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Dr. Paul Marik is a renowned intensivist and a confirmed critical care skeptic. He has broken down many myths such as the use of CVP for volume assessment. I recorded a lecture he gave to the Sepsis Collaborative I co-chair. It is an amazing lecture.

I agree with some of it and have quibbles with other parts, but it is a must-listen. In one week, I will publish a wee with the areas I see differently; in the interim think about your own viewpoint so that we can discuss it all in the comments.

Dr. Marik's Previous Visits to EMCrit

* CVP and Fluid Assessment

* Maybe Groin Lines Aren't that Bad

Dr. Marik's Updated Hemodynamic Management Flowsheet

 

Now on to the Podcast...

Now I should be doing a SMACC Back on Roger Harris' talk on the Right Heart as he surely cast a gauntlet in my path, but that would probably just encourage him : ). Instead, lets talk about...

Simon Carley on Educational Leadership and Subversion

This SMACC-Back deals with Simon Carley's lecture from SMACC 2013. If you haven't seen it yet, watch now--it is incredibly good:

The line that resonated with me was,

The first principle of Leadership is Excellence. The most important thing for an educational leader is that they are clinically credible. "Those that can't do--teach," is crap in medicine.

So utterly true!

 

Tangentially, one of my colleagues recommended a book to me entitled, Multipliers: How the Best Leaders Make Everyone Smarter.

Wow, what a horribly misguided tome. To hear why I think this, listen to the wee.

Get your SMACC 2014 Abstracts in ASAP

The closing date for abstracts for SMACC is Friday the 22nd of November

Be part of the action!

Submit here.

Now on to the SMACC Back...

Just got back from Toronto, where I learned about Chubby Bunny.

Chubby Bunny by Derby

But what we are actually going to talk about today is the management of Severe Hemorrhage from Mid-Face Blunt Trauma

Algorithm

Ann Plast Surg 2012;69:474

Take the Airway

Suction-as-you-go ETT Set-up

Partner Suction a la Strayer

These airways are all Cricon 3

Anterior Packing

I use Rapid-Rhino 5.5 cm but you go with whatever you are comfortable with. Soak it in STERILE WATER, not saline despite what i blathered in the audio (Thanks Brent!)

Posterior Packing

We use foleys in preference to commercial devices for standard epistaxis. This series explains why: (Injury. 2003 Dec;34(12):901-7. Complications with use of the Epistat in the arrest of midfacial haemorrhage.)

Use 12 - 14F (or whatever you got)

Witness passage into the posterior pharynx from both foleys with laryngoscope

Inflate a smaller volume first (6-8 mL) and then apply traction until it wedges, this allows the balloon to wedge in the posterior choana

Inflate to 20 ml

Apply traction

I use the system at the end of this video on Blakemore Passage

Reapply the anterior packs bilaterally

Temporary Fracture Fixation

Image from Injury  Volume 34, Issue 12, December 2003, Pages 901–907 Holmes et al. From that article, "When there is a mid-palatal split, however, this haemostatic technique will possibly fail and additional measures will be required to achieve haemostasis. The split palate should be stabilised with a transpalatal circumdental wire , before placing packing."

Angiography

IR of the internal maxillary is usually what is needed

May also be branches of ethmoidal in skull base fx

TXA for Epistaxis

EM Lit of Note's Review

McKesson Oral Prop?

EMJ 2010; 27 :156 e 158. doi:10.1136/emj.2008.070219

Anyone know about this? Comment in the show notes.

Additional References

* Case Discussion (Ann Plast Surg 2--1;46:159)

* Case Series on IR (J Trauma 2003;55:74)

* Another Case Series on Management (J Trauma 2008;65:994)

*  A Decade's experience with balloon tamponade fro traumatic hemorrhage (The Journal of Trauma: Injury, Infection, and Critical Care Issue: Volume 70(2), February 2011, pp 330-333)

We discuss the management of asymptomatic markedly elevated blood pressure as evaluated by the ACEP Clinical Policies Committee in Sept 2013.

The Policy

ACEP Management of Asymptomatic HTN 2013

The Questions and the Recs

In ED patients with asymptomatic elevated blood pressure, does screening for target organ injury reduce rates of adverse outcomes?

Patient Management Recommendations

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations.

* In ED patients with asymptomatic markedly elevated blood pressure, routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) is not required.

* In select patient populations (eg, poor follow-up), screening for an elevated serum creatinine level may identify kidney injury that affects disposition (eg, hospital admission).

 

In patients with asymptomatic markedly elevated blood pressure, does ED medical intervention reduce rates of adverse outcomes?

Patient Management Recommendations

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations.

* In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required.

* In select patient populations (eg, poor follow-up), emergency physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control. [Consensus recommendation]

* Patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up. [Consensus recommendation]

What is EMCrit Drinking?

Now on to the Podcast...

 

This lecture was from the final day of SMACC 2013. It was based on a case I saw at Janus General Hospital.

[vimeo 76743429 w=620]

Blakemore Placement

In the lecture I talk about a life-saving Blakemore Tube placement. I suspect some of you may need a reminder of the intricacies of this device, so I made a video and cheat-sheet.

Now on to the Podcast...

 

In recent lectures, I talk about a life-saving Blakemore Tube placement. I suspect some of you may need a reminder of the intricacies of this device, so I made a video and cheat-sheet.

Improved HD Video

Jess Mason took the moves in my original video and had it recorded professionally

Securement using ETAD Device

Jess Mason made this nice video on how to secure the Blakemore

What you need:

* Blakemore

* Salem Sump

* 60 ml Luer-lock Syringe

* 60 ml Slip-tip Syringe

* 2 x-mas tree to male luer lock converters

* 3 three-way stopcocks

* 3 medlock caps

* Surgilube

* Roller-bandage

* 1 1-liter bag of crystalloid

* Optional: 2 Hollister ETAD ET tube securing devices

* Possibly: Laryngoscope, Magill Forceps

Gastric Port

Esophageal Port

 

How to Do it:

* Patient should be intubated and the head of the bed up at 45 degrees.

* Test balloons on Blakemore and fully deflate. Mark salem sump at the 50 cm mark of the Blakemore with the tip 2 cm above gastric balloon and then 2 cm above esophageal balloon.

* Insert the Blakemore tube through the mouth just like an NGT. You may need the aid of the laryngoscope and sometimes McGill forceps. Make sure the depth-marker numbers face the patient’s right-side.

* Stop at 50 cm. Test with slip syringe while auscaltating over stomach and lungs. Inflate gastric port with 50 ml of air or saline.

* Get a chest x-ray to confirm placement of gastric balloon in stomach.

* Inflate with additional 200 ml of air (250 ml total)

* Apply 1 kg of traction using roller bandage and 1 liter IV fluid bag hung over IV pole. Mark the depth at the mouth. The tube will stretch slightly over the next 10 minutes as it warms to body temperature.

* After stretching, the tube may be secured to the ETAD tube holder.

* Insert the salem-sump until the depth marked gastric is at 50 cm on the Blakemore. Suction both Blakemore lavage port and salem sump. You may need to wash blood clots out of the stomach with sterile water or saline.

* If bleeding continues, you will need to inflate esophageal balloon.

* Pull salem sump back until the esoph. mark is at the 50 cm point of the Blakemore. Attach a manometer to the second 3-way stopcock on the esophageal port of the Blakemore. Inflate to 30 mm Hg. If bleeding continues, inflate to 45 mm Hg.

* Consider switching traction to Hollister ETAD Device.

Here is a cheat sheet for Blakemore Placement in PDF Form

How to Build a Simulator

Paper from JEM

Bougie Aided Placement Technique by Whitford

Questions to be answered?

* Can ultrasound obviate the need for radiographic confirmation prior to inflation? One letter to the editor says yes, but the image doesn't seem to confirm anything. (Emerg Med J 2006;23:487)

 

This was my favorite lecture from SMACC 2013. If you are not moved and inspired then your heart is made of stone.

This is a Cliff Reid lecture; if you want more Cliff, see these incredible lectures and podcasts:

* Chicken Bombs and the Muppet Factor

* Mind of the Resuscitation Interviews Part I

* Mind of the Resuscitation Interviews Part II

* Own the Resus Room

I'll post my own final SMACC lecture in 1 week and then we are done with SMACC 2013.

Want the Slides and a Beautiful Blogpost on the Lecture?

Head on over to the post on the Resus.me Site

Need an Audio-Only Version?

Right-Click Here and Choose Save-as

Now on to the Vodcast...

Can we give vasopressors peripherally? And if we do, what if they leak?

I interview Roger Harris about SMACC Gold. Come to smacc.net.au to hear more.

Mind of the Resuscitationist

This was Cliff Reid's opening lecture from SMACC 2013. Cliff Reid runs the amazing Resus.me site and any listener of EMCrit knows that I have an enduring (and purely platonic) love for Cliff and all of his teachings.This lecture was on Making Things Happen and it is my #2 favorite lecture from the conference. My number one favorite was also by Cliff, but you'll have to wait a bit for that one.

Want More Reid?

* Chicken Bombs and the Muppet Factor

* Mind of the Resuscitation Interviews Part I

* Mind of the Resuscitation Interviews Part II

* Own the Resus Room

Want the Slides?

Need an Audio-Only Version?

Right-Click Here and Choose Save-as

Now on to the Vodcast...