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@docjohnhinds is the man behind Cricolol

I recently brought him to our EM Critical Care Grand Rounds at @stonybrookem

He gave two fantastic lectures! I then brought him back to EMCrit Studios to record a few of the take-home lessons from his talks.

See Cases from the Races on the RagePodcast site to see the inspiration for this 'cast.

Blunt Traumatic Arrest: a Road Racing Doc's Approach

If the patient is in blunt traumatic arrest, John and his team immediately perform the following before any further assessment:

* Intubation using a bougie and confirmed by waveform CO2

* Perform Bilateral Finger Thoracostomy

* Place Pelvic Compression Device

* Straighten Long Bone Fractures to Length

* Administer Fluid Bolus (Administer Blood if In-Hospital)

Only then reassess and decide what to do

Impact Apnea

Airway positioning and rescue ventilation can save a life

More on this soon when the Wilson, Hinds, Davies study is published. Until then, see the LiTFL CCC Entry

Central Line Placement

In John's unit, they use infraclavicular left subclavian for all ICU CVC placements

Hug a Researcher

EMCrit specializes in Type 2 Translation and Implementation. That crap wouldn't exist without the researchers. Go find a Critical Care Researcher today and give them a hug.

But they Weren't Sick Enough...

SSC Reverses their Stance on EGDT (Sort of...)

What do folks thing EGDT still brings to the table?

Cognitive DeBiasing

Please ask yourself, before you air your viewpoints in public, are you displaying Confirmation Bias

Shown to Me by G. Kovacs

 

So the Arise Study (Australasian Resuscitation In Sepsis Evaluation) just dropped. The amazing guys at the Bottom Line did a summary (saving me a bunch of work)

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

Baseline Characteristics

Table S5-Therapies in the first 6 hours and 3 days

Videos from a Prime Author

Hear from Sandra Peake

Recognition-Find em' Early

SIRS+

Lactate or Persistent Hypotension (Arise used 1 liter)

I would use STOP Sepsis Campaign Modification of SIRS Critieria, so you don't need to wait for cbc

Treatment-Treat the Source/Perfuse the Tissues

Antibiotics

Another trial showing early abx are associated with goodness

If a patient is sick and you don't know what is going on, just give them appropriate spectrum abx. If a patient is persistently hypotensive and you don't know why--give them abx.

A very cute antibiotic summary

Source Control

Early, early, early

Don't box 'em with the tube

See the Hemodynamic Kills Lecture

The Right Amount of Fluid

Use whatever method you want, but you should probably give between 3-4 liters

Early Vasopressors

Give them peripherally to get them in fast and then you should probably put in a line

If you have given 3-4 liters, the patient probably deserves pressors for venous squeeze before giving more fluid

Check Your Work

Serial lactates?

Put them in a Monitored Setting

b/c of the way septic patients die

Other Stuff

Blood

No role for blood, except in niche cases, until Hb < 7 from the recent TRISS Trial (PMID 25270275)

Fewer pts got blood in EGDT group of either ProCESS or ARISE than the original EGDT study

Dobutamine

who the hell knows

Want to Hear from the Primary Investigator?

Oli Flower did a podcast in which Anthony Delaney addresses many comments from this post. Here's Oli:

Thanks Scott for your insights on ARISE and the state of play of sepsis management in 2014.

These open discussions that your podcast stimulates are incredibly important and essential for translating research findings into practice, and getting the important messages and critical interpretation of the data to as many people as possible!

Yesterday I interviewed the ARISE PI Anthony Delaney to hear his take, now he’s allowed to finally talk about the results, and I went through a lot of your listener’s comments to get an answer from the horse’s mouth.

The interview is here:

http://intensivecarenetwork.com/delaney-arise-study-emcrit-dogmalysis/

Cheers,

Oli

What do you think?

A few months ago, we spoke about REBOA-resuscitative endovascular balloon occlusion of the aorta. You might have thought to yourself, "Interesting, but I'll never be doing that." Well, not so fast, on today's podcast we speak to the retrieval doctor that performed the first REBOA in the field.

REBOA in the Field and the ED

In London, the idea of bringing REBOA to the field and the ED was made reality by Gareth Davies. Dr. Davies is Chair and Medical Director of the London Air Ambulance (London HEMS), one of the best HEMS services in the world. In the first part of the podcast, we hear how he conceptualized and enacted the plan to bring REBOA to the field.

REBOA Training at London HEMS (Photo by Andy Patton @AndyP_91)

The First Prehospital REBOA

Then we speak with Jonny Price, Anesthesia and Intensive Care registrar doing a secondment in HEMS. At the time of the events of the podcast, he was flying with London HEMS. His story of the first prehospital REBOA is fascinating.

Special thanks to Cliff Reid for making these interviews possible.

Update

Here is the hot-off-the-press article on the technique: Resuscitation 2016 Jul 1; Resuscitative endovascular balloon occlusion of the aorta (REBOA) in the pre-hospital setting: An additional resuscitation option for uncontrolled catastrophic haemorrhage.S Sadek, D J Lockey, R Lendrum, Z Perkins, J Price, G E Davies PMID: 27377669

Now on to the podcast...

Promotions:

ATACC Trauma Textbook

A free trauma textbook that is simply amazing and the best example of FOAM brought to traditional media that I have ever seen--want it? I bet you do. I could have written an entire post on this book, but luckily someone did it for me:

Tim Leeuwenburg on the ATACC Textbook

Just want to download it?

* The Ibooks Version can be found at this link

* or go to the ATACC site for the PDF versions

POCUS Ultrasound Book

My friend and ultrasound maven, Rob Arntfield is one of the editors of an amazing new Ultrasound Book

Here are some of the reasons why it is so good

* -44 chapters

* -60+ authors

* -285 videos

* -geared to be first ever book to support all specialties at different providers levels.

* -Inkling reading experience (laptop/phone/tablet) is amazing, with embedded videos in the chapters and high quality cases

* -The references are in the online version and have hyperlinks for the PMID allowing immediate access to the root literature

Buy the book

Get the POCUS book on Amazon

Win the book

Simply "like" the EMCrit Facebook Page and I'll choose a winner from there

Stony Brook Department of EM

We want the best medical students, faculty, and ED Intensivists

Check us out at the Stony Brook EM Page and contact me if you are interested or have questions

Aggressiveness and the New Cutdown with Leon

Here is an instructional video on the procedure

Now on to the Wee...

Today, I interview Mike Lauria on the concepts of toughness and resilience.

The Rationale of Selection Courses/Indoc

80-90% Attrition for the PJs Indoc

One of the things that people, I think, find distasteful about selection programs in the civilian word is that it uncovers fundamental weaknesses and shortfalls.  This is no commentary on the intrinsic worth of the individual.  It doesn't necessarily mean that they are smart or dumb.  But it is indicative of some inability or failure to meet a standard.  While it is hard for many civilians (and military members for that matter) to swallow, perhaps not everyone is cut out for a particular discipline.  Maybe we shouldn't be forcing training, pushing people along, coddling individuals to maintain the outward appearance that a program is "successful" if an individual can't make it through some sort of initial pipeline.  Perhaps a benefit of selection is making sure that the right people are there to begin with and the individuals that were simply not made for it are directed elsewhere.

I lost the source for the above quote, but I think it describes the process well. If anyone has it, please send me the attribution.

Builds an innate Espirit de Corps and a common thread of self and team-reliance

Residency as the Pipeline

Should we have culmination tests and exercises at the end of residency?

Stress Inoculation/Cognitive Tempering

Mike discusses four stages to do this right:

* Conceptualization-give a background of stress responses, why they happen, and what to expect.

* Train and educate on the skills and tasks we want to see performed under stress. Then give the tools to deal with the expected stress. The latter is where we may be failing our learners

* Do a dry run to train in simulation without added stressors

* Run the same training with stress inoculation

How can we make #4 work in EM/CCM?

Sound, distractions, equipment failures, and deliberate poor communications

So what tools can we offer for #2?

Mike offers an acronym: Beat The Stress, Fool

* B is for Breathe. Breathe tactically. See the On Combat Podcast for a description (and there is an app for that too: Tactical Breather App)

* T is for Talk. Self Talk. Positive self-talk is used by athletes and any elite performance group.

* S is for See. Visualization. Visualize yourself performing the task exactly how you want to see it done.

* F is for Focus. A key word to activate the state you want. Mike has chosen "focus" as his word. We then had a brief discussion of the book, the Art of Learning by Josh Waitzkin. The author creates an entire relaxation and mindset ritual that eventually gets boiled down to a key word or short set of actions. You'll be hearing more about this book on the podcast.

When Mike asked if I had anything to add to this excellent set of tools, I discussed this TED Video by Dr. Amy Cuddy:

 

So maybe...Beat the Stress, Foolish Padawan with a P for posture??

Too Much Macho Militarization?

Mike posted a Youtube Video Addressing this question

Cliff Reid's Resus.me Post on Self-Defense

During the intro, I discussed the contentious self-defense post on resus.me

First10EM Magnum Opus on Performance Under Pressure...

Over at EDECMO we talk about the huge benefits of ECPR demonstrated by the fact that there are neurologically intact survivors when ECMO is initiated at the point of cessation of standard ACLS. But what if standard ACLS had not stopped... What if you just kept going?

Mirroring Cliff Reid's amazing talk: When Should We Stop Resuscitation?, I present Sam Ghali's (@EM_ResUS) case.

From Sam Ghali:

I just experienced probably the most amazing case I’ve ever been a part of this past Monday.     This case has become the talk of the place, as it was very controversial within the world emergency medicine, critical care and cardiology here @ Janus General.  It was discussed in M&M and there is gonna be a joint multidisciplinary thing, etc.  But otherwise there is no one else’s opinion I would be more interested to hear than yours, so I wanna share it with you:

I was working shift in Major Treatment Area here at Janus General, and we hear we’re getting a med resusc… rolls in a guy looks to be in about his 60’s (turns out he was 59).  Story was :

Witnessed Arrest with bystander CPR… shockable for EMS, but shocked 6-7 times… meds given were for some reason only bicarb and Lidocaine (not sure why?)

I will share with you my documentation, only b/c it will save me tons of typing and I trust sending it to you..

This patient was seen in the resuscitation bay along side Dr. XXXXX concurrently.  This patient presents status-post witnessed cardiac arrest after return of spontaneous circulation.  His rhythm was always shockable per EMS.  He arrived with a King airway in place.  There was a large air leak noted.  CPR was in progress shortly after arrival as he was noted to not have pulses.  Chest compressions were resumed immediately and multiple rounds of CPR with multiple rounds of epinephrine, and medications including amiodarone, bicarbonate, calcium, magnesium were administered.  Please see nursing medications charting.

Multiple echocardiographic images were obtained by myself.  Please see computer for images.  The patient was noted to be in and out of ventricular fib.  CPR was continued in line with ACLS protocol.  The King Airway was removed and endotracheal intubation was performed by myself using a MAC 4 blade and an 8.0 endotracheal tube without difficulty.  There was good condensation on the tube, good chest rise, and end tidal CO2 was detected immediately with excellent wave-form.  Intra-code bedside echo was performed and revealed no evidence of right ventricular enlargement or strain on echo, or any other signs of massive pulmonary embolism.  There was also no pericardial effusion.  Echo did show akinesis/hypokinesis inferiorly and somewhat laterally as well.  The inferior wall was essentially akinetic.   Anterior wall motion was clearly preserved.  This was best seen on the parasternal long and short axes.

There was very high suspicion for acute coronary event.  Furthermore there was no evidence of hypoglycemia, hyperglycemia, hypokalemia, hyperkalemia.  The patient’s pH was noted to be significantly acidotic, and 2 additional ampules of sodium bicarbonate were administered at that time.  There was good sliding bilaterally on ultrasound.  There was no evidence of massive pulmonary embolism on echo, and there was no evidence of pneumothorax.  Intravenous fluids were pressure bagged in.  There was no significant hypothermia.   End tidal was difficult to interpret due to multiple ampules of sodium bicarbonate.  After nearly 45 minutes of aggressive CPR the decision was made to use thrombolytics because we felt strongly that this was an acute myocardial event, it was also strongly felt that without thrombolytics stabilization and termination of electrical storm could otherwise not be accomplished,

Note: To do this technique properly, it is imperative you read this post (choosing the correct DBP); you should also probably listen to that podcast.

Today on the podcast, I address the last little bit from my SMACC lecture on the new management of the intra-arrest: hemodynamic, individualized dosing of epinephrine.

The podcast is interspersed with clips from Professor Norman Paradis

Articles/Posts on Epinephrine by ACLS Guidelines

* [cite source='pubmed']15306666[/cite],

* http://www.emdocs.net/epinephrine-cardiac-arrest/

* http://www.jems.com/article/patient-care/new-resuscitative-protocol

* [cite source='pubmed']24846323[/cite]

* [cite source='pubmed']19934423[/cite]

Epinephrine Dosing Based on DBP

Three Swine Study

(Crit Care Med. 2013 Dec;41(12):2698-704)

(Resuscitation. 2013 May;84(5):696-701)

[cite source='pubmed']25321490[/cite]

[cite source='pubmed']24945902[/cite]

Here is the abstract from the latter study:

AIM: Advances in cardiopulmonary resuscitation (CPR) have focused on the generation and maintenance of adequate myocardial blood flow to optimize the return of spontaneous circulation and survival. Much of the morbidity associated with cardiac arrest survivors can be attributed to global brain hypoxic ischemic injury. The objective of this study was to compare cerebral physiological variables using a hemodynamic directed resuscitation strategy versus an absolute depth-guided approach in a porcine model of ventricular fibrillation (VF) cardiac arrest.

METHODS: Intracranial pressure and brain tissue oxygen tension probes were placed in the frontal cortex prior to induction of VF in 21 female 3month old swine. After 7minutes of VF, animalswere randomized to receive one of three resuscitation strategies: 1) Hemodynamic Directed Care (CPP-20): chest compressions (CCs) with depth titrated to a target systolic blood pressure of 100mmHg and titration of vasopressors to maintain coronary perfusion pressure (CPP)> 20mmHg; 2) Depth 33mm(D33): target CC depth of 33mm with standard American Heart Association (AHA) epinephrine dosing; or 3) Depth 51mm(D51): target CC depth of 51mm with standard AHA epinephrine dosing.

RESULTS: Cerebral perfusion pressures (CerePP )were significantly higher in the CPP-20 group compared to both D33 (p<0.01) and D51 (P=0.046), and higher in survivors compared to non-survivors irrespective of treatment group (P<0.01).Brain tissue oxygen tension was also higher in the CPP-20 group compared to both D33 (P<0.01) and D51 (P=0.013), and higher in survivors compared to non-survivors irrespective of treatment group (P<0.01).Subjects with a CPP>20mm Hg were 2.7 times more likely to have a CerePP>30mm Hg (P< 0.001).

CONCLUSIONS: Hemodynamic directed resuscitation strategy targeting coronary perfusion pressure>20mmHg following VF arrest was associated with higher cerebral perfusion pressures and brain tissue oxygen tensions during CPR. University of Pennsylvania IACUC protocol #803026.

Perhaps we can extrapolate from these pig studies to--shoot for SBP of >=100 with compression efficacy and CPP>20 (DBP>40) with vasoconstriction. REBOA or SAAP may solve both

Human Study by Dr. Paradis

Coronary Perfusion Pressure and the Return of Spontaneous Circulation in Human Cardiopulmonary Resuscitation

[cite source='doi']10.1001/jama.1990.03440080084029[/cite]

Coronary perfusion pressure (CPP),

Mind of the Resuscitationist Wee

Mike Lauria is the @resuspadawan. You'll be hearing a lot more about Mike when he comes on the show for an interview. For now, know that he was Air Force Pararescue, now a medic on the Dartmouth-Hitchcock Advanced Response Team (DART), and will be starting medical school in the Fall. He has a special interest in cognitive decision making under stress, aka the Mind of the Resuscitationist.

Recognition Primed Decision Making (RPD)

Sources of Power by Gary Klein

OODA Loop

From 40-second Boyd. Read a summary on wikipedia

Cognitive Unloading

* Standardization & Preparation

* Checklists

* Premade Decision Points and Triggers

Cognitive Rally Points (Stop Points)

* Hard and Soft Rally Points

* Take a Deep Breath

Build Decision Making Power

* Deliberate Practice

* Review Experiences

* Timely Expert Feedback

* Socratic Method-Suck it Up!

* Simulation

Stress Inoculation

* Cognitive Tempering

* The Rule of 130%-do the basics better than anyone else

* Limbic Learning-emotional reaction burns it in

* Train until you can't get it wrong

* You fall to the level of your training

Stay Flexible

* Cognitive Flexibility

* Acknowledge BIases

* Ask disconfirming questions

The Slides

Articles

* Resilience Training for Nurses

Update

See this amazing comment on Mike's Lecture

Now on to the Lecture...