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Proning is one of the only evidence-based techniques to affect the mortality of ARDS patients. I've been wanting to do an episode on proning for a while. Serendipitously, Joseph Tonna recently published a piece on the topic in the ACEP Critical Care Section Newsletter. Dr. Tonna is a fellow in Anesthesia Critical Care at the University of Washington. He recently did a rotation on a refractory ARDs unit (read about all of his experiences below) and learned the way they prone. We discuss it on the podcast today.

ResusReview's Checklist

Proning Checklist

Article on the Physiology of Proning

Eur Resp J 2002;20(4):1017

Meta-Analysis of RCTs on Proning

Crit Care Med 2014;42(5):1252

LITFL's CCC Entry on Proning

Lots of good stuff here

Video on Proning from the Guerin Study

Here is the Dr. Tonna's Original Piece:

Prone Positioning: An experience of actually doing it

by Joseph E. Tonna, MD, Associate Newsletter Editor. This piece was originally published in the ACEP Critical Care Section Newsletter

 

Most intensivists have read Guérin’s 2013 NEJM study on the mortality benefit of prone positioning. Previous studies [1,2] have established that dorsal consolidations improve when the patient is placed prone. Taken together, the practice of prone positioning in select patients makes sense. Despite this, I haven’t found that it is done as often as one might infer from the robustness of its benefit in this study or others. In my experience, while we are likely to notice the profound dorsal pulmonary consolidations on our patient’s CT scans, we don’t take the next step and actually prone the patient until we have already progressed further down the path towards worsening hypoxemia—often only when the pO2/FiO2 ratio is well below 150 on upwards of 70% FiO2. At this stage, we begin to consider the patient “refractory” and allow ourselves to begin the intellectual path of discussing the evidence for and risk/benefit or cost/benefit of therapies like inhaled nitric oxide (iNO), epoprostenol, prone positioning, high frequency ventilation, paralysis or extracorporeal membrane oxygenation (ECMO). The evidence for many of these therapies is thin at best, and given how infrequently we reach these states of worsening refractory hypoxemia, and gain personal experience with implementing them, many newly trained intensivists will finish training having managed no more than a handful of patients on these therapies. As we all know, increased volume leads to increased comfort and competence; so as part of my fellowship training, I wanted to know what it looked like to routinely implement these therapies. Did they work? What did this process actually look like?

Prior to turning a patient prone, the medical team places pillows on the chest, the thighs, and the feet. Sheets are used to wrap the patient in preparation for proning.

I had the opportunity recently to train at Legacy Emanuel Medical Center in Portland, OR at the Randall & Emanuel Severe Cardiopulmonary Failure and ECMO (RESCUE) Center under two talented surgical intensivists, Drs. Andrew Michaels and Sandra Wanek. Patients brought to this unit have already failed conventional therapies for hypoxemic respiratory failure, and often already have a P/F of <100 on 80-100% FiO2. These patients have not only failed excellent critical care,

Recently, I got to talk to Sean Townsend, MD; a critical care doc and a member of the Surviving Sepsis Campaign (SSC) steering committee. The spark for this conversation was the recent SSC response to the ProCESS trial (read below) as well as the elimination of CVP and ScvO2 from the National Quality Forum (NQF) sepsis bundle.

* Harmonization Paper that Dr. Townsend Mentioned (Intensive Care Med. 2013 Oct;39(10):1760-75.)

* Definitely read this editorial on legislating sepsis care

* Here is the SSC response to ProCESS:

Surviving Sepsis Campaign Responds to ProCESS Trial

The Surviving Sepsis Campaign (SSC) has received many inquiries regarding the recent publication of the Protocol-Based Care for Early Septic Shock (ProCESS) trial’s effect on the continuing activities of the Campaign.

* The ProCESS trial reflects the consensus that early diagnosis of septic shock is essential. Notably, all groups in the study received on average more than 2 liters of fluid prior to randomization and more than 75% received antibiotics prior to randomization--both elements of the 3-hour Surviving Sepsis Campaign bundle. (2) The editorial accompanying the ProCESS study highlights these points. (3)

* The 18% mortality rate in the “usual care” arm of ProCESS illustrates a dramatic change in the management and outcomes of patients with septic shock. (1) In comparison, septic shock mortality was 46.5% in the 2001 early goal-directed therapy trial by Rivers. (4) Given that 70% of the hospitals in ProCESS had some form of “sepsis protocol,” we believe this mortality rate demonstrates the success of the SSC in increasing awareness and attention to the challenge of early identification and management of these vulnerable patients.

* Given the remarkably low mortality rate in the control arm of ProCESS, the existence of sepsis protocols in the majority of participating study institutions, and the pending results of 2 large ongoing trials (the Australian Resuscitation In Sepsis Evaluation Randomised Controlled Trial [ARISE] and The Protocolised Management in Sepsis Trial [ProMISe]), the SSC has no plans to revise the bundles or National Quality Forum (NQF)-endorsed measures at this time.

* ProCESS does not address the protocolized management of patients with severe sepsis without septic shock, a group of patients for whom early detection and treatment remain critical. The aggressive protocolized management of these patients who do not yet have shock has likely lowered severe sepsis and septic shock mortality since the inception of the SSC. The recently formed Society of Critical Care Medicine/Society of Hospital Medicine (SCCM/SHM) Early Diagnosis and Treatment of Severe Sepsis on the Hospital Floors Collaboratives will focus in large part on this population. Further, the ProCESS results have no impact on the 3-hour bundle, which is the primary focus for the Collaboratives.

* Regarding the SSC 6-hour bundle:

* A companion paper appears to support a mean arterial pressure (MAP) target of 65 mm Hg, which is one of the indicators in this bundle. (5)

* The ProCESS paper does not address repeating lactate measures in patients with elevated lactate while literature supports doing so. (6,7)

* The majority of the patients in the usual care (56.5%) and protocol-based standard care arms (57.9%) of ProCESS had central lines inserted as part of clinical care. (1) The 6-hour bundle asks only that central venous pressure (CVP) be measured and that a venous blood gas be sent fr...

A few weeks ago, we discussed REBOA, a cutting edge procedure to control hemorrhage. Let's go beyond cutting edge to the future of trauma and medical arrest care using a similar aortic catheter. This one allows you to administer blood and drugs to the proximal aorta.

Jim Manning, MD has been working on these issues for over two decades in his lab in North Carolina. This may very well be the future of CPR for medical and traumatic arrests.

Here are Dr. Manning's Disclosures: Inventor on patents for the Selective Aortic Arch Perfusion technology that are assigned to the University of North Carolina at Chapel Hill; Co-Founder of Resusitech, Inc., a medical device company developing invasive resuscitation technologies.

Selective Aortic Arch Perfusion

 

SAAP Catheter Prototype

The following slide shows where SAAP may fit in with the other therapies for cardiac arrest:

And this one shows a possible progression during arrest:

Update: Want More?

Jim gave a lecture for GSA HEMS that is fantastic!

What do you think? Comment Below.

Now on to the Podcast...

The Case:

Rob got permission to share:

INITIAL PRESENTATION:

30 year old male with past history of SCC of the tongue at age 14 who presented with cough, and dyspnea with concerns for recurrent pneumonia. He was still on antibiotics and steroids after a recent hospitalization for pneumonia.

His cancer recovery was hampered by osteo-radio-necrosis of his jaw, and he was left with a scarred larynx, baseline trismus with incisor to incisor distance of <2cm, and some thickening of the anterior neck tissues. He had a G-tube for feeding.

He had normal room air sats, no stridor, productive cough and no fever. Chest Xray was normal, and he was considered safe to go home and follow up with his pulmonologist the next day. The family was nervous about going home so he was observed overnight in the ED.

A very specific discussion was has with the patient regarding the challenges emergent management of his airway would represent:

“I love to manage airways, but your airway scares me, and I would never want to be the one to intubate you”

“If you have an airway emergency on the floor, it would take longer for someone to cric you than if you had an airway emergency at home, and had to present via ems and have a surgical airway performed in the ED”

He was discharged from the ED the next morning with some racemic Epi to try at home.

 

RE-PRESENTATION:

He represented 4 days later in respiratory distress with 36 hours of ‘anxiety’ symptoms that had not been helped by escalating doses of benzodiazepines.

No fever, no cough, very hoarse voice at home.

 

HR 140, BP 160/110, RR 29. Sats 86% RA, 98% 15L NRB

ETCO2 84.

 

Altered, sweaty, moving minimal air, and non verbal with significant stridor.

Initial interventions:

Racemic epi nebs,

125mg solumedrol iv

Glycopyrollate 0.2 mg iv.

Lido 4% neb.

 

VBG: pH 7.17, pCO2 104.

 

Anesthesia was called for Awake FiberOptic Intubation (AFOI) if a trial of BiPAP failed. Due to concerns that NIV could worsen his laryngeal irritation, or that giving Ketamine to help him tolerate the BiPAP could cause laryngospasm (est 1:200 risk) BiPAP was not started until anesthesia was present and ready to perform AFOI.

 

Anesthesia presented promptly and agreed with AFOI plan after BiPAP.

Beside table was set up with 4x4’s with betadine, trach (6.0mm), pocket bougie, and #10 blade scalpel, and gloves. Lido 1% w epi was prepared.

Pt kept at 20 degrees HOB elevation, NC at 15L, then BiPAP at 15/5 was started with no decrease in his work of breathing.

 

3 AFOI attempts were made, with each attempt aborted once sats hit 90%, the patient was hard to bag due to laryngeal stenosis, but with assisted spontaneous ventilations additional attempts were considered appropriate.

The neck was palpated, and prepped prior to first AFOI, and injected w lido w epi after 2nd AFOI.

3rd AFOI was with glidescope assist. Glidescope could barely fit into the mouth, and there were no obviously recongnizable laryngeal structures.

During 3rd AFOI cricothyroid membrane was punctured with 27g needle on the Lidocaine with epi syringe and air was aspirated to confirm location.

The patient received 1mg per kg Ketamine iv prior to incision for cricothyrotomy.

With sats of 92%, a midline 3cm incision made, then horizontal incision 1.

We had a case a few months ago at Janus General--very sad and very scary. The patient came in after a house fire. He had some burns, but not enough to be the cause of his arrest. Instead, it had to be the asphyxia and possible toxicology of the smoke inhalation. I wanted to get a better idea of ideal care for these patients; for that I needed a toxicologist.

Few tox folks are smarter than Lewis Nelson, MD of the NYC Poison Center.

Note: In this episode we don't deal with the thermal injury of smoke inhalation

Cyanide Toxicity

* Empiric administration of  Hydroxocobalamin 5 g rapid IV drip x 1

* Even better if this can be given at the scene as soon as the patient arrests or is profoundly hypotensive

* Messes with labs that use colorimetric probes (cooximetry, lactate, LFTs, etc.) Get blood for cooximetry before giving the med if at all possible

* Dr. Nelson doesn't recommend giving sodium thiosulfate in addition to the Hydroxocobalamin

* An IM version is in the pipeline--this will be easier for EMS/emergency use

Hydroxocobalamin

You'll need 200 ml of Saline

Carbon Monoxide

* Put the patient on 100% fiO2

* Not much to do beyond that until the patient stabilizes

* See LITFL for more on CO

Methemoglobinemia

* Caused by Hb oxidation from the heat of the fire

* Administer Methylene Blue 2 mg/kg x 1 IVP

* May be worthwhile to start a drip if patient has resistant hypotension, but this is an unproven therapy

Now on to the Podcast...

Today, I got to interview one of the superstars at Shock Trauma on REBOA (resuscitative endovascular balloon occlusion of the aorta).

Balloon occlusion of the aorta was first described in 1954 (Surgery 1954;36(1):65). Other older articles include (Ann Emerg Med 1986;15(12):1466, J Endovasc Ther 2000;7(1):1, Endovasc Ther 2005;12(5):556).

The Shock Trauma Center (STC) Approach to REBOA

Gain Access to the Common Femoral Artery with Femoral A-line Kit

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

* Use either 18 arterial line set or Cook 5f Central Venous Cath (G02070)

Float the Wire

* STC uses Boston Scientific Amplatz superstiff wires (0.035in/260 cm/straight floppy tip)

* Measure externally from the catheter to the level of the 2nd rib--mark this level on the wire (At STC, they use Avery 5422 stickers)

* Advance the wire floppy-end first to the marked depth

* Confirm location with either radiograph or fluoro before proceeding

* Mark the proximal end of the wire with a pen on the sterile drape

Place the Sheath

* At STC, they use a Check-Flo Performer Introducer (12 fr, 30cm)

* Remove the femoral artery catheter

* Measure the introducer externally from groin to just below the umbilicus (make sure you are measuring the catheter, not the dilator). Mark with a sticker

* In some cases, you need to dilate the vessel to accept the introducer; in most cases the internal dilator is sufficient

* Place the introducer to the previously marked level

* Critical Move: Removal of the dilator can screw everything up. The operator should lock the sideport of the dilator between their fingers and grip tight and with the other hand, hold the wire proximally. Allow assistant to pin and pull the dilator. If they mess up, you are still controlling the sheath and the wire. If some of the wire gets pulled, have your assistant reinsert without you letting go of sheath or wire.

Place the Coda Catheter/Balloon

* Grab a CODA balloon catheter (32 mm-balloon)

* Measure externally; Zone 1 is measured to the xiphoid, Zone 3 is measured to just above the umbilicus. Measure at the proximal portion of the balloon

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

 

* Remove all air from the balloon using saline syringe

* Insert the CODA catheter

* The wire stays stationary throughout

Inflate the Balloon

* Use a 30 ml syringe, ideally filled with 20 ml of NS and 10 ml of omnipaque (lohexol); use just saline if contrast not available

* Inflate until resistance goes to moderate (would love to know what luminal pressure this corresponds to). 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 infaltion is far harder than you may think. For me, it is the maximal force I can apply with 1 hand.

Secure Everything for Transport

* Here's how they do it at STC

* Mark the levels of everything so you can verify there has been no migration

Get an Xray when time allows

The ProCESS trial was published less than a week ago (The night before my SMACC lecture on severe sepsis--dohhh!)

If you have no idea what I'm talking about, climb down from your mountain-top monastery, find a damn iphone and read this:

ProCESS Trial in the NEJM

As soon as I returned to the states, I begged and pleaded with the study author, Dr. Derek Angus, to give us his thoughts, he kindly acceded.

Dr. Angus is chair of the Department of Critical Care Medicine and Distinguished Professor and Mitchell P. Fink Endowed Chair of Critical Care Medicine at the University of Pittsburgh Schools of the Health Sciences and UPMC Health System. His accomplishments are too numerous to list here, so check out his bio page.

I will be adding a ton of stuff to this page regarding the trial ASAP; for now I just wanted to get Dr. Angus's interview up on the site.

Most Important Table

Updated Table S4

 

Other Stuff Mentioned

Supplementary Material for ProCESS (this is the corrected version)

High versus Low Blood-Pressure Target in Patients with Septic Shock

Excellent Posts in the FOAMcc World

* From ResusMe

* From ALIEM

* From PulmCCM

* From St Emlyn's

Now on to the Podcast...

There is a really smart anesthesiologist out there called Nicholas Chrimes. He along with his mate Peter Fritz invented the Vortex Approach to Airway Management. He also runs a blog called Clinical CrEd.

He did a post advocating the Mapleson B Circuit as the Ultimate Preox Device

What is the Mapleson B? The Mapleson circuits were used for anesthetics in the good old days. At least in the US, we have move to bigger, and arguably better designs for our operative patients. Many would have thought this device would have been consigned to the trash heap, but seemingly not.

from anesthesia 2000

My Recommended Approaches

I recommend two approaches to preox: standard and shunt physiology strategies. I outlines these strategies in the paper Rich Levitan and I wrote.

Standard: NRB @ >=15 lpm and NC @ 10-15 lpm for 3 minutes

Shunt Physio: Choose 1

* BVM with PEEP Valve & NC @ 10-15 lpm

* NIPPV Ventilator with NIPPV Mask or BVM Mask & NC @ 10-15 lpm

Nick makes a number of arguments as to the superiority of the Mapleson circuit over these standard techniques. His points are excellent, but I disagree with pretty much all of them--I think it becomes a question of perspective.

Automatic Checking

Yes, using the same device for reox and preox makes sure the reox device is there and hooked up, but this for me is an inadequate argument to dispense with NRB/NC set-up.

Multiple BVM Masks

We don't have these readily available in any ED or ICU I've worked in. We have neonate, peds, and adult. Our masks also are not inflatable.

PEEP

PEEP is good, Mapleson may or may not be a good way to provide this for the reasons I've mentioned in the wee, but a BVM with a PEEP valve or a vent are at least as good.

ApOx

Mapleson may provide this better than BVM, but not as well as a NC, which should be on during any intubation.

ETCO2

No advantage of Mapleson

Low resistance

Maybe this matters, as soon as you put on the PEEP, I can't imagine this difference persisting

Room Air Entrainment

Release your seal for even one breath and you have blown denitrogenation. Always, always use a strapped system if possible=NRB/NC, NIV mask, or BVM mask with OR straps.

Troubleshooting Leaks

This is the real area in which Nick and I differ. Nick makes the point that a good seal in preox guarantees a good seal in reox--this may be true, but it is unimportant. What I care about is does a bad, one-handed seal in preox mean I won't be able to reox with the BVM--this is entirely untrue. If I did to an awake patient what I will do to them when asleep and desaturating, they would, quite rightfully, punch me in the face.

Anesthesiologists should use Mapleson B/C; ED/ICU should only use BVM +/- PEEP Valve with two hands and oral airway and a rocking triple maneuver (that no pt should experience if they are conscious) otherwise they should be NIV mask with straps or (BVM mask with straps).

This is the same reason I tell my residents to just train with Macintosh blades.

Primary and secondary leaks are the main thrust of Nick's love for the old-timey circuits. But all of us have appreciated this easily by squeezing the bag-valve-mask: Easy-squeezy or Hard Squeezy

ETCO2 with a monitor you can see

Is he holding or squeezing?

My friend and all-around incredible guy, Rich Levitan, speaking on the Surgical Airway.

Update:

1. See here for the EMCrit take on Surgical Airway

2. Subsequent to publication of the podcast, Rich Levitan received this letter:

Rich,

I met you about 4 years ago and we had talked about airway training as you can see in the email below. First off I would like to thank you for your presentation at SOMA (or SOMSA) 2013. It was enlightening for me and I appreciated the discussion.

I am writing you about an airway lecture that you gave in a 2014 conference which was subsequently posted on EMCrit as podcast 119. Although the lecture was excellent, I would like to bring two small inconsistencies about the video portion to your attention:

1)      Just for the sake of clarity, the soldiers featured in the video were actually from the 101st airborne, which is a conventional airborne unit staged out of Ft Campbell KY and they were performing operations in Afghanistan. These are not Special Forces soldiers and in fact, are not affiliated with Special Operations at all. The medics in the video received entry level medical training at Ft Sam Houston, home to AMMED. The scope of their training is relatively narrow in comparison to that of the Special Operations Medic.

The majority of Special Operations medics are more familiar with the cricothyrotomy procedure and are competent/confident enough to perform it when the injury pattern dictates the need. In fact, the majority of the cricothyrotomies performed at the point of injury, in combat, are performed by SOF Medics and not by conventional medics. This is not to take away from the amazing work that Dr Bob Mabry has done with the entry level training at Ft Sam.

2)      The injured soldier in the video is actually an Afghan soldier working alongside American Troops. This is not one of their buddies. This is not to say that bonds never get formed between American Troops and the members of the local population because they certainly do, but a safe assumption here might be that the provider and the casualty do not even know each other’s names.

I don’t know why I am so compelled to address this, maybe it is a little bit of foolish pride in my Special Forces lineage but nevertheless being a man of science I am sure you desire the same level of accuracy in medicine as you do in all things.

Thank you again for all the support, hard work and passion you bring to emergency medicine!

 

Rich Levitan's New Advanced Airway and Endoscopy Course

http://www.ceme.org/advanced-airway-endoscopy-course

Now on to the Vodcast...

Editor's Note 6/4/20: In the wake of the devastating incidents of police violence, many with racially biased overtones, the kill or be killed attitude endorsed by Dr. Grossman has justifiably come under fire. A few folks have asked (some, not so nicely) that this episode be taken down. While we sharply disagree with that aspect of Dr. Grossman's work, none of those aspects are discussed in this podcast. We feel it would be a loss to the resus community to take down this episode. Instead, please separate the things discussed here from other problematic facets of his recommendations.

===

Today I am joined by the master of all things Mind of the Resuscitationist, Cliff Reid of resus.me and the Rage Podcast. In the first ever EMCrit Book Club, we discuss a book I read years ago and recently reread:

On Combat by Dave Grossman has enormous relevance to resuscitationists. I feel the entire book is worth reading, but we zoned in on the really juicy bits.

Section I - Physiology of Combat

Chapter Two - Stress Responses to Combat

We briefly discuss bowel and bladder control as they relate to stress

Chapter Three - Sympathetic & Parasympathetic Responses

Parasympathetic backlash-a time of cognitive danger

"The moment of greatest vulnerability is the instant immediately after victory" --Napoleon

Adapt a 360 degree visual sweep for threats (keep looking at all of your patients vitals and remember to bag)

SWAT Team Acronym-L.A.C.E. liquids, ammunition, casualties, equipment; For us--check your team, immediate reset of resus bay, drink something, debrief

Burn off the adrenaline dump

Conflict with colleagues. Exercise, Punching Bags? If a horrible call is reported on the EMS phone, but never shows--run a sim to burn the epi.

Sleep Deprivation-Caffeine can be our friend, nicotine not so much. If you are too exhausted to perform, tell a colleague and take a nap.

Chapter Four - Colored Conditions

originally from Bruce Siddle, Sharpening the Warriors Edge

Heart rate and task performance: heart rates are a guide, getting there by exercise is not the same as by fear/stress, so HR is merely an associated marker

Yellow 90-120, Over 115 and fine motor skills performance degrades significantly

Red 120-150, a 145 HR seems to be the break-point for optimal performance of complex skills

Black >150 and badness ensues, (or >175 in the highly trained, they get a gray zone)

* Fine motor skills-precision tasks

* Gross Motor Skills-ape skills

* Complex-a combination of maneuvers or use of multiple body parts

SWAT team breaking down door function in condition red (or gray), but they have trained until the necessary tasks that require fine motor have been practiced till automaticity

Unified Model of Stress and Performance

 

We need to train how we fight

Stress Inoculation Training and (Academic Medicine 2009;84(10):S25)

We are currently wasting high fidelity simulation, it should purely be for stress training. Perhaps, we should create a hell week for our 2nd years.

Stay in yellow (alert, but with fine motor control) - yellow dot stickers to...