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In this Hurricane Sandy episode of the EMCrit podcast, I talk about the confirmation of two of my clinical prejudices.

Chloride Poisoning

So I've always preached that grabbing normal saline for every ED patient is poor thinking and poor practice. We discussed this topic in the 4th Acid-Base Podcast on Fluids. Up until now, I did not have great evidence for my prejudice; now at least, I have reasonably good evidence:

Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte (Ann Surg. 2012 May;255(5):821-9)

Association Between a Chloride-Liberal vs Chloride-Restrictive Intravenous Fluid Administration Strategy and Kidney Injury in Critically Ill Adults (JAMA. 2012 Oct 17;308(15):1566-72)

Definitive? Nope, but it just seems like good medicine to treat fluids like any other drug and actually choose the ideal one for the clinical situation.

Resus.me Post: What’s with all the chloride? An assault on salt | Resus M.E!

Upate:

Association Between the Choice of IV Crystalloid  and In-Hospital Mortality Among Critically Ill Adults With Sepsis

Karthik Raghunathan (Crit Care Med 2014 citation pending)

A Diversion on Osmolality

Peter Sherren made a great comment in the podcast on the Brain Code regarding my statement that lactated ringers is an inappropriate fluid in high ICP. So I had a bit of a think on the topic and then was baffled as to why LR has a Na of 130 and yet a Osm of 272-5.

Brian Hayes responded to a tweet on the topic with what is probably self-evident to everyone but me: the Osm calculation we use is actually a crappy short cut; all components of a fluid need to be calculated to get the real Osm. Yet, when I thought about this still further, I realized that what is written on the bag is not actually the in-vivo Osm effects. Instead, the Na is probably the key.

Want proof of this concept? D5W has an Osm of 252 on the bag, but the effective Osm is 0 as soon as your cells take up the glucose.

So can you use LR in high ICP, yes probably not too big a deal, but the net Osm effects will probably be to lower the serum Na and Osm. If you buy choosing the ideal fluid for acid-base, it probably makes sense to choose the ideal fluid for Osm as well. Maybe this prejudice will be verified 5 years from now with a real article.

Here is the article I mentioned on the Osm effects of LR on healthy volunteers: (Anesth Analg 1999;88:999 –1003)

Here is an Osm calculator from GlobalRPH.

A Diversion on the need for Conversion of the Buffer Bases

Want what I think is the ideal resus fluid? Mix this on the fly:

Ultimate Resus Fluid? 1 amp of 44.6 bicarb in 500 ml of NS makes 550 of total volume= Na 121.6 Cl 77 Bicarb 44.6   to extended out to 1 liter= Na 217 Cl 138.6 BiCarb 80   1.3% Balanced Saline solution

There is ABSOLUTELY no evidence for this. If someone wants to do the study,

The Post-Intubation Package

There is a ton of stuff to do post-intubation besides confirming the tube and giving the team high-fives. What we do in the ED has ramifications on the patient's course in the hospital. Preventing badness starts with us.

Achieve Adequate Analgesia and Sedation

I won't belabor this, because I've discussed it in so many other podcasts, such as the one about not leaving your patient in a nightmare

Secure the Tube Well

We use the Hollister Anchor Fast (as always, no conflicts of interest).

Raise the Head of the Bed to at Least 30°

May or may not help prevent VAP, but it definitely helps lung mechanics

Confirm Lung Protective Vent Settings

See the Dominating the Vent Lecture for more on all that

Humidify the Air

Either with a humidification circuit on the vent or a Heat-Moisture-Exchanger (HME)

Place In-Line Suction and then Actually Use It

In-line is probably no better than intermittent with sterile technique, but who is actually going to use sterile technique

Suction the mouth each time you suction the tube as well

Hook Up the ETCO2

You read NAP4 right? Continuous waveform ETCO2 until the ET tube gets pulled

Cuff Pressure

Too low and you risk micro-aspiration and VAP, too high and the patient has the potential for ischemia. The ideal pressure is between 20-30 cm H20. Use a cufflator.

Gastric Tube

Empty the stomach to reduce the chances of aspiration

Nebulizers/MDI

If they were intubated for reactive airway disease, then they need frequent nebs. In some hospitals, all patients get intermittent MDIs. Make sure to remove the HME for nebulizer or MDI treatments.

Prevent Aspiration past the Cuff of the ETT

Cuff Lube

Lube on the tube cuff may help avoid micro-aspiration (Anesthesiology 2001; 95:377–81 & Anaesthesia. 2006 Feb;61(2):133-7.)

Continuous Subglottic Suction ETTs

BestBets: Continuous subglottic suction is effective for prevention of ventilator associated pneumonia

May prevent 4 cases annually if used for all patients in an average US hospital (Critical Care 2012, 16:446)

A listener, Dan Hierholzer, DO (last name:  Here-Hole-Zer) reports on 1 issue with these tubes: they have a wider external diameter so if you are trying to pass them through an intubating supra-glottic airway, you need to go 1 size lower. Dan demanded a shout-out to the residents at Geisinger Medical Center in exchange for this excellent tip.

Get a Blood Gas

I like arterial,

Crack to Cure

All the way back at podcast 36, I discussed traumatic arrest in the ED. In that episode, I laid out a general approach to patients coding from trauma, in this one I discuss only the performance of the procedure of ED thoracotomy.

This lecture was given at the 2012 ALLNYC EM Conference.

Here are the videos from the lecture:

* ER thoracotomy.MP4 - YouTube

* Open Thoracotomy - YouTube

* thoracotomy.flv - YouTube

Articles to Read

* Why You Should Consider Empiric Clamshell

You Also Need to Watch

* John Hinds on Crack the Chest, Get Crucified

Nice Diagram

I quibble with some of this, but it is beautiful none-the-less

from @learnEDjon

Most Recent Guidelines from EAST

Full Text of EAST Resus Thoracotomy Guidelines

Strayer's Summary Slide

Update

* If cardiac wall motion or pericardial fluid, go forward--if not, don't. From Surgical Lit

* Review Article Paulich and Lockey (BJA Education 2020;20(7):242)

*

Need the audio-only version?

Right click here and choose save-as

Now on to the Vodcast...

The difference between screening, rule-out, and risk prediction criteria.

Today, I put on my head-shrinker cap (it is a fez) and get Cliff Reid on the coach. You know Cliff from his previous podcasts:

* Interview with Cliff Reid: Part I

* Interview with Cliff Reid: Part II

* Cliff's Tips for Occasional Intubaters

* A Discussion regarding NAP4

and his insanely good blog:

Cliff discusses a case of an out-of-hospital cardiac arrest that he has been ruminating about for the past few days. Here are the teaching points that came out of the case:

Can we lyse intra-arrest?

We will discuss this question in a future show. For now, I would say if you strongly suspect PE or MI and you have exhausted other options, intra-arrest lysis is still an option.

The pulse you feel in the groin may be the vein

During the discussion Cliff mentions that he demonstrated to his whole team that the pulse they felt in the groin was the femoral vein. Use ultrasound for all intra-arrest groin catheter placements.

Securing lines during a code

I use 2" tape. Cliff mentions during the discussion and on his blog, using tissue glue instead.

Continue CPR if there is an a-line pulse, but the pressure is low

Otherwise these patients will just re-arrest. Here is an article on thoracic pump vs. cardiac pump.

Percussion Pacing

Never heard of this? Read this manuscript on percussion pacing.

The Ethics of Different Capabilities at Geographically Close Hospitals

I want to hear what you folks think about this. Should all sick patients be taken to the closest hospital that has the most potential life-saving capabilities? Is there ny reason to bring really sick patients to tiny hospitals if the trip to a more advanced hospital only adds a few minutes? Let me know in the comments what you think.

The Mind of a Resuscitationist - A Resuscitationist Agonizes

This is why I really wanted to post this podcast. I run a series called the Mind of a Resuscitationist. For instance, the episode on

* Logistics not Strategy

Today's episode hits another key point to a resuscitationist's mind: we agonize. We dissect every case that did not go perfectly to figure out if there was ANYTHING that could have gone better, been done smoother. This obsession leads to ulcers and interrupted sleep patterns AND better outcomes in the future.

Please share your thoughts below. Now, on to the podcast...

From American College of Chest Physicians

Antithrombotic Therapy and Prevention of Thrombosis, 9th ed Guidelines

Chest 2012;141:7S-47S (Executive Summary)

For outpatient treatment, start 10 mg daily for the first 2 days followed by INR measurements

Give 1 day of LMWH or UFH before initiation, if treating VTE

If the patient is on VKAs, avoid NSAIDs and certain ABX (table 8 from full guidelines)

Avoid anti-plt agents unless clinical condition warrants

Normal goal is 2-3, including antiphospholipid

No need to taper when d/cing

Heparin – 80/18 for VTE, 70/15 for cardiac or stroke patients

For outpatients with VTE treated with SC UFH, they suggest weight-adjusted dosing (first dose 333 units/kg, then 250 units/kg) without monitoring rather than fixed or weight-adjusted dosing with monitoring

High INRs

4.5-10, no bleeding: no vitamin K necessary

> 10, no bleeding: Oral Vitamin K

If anticoagulant related major bleeding: 4-factor PCC and Vitamin K Slow IV Injection

See Michelle Lin’s Paucis Verbis on the same

Critically Ill Patients

Recommend against routine screening

Use LMWH or LDUH in all patients unless contra-indicated

For travelers at risk of VTE, use graded compression stockings; do not prescribe aspirin or anticoagulants

Diagnosis of DVT

Low Risk

moderate sens d-dimer, high sens d-dimer, or CUS of proximal veins only. D-dimers are preferred

If d-dimer is positive, get Compression Ultrasound (CUS) of proximal veins

Moderate Risk

Use High sens d-dimer, CUS of prox, or CUS of whole leg

Can stop if high-sens D-dimer is negative

If no d-dimer or d-dimer postive, need a second CUS 1 week later if only prox CUS done

If whole leg CUS is negative, you are done

High Risk

Prox CUS or Whole Leg CUS

If prox CUS and d-dimer negative as well, done

If d-dimer positive or only prox CUS, get 1 week f/u CUS

If whole leg CUS is negative, you are done

Recurrent

In patients with past DVT, recommend high-sens d-dimer, if positive get Prox CUS and 1 week Prox CUS

If negative, get just one Prox CUS

If the old CUS is not available, confirm with venography if positive CUS

Upper Ext

Go right to Doppler CUS for upper extremity dvt suspicion

Treatment of DVT

Start with IV or SQ UFH, LMWH, or fondaparinux (Latter two preferred)

If high pretest, start heparin immediately; If moderate, start heparin only if diagnostic tests are expected to be > 4 hours delayed

Isolated distal DVT-serial CUS rather than treatment unless severe symptoms or risk factors for extension (see full text)

Ambulate DVTs, no bed rest

In patients with hypotension (SBP) < 90 and PE, give systemic thrombolytics (through peripheral, rather than PA cath)

Atrial Fib

Chads 0 – nothing

Chads 1/2 – VKA/oral anti-coag; Dabi is preferred

If a-fib > 48 hours; give 3 weeks of VKA/dabi before cardioversion. Or get TEE with LMWH. Follow with 1 month of Vka/oral anti-coag

If a-fib < 48 hours; Start LMWH and then VKA for 4 weeks

If hemodynamically unstable, treat with anticoagulation ASAP preferably before cardioversion and then continue for 4 weeks

Treat a-flutter like a-fib for all of the above

Stroke

If hemorrhagic,

Yearning for some trauma aren't you?

Today I got a chance to interview Karim Brohi (@karimbrohi). He is a trauma and vascular surgeon in London and runs the incredible Trauma.org site. Dr. Brohi has consistently been on the cutting edge of hypotensive resuscitation, hemostatic resuscitation, and massive transfusion.

Dr. Brohi's Lecture on Hypotensive Resuscitation

Dr. Brohi gave an amazing lecture on hypotensive resuscitation. I highly recommend giving it a viewing.

You can view the lecture here;

or on the trauma.org site.

Here are the questions that remained after watching that lecture:

What is the MAP goal you use for resuscitation of unstable hemorrhage patients?

What are you doing with your suspected intracranial bleed patients with concomitant hemorrhage on call today?

What do you think of Dutton's idea of high flow, low pressure resuscitation using solely FFP/Blood as resus fluid and fentanyl to cause sympatholysis?

Traumatic Arrest

Is there any role for closed chest CPR in arrest from hemorrhage. If not, why is it so pervasive amongst EM and Gen Surg doctors? How do we abolish this practice?

Any role for drugs?

Do you bother with cross-clamping?

Check out this previous podcast on traumatic arrest.

Massive Transfusion

Are you using any of the scoring systems or instead, gestalt?

Are you using TXA? If so, when and in which pts?

When does TEG or ROTEM enter the picture?

Hypertonic saline?

Tell us a bit about Cryostat?

More Podcasts on the Above

* First listen to Richard Dutton on his vision of hypotensive resuscitation.

* Next, listen to one of the Crash2 authors, Tim Cook, to discuss the use of tranexamic acid in trauma.

To Close

https://twitter.com/karimbrohi/status/234663124567990273

Did you Like this Post? If so, then retweet it...

https://twitter.com/emcrit/status/242372176546770944

What do you think about ACLS and Traumatic Arrest? Comment below...

Now on to the Podcast:

When I read a recent meta-analysis by Paul Marik, the first thing I did was bang my head against the wall 10 or 20 times. For seven years I have been trying to get people to put in neck lines because we KNOW the infection and DVT risk is lower, right? Well Dr. Marik's review may significantly lower our certainty. You remember Paul Marik; he was on the show discussing fluid responsiveness a few months ago. He is a Professor and Division Chief of Pulmonary Critical Care at Eastern Virginia Medical Center.

Well, let's get to the actual meta-analysis on femoral central lines first...

The Meta-Analysis

Marik, Flemmer, et al. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: A systematic review of the literature and meta-analysis. Crit Care Med. 2012 Aug;40(8):2479-85.

Some of the Component Articles

Nagashima et al. To reduce catheter-related bloodstream infections: is the subclavian route better than the jugular route for central venous catheterization? J Infect Chemother. 2006 Dec;12(6):363-5.

Lorente et al. Central venous catheter-related infection in a prospective and observational study of 2,595 catheters. Crit Care. 2005; 9(6): R631–R635.

The Two Studies from Wales by Harrision et al.: 2009 data, 2010 data

The Plots

Femoral vs. Subclavian

Femoral vs. IJ

What to make of all this?

I believe the data from this meta-analysis still show that neck lines have less infection risk than groin. But what this article does establish quite a bit of doubt on this answer. I think this will allow for further trials, though the numbers will have to be large and the study well done. ANZICS can you help us please???

Update:

This trial looked at IJ vs. femoral by using data from 2 RCTs of biopatchs. Up until the 5 day mark, no difference between the two sites. ( American Journal of Respiratory and Critical Care Medicine 2013;188: Jugular versus Femoral Short-Term Catheterization and Risk of Infection in Intensive Care Unit Patients. Causal Analysis of Two Randomized Trials )

This newest trial puts subclavian definitively on top (N Engl J Med 2015; 373:1220-1229)

What do you think? Leave your thoughts in the comments below.

Now on to the Podcast:

 

 

 

Another ENLS topic: Ischemic Stroke. But not the entire subject, and not even whether we should give tPA to stroke patients. Why not the latter topic--because I am not smart enough to know the answer. For that listen to David and Ashley and make your own decision. What we will talk about today is reducing door to tPA time.

There was a recently published study that gave an excellent description of one center's interventions to get their door to tPA time down to a ridiculously low level.

(PMID 22622858)

Here are the interventions they used:

The American Heart/Stroke Associations also have some resources on reducing door to tPA time.

The EMCrit Checklist

Here is the checklist of my interventions to reduce door-to-tPA-time:

Click Image for PDF

EMCrit Art Contest

Click on over to see the finalists and vote

What do you think about consent for tPA or anything else we spoke about today--leave a comment. Now on to the podcast...

Today we are going to discuss increased intracranial pressure (ICP) and herniation. This is the first of 13 lectures to go with the upcoming Emergency Neurological Life Support Course that I co-chair.

Screen for Increased Intracranial Pressure

Matt & Mike's Ultrasound Podcast on Ocular Ultrasound

Tier 0

Head of Bed Up

Temp Normal

PaCO2 35-38 mm Hg

Control Pain/Sedate if Intubated

Tier 1

Osmotic Therapy

Mannitol

Hypertonic Saline

Sodium Bicarb

Tier 2

Propofol (or Phenobarb) Drip titrated to take patient to low levels of sedation scales (5-200 mcg/kg/min)

CPP Optimization

Tier 3

Decompressive Craniectomy

Induced Hypothermia

Pentobarb

Moderate Hyperventialtion (I reserve for patients who are herniating)

Want more Tier 3 therapies?

Get Thomas Scalea's Lecture on TBI/ICP

* Already a EMCrit CME Member, go to the CME Learning Site.

* Want to become a member? Go to the CME Signup Page.

* Are you in-training in a medical profession, go to the EMCrit In-Training Page.

Now, on to the podcast...