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This is part II of the Brindley Sessions on Rudeness. If you haven't yet, you should listen to Part I:

Brindley Session I - On Rudeness

In this podcast, we discuss some more concrete approaches to dealing with rudeness. I also had a chat with Paul Jhun on these issues with the ALiEM wellness thinktank.

Some Things We Mentioned

Vic Brazil's Tribalism Talk

Timing, Tribes, and STEMI from SMACC Gold

and the book she mentions:

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Very Rough Sketch of the EM Culture Requests for Folks Visiting our Department

* Be Polite

* Be Kind

* Be Open Minded

* Be Communicative

* Be Non-Accustory - errors should be looked at as an opportunity to discuss, learn, and make things better in the future

Links of Interest

* Seems these issues are going on in the UK as well

Buy a Ticket to the EMCrit Conference

* EMCritConference Site

Now on to the Podcast...

So we've discussed hyponatremia a ton on the blog site. That's because hyponatremia has become a little bit sexy. Not so with sodium that is too high. But I've seen a bunch of less than ideal management of hypernatremia, so I figured it is time to put out a podcast about it. This is mostly so I have a place to go to look all of this up.

Join us at the EMCrit Conference Jan 11 2017

EMCrit Conference Site

Articles

* Androgue-Madias from NEJM

* Hypo and Hypernatremia in the Crit Ill

* Hypernatremia in the Critically Ill

Read this Book

* Joel Topf is of PBF is 2nd author of an excellent fluids and electrolyte text. He has released it for free on the Precious Body Fluids Blog

How do you become Hypernatremic

Loss of free water and/or

Loss of hypotonic fluid and/or

Increased Solute and

thirst or access to water must be thwarted

Hypernatremia Results in...

* Impaired glucose metabolism

* Rhabdo

* AMS

* Seizures

Avoid Iatrogenic Complications

Cerebral Shrinkage is Bad

Causes of  Hypernatremia

Extrarenal water loss

* Dehydration by exposure

* Burns

* Gastric losses

* Diarrhea (Lactulose)

* Fever

Salt gain

* Infusion of sodium-rich fluids of some sort (eg. hypertonic saline)

* Ingestion of sea water

* Salt pica

Nephrogenic DI

* Hypercalcemia

* hypokalemia

* Lithium

* Pyelonephritis

* Medullary sponge kidney

* Multiple myeloma

* Amyloid

* Sarcoid

Central DI

* Traumatic brain injury

* Pituitary tumour

* Meningitis

* Encephalitis

* Tuberculosis

* Sarcoidosis

* Idiopathic

* ICH

Renal losses

* Glucosuria

* Mannitol

* Urea therapy

* Loop diuretics

* Post obstructive diuresis

* Hyperaldosteronism

* Cushings

This table stolen directly from Deranged Physiology (primarily b/c I hate making html tables)

Chart of Figuring Out What the Hell is Going On

from Lindner et al article linked above

Treatment

Stop or Correct the Underlying Cause

Correct Quickly if Na got high superrapid-style (Idiots drinking a quart of soy sauce)

Correct < 10 meq/day (< 0.5 mmol/L/hr) if the Na went up gradually (2-3 mmol/L/hr if rapid rise in sodium)

Oral/Gastric Tube is the safest way to correct

Administer Hypotonic Fluids (D5W, 1/4 NS, 1/2 NS, sterile water (central line))

Do not administer NS unless pt is HYPOVOLEMIC (NS doesn't work!!!; see Androgue-Madias for mathematical demonstration of this)

So you have an unresponsive patient. The CT is negative. What now? Coma is tough! The differential is long and filled with many life threats. Today, I talk to Eelco Wijdicks about some specific questions regarding the evaluation of the comatose patient in the first few hours in the ED or ICU.

Eelco Wijdicks MD PhD is Professor of Neurology and Chair of the Division of Critical Care Neurology and currently practicing in the Neurosciences Intensive Care Unit at Saint Marys Hospital (Mayo Clinic Rochester). He is the founding editor of the journal Neurocritical care, the official journal of the Neurocritical Care Society.He has over 650 research papers,book chapters,topic reviews and editorials to his credit.

Join the RLA

Resus Leadership Academy

Eelco's Book

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[easyazon_link identifier="B00KMVTYDQ" locale="US" tag="emcrit-20"]The Comatose Patient[/easyazon_link]

Coma Differential

from Eelco's review article below

Legend: Initial thoughts on coma in the ICU. This algorithm is a simplification of clinical practice. Localization and withdrawal motor responses are most probably not associated with brainstem involvement, and therefore the dichotomy is made. Once abnormal brainstem reflexes are found, two options are likely—acute hemispheric mass or acute brainstem lesion. Bihemispheric injury is structural or physiological and further differentiated into specific locations and suggestions for tests. ABG arterial blood gas, CSF cerebrospinal fluid, CT computed tomography, CTA computed tomography angiography, EEG electroencephalogram, SAH Subarachnoid hemorrhage

The Coma Neuro Exam

* Carefully examine the eyes (Vertical Skew, Anisocoria, Eye Movements)

* Check Brainstem Reflexes

* Check Tone

* Assess the FOUR Score

Full Outline of UnResponsiveness (FOUR) Score

FOUR Score Handout from the Mayo

Coma Review Articles

* Eelco's Amazing Article on Coma Basics

* Traub-Diagnosis and Management of Coma

* Why you may need a Neurologist to see a Comatose Patient in the ICU

Now on to the Podcast...

 

Way back in episode 60, I discussed the chemical takedown. My buddy Reub Strayer blew that podcast away with his lecture at SmaccDUB. This lecture was note-perfect and enhanced by Reub's inimitable presentation style. I know you'll enjoy it.

For more Strayer goodness, head on over to the EMUpdates Site.

Slides

Now on to the Vodcast...

The Brindley sessions brings the brilliance of Peter Brindley to the EMCrit Podcast. Our first topic of conversation is rudeness and its ill effects on the medical team. Peter gave a great lecture on this topic at SmaccDUB, but I wanted to hear more.

Part II on Rudness is now up as well

Dr. Peter Brindley

Peter Brindley MD, FRCPC, FRCP (Lond), FRCP (Edin), Full-time Critical Care Doc from the University of Alberta Hospital. To the surprise of many (himself included) he is a Professor of Critical Care Medicine, Anaesthesiology, and Medical Ethics. He has authored 90 peer-reviewed manuscripts, 25 book chapters, 50 lesser manuscripts, and has two textbooks pending. He has given over 300 invited presentations in 10 countries, and over 30 plenaries. He was a founding member of the Canadian Resuscitation Institute; and was perviously Medical-Lead for Simulation, Residency Program Director, and Education Lead at the UofA. He has advised the Canadian Patient Safety Institute, and the Royal Colleges of Canada and of Edinburgh. There are many better speakers, but none happier to be here. He welcomes questions; comments and especially disagreements: after all he doesn’t wish to be wrong a moment longer than absolutely necessary.

Some Studies & Papers

* RCT of the effects of rudeness on team performance (CoreEM discussion of this paper)

* Improving Verbal Communication in Critical Care

* Improving Teamwork

* Questionnaire Study on Rudeness

* More Rudeness

* McLuhan on the Medium is the Message

Verbal AiKiDo aka Dealing with Assholes

Psychologist Albert Bernstein recommends these three tips:

* Say, "Please speak more slowly, I’d like to help" or some variation thereof. Doesn't matter if they are already speaking slow as molasses.

* Ask, "What would you like me to do to make this better." or ANY other question. Questions short circuit the anger cycle.

* Let them have the last word

See more from this post

Rudeness Affects Team Performance as well

Pediatrics. 2017 Jan 10. pii: e20162305. doi: 10.1542/peds.2016-2305.

Rudeness and Medical Team Performance.

And Another...

Incivility

Now on to the Session...

Recently, I wrote an article for the Annals of Emerg Med on initial mechanical ventilation settings in the ED. Two letters to the editor were sent regarding the article. As usual, the number of words I was given to respond to these letters was grossly inadequate. So the replies the letters deserve are posted in this wee.

The Original Annals Article

* mech-vent-article

The Letters to the Editor

* Letter One

* Letter Two

Some Articles of Interest

* Breath Stacking Dysynchrony (Beitler, J.R., Sands, S.A., Loring, S.H. et al. Intensive Care Med (2016) 42: 1427. doi:10.1007/s00134-016-4423-3)

* Lung-Protective Ventilation With Low Tidal Volumes and the Occurrence of Pulmonary Complications in Patients Without Acute Respiratory Distress Syndrome: A Systematic Review and Individual Patient Data Analysis. (Crit Care Med. 2015 Oct;43(10):2155-63. doi: 10.1097/CCM.0000000000001189.)

* Chatburn - A taxonomy for mechanical ventilation

Now on to the Wee...

So we have discussed my preference for surgical over needle-based techniques for front-of-neck-access (FONA) many times on the podcast. You can see the needle vs. knife discussions in some of the earlier posts as well. Cut to air just works better in my opinion. If you'd like to see how I advocate you perform this procedure, come to the EMCrit Cric Page. This debate has heated up as the airway society of the UK has recently recommended scalpel-bougie cricothyrotomy as the first technique for FONA. Editorials explain why this decision was made. Currently, the Australians are still recommending needle-based techniques. So, to add gasoline to the debate, today I interview Laura Duggan, MD.

Laura completed residencies in both paediatrics and anesthesiology, as well as a cardiothoracic anesthesiology fellowship. She practiced for a time as a paediatric emergency physician in Canada. She now practices cardiac and general anesthesia at a level 1 trauma centre. In short, she is the perfect person to discuss these issues with. I got to chat with Laura at SmaccDUB about a paper she had just written on the high failure rate of transtracheal jet ventilation in can't intubate, can't oxygenate situations.

Laura's TTJV Failure Paper

* TTJV by Duggan et al.

Recent EM Paper regarding Needle Cricothyrotomy

* Marshall et al in academic_emergency_medicine

The Airway App

Download it on the Airway Collaboration Site

The Ventrain Device

I tested this device on the bench (no COI) and the reason I think it is the best of the crop is its active exhalation and the ability to monitor ETCO2. They sell it in kits with a proper cannula as well.

* [cite]24980421[/cite]

* [cite]:21177698[/cite]

* [cite]20100697[/cite]

Other Jury-Rigged Techniques (None are Recommended)

3-Way Stopcocks are Probably Inadequate

Catheter or cath with 3-way stopcock is prob. inadequate for exhalation unless 13 seconds between breaths (Anaesthesia 2009;64:1353 and Pediatric Anesth 2009;19:452)

Use a Ventilator

Br J Anaesth 2013;110(3):456

Additional

* [cite]22436319[/cite]

*

Mann, C.M., Baker, P.A., Sainsbury, D.M., Taylor, R., 2021. A comparison of cannula insufflation device performance for emergency front of neck airway. Paediatr Anaesth 31, 482–490. https://doi.org/10.1111/pan.14128

Ventrain was the only device in this study that did not produce potentially injurious pressures, but ENK was pretty good and device below has not been tested

Also See

The original needle vs. knife for Andy Heard's Method

If you had to use one, here is the one Ric Solis and I Conceptualized

So, last year Amato et al published a paper on Driving Pressure:

Driving Pressure and Survival in the Acute Respiratory Distress Syndrome

It contained an incredibly interesting theory--driving pressure may be a much better measure of lung protection than Plateau Pressure. Driving pressure is Vt/Crs (Vt being tidal volume based on ideal body weight and Crs is the compliance of the respiratory system. In patients who are not spontaneously breathing, driving pressure could also be calculated by Plateau Pressure minus PEEP. These graphs explain how it can be both:

from Brower R.

from JE Kenny

Based on the study, a driving pressure < 15 seems associated with lower mortality, even in patients with elevated plateau pressures. Conversely, patients with Plats < 30, but driving pressures >=15 still seem to be at risk. The study also offers a possible explanation for why the ARDSnet higher PEEP trials did not show benefit--higher PEEP only seems to help if it leads to reductions rather than elevations of the driving pressure (due to lung recruitment).

In this episode, I dicuss the logistics of Driving Pressure with Dr. Roy Brower, senior author of the study. Dr. Brower is a professor of Medicine and Medical Director of the MICU at the Johns Hopkins Hospital. He has over 150 publications, numerous national teaching awards and is the most recent recipient of the ATS Life Time Achievement Award (intro cribbed from MCCP).

After listening to the show, if you want to hear more of the underpinnings of driving pressure, listen to Dr. Browers lecture on the amazing Maryland CC Project:

Brower on Driving Pressure

Additional Reading

* From LitFL CCC Project

* ICU Physiology by JE Kenny

* Gattinoni on PEEP Selection

Now on to the Podcast...

Watch/Read these to Start

Vipassana

* Book: The Mindful Geek: Secular Meditation for Smart Skeptics

* Book: Waking Up: A Guide to Spirituality Without Religion

Stoic Philosophy

* Book: A Guide to the Good Life: The Ancient Art of Stoic Joy

* Video: A Guide to the Good Life

* Book: The Obstacle Is the Way: The Timeless Art of Turning Trials into Triumph

Science

Scientific American Article on the Mind of a Meditator

Other Links of Interest

* How to Meditate

* Need it in Animated Form?

* Pablo Neruda’s Ode to Silence

Muse Headband

* Muse: The Brain Sensing Headband – Black

The Slides

Kettlebells for the Brain – Scott Weingart from Royal North Shore Hospital & UTS

We miss you, John!

Now on to the Vodcast…

The Right Ventricle gets no respect, but it is an easy source of clean kills in the ED. We haven't covered pulmonary hypertension and acute on chronic RV failure on the show yet--we need to fix that ASAP. So, let's hear from Susan Wilcox, MD on this critical topic. She just wrote an amazing review on the subject for Ann Emerg Med and as an EM Intensivist, she is the perfect person to talk on this topic.

Best Current Review for EM

* Ann Emerg Med 2015;66(6):619 by Susan R. Wilcox, MD

Other Articles to Check Out

* Inten Care Med 2014;40:1930

* 21700906

* Crit Care Clin 2014;30:475

* CCR-4-49

* DOI 10.1111/anae.12831

Note: A good portion of these shownotes were contributed by Gregg Chesney, MD; ED Intensivist

Some Info

RV function determined by 3 P’s: preload, pump (RV contractility), and pipes (afterload)

RV is different than LV

* Thin walled, less muscular, more compliant, working against less afterload (PVR 1/10 of SVR)

* More dependent on volume loading than pressure to accomplish work of ventricle

* LV contracts in a wringing motion, RV contracts in a longitudinal up-and-down motion and compresses medially against septum

* RV doesn’t adapt well to acute changes in pressure/volume à dilates and becomes stiffer (takes 96 hrs to adapt)

Ventricular interdependence = LV and RV function are dependent on one another.

* LV preload = RV stroke volume, failing RV = decreased LV preload

* LV and RV share a muscular septum - contributes 20-40% of the work of RV contraction when LV contracts

* Dilated failing RV pushes IV septum into LV impairing LV filling/contractility and also impairing role of RV septum on RV contractility

RV Spiral Of Death

 

RV ischemia is the common final pathway that contributes to progressively worsening acute RV failure

Types of Pulmonary Hypertension

Causes of RV Failure can be broken into 4 Categories

from King et al

ECHO: How to evaluate for RV failure at bedside

* Apical 4 chamber to evaluate relative size of RV to LV and to evaluate how RV “looks”

* If you are skilled, focus on lateral tricuspid annulus movement (TAPSE) 1.6

* McConnell’s sign may be indicative of acute RV failure with RV ischemia, not just seen in acute PE

* Parasternal short at level of mid-papillary to eval relationship between volumes and size of LV and RV and intraventricular septum – look for septal shift and the "D" Sign

* Plethoric IVC regardless of volume Status

* As RV dilates in chronic failure, there will be disruption of the tricuspid annulus leading to tricuspid regurg

 

Six step approach to management of acute RV failure

Step 1: Optimize volume status

* Lasix vs. fluids, use PSAX echo view to decide

* Err on the side of volume constriction, they are often overloaded unless the patient has a known source of volume loss