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In Ep. 138, we discussed the basics of vasopressor and inotrope use. During that podcast, I promised we would go more in-depth in subsequent episodes--this is one of those that will fulfill that promise. Angiotensin II is a new (old) player on the field. To discuss this topic and more on vasopressors, I asked Dr. Mink Chawla to join me on the podcast.

Conflict of Interest Disclaimer

Dr. Chawla is the CMO of La Jolla Pharmaceuticals, the manufacturer of Angiotensin II

Bio for Dr. Chawla

Dr. Chawla is Chief Medical Officer of La Jolla Pharmaceuticals. Dr. Chawla was an Professor of Medicine at the George Washington University, where he had dual appointments in the Department of Anesthesiology and Critical Care Medicine and in the Department of Medicine, Division of Renal Diseases and Hypertension. Dr. Chawla was also the Chief of the Division of Intensive Care Medicine at the Washington D.C. Veterans Affairs Medical Center. During his tenure at George Washington, Dr. Chawla was the designer and lead investigator of a pilot study called the ATHOS (Angiotensin II for the Treatment of High Output Shock) trial.  Dr. Chawla was an active investigator in shock, inflammation and extracorporeal therapies, including: continuous renal replacement therapy, dialysis and albumin dialysis. Dr. Chawla is also the author of over 100 peer-reviewed publications and an Associate Editor for the Clinical Journal of the American Society of Nephrology.

Dr. Chawla's Maryland CC Project Lecture

* Link to the Maryland CC Project Video

* Link to the Maryland CC Project Shownotes

Article Mentioned Regarding IntraOp Hypotension

* Walsh & Sessler et al.

* Also Check out: (Intens Care Med 2018;44:811)

Now on to the Podcast...

Angio II Papers

* The use of angiotensin II in distributive shock-

* Angiotensin II for the Treatment of Vasodilatory Shock - NEJM - 2017-(Athos 3)

* Angiotensin-II- More Than Just Another Vasoconstrictor to Treat Septic Shock–Induced Hypotension

* ATHOS-3 protocol & editorial, CCR_Mar_17_text[1]

* ATHOS-3_appendix

* Chawla-ATHOS-Crit Care-2014-(Athos 1)

* Clinical_Experience_With_Angiotensin_II

Links of Interest

* Vasopressor Basics Show

* PulmCrit's Voodoo

*

Hey Folks

For episode 200 of EMCrit, my friend Rob Orman of ERCast interviews me on some non-clinical topics--you've been warned.

Today, I am joined by my buddy and pulmonary-critical care stud, Oren Friedman, to discuss the management of Massive Hemoptysis

See More from Oren

* Clot Management of Massive and SubMassive PE

* Hemodynamic Management of PE

Some Basics on Massive Hemoptysis

* LitFL

* First10 EM

* Review by Sakkour on Massive Hemoptysis

* IBCC chapter  Severe hemoptysis

* A Wee Bit More on Massive Hemoptysis

Intubate Big

Localize

C-XR, chart review, and initial bronch. Remember Oren's tip: if you get in there and can't find any bleeding, temporarily disconnect the vent

Is it Amenable to Bronch Treatment?

If not, Block; preferably at the segmental level

Use a bronchial blocker, not a double lumen tube

Uni Blocker

EZ Blocker

A poor 2nd choice is mainstem intubation

Bougie for selective lung

Then Get a CTA of the Chest

make sure to order a delayed phase to see the systemic circulation as well

Then go to IR for Bronchial Artery Embolization

95% of the lesions will arrise from the bronchial circulation. The ones that don't are PE, Pulmonary Art Catheter mishaps, and AVMs of the Pulmonary arterial circulation.

If that fails, Surgery or ECMO

Updates

* Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018 Oct 12. pii: S0012-3692(18)32572-8. doi: 10.1016/j.chest.2018.09.026.

* Great Review Article from CHEST

Now, On to the Podcast...

Today, we discuss the topic of insulin pumps. Heralded as a huge advance in the management of insulin-dependent diabetes mellitus (IDDM), they also bring a bit more complexity to the mix. To sort through this confusion, I brought my friend Josh Miller (@glucosedoc) on to the show to discuss.

Josh Miller, MD

Dr. Joshua D. Miller is the Medical Director of Diabetes Care for Stony Brook Medicine and an Assistant Professor of Endocrinology & Metabolism in the Department of Medicine. He is dual board-certified in Internal Medicine and Endocrinology, Diabetes & Metabolism.  Dr. Miller has vast experience helping people with diabetes to conquer the challenges of living with the disease; he has been living with type 1 diabetes for over twenty years. He is an expert in insulin pump and glucose sensor management as well as the transition of care to adult endocrinology for young adults with diabetes.

What we Covered

Tell Us About Insulin Pumps

* Settings (Basal, Bolus)

* What can go wrong

* How do we know if it is functioning

* How to turn it Off

* Site Infection--is this even an issue?

* More on Insulin Pumps

What do We do If Pt with PUMP has DKA?

* Leave It on or

* Supplement or

* Adjust Settings or

* Turn it off--if so how to take pt settings into account

Basal Insulin in the Critically Ill

* How much and how

* Insulin Drip

* Is Lantus Safe-how much and when

Euglycemic DKA

* what agents (SGLT2)

* how to manage

* See also RebelEM

Hypoglycemia with a Pump

from Josh: Hypoglycemia in a patient with diabetes on pump is multifactorial. If the hypoglycemia is so severe as to warrant admission, I would suspend or remove the pump. The patient should undoubtedly be assessed for insulin pump competency and diabetes self management skills. Acutely, patients should know how to temp basal or suspend the pump. Rarely would we treat through the insulin with dextrose and continue 100% basal delivery. If the patient is altered in any way, the pump should be suspended (by someone knowledgeable about pump function) or removed and an alternative SQ insulin regimen should immediately be pursued. The risk of course is forgetting the depot regimen and, once hypoglycemia resolves, causing ketosis.

Take home point: hypoglycemia on pump = call endocrine immediately.

Additional Info

Br. J. Anaesth.-2016-Partridge-18-26

Now on to the Show...

So Josh's post yesterday (Rocketamine vs. keturonium for rapid sequence intubation) sparked much controversy and comment. I wanted to wade into the conflict, hence this wee.

Rocuronium Administration-Prior to Sedative

Administering roc as first drug is a variation of the timing principle demonstrated in a bunch of studies RCTs, here are 4 of them:

* http://www.ncbi.nlm.nih.gov/pubmed/9195356

* http://www.ncbi.nlm.nih.gov/pubmed/9585312

* http://www.ncbi.nlm.nih.gov/pubmed/7923516

* https://www.ncbi.nlm.nih.gov/pubmed/21547177

The most effective way to administer the med is actually to administer the sedative 15 sec after the roc, but most do not go that far. An easier to justify method is:

* Roc

* Induction agent

* Flush

This is my method for etomidate or propofol. For ketamine, I prefer DSI-type administration.

Update

* Driver et al. did an RCT https://doi.org/10.1111/acem.13723

Listen to the Wee to Hear my Thoughts...

The hands-on of orchestrating a massive transfusion protocol

Trauma Year in Review 2016 from SMACCdub

by Chris Hicks and Andrew Petrosoniak

The science of trauma resuscitation has undergone a fairly massive evolution in the past decade.  This talk was our attempt to summarize the best-of-the-best in trauma literature from the past several years, and package it into a series of clinically useful recommendations (i.e., our evidence-based opinions).  This talk was live peer reviewed by trauma surgery deity Karim Brohi, who gave us a thumb’s up (although you kind of had to be there).

 

Here’s a run-down of our take-home points:

Use the Clamshell

Unless you’re a thoracic surgeon, consider the bi-thoracotomy as your initial approach to resuscitative thoracotomy. Don't operate in a hole – give yourself the best exposure, and the best shot at fixing the problem.

* Ref: WJS 2013, 37: 1277-1285

* How-to guide: http://emj.bmj.com/content/22/1/22

Prognosticate with POCUS

Point-of-care ultrasound (POCUS) has an ever-expanding role in trauma resuscitation, including prognosticating in cardiac arrest. In this study, patients with no cardiac activity and no pericardial effusion had no survival.

* Ref: Ann Surgery 2015, 262(3): 512-518

Get with the Guidelines

The EAST thoracotomy guidelines might be the most useful and evidence-based set of recommendations for the management of traumatic cardiac arrest yet. Bottom line: VSA trauma patients with penetrating thoracic injuries and an arrest time of < 10 minutes deserve a resuscitative thoracotomy – these are salvageable patients, and deserve an aggressive approach.

* Ref: Critical Care 2013, 17:308, J Trauma 2015, 79(1): 159-173

* Compare and contrast – WEST guidelines (2012): http://bit.ly/2mFemtM

Skip the Films

Stable patients with a plan for CT imaging don’t need a chest x-ray or pelvis x-ray. Not all patients undergoing CT need the full “pan-scan”. In the middle are assessable patients with reassuring vital signs, POCUS +/- x-ray imaging: they can be admitted for observation, or discharged.

* Ref: http://bit.ly/292tAUm

* In the same spirit – local wound exploration for anterior abdo stab wounds can eliminate the need for CT imaging, admission: https://www.ncbi.nlm.nih.gov/pubmed/22182859

Crystalloids kill

The paradigm of 1-2L of crystalloid boluses in hypotensive trauma patients is harmful and should be abandoned. If PRBCs aren’t immediately available, give small boluses (250 cc at a time) for patients with sBP < 70, altered mental status or loss of peripheral pulses. NICE guidelines restrict crystalloids to pre-hospital only.

* Ref: BJM 2012; 345: 38-42, http://bit.ly/292tAUm

Be Propper PROPPR

PROPPR in a nutshell: A balanced ratio of blood products (approximating 1:1:1) is probably the optimal approach for patients who are bleeding to death; also, platelets are pretty important early in trauma resus.

* Ref: JAMA 2015, 313(5): 471-482

Who Needs Mass Trans?

Predicting the need for massive transfusion in trauma is tricky. Relying on gestalt alone is associated with under-resuscitation in about one third of patients, even when trauma experts are making the call. In tricky situations, use the ABC score or shock index to improve situation awareness.

* Ref: Injury 2015, 46: 807-813, J Trauma 2009, 66: 346-352

Drop the dose

Trauma patients in profound shock don’t need the Full Monty when it comes to induction agents for RSI. Even the all-mighty ketamine can have negative hemody...

Friend to the show, Jim DuCanto has been obsessed with SALAD. Not the leafy greens delicately touched with a tart emulsion, but with Suction Assisted Laryngoscopy and Airway Decontamination (SALAD). Jim DuCanto, MD  is an anesthesiologist extraordinaire with a constant drive to perfect new airway techniques and document them on video along the way.

COI Statement

Dr. DuCanto invented and receives royalties on the DuCanto Catheter from SSCOR and the Nasco SALAD mannequin

Read More about SALAD from Taming the Sru

* TtS Post

Esophageal Diversion Maneuver (Intentional Esophageal Intubation)

deliberately insert the ETT down the esophagus and gently inflate the balloon

There is lit for this [cite source='pubmed']25943615[/cite]

SALAD Park Maneuver

Keep tip of suction catheter in the esophagus on the left side of the mouth

SALAD Techniques

Meconium Suction Set-Up

Here was our original letter (J Clin Anesth, 23 (2011), pp. 518–519) (fulltext)

It was recently validated (The Journal of Emergency Medicine Volume 52, Issue 4, April 2017, Pages 433–437)

Large Bore Suction Surrogate

Wanted to run something by you. I'm an EM-3 in Cleveland at University Hospitals rotating up in the CT-ICU at my institution with a CA-2. We were just fooling around with mechanisms to make large bore suction improvisation kits, and stumbled upon a VERY good one I didn't see on your site. 7.0 ETT with the adapter pulled off. Hook that up to suction EXTENSION tubing with the little white plastic adapter that comes with the extension tubing. Connect that tubing adapter directly to the 7.0 ETT on one end, and the tubing it is meant for on the other. Should have a small gap of that adapter bridging between the tubing end (traditionally a blue end I believe) and the ETT. Doesn't work with larger bores we found out. Easy as that. Drained 750cc of fluid in less than 3 seconds on repeat testing with continuous suction. No meconium aspirator needed (for those working in the community), and because it is an ETT, there is the built in hole at the end of the tube to prevent suck down events onto tissue in the oropharynx.

-Chris Peluso ( [email protected] )

SALAD Comic

More Stuff

* SALAD Facebook Page

* SSCOR Site

* Taming the SRU write-up of SALAD

* DuCanto Suction Catheter

* General Description of system and demonstration by Jeff Hill of the University of Cincinnati’s EM Program

* Product page of SALAD Mannequin

* University of Wisconsin HEMS Fellow with the “Static” Excercise

* University of Wisconsin HEMS Fellow with the “Dynamic” Excercise

* University of Wisconsin HEMS Attending takes on the SALAD Simulator

 

Read Josh's Post on the Metabolic Resuscitation of Sepsis first, then listen to this interview with Paul Marik:

Note to Listeners:

I took down the original version and put up this edited version. The only difference from the original is some additional comments added at 13:03 to give a more accurate perception of the current level of evidence of this therapy.

Please, please read the Pulmcrit post listed above before listening.

On to the Wee...

Read Josh's Post on the Metabolic Resuscitation of Sepsis first, then listen to this interview with Paul Marik:

On to the Wee...