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Today, we discuss the PROPPR Trial with its lead author, John Holcomb, MD. This was an RCT of trauma patients with severe hemorrhage. It pitted 1:1:1 matched product transfusion with a 1:1:2 control group. Dr. Holcomb is a Trauma Surgeon at University of Texas, Houston. He spent decades in the military as a surgeon before continuing his career in Houston.

This podcast is coming out a week early, but it is too good to wait!

The Study

PROPPR Trial from JAMA

Study Summary

As per their routine, the Bottom Line Review summarized the study beautifully:

Sorry, you do not have iframe working. Click here to go to the article.

Questions I discussed with Dr. Holcomb

* If you had to give the elevator pitch for the take-home message of the trial, what would it be?

* The doubters may say that the control group in the study should have been 1:3 (plasma:rbc) or even no fixed ratio, but solely an INR/Plt lab based approach. They may say that PROPPR shows 1:1:1 is as good as or better than 1:1:2, but may not be better than a much lower rate of plasma and PLT transfusion. What do you say to this line of commentary?

* The trigger for massive transfusion in the PROPPR trial was ABC>=2 or clinician judgment. Do you bother with scores in your personal practice? Should we be using them?

* In the 1:1:1 group, platelets were given up front (0 unit mark). In the 1:1:2 group, they were only given after 9 units of product. What was the rationale for this? Do you think it might have made a difference?

* It seems the 1:1:2 group played catch up for plasma over the next 24 hours. Do you think this supports the contention that early 1:1:1 may spare the need for products down the road, especially in light of the fact that exsanguination deaths were an early phenomenon.

* Median RBCs were 9 units over 24 hours, which means over half of the patients did not receive the 10 units of RBC that traditionally define Massive Transfusion. Should we redefine MT? What is the point at which it was beneficial to have matched plasma/plt to RBCs.

* This trial was not designed to look at this question, but I want to know what you think. In 2015, should we be using the empiric ratios of the PROPPR trial or should we be switching to a visco-elastic (TEG/TEM) based strategy?

* Let’s do some rapid fire… Aside from the randomized intervention, the trial was pragmatic, so I would love to hear your personal feelings and practice on:

*BP goal

*TXA

*Cryoprecipitate

*Crystalloids

* Most studies have a back story—something all of the researchers know, but is not reflected in the word-trimmed, published version. What are we not seeing in the published form of the PROPPR study?

Some key points from the discussion

* Our current definitions of massive transfusion are outdated. Better may be the Critical Administration Threshold--if you give 3 units of blood in any 1 hour period, it is a massive transfusion. But...

* Dr. Holcomb doesn't wait for the 3 unit threshold. At his shop, they try to make the 1st unit transfused plasma or platelets and start matched transfusion from that point forward.

* In the PROPPR trial, only about 2/3 of the patients received TXA, but CRASH2 indications would have had all of them receive it. Dr. Holcomb uses TEG to decide, and wants to see more RCTS (they are being done) to better clarify the role of TXA. For more on that though,

This is a lecture by Oren Friedman from the 2015 EMCrit Conference. See Oren's previous lecture on Clot Management in Pulmonary Embolism for the complete picture.

Watch the Video

See the Slides

Click here for Mobile Version

Additional Information

* Does epoprostenol work for these patients? Not according to this small RCT  [cite source='pubmed']20353588[/cite]

* NO in 4 pt case series

* If the patient codes, definitely give lytics if there are no contraindications, or so says the PEAPETT study (10.1016/j.ajem.2016.06.094)

* Pathophys of the Pulmonary Vasoconstriction (Cardiovasc Res 2000;48:22)

For More, See this Excellent Post:

* PulmCrit on Crashing PE

* Sara Crager has an amazing lecture for EMRAP subscibers

Now on to the Podcast...

Post Three of Janu-Airway

I just finished teaching at one of the best airway courses I have ever participated in (well actually, it's been a few months now). The highlight of the course was meeting Prof. George Kovacs. He has been obsessed with airway for decades. I picked up a number of great tips from him and I'm sharing those tips with you today.

Anesthesia for Awake Intubation

See this lecture to understand the intricacies of Awake Intubation

* EZ Atomizer

* George uses 15 ml of Lidocaine 4% in the EZ atomizer

* 5% Paste on a Tongue Depressor

* 10% lidocaine would be wonderful to spray down the cords (not available in USA)

EZ100m Disposable Atomizer

Not Seating Fully in the Vallecula

The Move: Lift the Head

Bagging Grip

Underhand grip, like you are holding a football

How to Build Direct Laryngoscopy Muscles

Residents don't lift enough

Two-Hand Lift

Lock and Load and Potato Sacks

the following video demonstrates all of the best-look laryngoscopy techniques we have discussed thus far:

VL/Long Scope Combo and the Triple Set-Up

* Video Laryngoscope

* Fiberoptic Scope

* Surgical Airway Supplies

Effect of Dynamic Versus Stylet-Guided Intubation on First-Attempt Success in Difficult Airways Undergoing Glidescope Laryngoscopy: A Randomized Controlled Trial.  Anesth Analg. 2019 Mar 7. doi: 10.1213/ANE.0000000000004102.

How to ask for In-Line Stabilization

* Take Off the Collar!

* Ear-Muffs Approach to prevent obstruction of jaw mobility

Automation Addiction

The FAA Report and its ramifications for Crit Care Airway Management

Want More from George?

* Procedural Skills in Medicine (pdf)

* George's Talk on Human and Psychological Factors in Airway Management From EM London

* Airway in a Minute Videos on George Kovacs Youtube Channel

* AIME Airway Site

* Airway Management in Emergencies Monograph

* George's EMCrit Guest Post on Antifragility

Here is a bit of follow-up on prior EMCrit discussions and some new stuff for Janu-Airway

For all of the shownotes, come to the EMCrit Preox Page

Now on to the Wee...

A case of anatomically and physiologically difficult airway presented live at #EMCritConf 2015. This case was imaginary and took place at Janus General.

HOp Killers

Low SvO2 as a Source of Hypoxemia

Low SvO2

A combo of Low SvO2 and Shunt=Real Badness

Use an Intubation Checklist

Have a Failed Airway Plan

A Better BVM

* Pressure Gauge

* One-Way Exhalation Port

* PEEP Valve

* ETCO2

Dump Kit

Directly stolen from Sydney HEMS

The kit is the Aeromedic RSI Kit D953 from DHS of the Byron Group in Sydney

Here is a video on how Sydney HEMS sets up their kits

Hemodynamically Unstable Intubations

Laryngoscope as a Murder Weapon: Hemodynamic Kills Podcast from SMACC

Updated Cormac-Lehane Grading

Cook TM. Anaesthesia. 2000 Mar;55(3):274-9.  A new practical classification of laryngeal view.

NAP4 Study

Podcast with Cliff Reid

Scalpel Finger Bougie Logo

by Tor Ercleve

Lecture from SMACC on Crics

Cut to Air from SMACC Gold

Now on to the Podcast...

 

Welcome to our annual rehash of the goodness of the past year. Here is just a sampling of the great FOAM that I've discovered throughout the year:

Chris Nickson, Cliff Reid, Haney Mallemat, Michaela Cartner and Karel Habig

* The RAGE Website

* Subscribe to the RAGE Podcast on Itunes

Rob Mac Sweeny

* Critical Care Reviews

* Here's a wee

* Register for the Weekly Email

Leon Gussow, Theresa Kim, Steve Axe, Jenny Liu

* The Poison Review Podcast

* Subscribe in Itunes

Duncan Chambler, Dave Slessor, Steve Mathieu, Adrian Wong

* The Bottom Line Review

Jeff Hill & Bill Hinckley

* Taming the SRU Site

* Subscribe on Itunes

Alex Yartsev

* Deranged Physiology Site

Simon Carley, Rick Body, Natalie May, Iain Beardsell, Alan Grayson

* St. Emlyn's Podcast

* Subscribe on Itunes

Non-Medical Stuff

Books

* The Name of the Wind

* The Golem and the Jinni

Podcasts

* You are not So Smart

Want more Best of?

*

Today I am joined by a good friend Sergey Motov, MD. Sergey is an EM doc with a particular interest in pain management in the ED. Sergey recently, as part of a approved study, ran an entire ED shift without a single administration of an opioid for pain. Can it be done?

The Pain-Free ED

Sergey has an amazing site, with resources and lectures: The Pain-Free ED

The Concept and Rationale of an Opioid-Free ED: Why do we need alternative to opioids in the ED?

No consensus on optimum opioid doses (weight-based, fixed, nurse initiated?)

* http://www.ncbi.nlm.nih.gov/pubmed/24210367

* http://www.ncbi.nlm.nih.gov/pubmed/23264318

* http://www.ncbi.nlm.nih.gov/pubmed/20825766

* http://www.ncbi.nlm.nih.gov/pubmed/16898939

Poor titration practices

* http://www.ncbi.nlm.nih.gov/pubmed/21908134

* http://www.ncbi.nlm.nih.gov/pubmed/20825766

Overdosing hydromorphone/ under-dosing morphine

* http://www.ncbi.nlm.nih.gov/pubmed/16898939

* http://www.ncbi.nlm.nih.gov/pubmed/19426295

Severe side effects ( especially geriatric patients)

* http://www.ncbi.nlm.nih.gov/pubmed/24033733

* http://www.ncbi.nlm.nih.gov/pubmed/24629443

Begetting Addiction

Regulatory concerns of prescribing opioids.

Concept of Multimodal Receptor/Channel Targeted Analgesia (RCTA)

Cox Inhibition

COX 1-2 - NSAIDS ( renal colic, back pain; by honoring “Analgesic Ceiling” concept)

COX 2 -Cox 3 - Acetaminophen (as well as TRPV1( capsaicin receprots) , cannabis, endogenous opioids)

* http://shortcoatsinem.blogspot.com/2012/03/iv-acetaminophen-all-rage.html

* http://www.anesthesiologynews.com/download/SR122_WM.pdf

* http://emj.bmj.com/content/early/2011/02/28/emj.2010.104687

* http://www.beat-journal.com/BEATJournal/index.php/BEAT/article/view/45

* http://www.ncbi.nlm.nih.gov/pubmed/25197573

* http://www.ncbi.nlm.nih.gov/pubmed/24381620

* http://www.ncbi.nlm.nih.gov/pubmed/22186009

NMDA antagonism- ketamine ( IV push, drip, continuous infusion as adjunct to opioids or single agents)

* http://www.ncbi.nlm.nih.gov/pubmed/25197290

* http://www.ncbi.nlm.nih.gov/pubmed/23602757

* http://www.ncbi.nlm.nih.gov/pubmed/23159425

The Basics of Vasopressors

There is a ton to speak about regarding vasopressors, but before we get to the edge cases, we need to set-up a foundation.

Types of Shock

* Obstructive

* Hypovolemic

* Cardiogenic

* Distributive

It's all about flow!

* Should we get rid of blood pressure?

Critical Perfusion Pressures

* CV Collapse 35 mm HG (51 mm Hg in critical AS pts) in one study (Crit Care 2014;18:719)

* SBP < 80 or DBP < 50 lead to trop rise during post-partum hemorrhage (Anesthesiology 2004;100(1):

30–6)

* MAP of 50 in non-vasculopath dogs for the brain? [cite source='pubmed']9692450[/cite] and Blood Pressure and the Brain: How Low Can You Go? [Anesth Analg 2019;128(4):759]

* MAP of 65 for the heart? (Dunser et al. think it is 45-50 for the heart)

* MAP 65-75 for the Kidneys? [cite source='pubmed']18382191[/cite]

When we put someone on a vasopressor, what are we hoping to accomplish?

* Critical Perfusion Pressures (Heart will get better, but may look worse)

* Increase Venous Return

* Avoid Gut Ischemia and Flow Reduction

Norepi Increases Venous Return as well as Constricting Afterload

* Crit Care Med. 2012;40(12):3146-3153

* Crit Care Med. 2011 Apr;39(4):689-94

* Crit Care Med. 2013 Jan;41(1):143-50

* Critical Care 2007, 11(Suppl 2):P37

* Critical Care 2010, 14:R142

* Anesthesiology 2014; 120:365–77

* Want to understand the physiology of venous return?

MAP of 65 or Higher?

No benefit to 80-85 group [cite source='pubmed']24635770[/cite]

The 65-Trial may indicate that 60 is as good as 65

Vasopressor Flow Chart

Update: The Hinds Perspective

Various Vasopressors

Terminology

* 'pressors/catecholamines/inotropes are not so helpful

* Pure Pressors

* Inopressors

* Inodilators (another show)

Why Norepi?

[cite source='pubmed']10966247[/cite]

Should become weight based

Should tolerate tiny doses

Why Not Dopamine?

'cause it is crappy

Vasopressin

Phenylephrine

Epinephrine

Effects on Mortality

Early norepi was better than later norepi [cite source='pubmed']25277635[/cite], [cite source='pubmed']25072761[/cite]

Up and Coming Vasopressors to be Discussed in Future Episodes

Methylene Blue

Angiotensin II

ATHOS Trial

Peripheral Vasopressors

EMCrit Episode 107

Very Good Review Article on the Effects of Vasoactive Agents on Microcirculation

Great Review [cite source='pubmed']20811874[/cite]

Review Articles

[cite source='pubmed']12386503[/cite]

[cite source='pubmed']21097695[/cite]

Moving beyond BP cosmetics by Dunser

Understanding Venous Return

[cite source='pubmed']24966066[/cite]

So my friend Michelle Lin was kind enough to solicit a "How I Work Smarter" piece on her excellent ALIEM blog. One of the things I mentioned in that piece was a book called Getting Things Done. I've since gotten a bunch of questions and comments about the book. I'd like to take a brief diversion from the main topic of EMCrit and discuss a bit about the book and productivity for docs and resuscitationists.

The Books

* Getting Things Done by David Allen (A new edition, the first in years will be out in 3-4 months)

* The Organized Mind

The Philosophy

A clear mind eliminates stress and allows creativity, so...

Capture all the things that need to get done into a logical and trusted system outside of your head and off your mind, and...

Discipline yourself to make decisions about all the inputs you let into your life, so that you will always have a plan for next actions that you can implement or renegotiate at any moment

(altered from Mindzone Wiki)

Problems with the Book

* Mindset of the Author

* Based on an erstwhile paper-based world

* Can be read as Dogma

The Steps of GTD

Collect/Process/Organize/Review/Do

1. Collection/Universal Capture

* Index Cards

* Drafts for IOS

Inbox(es)

* Email

* Paper Landing Station (The Traditional/Actual Inbox)

* Pocket for Web and IOS

2. Process

What is it?

Is it an action, spam, or something non-actionable you want to keep?

Action Processing

* Decide if you want to Do it, Don't do it, Delegate it, or Put it in your system

* Is it a project?

* What is the physical next action that must occur to bring you 1 step closer to completion

Next Actions & Projects

Reference Processing

Things you just want to keep or references for actions

Eliminate Paper!

* Evernote

* Scansnap Scanner (this item will change your life)

 

3. Organize-If you are not doing it right now, put it in the system

* NirvanaHQ or Omnifocus

* GCal with Fantastical

* Add all reference material as links in your system

Calendar

Only things that absolutely must happen at this date/time

Lists on Task Management System

Especially important to have a someday/maybe list, a waiting list, and have a thorough understanding of scheduled events.

4. Review

Daily

* Try to process all email

* Kill all paper

* Clean off Desktop

* Look at Calendar

* Look at Focus and Inbox

* Make a To-Do Card

* Pack for next day

Weekly

(this list is from Mindzone wiki)

* Loose Papers

* business cards, receipts, etc.