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Here is the policy:

Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department

They addressed 4 questions:

1. In patients undergoing procedural sedation and analgesia in the emergency department, does preprocedural fasting demonstrate a reduction in the risk of emesis or aspiration?

Level B recommendations. Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia.

2. In patients undergoing procedural sedation and analgesia in the emergency department, does the routine use of capnography reduce the incidence of adverse respiratory events?

Level B recommendations. Capnography* may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone in patients undergoing procedural sedation and analgesia in the ED.

3. In patients undergoing procedural sedation and analgesia in the emergency department, what is the minimum number of personnel necessary to manage complications?

Level C recommendations. During procedural sedation and analgesia, a nurse or other qualified individual should be present for continuous monitoring of the patient, in addition to the provider performing the procedure. Physicians who are working or consulting in the ED should coordinate procedures requiring procedural sedation and analgesia with the ED staff.

4. In patients undergoing procedural sedation and analgesia in the emergency department, can ketamine, propofol, etomidate, dexmedetomidine, alfentanil, and remifentanil be safely administered?

Level A recommendations. Ketamine can be safely administered to children for procedural sedation and analgesia in the ED. Propofol can be safely administered to children and adults for procedural sedation and analgesia in the ED.

Level B recommendations. Etomidate can be safely administered to adults for procedural sedation and analgesia in the ED. A combination of propofol and ketamine can be safely administered to children and adults for procedural sedation and analgesia.

Level C recommendations. Ketamine can be safely administered to adults for procedural sedation and analgesia in the ED. Alfentanil can be safely administered to adults for procedural sedation and analgesia in the ED. Etomidate can be safely administered to children for procedural sedation and analgesia in the ED.

Tell me what you think in the comments

Now on to the Podcast...

If you are an EM:RAP listener, you have probably heard Mel Herbert's story of 2 cars crashing right outside of his house. Mel realized he did not stock a medical kit in his house with the necessary crucial supplies for an emergency scene. I realized I don't either (there is one in my car). So, I reached out to the master of preparedness, Dr. Keith Conover.

Everyday Emergency Kit

We spend the 1st part of the show discussing the everyday kit which Dr. Conover has with him (or in eye shot) pretty much always. He carries it in a fanny pack--I'm not sure if I can be persuaded to do this, but you should probably keep a kit with at least these items in your car or house.

On the topic of fanny packs...

Well anyhooooo, here is the list

We also discussed the Daypack Medical Kit for your House/Car

* Daypack Med Kit

Digital Intubation

* Rich Levitan has an amazing article on the topic of Digital Intubation (Note: I can't find this online anymore so this is a Crashing Pt Copy)

* Here is an amazing entry on the Life in the Fast Lane CCC

Equipment we Discussed

Tourniquet

The CAT Tourniquet is the best one yet

Disposable Laryngoscopes for Kits

* Surescope

* Truphatek Trulite (This one folds up and is Rich Levitan's Rec)

Headlamp

I recommend the Zebralights, this is the one I use:

Zebralight H502W

SAM Splint

The SAM Splint is EMS standard stock

Trauma Bag

In his trunk, Dr. Conover has this prestocked trauma kit.

Pelvic Binder

Dr. Conover actually carries a pelvic binder in his trunk as well (no comment), he stocks the SAM II Pelvic Splint.

Other Crucial Links

* SAR Gear

* Wilderness Medical Kit

* Dr. Conover's Full File Repository

Update - Stuff EMCrit Likes

The folks at microbvm

sent me their pocketbvm

Here is one of my favorite segments from the 2014 EMCrit/ISMMS Conference. My chair Dr. Andy Jagoda debates my friend Dr. Anand Swaminathan.

The debate seemed relevant because ACEP, a major US emergency medicine organization, released clinical guidelines markedly increasing stress on thrombolysing stroke. These clinical guidelines were sent back by ACEP's council for further commentary and assessment, a move unprecedented in the history of the organization.

ACEP Clinical Guidelines from 2013

Pro Side

Dr. Jagoda took the Pro stance.

Here are his slides

Con Side

Dr. Swaminathan took the con stance. Check out his site, EM Lyceum for more FOAM goodness.

Here is his slideset

Now on to the Podcast...

All the way back on Podcast 21, I advocated for better post-intubation sedation in the ED. Well, now it turns out that if you are still using just lorazepam and vecuronium you are now even further from the ideal.

It is all about Sleep and Orientation

Bad sedation strategies destroy sleep architecture and orientation, then patients become crazy.

Delirium=Death

* The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med 2001; 27:1892–1900

* Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291:1753–1762

* Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med 2009; 35:1276–1280

* Delirium leads to long-term cognitive impairment (N Engl J Med 2013; 369:1306-1316) HT to @icudelirium

* Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med 2009; 180:1092–1097

* Deep sedation associated with higher mortality (Critical Care 2015, 19:197 )

It doesn't matter if we screw it up Downstairs, they can Fix it in the ICU

Ummm, not so much if you believe the SPICE Study-In 251 critically ill patients at multiple centers, we identified deep sedation within 4 hours of commencing ventilation as an independent negative predictor of the time to extubation, hospital death, and 180-day mortality. The early phase of ICU sedation is usually unaccounted for in randomized controlled trials due to late randomization. (Am J Respir Crit Care Med Vol 2012;186(8):724–731)[cite source='doi']10.1164/rccm.201203-0522OC[/cite]

A1 Sedation - Analgesia First

Stick your finger down your throat--now leave it there

Strom et al. evaluated this: RCT of 140 patients-analgesia vs. analgesia+sedation. Analgesia only showed shorter vent time and ICU LOS.[cite source='pubmed']20116842[/cite]

Analgosedation: a paradigm shift in intensive care unit sedation practice,[cite source='doi']10.1345/aph.1Q525[/cite].

Just put patients on a fentanyl drip. If not go with dilaudad IV. When remifentanil is cheap, we'll switch to that in a bunch of patient categories.[cite]15329588[/cite]

Then evaluate pain and decide if the patient needs additional pushes of pain meds.

Consider using the Behavioral Pain Scale (Crit Care Med 2001;29(12):2258) HT to Nikolay Yusupov

Myth - We can prevent PTSD if we Black Out the ICU Experience

just the other way around

Myth - Benzos are just Swell

Not so much-Benzos lead to longer length of stay, longer vent time, and increased delirium.

Benzodiazepine versus nonbenzodiazepine-based sedation for mechanically ventilated, critically ill adults: a systematic review and meta-analysis of randomized trials,[cite source='doi']10.1097/CCM.0b013e3182a16898[/cite].

Myth - Short-Acting Sedatives and Analgesics Go Away Quickly

You need a goal, like RASS

Here is the RASS Scale from the amazing ICU Delirium Site

Myth-Pain is a Great Pressor

Patients should never be undersedated due to hemodynamics

Patient Scenarios

Standard Critically Ill Patients

Fentanyl and Dexmedetomidine (or Propofol)

 

Dan Herr's Method of Dex Titration

Neuro Patients/DTs

Social Media Update

* Use either RSS or the email updates feature (find both on the home page)

* If you have a comment on an EMCrit Podcast or Post, please put it on the blogpost on emcrit.org

* If you have something pithy to say, use twitter

* If you have a case or a question unrelated to an EMCrit Podcast or Post, use Google Plus or post to the FOAMcc Google Community

* If you like being screwed and having your information manipulated, use Facebook

 

Best of 2013

Blogs

* Expensive Care Blog by David Anderson? (See Own The Bronchial Blocker, Rent The Double Lumen Tube)

* Resus Review Blog by Charles Bruen (See the tPA Mixing Tutorial)

* Scancrit Blog by Thomas and K (See Central vs. Peripheral Pressure)

* The Short Coat Blog by Lauren Westafer (See Metacognition for the Pragmatist )

* Emnerd Blog by Rory Spiegel (See The Adventure of the Speckled Band)

Niche Sites

* Closing the Gap by Brian Lin (See the Running Subcuicular Suture)

Podcasts

* Maryland CC Project by John Greenwood, Jim Lantry, and Michael McCurdy (See Changing the Face of Massive Transfusion)

* SGEM Podcast by Ken Milne (See Should I Stay or Should I Go (Biphasic Anaphylactic Response)

Social Media Guidelines

* Health on the Net HONcode Principles

* Time for a FOAM Charter

Previous Year's Best ofs

* Sexy Six for 2014

* Natural 7 for 2012

* Hard Six for 2011

* Dirty Dozen for 2010

A Product I Recommend

Toxicology-in-a-Box

by Brian Kloss and Travis Bruce

Happy Solstice Everyone!

I've been waiting for this one for a long time. I get to interview Dr. Stephen Bernard on the topic of post-arrest care.

 

Professor Stephen Bernard

Senior Intensivist, The Alfred Hospital

Professor Stephen Bernard is a senior Intensive Care Physician at the Alfred Hospital and Director of Intensive Care at Knox Private Hospital in Victoria, Australia. He is also Medical Advisor to Ambulance Victoria.

 

Last Week, I posted Part I of this interview on Post-Arrest Care 2013

This is Part II.

My discussion with Dr. Bernard was based on a talk he gave at the Australasian College for Emergency Medicine

Photo by Brian Burns

MAP Goals

SBP of 120 mm hg? The paper was just published ahead-of-print

The other paper Dr. Bernard Mentioned is Gaieski et al. (Resuscitation 2007;73:29-39)

Sedate

If cooling to 36, it is a lot easier to get away with standard sedation practice as the hypothermia-slowed metabolism is no longer a big problem

Cath lab with ECMO or LUCAS2 for refractory arrest

It can be done! And if we can do it, is "stay-and-play" on scene still a good strategy?

CHEER trial (CPR, Hypothermia, ECMO and Early Reperfusion)

CHEER Trial Protocol

15 F arterial cath and a 17-19 F venous catheter under ultrasound guidance, with the only pause during compressions being the initial vessel puncture and 1st wire advancement

Intraarrest Hypothermia?

The animal data look good, but need human trials that show benefit. If you do it, then these patients may need a deeper degree of hypothermia (33 C?).

Prehospital Hypothermia and is Quicker Better?

Dr. Bernard's trial did not show benefit for prehospital cooling [cite source='pubmed']20679551[/cite]

and the in-press study by Kim et al. showed the same [cite source='pubmed']24240712[/cite]

More from Steve can be found at the EDECMO Podcast Site

Now, on to the Podcast...

I've been waiting for this one for a long time. I got to interview Dr. Stephen Bernard on the topic of post-cardiac arrest care.

Professor Stephen Bernard

Professor Stephen Bernard is a senior intensivist at the Alfred Hospital and Director of Intensive Care at Knox Private Hospital in Victoria, Australia. He is also Medical Advisor to Ambulance Victoria. Dr. Bernard was the lead author on one of the original establishing studies for post-arrest temperature management.

 

My discussion with Dr. Bernard was based on a talk he gave at the Australasian College for Emergency Medicine

Photo by Brian Burns

Maintain 36 C for 24 Hours

Dr. Bernard and the Alfred Hospital in Australia are moving to the protocol outlined in the TTM trial

Is there anyone who still deserves to be cooled to 33 C?

Dr. Bernard feels patients that get intra-arrest cooling may still benefit until we have further trial results.

Neuro-Prognosticate as per the protocol in the Nielsen trial

Chris Nickson summarized the Neuro-Prognostication Protocol wonderfully

Time Zero Prognostication

It is tough. Unwitnessed asystole is probably one situation in which you can choose a palliative route if the situation otherwise supports it.

Pt should be taken to a 24/7 cardiac interventional center

This doesn't necessarily mean the patient needs to go to the lab immediately, they just need to be able to go when needed

Lower FiO2

Maintain an SpO2/SaO2 between 90-95%

Normal PaCO2

No hypocapnea, Perhaps slight hypercapnea

Tune in Next Week for Part II of the Interview

More on the TTM Trial

* My initial Wee

* A quick interview with Jon Rittenberger

The Thoughts of Others

https://twitter.com/JAMyburgh/statuses/402940221630603264

https://twitter.com/JAMyburgh/statuses/403351251791781888

More from Steve can be found at the EDECMO Podcast Site

Now, on to the Podcast...

Last week I posted a lecture an incredible by Paul Marik on Fluid Management in severe sepsis. The lecture is the equivalent of a bucket of ice water poured over your head. Now let's give you a towel and discuss.

Want to add a journal club to this flipped classroom?

Then read these pieces in Critical Care:

* Bellomo on Norepinephrine and the Kidney

* Rethinking Resus Goals by Dunser

* Response: Rethinking Resus Goals by Marik and Bellomo

* Pharmacodynamic Analysis of a Fluid Challenge (Crit Care Med 2016;44:880)

The Low-Fluid Volume Early Pressor Experiment has Already Been Tried

It was called standard care 15-20 years ago--patients did not do all that well.

Should we Increase DO2?

We know from that shooting for supranormal DO2 is actually harmful. The original goal-directed therapy trials did not pan out and this may be why.

There is definitely a group of Severe Sepsis patients that are receiving inadequate oxygen delivery. I have treated these patients; I have documented ScvO2s in the 50's and 60's on initial check in a EGDT-type algorithm.

Far more commonly, patients are in pure vasodilatory shock (Jones' trial patients). The latter fact doesn't disprove the former. Using the studies demonstrating the deleterious effects of shooting for above normal delivery doesn't say anything about normalizing patients with low delivery.

Marik's Goals

* Achieve adequate perfusion pressure

* Improve microcirculatory flow

* Limit Tissue Edema

All right on point; how do we get there is the question.

Rivers Trial as a Waterfall?

This is not actually what that trial showed. And the way CVP was used was not actually debunked by the 7 mares article (Note: I'm not advocating you use CVP, I'm just pointing this out! We have better ways to accomplish assessing fluid responsiveness so CVP should be sent to the junk bin)

I will make the utterly blasphemous statement that Dr. Rivers and Dr. Marik are actually in near-complete agreement if you followed both of their protocols explicitly in the ED.

MAP and Association to Survival

Not sure what this is proving: both groups (the flow-optimizers and the desert-inducers) believe in shooting for MAP goals. Patients in whom it is impossible to get the MAP up will die more frequently.

But is it Flow or Pressure that Matters?

I must say, I am still in the tissue flow camp

On to the Glycocalyx

Now this is where stuff gets really interesting. Every day, there is increasing research and more publications on the fundamental role of the vascular glycocalyx. But how do we integrate this clinically?

Chris Nickson tweeted this amazing lecture from Rob Wise. It will explain the Glycocalyx in 5 minutes. It lives on Life in the Fast Lane.

 

Now as to its relation to fluids in sepsis, we are being told hypervolemia is bad. But if the fluids are leaking from the vascular space are we ever seeing hypervolemia in the vasculature or is the problem whole body volume overload--not if we believe BNP/ANP are the root of the problem, they only respond to vasculature fluids. If we are doing a fluid responsiveness strategy, we should not be seeing the vascular overload.

Do balanced vs.

Just posted a wee on the game-changing TTM Trial

Managed to get Jon Rittenberger, MD on the line to discuss the implications. Jon wrote the editorial that accompanied the TTM trial and he is an accomplished Resuscitationist and a clinical leader for the U. Pitt post-arrest management team.

Here are Jon's thoughts on what we should do with this trial tomorrow. I add my own opinion at the end. In the next couple of weeks, you'll hear from Stephen Bernard to get his take on the study.

The 2nd article mentioned by Jon is this one:

Kim, F et al. Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac Arrest A Randomized Clinical Trial JAMA 2013

Prehospital hypothermia in this study and the Bernard trial has not seemed to pan out. Intra-arrest is still in play however.

My Take as of Now

* In the setting of advanced post-arrest care, active temperature management, and protocolized neuro-prognostication; the TTM trial demonstrated no significant outcome difference or trend towards outcome difference when patients were cooled to either 33 or 36C

* Hemodynamics were poorer in the 33C group (This was not mismatching, SOFA-C same on day 1 and much worse in 33C group on day 3; this was a secondary outcome and therefore the study can't demonstrate if this was a significant finding) [Table S2 Supplement]

* Complications were less frequent in the 36C group

* A majority of patients are probably best managed at or near 36C

* In the neurocritical care literature, 35C seems to offer moderation of intracranial pressure

* At Janus General, we will target a temperature range between 35-36C for our V-fib, V-tach, and PEA patients in whom we are pursuing an aggressive treatment path

* Unwitnessed asystolic arrest patients were left out of the HACA, Bernard, and TTM trial. In this group there is little guidance and it may be reasonable to continue cooling to 33C as this group is most likely to have the most severe post-arrest neurologic injury.

Interview with the Lead Author of Trial from the ICN

Matt MacPartlin interviewed Niklas Nielsen, the author of TTM. He is joined by Anders Aneman, one of the local site investigators to discuss this game-changing study.

Other Thoughts

See this great post from the folks at the Intensive Care Network as well.

The folks at St. Emlyn's offer a  more cautious approach.

Updates

JAAM-OHCA TTM Trial

Now on to the Wee...

The TTM Trial was just published today in the NEJM (Nielsen et al. Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest NEJM 2013;epub Nov 17, 2013)

For my take and the take of Jon Rittenberger, come to the 2nd TTM Post

but even more important is to hear from the primary author himself: Niklas Nielsen on the TTM Trial

Study Design

International multicenter RCT

Inclusion criteria: Age >= 18 years, out-of-hospital cardiac arrest of presumed cardiac cause, unconsciousness (Glasgow Coma Score <8) after sustained return of spontaneous circulation (ROSC) (20 minutes of circulation).

Exclusion criteria: Conscious patients, pregnancy , out-of-hospital cardiac arrest of presumed non-cardiac cause, cardiac arrest after arrival in hospital, known bleeding diathesis, suspected or confirmed acute intracranial bleeding, suspected or confirmed acute stroke, temperature on admission <30°C, unwitnessed asystole, persistent cardiogenic shock, known limitations in therapy, known disease making 180 day survival unlikely, known pre-arrest cerebral performance category 3 or 4, >240 minutes from ROSC to randomisation.

Primary outcome: Survival to end of trial (at least 180 days).

Secondary outcomes: Composite outcomes of all-cause mortality and poor neurological function (Cerebral Performance Category (CPC) 3 and 4 and modified Rankin Scale (mRS) 4 and 5) at 180 days. All - cause mortality and CPC and mR S at 180 - days. Adverse events: Bleeding, pneumonia, sepsis, electrolyte disorders, hyperglycaemia, hypoglycaemia, cardiac arrhythmia, renal replacement therapy.

Tertiary outcomes: Complete neurological recovery. Best neurological outcome during trial perio d. Quality of life according to SF - 36. Biomarkers at 24, 48 and 72 hours

Intervention: The core body temperature will be set as quickly as possible at the predefined target temperature, according to intervention allocation, with 4°C intravenous solutions, 43 ice - packs 8, 44 and commercially available cooling devices 45 at the discretion of the treating physician . The target core temperature is then maintained for 24 h. After the maintenance period core temperature is gradually raised to normothermia of 37°C during 8 hours with a rewarming rate of 0.5°C/hour in both groups. Body temperature is then maintained at normothermia 37 ±0.5°C until 72 hours from sustained ROSC in both treatment groups, as long as the patient is in the ICU, using pharmacological treatment and temperature management systems when applicable

See all of the nitty-gritty in the appendix

rewarmed at 0.5 C/hr and then induced normothermia (37.5 C) for 36 hrs post arrest

Nonblinded to temp allocation, but neuro assessment was blinded

fluids icepacks surface and intravasc cooling-- 1/4 intravasc and rest surface

900 pts give 90% power to detect 20% difference

80% shockable, 12% asystole

Table S2 - SOFA-C Scores in the first 72 hours

*SOFA denotes Sequential Organ Failure Assessment, SOFA-C denotes the cardiovascular subcomponent of the SOFA score. SOFA-C=0 No need for inotrope or vasopressor, mean arterial pressure (MAP) > 70mmHg, SOFA-C =1 MAP < 70mmHg, SOFA-C=2 any dose of dobutamine or dopamine <5 ìg/kg/minute,