EMCrit FOAM Feed

The Best Paper and the most amazing site

Guidelines for Tracheostomy and Laryngectomy Emergencies (Anaesthesia 2012;67:1025)

from the National Tracheostomy Safety Project (NTSP), the ultimate site for trach emergency management

Bedside Signs

Get the Tracheostomy Sign as double-sided sign for the bedside

Get the Laryngectomy Sign as double-sided sign for the bedside

Here is the version to edit your own signs

Now on to the Podcast...

Not enough people are doing awake intubation in the ED or doing it as quickly as possible in the ICU. I have spoken about the technique many times on EMCrit. This lecture was specifically crafted for the EMCrit audience by my friend and airway guru, George Kovacs. I consider it to be the definitive discussion on emergent awake intubation.

For the equipment links, go to the Rapid Sequence Awake Post

Previous Podcasts on Awake Intubation

* The original method (I've moved away from the teachings here with the availability of better equipment)

* The Rapid Sequence Awake Intubation

Awake in Halifax, Part I - An interview with Ian Morris, Anesthesiologist

More Great Stuff from George Kovacs

* Lights Camera Action: Redirecting Videolaryngoscopy (Guest Post)

* Antifragile in EM by George Kovacs

* George's Self-Intubation

Sign up for REANIMATE4

REANIMATE Site

Now on to the Vodcast...

At SmaccDUB, I got to debate my friend and head wizard of St. Emlyns, Simon Carley. Our topic was, Emergency Medicine (EM) is a Failed Paradigm. I took the pro side--it was a ton of fun. Take a watch and then tell me what you think in the comments section below.

The St. Emlyn's Post

Simon wrote a wonderful blogpost about the debate.

The Slides

Additional Links of Interest

Graham Walker on "Emergentology: Don't Worry; We'll Handle It"

Transcript

(note-it is computer generated so many errors)

EM_is_a_Failed_Paradigm

The Video

 

I have a friend named, Ash. She is a nurse, a veteran, a prehospital/retrieval provider, and a... badass. She gave this talk at SmaccDUB. I loved it so much; I hope you do as well:

Blurb

Time tested rules and myths explored in a real life adventure, meant to honor and display the courage, commitment and sacrifice made by emergency medicine and critical care professionals around the globe. In a painfully honest reflection, Ashley crushes stigma and leaves us acutely aware of how our words and actions affect our colleagues and those that we love.

The Talk

People have a tendency to blame powerpoint (or keynote) for the horrible presentations they are forced to sit through. But the slides are merely an external manifestation of a deeper problem, just like the teeth of a meth addict.

For the past two years, I have been speaking at The Teaching Course in NYC. Two years ago, I gave a 60-minute talk on presentation creation (you can see that original talk below). This year, the course directors reduced my time to 30-minutes...resulting in a tighter and much better talk. That is what I am posting today.

The Twelve Steps

1. Admit you have a problem

2. Choose your Topic and your Purpose

3. Create Brainstorming Spaces

* Template for folders

* Mindmap reference book

4. Choose a Structure

5. Add the flesh

6. Work the Transitions

7. Visualize the Visuals

* Where to get Images from First10EM

8. Edit to Time

9. Mark the Stage

10. Create a "Handout"

11. Give it for Real

12. Do it Again

Bumper Slides and SignPosting

Keynoting

Bumper Slides

Other Things mentioned in the Talk

* Beyond Bullet points template

* Recorder recommendations

* Rich Borden Reference

* How to Sequence a Talk

* Ira Glass Quote

* 10 ways to end your talk

* Cicero rules for good talk

* Lawrence Lessing talk

* Multimedia Learning book

* Slideument reference

* Feedback form (see slides)

* Brief Feedback form (see slides)

* Using space information

* Nancy Duarte Reference and this one

* Presentation Zen

* Scriptwriting: Story by McKee

* Ed Tufte on Data Presentation

* Posture Reference

* Up resolution to PPT link

* Screencast on how to save as jpg (pending)

* Iskysoft Imedia Converter for Mac or Windows

* Share your checklist (pending)

* Good remote

* Test slide

* 20 Minute Rule

Books to Read

Politics

not even going to bother writing anything here, my country has gotten so ridiculous.

Why I'm Divorcing Twitter

* The Hey Girl Meme

* Feminist Ryan Gosling

* I was going to post he twitter threads from the EMCritConf discussing the meme here, but looking back at them today, I see a ton of them have been deleted. It prob. would have been poor form to call any particular person out by name anyway as I am sure there were innocents amongst the guilty.

The Intro to the EMCritConf 2017 - Full lectures will be posted on EMCrit soon

Now on to the Useless Wee...

 

The team has done a bunch of stuff on cardiac arrest here on the EMCrit site:

* Podcast 125 - The New Intra-Arrest (Cardiac Arrest Management)

* EMNerd: The Tell-Tale Heart

* Hemodynamic-Directed Dosing of Epinephrine for Arrest

* The Future of CPR

There has been a lot of interesting stuff that has come out since my SMACCgold talk. This podcast will bring you up to date on the crap running though my mind. Beware: very little evidence lies here.

The Syndromes of Cardiac Arrest

Refractory Vfib/Vtach (Electrical Storm)

* Anti-Dysrhythmics

See EMNERD's ALPS Post

* Dual-Sequential Defib

Amazing session on EMRAP by Zack Shinar (membership required)

Study of Dual-Sequential shows early double better than single (Resuscitation. 2019 Jun;139:275-281)

* Esmolol

Driver et al. (Resuscitation. 2014 Oct;85(10):1337-41 PMID 25033747)

500 mcg/kg IVP, can add a drip starting at 50 mcg/kg/min

See this great EMPharmD Post

* Take them to the Lab

* ECMO anyone?

Vasoplegia

Note:  I (we) have probably been misunderstanding this Vasoplegia, it is imperative you read this post (choosing the correct DBP); you should also probably listen to that podcast.

* High-Dose Epi

* Methylene Blue

What's the dose? Who knows? I give 2 mg/kg (but not in pts on SSRIs)

* REBOA

* Junctional Tourniquet

PREM/PRES

We did an episode on this topic on the EDECMO podcast (ignore the ECG stratification stuff--since been debunked).

 

Monitoring

* ETCO2

* Cerebral ox

* Ultrasound (preferably TEE)

Time Zero Prognostication

* What can we use??

* This retrospective study from France indicates that if the pt has the following 3: 1. OHCA not witnessed by emergency medical services personnel, 2. nonshockable initial cardiac rhythm, and 3. no return of spontaneous circulation before receipt of a third 1-mg dose of epinephrine then there was no RONF and the pts should be put on the donation path. (Ann Intern Med. 2016 Dec 6;165(11):770-778. doi: 10.7326/M16-0402. Epub 2016 Sep 13.  Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation)

Blood Gases during Cardiac Arrest

* From the book Cardiac Arrest

* Study on Blood Gases during Arrest

Nurse-Run Codes

Image Taken from the FOAMCast Episode

We've discussed SEPSIS a ton on EMCrit.

* Podcast 154 - Preemptive Sepsis Panel SmaccBack

* Wee - Cliff Deutschman with Additional Thoughts on Sepsis 3.0

* Renoresuscitation: Sepsis resuscitation designed to avoid long-term complications

* Podcast 112 - A Response to the Marik Sepsis Fluids Lecture

* Podcast 169 - Sepsis 3.0 with Merv Singer

* Podcast 89 - Lessons from the STOP Sepsis Collaborative

Recently, the Surviving Sepsis Campaign released their 2016 guideline update. Overall, I think this iteration moves the guidelines closer to the best evidence out there. Of course, when you travel that path it forces a divergence from the distinctly non-evidence-based CMS guidelines. In this Practical Evidence Podcast, we will discuss the SSC guidelines, the aforementioned divergence, and various alcohol recommendations. I brought on my buddy, Jeremy Faust, to discuss the changes. Jeremy is 1/2 of the FOAMcast podcast which just discussed the new guidelines in a recent episode.

Guideline Stuff

* The SSC 2016 Guidelines

* PDF Version of the SSC 2016

* Users' Guide to the Guidelines

* Our Emergency Medicine Clinics Article

The Guideline Recommendations

The Definition of Sepsis

They basically ratified SEPSIS 3.0

(Jeremy found where he saw the remnants of the old definition; it was in the Users' guide figure 2--super contradictory)

Fluids

30 ml/kg in the first 3 hours

Crystalloid first, then maybe albumin

Use dynamic markers and/or fluid challenges

Goal MAP>65

EGDT is no longer recommended

Lactate

attempt to normalize lactate

Blood Cultures

get them before antibiotics, if obtaining them will not delay the provision of antibiotics

Antibiotics

Within 1 hour of sepsis or septic shock

Vasopressors

Norepi is the first choice, add in epi or vaso

Do not use dopamine

Steroids

200 mg Hydrocortisone for patients who are still unstable after fluids and vasopressors

Blood

In most circumstances, use a trigger of <7.0 g/dL

The first thing to understand about Hypertensive Emergencies is that they look like emergencies

The second thing is in the short term, the only way to really fuck up non-emergent hypertension is by acutely lowering it too much

Hypertensive emergencies, hypertensive urgencies, markedly elevated blood pressure--ugggh! Hypertension is a real annoyance in emergency medicine. Folks get scared of numbers and encourage dangerous behavior because of them. It's a bit better in the ICU, where there is a filter to keep out non-emergent hypertension cases. "Hypertensive Emergencies" are a whole different bag. In these conditions, the hypertension is usually secondary to the actual emergency. So I prefer to call these emergencies with a side of hypertension.

Treatment Priorities

25% in the first hour

* Pain

* Inotropy/Chronotropy

* Arterial Vasodilation

The Meds

* Labetalol

* Esmolol

* Nitroglycerin

* Nitroprusside

* Nicardipine

* Clevidipine

* Fenoldopam

* Hydralazine Sucks

The Emergencies

ACS

SCAPE

* SCAPE Podcast

Aortic Dissection/AAA

*  Treatment of Aortic Dissection

Ischemic Stroke

* Stroke Podcast

ICH or TBI

aSAH

* Management of SAH

PreEclampsia/Eclampsia

Hypertensive Encephalopathy/Malignant Hypertension

a headache is not a hypertensive emergency unless the patient looks so bad that you are rushing her to CT

Usually (but not always) will have papilledema

Visual Changes, AMS, Confusion, Severe Headache, Coma

Tox

Sympathomimetic OD

MAO Inhibitors

Pheo

Acute Glomerulonephritis

Thyroid Storm

* Thyroid Storm Podcast

Want More Info?

* Great Htn Review Article from Paul Marik

* Fantastic post from the Strayer

* Long-Term follow-up shows hypertension in ED pts doesn't predict adverse outcome [Elevated Blood Pressures Are Common in the Emergency Department but Are They Important? A Retrospective Cohort Study of 30,278 Adults. Ann Emerg Med. 2021 Feb 9;S0196-0644(20)31363-9. doi: 10.1016/j.annemergmed.2020.11.005. ]

Now on to the Podcast...

Some topics that have been batting around my head over the past few months:

The Secret Sixth Cause of Arterial Hypoxemia

You should know the standard five:

* V/Q Mismatch (Deadspace)

* Low FiO2

* Hypoventilation

* Diffusion Abnormality

* Shunt (Usually Physiologic)

but the sixth cause can be particularly dangerous with cause #5, the physiologic shunt. The sixth cause is Low Mixed Venous Saturation (SvO2).

John Marinaro created this acronym for the causes above:

Shunt

Hypoventilation

Altitude/low PAO2

V/Q mismatch

Excess extraction of O2 from Hb (low SvO2)

Diffusion Abnormalities

 

Pure Vasoactives

It ain't phenlephrine anymore

Dissociated Awake for Critical AS/Pulmonary Hypertension

just keep loving this more and more. See the hemodynamically neutral intubation podcast for the final version of this idea.

Now on the the Podcast and Happy New Year...