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Joe Novak, MD was an F-15 Combat Pilot and now is an Emergency Physician. In this fantastic lecture, he brings the concepts of Combat Aviation to the art of Resuscitation.

The Boldface

aka the no-shitters things that must be absolutely incorporated into your memory and available for immediate execution. You should not need to think about what to do in these situations.

Checklists

Cognitive unloading and guarantee of the performance of critical actions. Use after addressing the boldface

Prioritization of Attention and Tasks

In combat aviation:

* Aviate

* Navigate

* Communicate

In EM & Critical Care:

* Resuscitate

* Differentiate

* Communicate

The Cross-Check

Keep coming back to the global patient picture before diving into any minutiae

Efficient and Unambiguous Communication

* Directive

* Descriptive

* Informative

Briefing

Pre-Brief

Planning: Mission, Defined Roles, and Set the tone

De-brief

Learning happens in the debrief

Perception-Decision-Execution

Pre-Flight Read Files

Can't fly until you have read and signed-off on any new procedures or techniques

 

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Now on to the Podcast...

I had a crazy case of Tricyclic Overdose while on an overnight shift at Janus General.

Initial and Post-Treatment EKGs

Initial

Post-Treatment

List of Tricyclic Agents from Wikipedia.org

* Amitriptyline (Tryptomer, Elavil)

* Amitriptylinoxide (Amioxid, Ambivalon, Equilibrin)

* Butriptyline (Evadyne)

* Clomipramine (Anafranil)

* Demexiptiline (Deparon, Tinoran)

* Desipramine (Norpramin, Pertofrane)

* Dibenzepin (Noveril, Victoril)

* Dimetacrine (Istonil, Istonyl, Miroistonil)

* Dosulepin/Dothiepin (Prothiaden)

* Doxepin (Adapin, Sinequan)

* Imipramine (Tofranil, Janimine, Praminil)

* Imipraminoxide (Imiprex, Elepsin)

* Lofepramine (Lomont, Gamanil)

* Melitracen (Deanxit, Dixeran, Melixeran, Trausabun)

* Metapramine (Timaxel)

* Nitroxazepine (Sintamil)

* Nortriptyline (Pamelor, Aventyl, Norpress)

* Noxiptiline (Agedal, Elronon, Nogedal)

* Pipofezine (Azafen/Azaphen)

* Propizepine (Depressin, Vagran)

* Protriptyline (Vivactil)

* Quinupramine (Kevopril, Kinupril, Adeprim, Quinuprine)

Additionally...

* Amineptine (Survector, Maneon, Directim) Norepinephrine-dopamine reuptake inhibitor

* Iprindole (Prondol, Galatur, Tetran) 5-HT2 receptor antagonist

* Opipramol (Insidon, Pramolan, Ensidon, Oprimol) ? receptor agonist

* Tianeptine (Stablon, Coaxil, Tatinol) Selective serotonin reuptake enhancer

* Trimipramine (Surmontil) 5-HT2 receptor antagonist and moderate-potency norepinephrine reuptake inhibitor.

And of course, the non-TCA agents...

* Diphenhydramine

* Cocaine

* Cyclobenzaprine (I add this one to the list, b/c there can be TCA-like effects in toxicity, but it seems the potential for cardiac effects is markedly less though still possible. (J Emerg Med 1995;13(6):781-5) This one is from Bryan Hayes)

Pharmacologic Effects of TCAs

K+ Channel Blockade

QTC Prolongation

NE & Serotonin Reuptake Inhibition

Initial hypertension quickly followed by hypotension

Na+ Channel Blockade

QRS Prolongation

Hypotension — depresses myocardial contractility

Ventricular dysrhythmias

Brugada-like findings on EKG

Muscarinic Anticholinergic Receptor Antagonism

Anticholinergic Toxidrome

Antihistaminergic

CNS stimulation or sedation

Alpha1 Adrenergic Antagonism

Hypotension

GABA-A Receptor Blockade

Seizures

This chart was taken from the excellent Resus Review Blog by Charles Bruen

Sodium Bicarbonate

Increases amount of drug in non-ionized form and may decrease binding to Na-channels [cite]11482860[/cite]

May need many, many amps. For some reason the sodium and the bicarb don't rise significantly in severe toxicity

My goals are QRS duration <100, hemodynamically stable, Na ~150, pH ~7.5

Electrolyte Abnormalities

Beware of hypokalemia and hypocalcemia

Send VBG with lytes at least Q1 hour

Hyperventilation

To promote alkalosis

Hypertonic Saline

If the patient is too alkalotic or out of amps of Bicarb

Janus General Hospital

Janus General is a virtual hospital where I will set all of my future cases. The inspiration for a virtual hospital comes from my friends at the St. Emlyn's Blog.

Where to Comment/Question

If it is about a blogpost/podcast, comment here on the EMCrit.org site

If it is a clinical question or discussion, go to the EMCrit G+ Community Page

If it is a quick comment or question, hit me on Twitter

If it is a problem with the EMCrit Site or the CME Site, come to the Contact Page

Direct Link to CME for Each Episode

Starting with episode 97, at the bottom of each post, there is a direct link to get CME:

Just returned from Castlefest 2013--best ultrasound conference ever!

So last podcast, I bashed on sodium bicarbonate or as John Kellum and David Story call it: chloride-free sodium. This episode I talk about all the good reasons to use NaBicarb. This is part of a series

* Part I lays out the background of the quantitative approach

* Part II puts it in mathematical terms to allow calculation of acid base status

* Part III takes you through some real world examples

* Part IV discusses the Acid-Base Effects of IV Fluids

* Part V down with the Bicarb

* Part VI is this one: ok, bicarb is not all bad

The Acid Base Series

EMCrit Podcast – Acid Base Ep. 7 – Bicarb Updates, Quantitative Approach, and Prof. David StoryPodcast 97 – Acid-Base VI – Chloride-Free SodiumPodcast 96 – Acid Base in the Critically Ill – Part V – Enough with the Bicarb AlreadyEMCrit Podcast 50 – Acid Base Part IV – Choose the Solution Based on the ProblemEMCrit Podcast 46 – Acid Base: Part IIIEMCrit Podcast 45 – Acid Base: Part IIEMCrit Podcast 44 – Acid Base: Part I

A physiology quandary

Owen, an anaesthesia registrar, wrote with this comment:

[...On increasing minute ventilation on vented patients with any bicarb given: Great idea and probably what most of us do, but even if you don't then with each breath the patient will be getting rid of more CO2 than previously so there should be more weak acid loss.]

This is one of those situations where I was gobsmacked for a second. When I started to think about this, it seemed intuitively wrong and yet conceptually right. I knew I needed to find someone far smarter than me. I reached out to Mel Herbert, who recommended David Story. Dr Story is Chair of Anaesthesia at the Melbourne Medical School and a physiology god. Here is his response:

Dr. Story, Here is the quandary. As you saw, I did that acid-base show with Dr. Kellum discussing NaBicarb use for the critically ill. Both Dr. Kellum and I believe and the evidence bares out that in a patient who can't get rid of the excess CO2, there will be negligible changes in pH from the bicarb administration.Now in an apneic patient, I think this is inarguable. However, in a mech. ventilated patient with no resp drive (let's say a pt we gave NMBs to), I perpetrated the situation would be the same. In response of my listeners brought up this question: If the minute ventilation is kept the same, but the ETCO2 rises (and by extension, the return of CO2 to the alveoli),

This is Part V of the EMCrit Acid-Base Talks. If you haven't listened to the initial series, you may be better off starting there:

* Part I lays out the background of the quantitative approach

* Part II puts it in mathematical terms to allow calculation of acid base status

* Part III takes you through some real world examples

* Part IV discusses the Acid-Base Effects of IV Fluids

* Part V is this one, down with the Bicarb

* Part VI ok, bicarb is not all bad

The Acid Base Series

EMCrit Podcast 44 – Acid Base: Part IEMCrit Podcast 45 – Acid Base: Part IIEMCrit Podcast 46 – Acid Base: Part IIIEMCrit Podcast 50 – Acid Base Part IV – Choose the Solution Based on the ProblemPodcast 96 – Acid Base in the Critically Ill – Part V – Enough with the Bicarb AlreadyPodcast 97 – Acid-Base VI – Chloride-Free SodiumEMCrit Podcast – Acid Base Ep. 7 – Bicarb Updates, Quantitative Approach, and Prof. David Story

Acid-Base Sheet

EMCrit Acid-Base Sheet

Today's topic comes from a debate I have been having with Steve Smith of the amazing EKG Blog. The main thrust of the debate started with this question...

Does Bicarb Fix pH if You Can't Increase Minute Ventilation?

 

When you can adjust PaCO2 to maintain a certain value (i.e. you increase minute ventilation), bicarb will raise pH as evidenced by this animal study (Crit Care Med 1996; 24:827-834). However, if you can't blow off the CO2 then the effects on pH will not be there (J Pediatr 1977;91(2):287).

In this study, NaBicarb did not correct the pH, while CarbiCarb did (Carbicarb: an effective substitute for NaHCO3 for the treatment of acidosis. (Surgery 102:835–839).

This review article recommends against bicarb for permissive hypercapnia (Intensive Care Med (2004) 30:347–356).

This study furthers the idea that NaBicarb is not all that great in closed systems (J Pediatr 1972;80(4):671) and then this discussion explores all of the biochemical reasons why administering bicarbonate as a rapid push in a closed system is a bad idea (J Pediatr. 1972 Apr;80(4):681-2.).

Here is a quote from another review article (Anesthesiology 1990;72(6):1064):

The key concept in the equation [above] is that pH is not related to the absolute value of either bicarbonate concentration nor PCo2, but rather to their ratio.

When exogenous bicarbonate is administered during acidemia,

Today, we discuss two new Trauma Guidelines

ATLS 9th Ed.

The 9th edition of ATLS has been published. In this episode, I review the changes from the 8th edition.

Management of C-Spine Injuries

We also go over the new management of spinal cord injuries from the Neurosurgeons

Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries from the American Association of Neurological Surgeons

(Neurosurgery 2013;72(supplement 2):1-259 Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries)

What's EMCrit Drinking?

Thomas Scalea is a legend! He is Physician-in-chief at the Shock Trauma Center in Balitmore. He started the EM program at Kings County in 1991. He is also an excellent doctor and a wonderful person. At the 2012 EMCrit Conference, he gave an amazing lecture on the cutting edge techniques they are using at Shock Trauma for intracranial pressure (ICP) management.

For the basics of ICP Management, check out this prior podcast.

Slides

Here is a pdf of Dr. Scalea's Slideset

Audio-Only Version

Need just the mp3? Right-click here and choose save-as.

Now on to the podcast...

I recently got an email from the creators of a new approach to airway management

What these two gentlemen have crafted is a paradigm called the vortex approach. It is best represented by this diagram:

And here are versions with even more information:

I could write about the method, but to do it true justice, it is better to watch this video:

http://www.youtube.com/watch?feature=player_embedded&v=HE_uy_1Skq8

The Shock Trauma Algorithm

Now you folks know I am partial to a modified-version of the Shock Trauma Algorithm for Failed Airway Management. It is bar none the simplest, most effective (and validated) algo I have come across. Or at least it was until I started parsing the Vortex Approach. The reason is that the Vortex Approach encompasses the STC algorithm in a way that is universal to all specialties and settings.

Ebook

Nicholas and Peter wrote a free ebook about the concept, which is available in a number of formats.

Websites

They also have a website set up for the Vortex Approach as well as other projects on their Clinical CrEd Site. The Vortex site also has videos demonstrating the approach in action in both an emergency department and operating theater intubation.

Podcast

Minh Le Cong did an interview with the two of them on his PHARM podcast site that is definitely worth a listen.

Apps I Liked

I was sent free evaluation copies of 2 IOS applications:

* The IOS version of PressorDex from the EMRA folks. The pocket-book was good; the app is even better.

* An application listing the most important critical care papers and a short summary of their impact. The app is called ICU Trials by Sean Kane. The link goes to the free lite version; if you like it buy the full version.

Now on to the Wee...

My friend Chad Meyers is an ED Intensivist from NYC. He gave this lecture at ALLNYCEM 2012, but the video sucked. He rerecorded it for the EMCritters.

I will be bringing Roger Harris, MD of SMACC and Sydney ICU fame on the show in the very near future to debate this very issue.

Need the audio-only version? Right Click Here and Choose Save-as.

CME is available for this episode

Now on to the Wee...

The Conference

SMACC 2013 was, bar none, the best Critical Care Conference I have ever attended!

The People

I got to meet people like...

Doug Lynch (@thetopend)

Victoria Brazil (@SocraticEM)

and Most Importantly,

to all of the wonderful listeners that introduced themselves--I Love You!

Jetlag

Great Article (CLEVELAND CLINIC JOURNAL OF MEDICINE 2011;78(10):675)

SMACC-Backs are coming...

The Clinical Stuff

IVC Ultrasound

SIMWars

* BP Rep Time

* Drip Sheets - See the EHCED drip-sheet project

* Tension Pneumo

* Bind the Pelvis