tox Guy, back on the show to discuss Physostigmine for anti-cholinergic toxicity. Bryan is a ED pharmacist with a fellowship in toxicology. He tweets as PharmERToxGuy and blogs at Academic Life in EM and on his own site, pharmertoxguy.com.

Use in Anticholinergic Poisoning

Physostigmine controlled agitation and reversed delirium in in 96% and 87% of patients, respectively (Ann Emerg Med 2000;35(4):374-81.). Benzodiazepines controlled agitation in only 24% of patients but were ineffective in reversing delirium.

Indications

Presence of peripheral or central antimuscarinic effects without significant QRS or QT prolongation

* Peripheral: dry mucosa, dry skin, flushed face, mydriasis, hyperthermia, decreased bowel sounds, urinary retention, and tachycardia

* Central: agitation, delirium, hallucinations, seizures, and coma

Hayes' Algorithm

* Physostigmine 1 mg IV over 5 minutes (mixed in 50 mL NS), can be repeated x 1, ~10-15 minutes after the 1st dose. Continuous cardiac monitoring and atropine at the bedside.

Contraindications (from package insert)

* Reactive airway disease, peripheral vascular disease, intestinal or bladder obstruction, intraventricular conduction defects, and AV block and in patients receiving therapeutic doses of choline esters and succinycholine.

* Known or suspected TCA OD

The Post on Bryan's Site

* Don’t be Afraid of Physostigmine

Nice Review Article

* Dawson et al.

Some Literature

* 1980's cases of asystole in TCA poisoning: https://www.ncbi.nlm.nih.gov/pubmed/7001962

* 1998 case of 15 year old with asystole in TCA poisoning: https://www.ncbi.nlm.nih.gov/pubmed/9655671

* Physo clearly beneficial over benzos: https://www.ncbi.nlm.nih.gov/pubmed/10736125

* Physo associated with less ICU admissions: 

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Now on to the State of the Crit...

So in prior posts, I have discussed the jerry-rigged "ultimate" BVM. But there is a better way--the creation of a manufactured BVM that helps us not kill patients.

It would have the following characteristics:

Facets of the Ultimate BVM

 

 

Now on to the Vodcast...

 

 

 

 

In Podcast 104, we discussed how to avoid killing hemodynamically unstable patients while intubating. Today's podcast takes that concept a step further to allow you achieve a hemodynamically neutral intubation.

The Pieces

Rapid Sequence Awake

Discussed in this podcast

or

Dissociated "Awake" Intubation

or

A Combination

then

you can consider a DSI for Hemodynamics, but only in non-tenuous patients

then

place the patients on CPAP/PSV mode with both set to zero

if the patient requires mechanical ventilatory support because they continue to decline, consider

Higher Vt/Lower Rate as per Davis et al.

and

Sedate with small hits of ketamine or fentanyl

Further Reading

* Pulmonary Hypertension Awake Intubation from CCM

Now on to the Podcast...

Bottom Line

* Fantastic look at the history of this issue

Farkas on Steroids in Septic Shock

* PulmCrit

European & SCCM CIRCI Guidelines

* Guidelines

Find the Livestream and then the Edited Version of the Session at this Link:

emcrit.org/adrenal

Updates:

* Intermittent seems to be better than continuous administration for steroids in septic shock

Now on to the Wee...

Happy Solstice!

A delightful and hilarious toxicology podcast started up a few months ago, the Dantastic Mr. Tox & Howard Show. I managed to get the hosts on the line to talk some tox.

Howard Greller (@heshiegreshie)

Dr. Greller is EM and toxicology out of St. Barnabas in NYC

Howard Greller

Dan Rusyniak (@drusyniak)

Dr. Rusyniak  is EM and toxicology at Indiana University

Dan Rusyniak

Opioids

* New York State Opioid Statistics

* DantasticTox Opioid Show

Intralipids

* The DantasticTox Lipids Show

* LipidRescue Site

Calcium Channel Blocker Overdose

* EMCrit CCB Episode

The Santa Beard

EEMCrit Conference

REANIMATE ECMO Conference

Now on to the Podcast...