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We've discussed REBOA before on the EMCrit Podcast with Megan Brenner. We also featured the first prehospital REBOA case. It was an interesting treatment, but an extremely complex one. That has all changed with the new ER REBOA catheter.

In this podcast, I discuss the new catheter from Prytime and then I interview Dr. Joe DuBose, a trauma and vascular surgeon who performed the first ER REBOA placement that resulted in a survivor.

Conflicts of Interest

Neither Dr. DuBose nor I have any conflicts of interest regarding the ER REBOA catheter or otherwise

Slides from Dr. DuBose's Case

ER REBOA Visual Tour

ER REBOA Placement Video

Steps to Placement of the ER REBOA Catheter

Gain Access to the Common Femoral Artery with a 7-French Introducer

* Just like normal for an arterial line, except make sure you are hitting common femoral and not superficial femoral artery. The point of entry should be 2 cm below inguinal ligament (estimate ligament by anterior superior iliac to pubic tubercle). This may be much higher than you are used to.

* Only some introducers will work:

Attach a Syringe to the Balloon Port of the REBOA Catheter

* Use a 25 or 30 ml syringe, filled with 24 ml of NS

Test the Balloon

* Inflate to test patency

* Make sure to fully deflate the balloon. Apply some extra suction to really shrink it down and then lock the balloon stopcock

Attach Transducer

* Attach a pressure transducer to the arterial line port. Zero the transducer to the phlebostatic access

Measure externally

* Zone 1 is measured with the proximal edge of the balloon at the xiphoid, Zone 3 is measured with the proximal edge of the balloon just above the umbilicus.

from J Trauma. 2011 Dec;71(6):1869-72

Insert the REBOA Catheter

* Use the orange sheath to straighten the p-tip

* Insert the orange sheath 1cm into the valve of the 7-french introducer

* Advance the REBOA catheter a few cm into the introducer

* Pull back on the orange sheath

* Advance the REBOA catheter to the predetermined depth

Inflate the Balloon

* Hold the REBOA catheter to prevent it from pushing out

* Open the Stopcock

* Inflate until resistance goes to moderate or the blood pressure on the arterial line tracing of the REBOA Catheter starts to increase. In general, this corresponds to 12-22 mls depending on the size of the aorta–but this must be individualized to the patient. The actual inflation is far harder than you may think. For me, it is the maximal force I can apply with 1 hand.

* Never instill more than 24 mls. Never more than 24

* Close the stopcock

Secure the Catheter

* If the catheter is not secured externally it will migrate out from aortic pressure, especially in zone I

* It will be an institution dependent choice as to how to ...

Cliff Deutschman, coauthor of the Sepsis 3.0 overview paper, reached out to me because he had additional thoughts he wanted to add to Merv Singer on Podcast 169. He also did not want Merv's mustache getting all of the sepsis attention.

Here is Cliff's Outline

* Additional thoughts on Sepsis 3.0

Now on to the Wee...

 

Sepsis-3.0 has been released!

Please read the paper!

Then read some of the amazing discussions from the FOAM community:

* Jeremy Faust and Lauren Westafer reveal the new sepsis definitions.

* Great links to pro/con discussion too by Natalie May and Richard Carden at St Elmyn’s.

* Justin Mandeville also summarises Sepsis 3.0 and uses the “rule of 2s” in his post from ICMWK.

Then read Josh's PulmCrit Post

And only then, listen to this discussion with Mervyn Singer, lead author of the new definitions.

Here from Cliff Deutschman as well

* On this EMCrit Sepsis Wee

Flowchart from the Paper

Links and Stuff

* SOFA Calculator

* NY STOP SEPSIS Collaborative Triage Screening

* SCCM Sepsis Redefined Resource Page

* More on Timing of Antibiotics from Salim

* Meta-Analysis that Salim Mentions (Crit Care Med 2015;43:1907)

Please let me know what you think in the comments section below.

Update

* Great post on the ICN

Now on to the Podcast...

A few years ago, I wrote an article about ED Intensivists and EDICUs. In the article, I discussed the hypothetical stand-alone EDICU. It is hypothetical no more. Kyle Gunnerson, with the support of his chair Bob Neumar, has created the EC3 at University of Michigan. Last week, I visited the unit--it was absolutely incredible! I invited Kyle to our RESUSCITATE NYC conference to discuss the great work he and his team have done.

Come to the Last Castlefest

This is the last one. Sign Up Now!

EC3 Tour

* Tour of the U Michigan EC3

ED Critical Care Ask Us Anything

* Read the description by Rob Huang

* See the Video

Now on to the Vodcast...

Sara Gray practices Emergency Medicine and Critical Care in Canada.  She works in both areas at St. Michael’s Hospital and is an Associate Professor at the University of Toronto.  Her academic interests include patient safety and knowledge translation, specifically how to optimize the care of critically ill patients in the ED.  Her most important achievements are her kids, who don’t care what she does at work all day, but who appreciate her chauffeuring skills and her sense of humor.She was a speaker at SMACCchicago; I thought her talk on ED Critical Care was just perfect for EMCrit.

Abstract

Is the care you deliver to critically ill patients in your ED the same as the care delivered in your ICU? And if not, why not?

Consider the challenges facing the delivery of excellent care in the ED, and be inspired to make changes at your hospital to improve your system. Learn ten strategies for optimizing the care of critically ill patients in your ED.

References:

1. Learn more about ED-ICU’s here at EMCrit

2. Consider a resuscitation fellowship like this one

3. There are zillions of articles about the benefits of simulation and training, here is a link to just one, if you only want to dip your toe in the water:

4. Audit and feedback around quality outcomes are a potential strategy. Read more about the pros and cons from the World Health Organization

Slides

http://www.slideshare.net/oliflower/optimising-critical-care-in-the-emerency-department-by-sara-gray?ref=http://www.smacc.net.au/2015/12/optimising-critical-care-in-the-emerency-department-by-sara-gray/

Now on to the Podcast...

Some Points on Acute Endocarditis from the Talk

* Keep Endocarditis on the radar for all febrile patients without a source

* Examine your febrile-listen for murmur and look at teeth

* Ask about teeth cleaning in past 2 weeks

* Even though we were taught about Janeway lesions and Osler’s nodes in medical school, the reality is that these peripheral manifestations of endocarditis occur in only about 10% of patients.  Listening for heart murmurs which are present in about 90% of patients with endocarditis is one of the most important physical exam maneuvers in patients who present with fever

* Various Ways to Categorize

* Native Valve | Prosthetic Valve | IV Drug User

* Right vs. Left-sided

* Acute vs. Subacute

* Acute Endocarditis may present so acutely that a murmur has not yet developed despite the patient being quite ill

* Oh so fastidious, the HACEK organisms are Haemophilus species, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae

* Endocarditis should be on your radar for any patient with valvular heart disease who presents to the ED whether they are febrile or not, especially if they are vaguely unwell

* Ideal cultures: 3 sets at 3 sites with an hour between first and last, each with a bunch of blood

* Coag-Negative Staph Aureus positive blood culture in a patient with valvular disease is endocarditis until proven otherwise, even though the majority of Coag Negative Staph Aureus positive blood cultures are contaminants. A blood culture positive for a particular type of Coag-Negative Staph Aureus called SLUG (Staphylococus lugdunensis) should raise the possibility of endocarditis even in patients without valvular heart disease

* Get nervous when the bacteria doesn't fit the crime

* No ED/ICU procedure requires prophylaxis

* 2/3 of L-sided emboli will be CNS. Brain emboli will be in the MCA territory

* Be scared of new-onset of CHF and CHF in young patients

* Look at the ECG for new heart blocks in patients with fever (Even 1st Degree HB) - Consider Valvular Abscess

* Antibiotic coverage-your empiric sepsis antibiotics + sepsis-dose Vanco will cover everything you need to worry about. Vanco alone will get the job done in almost every case

Indications for Operation

More Information

* Dave Carr on Anton Helman's Show

* Dave Carr from SMACC

* The AHA Guidelines (but highly recommend placing toothpicks under your eyelids before reading)

Now on to the Podcast....

End of Life Conversations are Hard

We stumble, we stutter, we say things that derail the discussion when we have a patient at the end of life. But how do we learn to do better? We model good behavior. But in order to do that we need to hear good discussions. I listened to Ashley Shreve's amazing SMACC Chicago talk:

SMACC Talk: What is a Good Death?

After listening, I wanted to bring Ashley back on to really get into the nitty-gritty of the semantics of End of Life discussions. Ashley has been on the EMCrit podcast before discussing Critical Care Palliation. Now lets hear from here again...

Tidbits I pulled out of the Podcast

* The three patients that will spur Ashley to try to have these discussions:

* 1. Advanced Cancer or Terminal Disease with Instability

* 2. Advanced Frailty/Dementia with Instability

* 3. Advanced Physiological Age (>85 y/o) with Instability

* Start with, "I'm so worried about your family member," and see the response

* Then, "Tell me how things have been going with your family member"

* Technique: Ask, Tell, Ask, Tell

* Know the trajectories of care for the diseases we deal with

* Does that mean you will do nothing? No, we actually want to intensify the treatment, with a focus on peace and dignity

* We don't want to artificially prolong the dying process

* Vitalists comprise 5-10% of the population, you are unlikely to convince these folks in the ED

* What if things don't get better?

Additional Resources

* Vital Talks Web Site

* Book: [easyazon_image align="right" height="75" identifier="0521706181" locale="US" src="http://emcrit.org/wp-content/uploads/2016/01/41VhxLk0IKL.SL75.jpg" tag="emcrit-20" width="50"][easyazon_link identifier="0521706181" locale="US" tag="emcrit-20"]Mastering Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope[/easyazon_link]

* Six ways to have End of Life Conversations with Compassion by Ashley

* Palliative Care FastFacts from Wisconsin

Now on to the Podcast...

So I was at the Blood & Sand conference a few weeks ago in the Bahamas. The highlight of the course was a lecture by Mike Mallin. The lecture is now on EMCrit--I'm sure you'll enjoy it.

Thoughts I had during the Talk & Meta Stuff

* Sympathetics lead to/augment: fight, flight, freeze, or shout

* We need to get Mike on to do a book club on

[easyazon_image align="none" height="160" identifier="B010EULHB6" locale="US" src="http://emcrit.org/wp-content/uploads/2015/12/51ZjACKHO4L.SL160.jpg" tag="emcrit-20" width="100"][easyazon_link identifier="0393326152" locale="US" tag="emcrit-20"]Deep Survival by Laurence Gonzales[/easyazon_link]

* Since I've started speaking about crics, I've received more than 50 emails from people who heard a lecture or a podcast and it gave them a boost to get the job done. That's why I keep putting up lectures like this one.

More on Surgical Airway

Well we have a wee bit on the EMCrit Surgical Airway Page

Now on to the Vodcast...