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Cliff Reid is the prototypical resuscitationist; he rocks! He has discussed his philosophies on previous episodes:

*

 A Resuscitationist Agonizes

* Part I of an Interview with Cliff

*

Part II of the Interview

And of course, Cliff's blog, resus.me, is some of the best retrieval and resuscitation information around.

I brought Cliff up to speak in my Critical Care Track at the 2012 Essentials of Emergency Medicine. Mel Herbert was kind enough to give me permission to post the lecture here. I think you'll love it as much as I do.

Need the audio-only version of Cliff's talk? Right click the link and choose save-as.

Now, on to the podcast...

Podcasts

* PHARM Podcast (Subscribe on Itunes)

* Intensive Care Network Podcast Podcast (Subscribe on Itunes)

Blogs

* Mojo RN

* PulmCCM.org

* Sonospot

* EM Ireland

* St Emlyns

Also See for more Best ofs

* Sexy Six for 2014

* 2013 Eight is Enough

* 2011 Hard Six

* 2010 Dirty Dozen

Thanks for Listening and Supporting EMCrit!

 

We have hit the 10,000 patient mark in the NYC STOP Sepsis collaborative. Here are some of the lessons learned...

Want to See the Protocols?

Recognition

* Let nurses handle recognition

Lactate

* Send lots of lactates

* Lactate turn-around 30 minutes or get Point-of-Care

* Run the lactates on a blood gas machine

* Make lactate >=4 a panic value

Treatment

* Prompt palliative vs. curative

* Non-invasive protocols have evidence and seem to be working

Want to See the Protocols?

Early appropriate antibiotics

* Empiric Abx Guidelines

* First dose of those antibiotics in the ED

* Simultaneous Infusions

Intubation

* Safe Intubation

Fluids

* Echo Assessment of Cardiac Output

* IVC ultrasound (Also check out the Stone Debate)

* If empiric fluid-loading, give 4-6 liters

Pressors

* Do a sterile neck line or a non-sterile femoral (which should be yanked and replaced as soon as the patient gets upstairs)

* Norepi should be your 1st pressor choice

Check Your Work

* Mandate repeat lactates

More Sepsis Resources

* Manny Rivers on Early Goal Directed Therapy

* A tirade on Sepsis Care in the ED (And additional follow-up) Back then there was no Non-Invasive Path

* That was until Alan Jones published his lactate clearance study

* Find a ton of evidence and other good stuff on the EMCrit Severe Sepsis Deep Dive Pages

 The Proposed NQF Measure

Read it and weep

Please contact the folks in your hospital that will be voting on the measure

On a Side Note...

EMCrit just broke the 3 Million Downloads mark. Yeah!!!!

Like this post? Then tweet the hell out of it

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The MOPETT Trial took sub-massive PE patients and randomized them to half-dose tPA vs. standard care. No bleeds in either group. 41% ARR of pulmonary hypertension at 28 months.

Study Description from the Author

PDF of his MOPETT presentation slides

 Does this change your game?

Update:

A new trial using a similar protocol showed benefit without complications (Clinical Cardiology Volume 37, Issue 2, pages 78–82, February 2014)

Articles:

* Latency of Pulse Oximetry Signal with use of Digitial Probes Associated with Inappropriate Extubation (J Emerg Med 2012;42(4):424)

* Latency and loss of pulse oximetry signal with the use of digital probes during prehospital rapid-sequence intubation. (Prehosp Emerg Care. 2011 Jan-Mar;15(1):18-22.)

* Rate of decline in oxygen saturation at various pulse oximetry values with prehospital rapid sequence intubation. (Prehosp Emerg Care. 2008 Jan-Mar;12(1):46-51.)

Dan Davis at his best:

http://vimeo.com/55375806

Did you like this episode? Then tweet the hell out of it...

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Now on to the Podcast...

Screening for by cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma 73:(5) Supplement 4, S301-S306, 2012.

Michael McGonigal has a great summary of the BCI guidelines on his Trauma Professional's Blog

Click here to download the blunt cardiac injury algorithm

What's EMCrit Drinking?

What is the best conference of 2013?

Ummm hello! It is SMACC!

SMACC

March 11-13, 2013

Sydney Australia

Submit Abstracts to the Conference

Find out More about SIMWars

See all of the amazing SIMWars Entry Videos on the ICN

 

In this Mind of the Resuscitationist Episode, I discuss stop points: one for when you are using multiple vasopressors and especially about a cognitive stop point whenever things are going south.

2nd Vasopressor Stop Point

Rapid Ultrasound for Shock and Hypotension (RUSH) Exam

The RUSH Exam will allow rapid diagnosis of the cause of non-trauma hypotension

Abdominal Compartment Syndrome

See this crashing patient chapter for more on Abdominal Compartment Syndrome

Update: Added....

* Is there actually hypotension? Consider femoral a-line. Consider dissection/vascular obstruction at the site of BP Measurement.

* Systolic Anterior Motion

* systolic anterior motion

* Consider Tox

* Is this actually cardiogenic shock from ischemia/MI rather than sepsis

* Is there occult right ventricular failure that could be treated (e.g. with pulmonary vasodilation)?

* Is there low cardiac output and impaired perfusion (e.g. mottling)? In that case, additional vasoconstriction may simply aggravate matters.

* Is there a failure of surgical source control or incorrect antibiotic selection?

* Is the patient on adequate adjunctive therapy (stress-dose steroid, possibly thiamine/ascorbate)?

* Is there a pH abnormality that merits correction (e.g. treatment of hyperchloremic metabolic acidosis with bicarbonate)?

* Is there autoPEEP

*

* Is there clinically significant hypocalcemia?

*

Cognitive Stop Points for the Resuscitationist

Use this method whenever the situation doesn't add up or is going bad:

* Announce you have no idea what the f**k is going on

* Eliminate ALL assumptions

* Troubleshoot like an engineer

Shoutouts

Ken Grauer sent me a copy of his new book, ACLS 2013 Pocket Brain Book. Check it out and check out his blog site as well.

My friend Clay Smith of the KeepingUp Podcast has just put out a new, FREE!, IOS app called Upshot that combines his literature reviews and podcasts into one beautiful package.

Did you Like this Episode? Then tweet the hell out of it:

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Now on to the Podcast...

Can the Inferior Vena Cava Ultrasound guide our fluid administration in the ED? Of course it can!

So I was getting on the plane to Las Vegas for Essentials 2012, on my iphone was the latest from Mike and Matt of the Ultrasound Podcast. Up pops Mike "the Rock" Stone interviewing my buddy, Haney Mallemat; these two ultrasound gurus discuss some ultrasound soundbites, but then... They both state that IVC ultrasound is useless for determining fluid responsiveness. It is worth taking a listen to that episode if you have a moment. So how can two brilliant guys get it so wrong? They just had their focus knob turned all the way to the right. Lets optimize their settings with an EMCrit Podcast.

Mechanically Vented Patients

Now, most of the podcast bashed IVC in spont breathing patients, but there was some overflow disparaging of IVC in mech vented patients, so let's get that out of the way first. There is plenty of literature for these patients. Put them on a temporary, high tidal volume (10 ml/kg). Get an IVC shot and if it increases in size by 15-18% (depending on the study), the patient is fluid responsive.

* Intensive Care Med. 2004 Sep;30(9):1740

* Intensive Care Med. 2004 Sep;30(9):1834

* Neurocrit Care. 2010;13:3

* J Trauma. 2007;63:495

* J Intensive Care Med. 2011 Mar-Apr;26(2):116

Spontaneously Breathing Patients

Now as the two ultrasound masters allude to, there have been a few studies showing IVC ultrasound assessment merely correlates with CVP  (it actually correlates with respirophasic CVP) and then use that fact to write off the IVC. Now we have maligned CVP as a marker of fluid responsiveness so IVC is crap as well, right?

There is evidence for the use of IVC as a marker of fluid status. In patients with ultrafiltration for congestive heart failure (Intensive Care Med. 2010 Apr;36(4):692-6) as well as fluid removal during hemodialysis (Clin J Am Soc Nephrol 2006;1:749 and Nephrol Dial Trans 1989;4:563). There was also a trauma study showing that fluid resuscitated patients with IVC collapse were more likely than those without to have recurrent hypotension (J Trauma. 2007 Dec;63(6):1245).

There was also a study just published in the Aussie EM Journal. This study was severely limited by the fact that none of these patients had any significant IVC collapse and the criterion standard is not a test any of us consider useful for cardiac index measurements; further, looking at the tables, some of the responder group did not seem to have any sig. increase in their CI in response to fluid. (Emerg Med Aust 2012;24:534).

And a meta-analysis study showing IVC's relation to fluid status (AJEM 2012;30:1414).

Luckily, there was also a recently published study with the table below (Crit Care 2012;16:R188).

Here is figure 1 from the study

Here is the area under the cure (AUC); you notice there are points with much higher specificity.

Update:

Hot off the presses, this study is more reassuring: (Shock 2013;39(2):155)

It lends additional credence to the use of dynamic IVC for fluid responsiveness.

It's not Fluid Responsiveness, It's Fluid Tolerance!

This is the crux of the matter. In the ED, we want to give a bunch of fluid, but not if we are going to cause pulmonary edema. The term, fluid tolerance, is a perfect description of this idea. Responsiveness is great, but all we want to make sure of is that we are not going to d...

 

Should we be prescribing opioids from the ED? This question is explored in the recent ACEP Clinical Policy on ED Opioid Prescriptions.