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This was my favorite lecture assigned to me at SMACC 2013. It discusses the search for excellence in our profession. I hope you enjoy!

Knowledge

Full list of journals I read

The Pareto Reduction to 12 for EM Critical Care

* Ann Emerg Med - Acad Emerg Med

* Am J Emerg Med

* Emerg Med J

* Br J Anaesth

* Anesthesiology

* Anesth & Analg

* Resuscitation

* J Trauma

* Crit Care Med

* Crit Care

* Intens Care Med

Insight comes from Knowledge (Psychol Sci. 2006 Oct;17(10):882-90). The prepared mind: neural activity prior to problem presentation predicts subsequent solution by sudden insight.)

More

* Mastery by Robert Greene

* Pragmatic Thinking by Andy Hunt

* Reading non-clinically is just as important to become an excellent physician and person, so go listen to Michelle Johnston's lessons from the classics lecture

* The 10,000 hour rule is essentially bullshit

* Mastery on the Doist Blog

Procedures

More

* Siamak Moayedi has one of the best lectures on procedural knowledge. The lecture is now available in video form as well

Critical Thinking

Rhetological Fallacies

I have a copy of this poster in both of my offices

PSYBlogs List of Cognitive Biases

If you don't know them, you are probably committing them

More

Mastermind by Maria Konnokova

Thinking Fast and Slow by Kahneman

Potholes

Dunning-Kruger Effect

* Kruger J, Dunning D. Unskilled and Unaware of It: How Difficulties in Recognizing One's Own Incompetence Lead to Inflated Self-Assessments. Journal of Personality and Social Psychology 1999;77(6):1121.

* Dunning D, Johnson K, Ehrlinger J. Why people fail to recognize their own incompetence. Current Directions in 2003 Jan.;Available from: http://cdp.sagepub.com/content/12/3/83.short

* Caputo D, Dunning D. What you don't know: The role played by errors of omission in imperfect self-assessments [Internet]. Journal of Experimental Social Psychology 2005 Jan.;Available from:

* Carter T, Dunning D.

The Airway Moratorium is Over!

In this podcast I talk about how not to kill the shocked/hypotensive patient in the peri-intubation. I gave this talk at SMACC 2013.

This lecture is part of the Laryngoscope as a Murder Weapon Series:

* Hemodynamic Kills

* Oxygenation Kills

* Ventilatory Kills

Eleni Salakidou's SmaccBYTE Entry

Nickson's Hierarchy of Resus Airway Needs

Literature

Best Review Article

Anaesthesia 2009;64:532

STC Review Article

Curr Anesthesiol Rep 2014;4:225

Hypotension in the peri-intubation is bad and is a source of mortality

Hemodynamically unstable or on pressors prior to intubation is the biggest factor assoc. with death and complications. (Schwartz et al. Anesthesiology 1995;82:367)

Heffner et al. J Crit Care 2012 Aug;27(4):417

Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department. (PMID 25402500)

Etomidate

Etomidate is probably safe in moderately shocked patients (Acad Emerg Med 2006;13:378)

Etomidate can definitely drop Blood Pressure (Crit Care 2012;16:R224)

Ketamine

Ketamine given to patients with horrible ejection fractions (Thangathurai et al.; Anesth 1988;69(3a):A79), in OR anesthetized pts (Prakt Anaesth. 1976 Dec;11(6):397-404) and In-Vitro human-tissue studies show Ketamine to be least cardio-depressant (Anesthesiology 1996;84:397). Another anesthesia study showed no drop from initial values after large and repeated doses (Br J Anaesth 1976;48:1071)

Best study, reasonable doses (CCM 1983;11(9):730) showed excellent stability

A further anesthesia study (Anesth and Analg 1980;58(5):355) 1/12 patients dropped HR with no effect on CI.

Cats did fine (Canad Anesth Soc J 1975;22(3):339). However if you give 10-100-fold doses to canine heart tissue then maybe (J Cardiovasc Pharmacol 1986;8:414) and (Anesthesiology 1992;76:564), in the latter, dogs got infusions at 25-100 mg/kg/hr.

Case report of 2 arrests post-ketamine (J Inten Care Med 2012; Dewhirst et al.)

Ketamine in ICP (Emerg med australia 2006;18(1):37-44)

Two RCTs of etomidate vs. ketamine showed both are equally hemodynamically stable, but this was full dose ketamine (Am J Emerg Med 2013;31:1124 and Lancet. 2009 Jul 25;374(9686):293-300). Middle dose may be even better.

Paralytics

Anesth Analg. 2000 Jan;90(1):175-9.

Other References Reviewed

Other Papers

Intubation in the Shocked Patient

Nickson's Pyramid

courtesy of Chris Nickson

Want the Slides

Slides for Hemodynamic Kills Lecture

Need the Audio-Only Format?

Right Click Here and Choose Save-as

New Study in JAMA:

JAMA. 2013 Jul 17;310(3):270-9. doi: 10.1001/jama.2013.7832.

Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial

Mentzelopoulos SD, Malachias S, Chamos C, Konstantopoulos D, Ntaidou T, Papastylianou A, Kolliantzaki I, Theodoridi M, Ischaki H, Makris D, Zakynthinos E, Zintzaras E, Sourlas S, Aloizos S, Zakynthinos SG.

Source  First Department of Intensive Care Medicine, University of Athens Medical School, Athens, Greece. [email protected]

Abstract

IMPORTANCE:  Among patients with cardiac arrest, preliminary data have shown improved return of spontaneous circulation and survival to hospital discharge with the vasopressin-steroids-epinephrine (VSE) combination.

OBJECTIVE:  To determine whether combined vasopressin-epinephrine during cardiopulmonary resuscitation (CPR) and corticosteroid supplementation during and after CPR improve survival to hospital discharge with a Cerebral Performance Category (CPC) score of 1 or 2 in vasopressor-requiring, in-hospital cardiac arrest.

DESIGN, SETTING, AND PARTICIPANTS:  Randomized, double-blind, placebo-controlled, parallel-group trial performed from September 1, 2008, to October 1, 2010, in 3 Greek tertiary care centers (2400 beds) with 268 consecutive patients with cardiac arrest requiring epinephrine according to resuscitation guidelines (from 364 patients assessed for eligibility).

INTERVENTIONS:  Patients received either vasopressin (20 IU/CPR cycle) plus epinephrine (1 mg/CPR cycle; cycle duration approximately 3 minutes) (VSE group, n?=?130) or saline placebo plus epinephrine (1 mg/CPR cycle; cycle duration approximately 3 minutes) (control group, n?=?138) for the first 5 CPR cycles after randomization, followed by additional epinephrine if needed. During the first CPR cycle after randomization, patients in the VSE group received methylprednisolone (40 mg) and patients in the control group received saline placebo. Shock after resuscitation was treated with stress-dose hydrocortisone (300 mg daily for 7 days maximum and gradual taper) (VSE group, n?=?76) or saline placebo (control group, n?=?73).

MAIN OUTCOMES AND MEASURES:  Return of spontaneous circulation (ROSC) for 20 minutes or longer and survival to hospital discharge with a CPC score of 1 or 2. RESULTS:  Follow-up was completed in all resuscitated patients. Patients in the VSE group vs patients in the control group had higher probability for ROSC of 20 minutes or longer (109/130 [83.9%] vs 91/138 [65.9%]; odds ratio [OR], 2.98; 95% CI, 1.39-6.40; P?=?.005) and survival to hospital discharge with CPC score of 1 or 2 (18/130 [13.9%] vs 7/138 [5.1%]; OR, 3.28; 95% CI, 1.17-9.20; P?=?.02). Patients in the VSE group with postresuscitation shock vs corresponding patients in the control group had higher probability for survival to hospital discharge with CPC scores of 1 or 2 (16/76 [21.1%] vs 6/73 [8.2%]; OR, 3.74; 95% CI, 1.20-11.62; P?=?.02), improved hemodynamics and central venous oxygen saturation, and less organ dysfunction. Adverse event rates were similar in the 2 groups.

CONCLUSION AND RELEVANCE:  Among patients with cardiac arrest requiring vasopressors, combined vasopressin-epinephrine and methylprednisolone during CPR and stress-dose hydrocortisone in postresuscitation shock, compared with epinephrine/saline placebo, resulted in improved survival to hospital discharge with favorable neurological status.

Justin Bowra gave a fantastic lecture on the use of IVC ultrasound at SMACC.

Here is the audio, if you want to hear the original lecture:

There was a post on Life in the Fast Lane by Justin as well.

His slides from the talk are here:

Now let's get to the SMACCing back...

I agree with 90% of Justin's talk, but as to the other 10%:

D-Dimer????

Mech Ventilated Patients

Collapse???

Diagnosis of Undifferentiated Shock

Quick look at size and collapsibility gives huge amounts of information

Fluid Responsiveness

Need a strategy for Spontaneously Breathing Patients

* Go bronze and give a bunch of fluid until you feel slightly uncomfortable

* Then go for the silver and resus until IVC starts to lose easily discernible collapse (20-30%)

* If you want to be really cool, at this point go for the gold-use some marker of stroke volume to see if additional fluid will be of benefit (either with empiric add. bolus or passive leg raise). If you want to be lazy, just put them on some norepi at this point.

Now if you use this strategy, you need to look at the operator receiver thingy-me-bobs [sic]

Spont. breathing IVC-CI trials fail due to the misfounded desire for dichotomy.

Lanspa

(Lanspa M et al. Shock 2013. 39(2). pp. 155-160)

Muller

(Muller L et al. Critical Care 2012, 16:R188)

This makes sense as respiratory-dynamic CVP demonstrates the same thing (Shock 2006;26(2):140)

Confounders:

Splint IVC open-Tamponade, Tension PTX, Massive PE, Status Asthmaticus, Right heart disease

Don't sniff test, don't tell the pt to do weird abdominal yoga breathing

Fluid Tolerance

IVCCI 15% had good accuracy (92% sens/84% spec) for CHF (Blehar et al. The American Journal of Emergency Medicine 2009;27(1):71)

and (Miller at al. Am J Emerg Med 2012;30:778) showed similar text characteristics.

by all means add in the Lichtenstein Lung Ultrasound, but only if negative when you start

We need more and better Studies

* Get a bunch of sick patients

* Do an IVCCI with a cut off of something like 30%

* Give fluid (500-1000 ml crystalloid)

* See if there was a 15% increase in SVi with a REAL cardiac output monitor or skilled evaluation of LV VTI

* AND

* see if there was a >5 mm Hg increase in arterial line MAP

and now on to the SMACC Down...

A few weeks ago, I interviewed Bryan Hayes, the Pharm ER Tox Guy, on the subject of avoiding medication errors during resuscitation. That was Part I; today we move on to Part II.

Bryan is a pharmacist with a fellowship in toxicology. He tweets as PharmERToxGuy and blogs at Academic Life in EM.

Insulin Drip Preparation

Flush 20- 50 cc of Insulin/NS drip through all IV tubing, before infusion begins (to saturate the insulin binding sites in the tubing) [UMD's protocol + Yale's]... Goldberg PA, et al. Diabetes Technol Ther 2006;8(5):598-601.

This article states you must prime 20 ml from a 100 ml bag containing Regular Insulin 1 unit/mL (Crit Care Med 2012;40(12):3266)

Nalaxone Dosing

 big doses are out, smaller doses are in.

I use 0.4 mg diluted in 10 ml of saline to yield 0.04 mg/ml. Give 1-2 ml at a time. If you think this is an opioid, but that amount didn't work, keep going--some overdoses require a ton of nalaxone

Hydromorphone

Hydromorphone dosing - why are our residents scared to give more than 4 mg of morphine, but have no problem giving 1 mg of hydromorphone (equal to 7 mg of morphine)?

Hydralazine

Hydralazine and its erratic blood pressure lowering in hypertensive emergency

Infusion Deadspace can delay drug initiation

Deadspace when initiating infusions on low ml/hr drips: this may result in an hour between initiation and drug reaching bloodstream. Should we infuse into flowing line? Draw up and inject until it hits vein?

(Anaesthesia 2013;68:640)

This article (Emerg Med J 2007;24:558–559) discusses the perils of ignoring deadspace for infusions

Syringe Labeling

Importance of labeling syringes properly

Should be Generic Drug Name and then concentration based contents (e.g. Succinylcholine 20 mg/ml)

(Br. J. Anaesth 2013;110:1056.)

Top Ten Drug Error Commandments (Abridged for ED Relevan ce)

* Never inject a drug from a non-labelled syringe

* Never inject a drug that you are not familiar with

* Keep all empty vials until you conclude resuscitation

* Whoever injects the drug is responsible for the drug

(Anaesthesia 2013;68:640)

and I would add a 5th

* Show the vial with the syringe you just mixed to whomever will be injecting

EMS Educast has a great podcast on human factors in medication errors

I've wanted to discuss tips and pitfalls for the FAST exam for a while now, but I needed a master to talk with. Luckily at Castlefest, I met Laleh Gharahbaghian, MD. She is the Ultrasound Director at Stanford's Dept. of Emergency Medicine as well as being too cool for school. She is also FOAMY with what I think is the best blog on all things point-of-care ultrasound: sonospot.com.

Sonospot Posts on the FAST

I was going to write up comprehensive show notes for this episode, but thankfully Laleh published a post that encompasses EVERYTHING we we spoke about. So go read the ultimate blogpost on the FAST exam.

The Right-Upper Quadrant

* SonoTutorial: The FAST Part 1: The right upper quadrant – the right way to do it

* SonoTutorial: The FAST Part 1a: The Right Upper Quadrant: Images That Could Fool You

* SonoTutorial: The FAST Part 1b: The Right Upper Quadrant: More images that could fool you

* Optimizing RUQ images

Update: Here is the article on Trendelenburg for Optimal RUQ (Am J Emerg Med 1999;17(2):118)

The Left-Upper Quadrant

* The FAST Part 2: Left Upper Quadrant

* SonoTutorial: The FAST Part 2a: Left Upper Quadrant – Images that could fool you…

* SonoTutorial: The FAST Part 2b: Left Upper Quadrant – More images that could fool you

The Pelvic View

* Sonospot will have a post on this coming up soon

The Heart

* SonoTips & Tricks: The FAST scan: The Cardiac views #FOAMed

* SonoTip&Trick: “I can’t tell if it’s a pleural or pericardial effusion.” Really? well here’s a tip

Pneumothorax

Laleh's post on a large pneumothorax trial

FAST is Specific for IntraABD Hemorrhage

J Trauma 2020;90(1):137

Why do we mess up the exam?

Laselle et al. published on why false-negative FASTs occurred [Ann Emerg Med 2012;60:326]. See this wonderful post from the Sonospot blog on the Laselle article and fals...

One of the best lectures from SMACC 2013 was Dr. John Myburgh on Catecholamines.

 

Here is the Video Version of the Lecture:

Or you can listen to the audio on the SMACC Feed or in Itunes

Now on to the SMACC-Back...

 

Bryan Hayes

Today I am lucky to have the opportunity to interview Bryan Hayes, the Pharm ER Tox Guy, on the subject of avoiding medication errors in the ED. Bryan is a pharmacist with a fellowship in toxicology. He tweets as PharmERToxGuy and blogs at Academic Life in EM.

Medication Errors during Resuscitations

* It is extremely easy to make errors during resuscitations. (Resuscitation 2012;83(4):482-7) Also, read the review by EMLitofNote

* Pharms in the ED may help (Ann Emerg Med 2010;55(6):513-21)

* Boarding Patients and Temp Nurses may make things worse (Ann Emerg Med 2010;55(6):522-6 and ( J Healthc Qual 2011;33(4):9-18)

* Excellent post on code medication error prevention

High-Risk Drugs

Bryan mentioned the PINCH acronym

Potassium, Insulin, Narcotics, Chemotherapy Agents, and Heparin

TPA dosing in stroke and PE

High stress and low use make this drug error-prone

The Resus Review wrote up tPA mixing instructions

The Drip Sheet Project

No calculators or mental math should ever be involved with Resus medication administration. Our drip sheet project attempts to prevent this. These sheets are printed out for mixing and then taped to the infusion pumps.

My tPA Drip sheet for acute stroke and PE

Here is Bryan's TPA Sheet as well:

EPINEPHrine

The root of all evil for drug errors!

Great article from the Nursing Literature (J Emerg Nurs 2013;39:151)

* Why the ridiculous dilution-dosing notation?

* Should we have multiple concentrations?

* Should we be giving IM dosing?

Are Epipens the Solution?

Bryan had an error where a 1 mg dose was given IV for anaphylaxis. Patient developed ECG changes and troponin leak. He removed the 1 mg/mL vials and replaced them with the much more expensive EPIpens. Other solutions: premade pharmacy IM Syringes or just dispense with IM and give IV infusion for all patients.

Kanwar M. Ann Emerg Med 2010;55(4):341-4

Why are premix bags not readily available everywhere? - Bryan outsources for 6.25mg in D5W 250ml (25mcg/ml) and 2mg in D5W 250ml (6mcg/ml)

Insulin Issues

HyperK

What is the proper accompanying dose of D50 when giving insulin IVP for hyperkalemia?

- 10 units of regular insulin in 500 mL of 10 percent dextrose, given over 60 minutes.

- 10 units of regular insulin bolus, followed immediately by 50 mL of 50 percent dextrose (25 g of glucose) is inadequate! This regimen may provide a greater reduction in serum potassium since the potassium-lowering effect is greater at the higher insulin concentrations attained with bolus therapy. However, hypoglycemia occurs in up to 75 percent of patients treated with the bolus regimen, typically about one hour after the infusion. To avoid this complication, infuse 10 percent dextrose at 50 to 75 mL/hour or give 2 amps of D50 (50 grams) and ensure close monitoring of blood glucose levels.

Update: One of the commenters below asked for a reference for the up to 75% statistic. Took some time to track it down,

Thanks for joining me on the wild ride of these first 100 episodes!

This was the opening lecture of SMACC 2013. Chris Nickson assigned me the lecture: What is the essence of critical care? In ruminating on that topic what I really came to is the essence of this blog and podcast. The video is here:

but I think I agree with Brother Minh that it works even better as a podcast.

Now on to the Podcast...

A listener, Øyvind S Holen, and the PrecordialThumper both alerted me to an article recently published by Paul Marik and Rinaldo Bellomo:

Lactate clearance as a target of therapy in sepsis: a flawed paradigm

In the paper, they discuss many of the misunderstandings re: lactate and lactate clearance. This wee is my response. I'd love to hear your opinions.

Update

New article on the Kinetics of Lactate Clearance

Now on to the Wee...