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When hyperthyroidism goes really wrong...

2 Opportunities for Residents:

Essentials of Emergency Medicine Fellowship for US Residents

Get all of the info on the EEM fellowship page

Knowledge to Action Fellowship (KTAF)

An amazing opportunity for EM Residents. Here is the info on the KTAF.

4 Conferences to Check Out:

1. Reanimate San Diego - Learn ECMO for ECPR in Two Days

February 2016

Click here to see all of the information on the most concentrated and enjoyable ECMO Conference designed for Resuscitation Doctors

2. Blood and Sand - Resuscitation, Airway and Ultrasound in the Most Beautiful Climes in the World

December 6-10, 2015

Here is the Blood and Sand Conference Info

3. Shock Symposium

June 2015

Mike Donino's Shock Symposium in Boston

4. SMACC

June 2015

A little over a month left until the best Resuscitaiton and Critical Care Conference in the world. Sign up for SMACC today!

Now Listen to the Audio...

If you haven't already, you must watch the Cricothyrotomy Wee

If you want to have any idea what I am talking about...

The Cric Wee

Here is the comment that sparked this podcast

How to Plan Your Airway

* Take Account of the Whole Situation, both Immediate and Delayed Issues

* Pick the Plan the Fails Best

What is a Bad Option IMrHO?

* Anything through the nose without cutting the wires

What are the Good Options

* Cut the Jaw Wires, Prep for Cric, Perform Awake Fiberoptic Nasal Intubation, then sedate/analgese

* Cut the Jaw Wires, Prep for Cric, Perform RSI, then sedate/analgese

* Perform an Awake Cric

* Perform an Awake Trach

How to Cut Jaw Wires (Arch Bars/Wired Jaw)

There will be 2-5 wires connecting the lugs of the arch bars--you need to cut all of them and retrieve the wires. There may also be elastic that needs to be cut. Medical wire-cutters are best, diagonal cutters also work. In a pinch, any heavy scissors will get through these wires. Then grab them with hemostats and pull them out.

from Jones RT et al. JEM

Not many articles in the literature on this topic, but here is one Jones RT et al.

I think it is essential to understand the hardware and how long it takes to cut the wires. So watch this wiring video and then this cutting the wires video.

Do Crics Need to Come Out Right Away?

Probably not

* American Journal of Otolaryngology 2000;121(3):195

* British Journal of Oral and Maxillofacial Surgery 2013;51:779

NAP4

In appropriate circumstances (prophylactic cricothyroidotomy) has numerous advantages, not least the potential to secure and check the ‘rescue airway’ in a calm and unhurried manner, without hypoxia, before an emergency arises      — NAP4 Study

* See this Prior Episode for a Discussion of NAP4

Online Etiquette when Discussing Cases

* Just be nice

* Assume that there were factors you might not understand because you were not there

* Phrase as, "I think if I was in this situation, I would have..."

* If you are going to go nasty, make sure you have the knowledge base to comment (this last one does not pertain to the comment above)

Consent for Filming

* discussed in the podcast

Other Discussions of the Case (For Better or Worse)

* Student Doctor Net

* Reddit

Now on to the Podcast...

My friend and former resident, performs a life-saving cricothyrotomy on a post-arrest patient.

Filmed by Reuben Strayer, MD and used with patient consent.

For more on Surgical Airway, come to the EMCrit Cricothyrotomy Page

Article on Arch-Bar Separation

 

See Part I First; you'll find the shownotes there as well

Part I of Who Needs an Acute PCI?

Now on to the Podcast...

A Guideline from the Steve Smith’s ECG Blog and the EMCrit Podcast

Today, I am joined by Steve Smith, creator of one of the best ECG blogs out there. We discuss who needs an emergent cath. Who should get a transfer to a PCI center? Wouldn't it be great if all of the possibilities were gathered in one place? Here you go...

The Printable Versions:

* The Complete Document

* The Cheat Sheet

The Video Version from theEMC

Who needs an emergency PCI?

Activate the Lab for unambiguous STEMI (only clear STEMIs have a 90 minute CMS mandate). Get Cardiology or Interventional Consultation for more complicated cases: difficult ECGs, subtle ST elevation, ST depression with ongoing symptoms, STEMI “Equivalents”. This requires a systematic approach, with buy-in from Cardiology that they will respond immediately to such requests for help. What do they get out of it? Fewer false positive activations and more activations for the subtle cases that need it.

Know that the ACC/AHA guidelines for NonSTEMI recommend < 2 hour cath for:

* Refractory ischemia

* Ischemia with hemodynamic or electrical instability

Proviso: Many non-interventional cardiologists do not understand these subtle ECG findings or pseudo-STEMI patterns. You must be a strong advocate! If you are worried, get serial ECGs, compare with an old ECG, and get a high quality contrast echocardiogram exam. Persistent occlusion of a significant epicardial coronary artery will nearly always have a wall motion abnormality if the echo quality is good, is done with contrast, and is read by an expert.

I. ACC/AHA Criteria

ST-elevation at the J point in 2 contiguous leads that reaches the following thresholds: [cite source='doi']10.1161/CIR.0b013e3182742c84[/cite]

* Men < 40 years of age: 2.5 mm in V2-V3 and 1 mm in all other leads

* Men > 40 years of age: 2 mm in V2-V3 and 1 mm in all other leads

* Women: 1.5 mm in V2-V3 and 1 mm in all other leads

These criteria are only 45% sensitive for MI as measured by CK-MB, and about 70% sensitive for acute coronary occlusion, with perhaps 85% specificity. Beware of early repolarization, LVH, and LV aneurysm as false positives. Beware of subtle ST elevation as false negatives. Other less specific but more sensitive criteria require “new” ST elevation.

II. New Left Bundle Branch Block

New LBBB alone is not an indication for cath lab activation. MI may also present in the context of old LBBB. Therefore, in stable patients, determine if there is a concordant ST segment, or an excessively discordant ST segment (see figure) and then use the algorithm below:

Activate if any of these three: [cite source='pubmed']24016487[/cite]

* In an unstable patient (hypotensive, Acute Pulmonary Edema, electrical instability, or looks sick) [cite source='pubmed']22766335[/cite]

* Sgarbossa Criteria (1 of the following) [cite source='pubmed']8559200[/cite] & [cite source='pubmed']22939607[/cite]

* Concordant ST-segment elevation of 1 mm in at least 1 lead

* Concordant ST-segment depression of at least 1 mm in leads V1 to V3

* Note: I reduce these two to simply: Concordant ST-Segment Deviation

* They have Smith-Modified Sgarbossa criteria [cite source='pubmed']22939607[/cite] Any single lead with at least 1 mm of discordant ST elevat...

Adaira Landry's excellent presentation that won the 2015 EMCrit Conference Blast Competition

Ice water submersion for rapid cooling in severe drug-induced hyperthermia.

* Laskowski LK et al. Clin Toxicol 2015 Mar;53:181-184.

* The Poison Review's Review

I gave this lecture at SMACC 2014. It combines many former podcasts so they are now directed here (Podcast 4 & 18)

Awake Intubation can save your butt!

It requires forethought and humility–you must be able to say to yourself, “I am not sure I will be able to successfully intubate this patient.” However, the payoff for this thought process is enormous. You can attempt an intubation on a difficult airway with very few downsides. If you get it, you look like a star, if you don’t you have not made the situation worse.

Two of my critical care resident specialists, Raghu Seethala and Xun Zhong, volunteered to intubate each other awake. The purpose of this was to let them gain experience, understand what their patients would feel during the procedure, and to prove that awake intubation can be done without complicated nerve block injections or fragile equipment, such as a bronchoscope.

Here is the procedure for ED Awake Intubation–EMCrit Style:

DRY THEM OUT & PRETREAT GAG

If you can give it early 10-15 min before topicalizing, it will be most effective.

* Glycopyrrolate: 0.2 mg IVP (No central effects – does not cross BBB. You can use atropine, but more side effects are possible)

* Suction and then pad mouth dry with gauze – you want the mouth very dry!

* Adminster Odansetron 4mg IV to blunt the gag-reflex

TOPICALIZE

* 5 cc of 4% lidocaine nebulized @ 5 liters per min

* Gargle with viscous lidocaine (4% best, 2% ok). Place a blob (~3 cc) on a tongue depressor, put it in the back of the throat and have the patient gargle and then spit. In Canada, they have 5% paste

* Spray the epiglottis and the top of the cords with a Mucosal Atomizer Device (MAD). The patient will cough during this spraying, wear eye/face protection. I usually spray between 3-6 mls above the cords

* Alternatively, use the EZ Atomizer to topicalize everything but through the cords

* Spray into the trachea (through the cords) with 4% lidocaine (3 cc). 10% lidocaine would be wonderful to spray down the cords (not available in USA)

* Have another syringe loaded with 4% lidocaine to spray with during the procedure

Note: the systemic and pulmonary absorption from this method is quite low. The only place to watch out is spraying the trachea. I would not spray more than 2-3 cc down the ol’ windpipe.

SEDATE (Choose one!)

* Ketamine and propofol in the same syringe makes Ketofol. The classic mix is 50 mg of ketamine to make 5 cc and 50 mg of propofol to make 5 cc. Put these both in a 10 cc syringe and shake. Depending on the patient’s hemodynamics, I sometimes will use more ketamine (75% instead of 50%). Give 1-2 cc every minute until you have the patient relaxed, but still breathing and arousable.

* Ketamine alone also works just fine. Start with 20 mg and give 10 mg every minute or so. Push slowly.

* Remifentanil is supposedly wonderful, I've never had it to play with

* If you have neither of these 2 mg of midazolam will do just fine.

The Rest

* Preoxygenate with NRB and Nasal Cannula or CPAP + NC

* Optimally position (ear to sternal notch) with the head tilted all the way back

* Restrain both arms with soft restraints to prevent the “grabbies”. Explain why, don't do this in the UK.

* Switch to just nasal cannula @ 15lpm. You may need to place back the CPAP mask between attempts

* INTUBATE with Fiberoptic laryngoscope and bougie

Resuscitation Leadership Academy

Haney Mallemat, Matt Dawson, Mike Mallin, Mike Stone, and I are starting a new project called the RLA. It is an online resuscitation fellowship--I think it is going to be fairly grand.

If you want more info, click on over to the Resus Leadership Academy site.

Resuscitation Stuff We Do Graphs

this idea was first introduced to me by my vent hero, Nader Habashi, MD

Here is the Phases of Fluid Therapy Article

Now on to the Wee...