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You are doing CPR wrong, or so says Felipe Teran, an ED resuscitation sonographer. Felipe has just started as a Resus/ED attending at University of Pennsylvania.

The Vodcast

Let us know what you think in the comments section below

 

 

This week a case to test your Resus chops. The care is not hard, the logistics definitely are.

Items of Interest

* Dirty Double

* Push-Dose Pressor Update

* RUSH Exam

* Hyperkalemia

* HOP Killers

* Peripheral Vasopressors

* SLED

Now on to the Podcast...

 

This is the next installation in the central line (and really any Seldinger procedure) microskills. You should have already watched the videos with the following microskills:

* Syringe Suction while Manipulating

* Needle Stabilization during Syringe Removal & Wire Insertion

* Wire Manipulation

* Dilation (this video)

* Bonus Skills (Wire Straightening without Cheater)

This microskill video discusses dilation. I see this being done improperly with incredible frequency, but people get away with their bad technique because they are using small dilators for small catheters. When you go big, you will do damage unless you know what you are doing.

Dilation Mantras

* Push & Rack

* Twist & Rip

* Pinch & Pull

Additional Tips

* Keep wire and dilator wet with saline (thanks for the reminder, Matt)

* Clots are your nemesis--if there are clots on the wire, clear them off before continuing to upsize your dilators

We've spoken a ton on EMCrit on Apneic Oxygenation and Preoxygenation, well here is some more. Nick Caputo and his Lincoln Airway Group did an amazing trial of ApOx in the ED. Rory recently wrote about it and there have been some amazing posts around the FOAM world as well (see Rory's post). Now I weigh in with my take and a discussion of my new thoughts on PreOx.

Three Items to Read

* The ENDAO Trial

* Sakles' Editorial

* The EMNerd Post

Also See

* Fellow Trial Post

* EMCrit Preox

Should we use Nasal Cannula?

I think yes, because:

* ApOx will still probably benefit some patients (probably those without sig. physiological shunt or those whom you have recruited)

* Makes BVM mask leaks better

* Allows apneic CPAP with the devices below

Why Doesn't It Work in this RCT?

* Great Preox

* Not Enough Potential for Sig. Desat due to rapidity and ease of intubation

* THRIVE NC is Different than Standard

* Physiologic Shunt-Shunt Fraction would be a great thing to know to interpret these studies

What Should be on the Patient's Face just prior to Induction

choose one:

* Vent as Bag with BVM Mask

* Oxylator with BVM Mask

* BiPAP Machine with BVM Mask

* Ultimate BVM with PEEP Valve, Pressure Gauge

All of the above should have a NC @ >15 lpm and ETCO2 capnography

Why not the Mapleson C (or similar)? I'd like a pressure gauge on that badboy to track each breath

Update

Ivan Pavlov updated the tables from our MA (Am J Emerg Med. 2017 Aug;35(8):1184-1189) to include the Caputo trial:

Clinically Sig. Hypoxemia

SpO2<80%

Death

Additional Articles of Interest

* Narrative review of ApOx in Anesthesia realm (PMID 28050802)

Update

Peter Young Sent me this interesting poster on THRIVE and Pressure

Now on to the Podcast...

An update on push-dose pressors

George Kovacs left a great comment on the hemoptysis post:

Great discussion.  Unfortunately with these cases getting the tube is THE major problem before we consider any bronchoscopic intervention. Here are my pearls based on experience and cadaveric simulations:

* Call for help: Patients with massive pulmonary hemorrhage die. Respect hemoptysis especially related to tumors or scenarios where there is an erosion into a vessel. They're ok until they're not and then its often too late,

* Send someone to the chart/x-ray to get info as to which side the pathology is on

* Raising the bed will help allow you to lift the epiglottis out of the pool of blood and see it more easily.

* Do the Ducanto thing... SALAD

* Hope that the disease is on the left. If you know this use a bougie and 1/4 turn to the right once (if) you feel clicks and place gently until holdup then go ahead with a BFT. As per the study quoted in this piece we have been able to consistently cannulate the bronchus of choice using a bougie in cadavers.

* If you are not sure of the side they are bleeding from then we would suggest a poor man's isolation technique using a 7.0 ETT and intubating the RM bronchus either with or without a bougie. The left side can then be accessed with a bougie again by a 1/4 turn to the left once in the trachea and advancing until gentle hold up at ~30 cm and placing a second 7.0 ETT. Yes I know that a bronch won't like these tubes but otherwise there is no opportunity for subsequent therapy as the patient drowns. It's an awful death. You can block the offending side with a foley.

* If bleeding is too much and SALAD etc approach fails... these patients die. One device that will be returning to the market developed here in Halifax is the lightwand and its the only device out there that will consistently be successful in a soiled airway.... IF YOU HAVE IT AND IF YOU HAVE EXPERIENCE WITH IT which most don't. It has saved my ass numerous times.

* If you can't see from above then FONA is indicated use a small ETT 5.0 and push it too hilt will usually go to RM bronchus. You will either be able to oxygenate or divert blood so now you can put a second tube in if necessary from above. Used a 5.0 ETT because takes up less real estate for second tube to pass from above.

* When your consultant comes down and complains about the size of tubes that are in place resist telling them to fuck off.

Now on to the Wee...

So my friend Laura Duggan has been engaged in a multi-prong project to save lives through the dissemination of surgical airway information. We've previously discussed the airway app to collect data on front-of-neck-access. Now she is releasing a cric model that blows the old ones I used to recommend out of the water. You want one of these models... You want one to practice the moves of surgical airway at least once a month. Laura is not charging for this model, she is releasing it into the wild as FOAM. You'll have to get it 3d printed yourself--we'll tell you how

Instructions for Printing

3D Cric Trainer Instructions

Where to Print

3Dsmith in Canada

3Dsmith.ca

Chris and Steve are brothers who own their small company

They are awesome

get  formlabs standard resin as the material and it will resist scalpels beautifully!

Shapeways for the USA

shapeways.com

Got my model

Went with the strong & flexible plastic for $21.78

feel is rough but function is great

Buy Kevlar if you plan on wearing this cric trainer

[easyazon_image align="none" height="160" identifier="B00QL4M1PG" locale="US" src="http://emcrit.org/wp-content/uploads/2017/07/411NpNhDT2L.SL160.jpg" tag="emcrit-20" width="160"]

[easyazon_link identifier="B00QL4M1PG" locale="US" tag="emcrit-20"]CRL Cut Protection Kevlar® Neck Protector 99995[/easyazon_link]

The Model (Send this to your 3D Printer)

* Full Resolution Plans

Go to Airway Collaboration Site

* www.airwaycollaboration.org/

Matt Mac Partlin Has a Cardboard Model

See the ETM/Vortex Version by Andy Buck (with a cool printable neck)

Disclaimer

If you decide to wear or have colleagues wear this, it is at your own risk. It is inherently dangerous to come at anyone with a scalpel

Now on to the Wee...

I am joined again by my good friend, Joe Bellezzo, to discuss the nurse-led code. I've been doing this at my two shops for about a decade. Joe, along with his partners-in-crime Zack Shinar & Chris Ho, have set up a beautiful process for nurse led code management at their hospital, Sharp Memorial in San Diego.

Stuff Mentioned in the Podcast

* Here is the tactical-approach podcast from EDECMO.org

* EMCrit Intra-Arrest Management Lecture

* Podcast 191 - Cardiac Arrest Update

The SBM Nurse Leader Responsibilities

* Call for Epi q 5 minutes. Once A-line is in, decide on epi based on art line DBP<40

* Pre-announce the rhythm check 30 seconds beforehand

* Call for the rhythm check

* Act as the receiver for all requests from the team and assign people to get these tasks done

* Spur doc-leader based on timing of code and any thoughts that occur while having a non-task focused view of the code

Update:

CANLEAD Study on the Nurse-Led Code in simulation

Now on to the Podcast...

This stuff is not sexy and frankly, it hurts my head. That is all the more reason to do a show on the new landscape of NOAC reversal. We must pursue rather than avoid the subjects we are weak on. But I needed someone far smarter than myself--I needed a EM PharmD. Nobody better to speak about this topic than Nadia Awad. Nadia is associate editor of the Emergency Medicine PharmD Blog. She is an Emergency Medicine Pharmacist at the Robert Wood Johnson University Hospital in New Jersey.

Laboratory Parameters for Monitoring Target-Specific Oral Anticoagulants

* Hawes EM et al. J Thromb Haemost 2013; 11:1493-1502.

* Cuker A et al. J Am Coll Cardiol 2014; 64:1128-1139.

* Favaloro EJ et al. Semin Thromb Hemost 2015; 41:208-227.

* Samuelson BT et al. Blood Reviews 2017; 31:77-84.

Interim Analysis of Idarucizumab: REVERSE-AD

* Pollack CV et al. N Engl J Med 2015; 373:511-20.

Clinical Experiences Reported in Literature with Idarucizumab Following Approval by FDA

* Reviewed on Emergency Medicine PharmD

Fantastic Review on Idarucizumab

* Miller et al.

Use of Extracorporeal Measures to Expedite Elimination of Dabigatran in the Setting of Life-Threatening Bleeding

* Awad NI et al. J Med Toxicol 2015; 11:85-95.

Andexanet Alfa

* Siegal DM et al. N Engl J Med 2015; 373:2413-2424.

* Connolly SJ et al. N Engl J Med 2016; 375:1131-1141.

Low-Dose FEIBA for ICH Induced by Factor Xa Inhibitors

Mao G et al. JEM 2016 [Epub ahead of print].

Aripazine (PER977) AKA Ciraparantag

* Ansell JE et al. N Engl J Med 2014; 22:2141-2142.

* Ansell JE et al. Thromb Haemost 2017; 117:238-245.

Recommendations for Reversal of ICH Induced by Antithrombotics from Neurocritical Care Society

* Frontera JA et al. Neurocrit Care 2016; 24:6-46.

Excellent reviews on Idarucizumab

* Ann Emerg Med 2017;69(5):554

* EM Lit of Note

Dosing

Monoclonal antibody

works within minutes

Thrombin time and ECT are best monitoring, aPTT if stone-cold normal prob. rules out Dabi

Package comes with 2 vials

2.5 gm each

5 gms is the initial dose

Give each over 5 minutes

Spike and hang vial

give 2nd vial with 15 minutes of first (no reason not to give immediately)

$4200 for both vials at Janus General

Dabi lasts 12 hours in normal patients, and antidote lasts same ostensibly

Kcentra Studies

* RCT of Kcentra (Circulation 2013;128:1234)

blood bank stuff: The basics of crit care transfusion medicine