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This is the another of the Laryngoscope as a Murder Weapon lectures; though in this case it is really more of an aggravated assault.

Who is this For?

Semi-elective intubations for patients with presumed or known elevated ICP

In TBI severity of brain injury doesn’t predict the lack of need for pharmacological blunting of increase in MAP or ICP [cite source='pubmed']23511147[/cite]

The prototypical case requiring this treatment is a high-grade SAH prior to securing the aneurysm

This is the same way we would intubate an aortic dissection patient

Preoxygenation

Ap Ox and high-flow fiO2 for the full 3 minutes or longer

ETCO2

Put it on the BVM

Non-Pharmacologic Methods to Blunt Reflex Response

Limit time of laryngoscopy and atraumatic laryngoscopy

Leave the patient upright until the last possible moment, then intubate in 20 degrees head-up

No-touch intubation with video laryngoscopy by the best intubator

Pretreatment

Control the BP BEFORE the intubation

Lidocaine

While there is evidence that it blunts ICP rise and cough response, there is no good evidence that this has clinical results.[cite source='pubmed']11696494[/cite] Literature is pretty good on endotracheal suctioning, but nothing on patient-important outcomes during intubation. Not hemodynamically active in this one study, but I have experienced radical drops in BP. [cite source='pubmed']22633717[/cite] This one shows the hypotension potential. [cite source='pubmed']25237632[/cite]

Local is more effective than IV. [cite source='pubmed']10861151[/cite]

Lidocaine References [cite source='pubmed']11696494[/cite], [cite source='pubmed']17358099[/cite], [cite source='pubmed']23683444[/cite], [cite source='pubmed']7772359[/cite],

Fentanyl

Dose 5 mcg/kg [cite source='pubmed']6318605[/cite], [cite source='pubmed']7032347[/cite]

All equipment meds must be prepared before administration. Someone must be watching the pt. You need to have push-dose epinephrine drawn up at the bedside if you are going to use fentanyl in these doses.

Remifentanil

Remifentanil can also be used, but I don't have so I can't speak about it

Esmolol

Dose 1.5-2 mg/kg ~ 3min beforehand

Combo of Esmolol and Fentanyl [cite source='pubmed']1363221[/cite]

[cite source='pubmed']7788827[/cite]

[cite source='pubmed']9084524[/cite],[cite source='pubmed']1672488[/cite]

Nicardipine

Dose 20 mcg/kg (average 1.4 mg)

[cite source='pubmed']21696933[/cite] and [cite source='pubmed']10553821[/cite] and Review Article (16978041)

Other Group's Recs

At this stage, Emergency Airway Course only recommends Lidocaine and Fentanyl: they state prefasiculation is dead

Osmotic Therapy

Probably a good time to give a dose of hypertonic saline

Induction Agents

Etomidate, Propofol, or Propofol/Ketamine (75%/25%). If Thiopental was still available, it would be on the list as well.

Muscle Relaxants

Rocuronium or Succinylcholine at full dose

Post-Intubation Sedation

Propofol and Fentanyl

Post-Intubation Ventilation

Shoot for 95% saturation, use PEEP only if necessary; but if it is necessary it is safe to use

Increase Respiratory Rate until ETCO2 of 35 mm Hg; then send a blood gas

Other Situations

Basilar Stroke and Stuttering Stroke-lower bp=screwed

Review Article

Has anyone found a good one for ICP

Here is a great article for the

We now have way too many treatment options for sub-massive and massive pulmonary embolism (PE) patients who aren't coding in front of you. How do you decide which one is right for your patient? To help answer this question, I am joined today by Oren Friedman, pulmonary critical care doc and one of the members of the Cornell PEAC team.

Cornell Pulmonary Embolism (PE) Advanced Care Team (PEAC), aka the CLOT Team

Oren Friedman MD, Pulm Crit Care; James Horowitz MD, Cardiology; Arash Salemi MD, Cardiac Surgery; Akhilesh Sista MD, Interventional Radiology

You can shoot the team an email: peadvancedcare at gmail dot com

Who Should We Treat?

Wood 2002 PE Mortality Curve

30% normotensive patients have RVD; 10% progressed to shock; 5% in hospital mortality[cite]10859287[/cite]

The Better Risk Categories for Pulmonary Embolism

* Well and Stable Sub-Massive

* High-Risk Sub-Massive

* Massive

PEITHO Trial

NEJM 2014;370(15):1402

Full dose tenecteplase with concurrent heparin

* Death or hemodynamic decompensation occurred in 2.6% of the tenecteplase group as compared with 5.6% of the placebo group

* Extracranial bleeding occurred in 32 patients (6.3%) in the tenecteplase group and 6 patients (1.2%) in the placebo group (P<0.001)

* Intracranial Bleed 10 patients (2%) in the tenecteplase group and 1 patient (0.2%) in the placebo group (P=0.003)

Also see my bud, Salim Rezaie's post on PEITHO and Konstantinides' prior study [cite]12374874[/cite]

Ryan Radecki made some great observations in his post on PEITHO

* The criteria for myocardial injury was a troponin I >0.06 ?g/L or troponin T >0.01 ?g/L.  These may be relatively inclusive thresholds.

* Not all placebo patients developing hemodynamic collapse received subsequent thrombolysis; likewise, almost half of those who received open-label thrombolysis had no hemodynamic collapse.

* Half the deaths in the placebo arm were “sudden unexplained” or “other”, compared with bleeding or stroke complications in the thromboysis arm.

TOPCOAT Trial

Jeff Kline's trial was stopped midway through due to an institution change. Complicated primary endpoint with promising, but unusable results [cite]24484241[/cite]

For the scoop on this one see the Bottom Line Review post on TOPCOAT

MOPETT Trial

Half-dose alteplase led to a marked reduction in pulmonary hypertension without sig. complications

Sharifi M et al. Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT trial). (J Cardiol 2013; 111: 273)

See this prior EMCrit Wee as well on MOPPETT

Update: This meta-analysis states that the half-dose may be appropriate, effective, and safe [cite source='pubmed']24412030[/cite]

Meta-Analysis

Chatterjee et al. have the most current meta-analysis on this topic (JAMA. 2014;311(23):2414-2421)

See the Bottom Line Review post on this study

Nakamura just published another MA this week; see Rory Spiegel's take on the two here

Is it just in the Oldies?

from inter-rescue.de

Today on the show, I talk with my friend Jim DuCanto, MD about the oxylator. Jim is an anesthesiologist extraordinaire with a constant drive to perfect new airway techniques and document them on video along the way.

What is the Oxylator?

A mainly plastic device about the size of your fist with a incredibly quick magnetic valve

It runs on pressurized wall or tank oxygen

Only two main controls, a pressure setting knob and a manual inhalation/automatic mode button

Manual Resuscitator Mode

Press the button and the device will give 30 lpm of inhalation until you let go or it hits the pressure limit you set

Automatic Ventilator Mode

Press in the button and give it a turn and the device switches to automatic ventilation mode. Think of it as a flow-controlled, pressure cycled ventilator in your hand

It gives 30 lpm fixed flow (slow, safe flow) until it hits the user-selectable pressure limit, it then cycles to passive exhalation until it reaches 2-4 cm H20 PEEP and then it begins a new breath

On a patient who is not spontaneously breathing, you can titrate that pressure setting to an inhalation time of 1 seconds; this will deliver 500 mls per breath

At those settings, the minute volume will be 10-12 liters/minute

from inter-rescue.de

Feedback

The device indicates when you are obstructing by clicking and tells you when there is a mask seal leak by not cycling to the next breath

It Solves the 5 Problems of the BVM

* We give too many breaths

* Those breaths are at too high a pressure

* The breaths are given too rapidly

* We get no feedback on whether the breath went in or it was given against an obstructed airway

* In a spontaneously breathing patient, the BVM will give variable FiO2s depending on the exhalation port

How we use it

We both use an inline hepa filter, ETCO2 port, and sometimes extension tubing. If you want to use it on a spontaneously breathing patient, OR mask straps are a great addition.

Two models

EMX (25-45 cm H20) and HD (15-30). There are also specialty models for chemical/explosive situations.

Here is Jim's Overview on the Device

https://vimeo.com/99412812

And here are the Slides from a lecture Jim gave at SAM

Here is an example of the use of the Oxylator for an OR Induction

 

Nasal CPAP in Unconscious Patient is More Effective than Full-Face Masks

Crit Care. 2013 Dec 23;17(6):R300.

Oxylator Product Page

This is the EMX Model

Disclaimer and COI

Neither Jim nor I take any money, kickbacks, or incentives from the manufacturer. Both Jim and I have been provided with Oxylators to test and research.

Now on to the Podcast...

This is the first SMACC-Back for SMACCgold. The creator of the lecture that led to this was Simon Carley. Simon is a brilliant emergency physician and lecturer who practices at St. Emlyn's. I can only imagine he was expecting this SMACC-Back as he all but threw his metal glove on the ground in front of me (all in good fun). Unfortunately, I was in another session during this lecture, but I've been eagerly awaiting it as many of the EMCritters came up to me afterwards to tell me about it.

My response will make no sense if you don't listen to Simon's talk first, so here it is. I advise watching the video, because I love watching the emotions flash across his face whenever he is lecturing–truly a captivating speaker.

Audio Only Version [right-click and choose save-as to download]

Also, please read the original post on St. Emlyn's.

Technology Adoption Curves

Diffusion of Innovations was a book I read in college. It explains how technology and ideas get taken up by a population. Here is an entry from wikipedia:

Diffusion of innovations is a theory that seeks to explain how, why, and at what rate new ideas and technology spread through cultures. Everett Rogers, a professor of communication studies, popularized the theory in his book Diffusion of Innovations; the book was first published in 1962, and is now in its fifth edition (2003).[1] The book says that diffusion is the process by which an innovation is communicated through certain channels over time among the members of a social system. The origins of the diffusion of innovations theory are varied and span multiple disciplines. The book espouses the theory that there are four main elements that influence the spread of a new idea: the innovation, communication channels, time, and a social system. This process relies heavily on human capital. The innovation must be widely adopted in order to self-sustain. Within the rate of adoption, there is a point at which an innovation reaches critical mass. The categories of adopters are: innovators, early adopters, early majority, late majority, and laggards (Rogers 1962, p. 150). Diffusion of Innovations manifests itself in different ways in various cultures and fields and is highly subject to the type of adopters and innovation-decision process.

The book posits that uptake is a bellshaped curve that looks like this:

Bayesian Approach to New Ideas

Anyone who looks at new evidence with tabula rasa is missing the point and is likely to get things wrong. Not only do we filter new evidences through out beliefs, we must do so. It is not irrational, it is essential-the process should be a willful and deliberate filtration of new information through your existing schema.

Update:

Simon responded to this SMACC-Back with a SMACC-Back-Back. Here it is:

https://twitter.com/EMManchester/statuses/482033046187950080

Update 2:

Rob Cooney weighs in

Now on to the SMACC-Back:

In this episode, I speak with Niklas Nielsen on his thoughts on the TTM trial.

Coverage of the TTM Trial

* EMCrit Coverage

* John Rittenberger's take

* Read this incredible TTM Post on LitFL

Kee Polderman's Editorial

* Crit Care 2014;18:130

Update

My theory on goal temp 33 causing a hibernation response was born out by

A. Lybeck, T. Cronberg, A. Aneman, et al.Time to awakening after cardiac arrest and the association with target temperature management

Resuscitation, 126 (2018), pp. 166-171

Now on to the Podcast

 

So yesterday, I spoke with Rob Mac Sweeney about Intra-Arrest Meds. On that cast, I told you today we would have a bit of discussion on Rob's FOAM. Well here it is...

Critical Care Reviews

It's amazing, it's hugely helpful, and it is free. Subscribe ASAP at criticalcarereviews.com.

 

Critical Care Horizons

Here is Rob describing this new journal:

Announcing a new development in critical care publishing.

It is with great delight we announce the launch of a new open access critical care journal. Critical Care Horizons is a fresh, original voice in the critical care literature, offering thought-provoking, cutting-edge commentary and opinion papers, plus state-of-the-art review articles. As a Journal, we see discussion, commentary, and the sharing of insight, experience and ideas, as central to progress in our speciality. We are free to publish with, free to read, opening authorship opportunity to all working with the critically ill. We are driven by a desire to improve the care we offer our patients, and operate without financial aim or incentive.

We strive to be different, combining the rapidity, broad exposure, and dynamic discussion characteristic of social media with the academic standards of an indexed, peer-reviewed journal. Covering the full spectrum of clinical care, we welcome submissions from all disciplines involved in the care of the critically ill and injured, from pre-hospital resuscitation to Emergency Department care to ICU-based management to post-discharge follow-up, and anywhere else.

The Journal publishes dynamically, releasing material to the website as the final PDF as soon as it has cleared peer-review and editorial processes. Issues will be published quarterly, with additional special editions and articles as required. The Journal is run on a not-for-profit basis, with editorial staff operating on a voluntary basis without monetary reimbursement.

Critical Care Horizons is aligned with the altruistic ethos of the FOAMed movement, and affiliated with several of the leading critical care and emergency medicine blogs. We have an energetic editorial board, consisting of a deliberate mix of clinicians active in social media and world renowned academics. This is a journal for the critical care community, by the critical care community, without access impediment or financial bias. This is your journal. We hope you will enjoy the content, get involved in the discussions available with each article, and, by publishing with us, share your thoughts and opinions with the world.

With this, we issue a call for both papers and peer reviewers. Neither finance nor profile will be an impedement to publication. The only barrier is you - your willingness to commit time to write and your ability to produce an engaging, skillfully written manuscript. If you have something interesting to say, but feel locked outside the traditional publishing environment, this is your opportunity. If you are an inexperienced author, please enlist the help of an experienced colleague, as formal scientific writing is a skill to be mastered. If you have an idea for a themed issue, and would like to act as a guest editor, please contact the editor-in-chief. Further affilitations from similar altruistic bodies and websites are welcome. The first articles will be published on January 1st 2015.

Join us on an amazing journey.

 

Rob Mac Sweeney - Editor-in-Chief

Rob Mac Sweeney is an anaesthetist-intensive care doc. His gig is evidence: analysis, assimilation, and dissemination. Tomorrow, you'll hear a ton more about the great stuff he does on sites such as Critical Care Reviews. For today, we discuss the topics raised in my recent posting of my SMACC Intra-Arrest Talk.

 

I received an email from a friend and colleague on how to build mental toughness in our trainees. After hearing the case that spurred the question, I actually began to believe the problem is actually one of self-granted permission to act and the conflict between errors of commission and errors of omission.

Recommended Reading/Listening

* Combating omission errors through task analysis and good reminders

* Rick Body has a great post on the silliness of the interpretation that, "First, do no harm," should inspire passivity

* Casey Parker could not be restrained by words in the comment section so he recorded his response discussing the 2 modes of a part-time resuscitationist

Listen to the wee to understand what the frack I am talking about...

Enough with cook book medicine and courses for dermatologists--let's provide cutting edge intra-arrest care

My favorite part of SMACCgold; buy some Cricolol