EMCrit FOAM Feed

A comment by Sean Marshall (scroll all the way down) got me thinking about bimanual larygoscopy. I realized, when I am doing video laryngoscopy, I don't need to really perform too bimanual anymore. Big paradigm shift since I strongly espoused the virtues ever since I learned the technique from Rich Levitan.

I now outsource external laryngeal manipulation to my assistant; or I do it for the intubator when one of my residents is that intubator. This outsourcing concept was first introduced to me by my friend, Reuben Strayer. He realized you could outsource suctioning. It was a natural progression for me to start outsourcing thyroid manipulation and now tube-prepassage.

LVAD Emergencies

These patients are super-complicated, luckily I got Zack Shinar, MD from Sharp Memorial in San Diego to try to wade through the morass.

All Situations

* Call the patient's VAD coordinator ASAP

* These patients may not have a palpable pulse. Listen over the heart to hear if the motor is working. Then use mental status, skin color/temp, and the machine flashing Low Flow as indicators that perfusion badness is occurring. Do a bedside echo. The MAP should be ~65 on manual doppler BP, Automated BP devices may give you a MAP as well. A-line MAP is the most accurate.

* Try not to cut or yank out the drive-line, 'cause that is embarrassing.

Poor Perfusion

* When in doubt, consider a fluid bolus. VADS love volume. If you need to improve hemodynamics with a working LVAD, consider preload augmentation and possibly afterload reduction (if MAP is high).

* Consider inotropes--if you think it is right heart failure, give dobutamine. If you think the patient is septic and has markedly reduced afterload, consider norepinephrine.

* On echo:

* Big RV, small LV=pulm hypertension or right heart strain/stemi. Correct hypoxemia and acidosis, consider volume, screen for RV STEMI, consider inotropes.

* Small RV-give volume

* Big RV & LV-pump failure or pump thrombosis.

Consider pump thrombosis--Signs of pump thrombosis are LVAD is hot, working hard, with high RPM, low flow, dilated RV/LV, and low MAP. Zack would give a bolus of 5000 U of Heparin in the decompensating LVAD that he thought was secondary to thrombosis (or if he just couldn't figure out what was wrong with a failing device). He would also consider tPA if he really thought it was pump thrombosis and the patient was decompensating and peri-code.

On ECHO, a dilated RV/LV could be from pump thrombosis or non-working pump (electrical issue for example).if you think that is the problem, heparinize.

Machine Not Running

Check batteries. Make sure all of the lines are connected.

Bleeding

These folks are prone to bleeding from the anticoag (and probably additional plt dysfunction from the device if I had to guess). So if they have altered mental status or neuro findings--consider hemorrhagic stroke.

Patient appears Infected

Drive-line infection-look at the site at entry to the skin. If the patient appears septic and you can't find a source, consider it a device infection until proven otherwise. Don't yank the device. Treat for health-care associated infection covering both hospital gram negatives and MRSA.

Patient is Coding

We need to AVOID CPR until the patient needs it and at point, what is the alternative? Can you rip out the device with CPR-yes! Many of the CT surgeons recommend not to do CPR, but you can't get deader than dead (I was not a philosophy major, so I could be wrong). Avoid CPR if at all possible, some of the 1st gen devices had hand-pumps you could use--the current generation don't. If you're the point where there is NOTHING else to do except CPR you need to use your clinical judgment.

Here is Zack's clinical judgment:

CPR is not recommended by the manufacturers secondary to potential cannula dislodgement.  I would not do CPR unless the pump was NOT working and the patient had lost their BP (MAP of 0).  This is the one scenario where you have to perfuse the brain no matter what the cost.  All other scenarios I would focus on how to get that pump operating better (at all).

Joe Bellezo then adds:

Just agreeing with Zack's thoughts on this. My approach to this is 'Look, Listen, and feel" - assuming a comatose LVAD patient.

Look: ...at all the connections. Everything connected? Ok. Look at the controller.

National Institute for Health and Clinical Excellence:

Acute upper GI bleeding: NICE guideline

http://guidance.nice.org.uk/CG141/NICEGuidance/pdf/English

Great Britain’s National Health Service has a group called the National Institute for Health and Clinical Excellence (NICE); this group has recently put out guidelines for the management of Upper GI Bleeds. Thanks to my friend, Cliff Reid, for bringing these guidelines to my attention.

The Guidelines

Before endoscopy, calculate a Blatchford Score consider discharge if the score is zero.

After endoscopy, calculate a Rockall Score, this helps determine disposition

Transfuse massively bleeding patients as per local protocols, realizing that both under- and over-transfusion are bad

Do not give platelets if the patient is not bleeding. If they are bleeding, give plts for count < 50,000.

Offer FFP to pts with fibrinogen < 1 g/L or INR > 1.5

Use PCC for patients taking warfarin and are actively bleeding

Do not use Factor VIIa until other methods have failed

Offer endoscopy for severe acute bleeding immediately after resuscitation

Do not offer PPI to patients with non-variceal upper GI bleeding unless endoscopy reveals an ulcer

Offer them if the patient has stigmata of recent hemorrhage on endoscopy

If patient still bleeding after intial endocscopy or rebleeds after repeat endoscopy, go to IR, then to surgery

In variceal bleed, they recommend terlipressin until definitive haemostasis or for 5 days

GIVE PROPH ABX for suspected variceal bleeds

Go to TIPS if endoscopic treatment is unsuccessful

What is EMCrit drinking?

Rodenbach, an amazing Flemish Sour Ale

Now on to the Podcast…

So my friend, Darren Braude and one of his co-attendings had a horrible airway case, which they presented on EM:RAP. I wanted to comment on the case, because there is so much great teaching fodder. If you have access to EM:RAP, go listen to this portion on the July episode first. I say it in the show, but let me be very clear here as well--the folks involved did an incredible job. These comments are solely Monday-morning quarterbacking.

I introduce two concepts in this wee:

Prepassing the bougie in the mouth and CricCon

Prepassing the bougie

I am fed up with having to look away from the cords on difficult airways, so I've taken to putting the bougie in the mouth at the level of the right molars before lifting to expose the glottis. A partner can do the same for you. Listen to the audio to get the full idea.

CricCon Readiness Level

Similar to the DefCon, the prior measure of US military alertness level, CricCon is what level of readiness you have to perform a cricothyrotomy. Hopefully this image explains it all:

Click here for Full Size

All airways should be level 5. Predicted difficult airways should always be at least a 4. In a "forced-to-act" situation you should be a 3. If the first attempt fails, I would move to a 2.

Update: CricCon2 has been released, check it out

Art Contest

Draw your vision of the EMCrit mascot and win a copy of Mike Winters' Emergency Department Resuscitation of the Critically Ill

See here for all the rules and details

Now on to the Wee...

I got to speak with Michael McGonigal, MD of the Trauma Professional's Blog about severe pediatric trauma in the ED.

Pediatric Glasgow Score

Best eye response: (E)

Eyes opening spontaneously

Eye opening to speech

Eye opening to pain

No eye opening or response

Best motor responses: (M)

Infant moves spontaneously or purposefully

Infant withdraws from touch

Infant withdraws from pain

Abnormal flexion to pain for an infant (decorticate response)

Extension to pain (decerebrate response)

No motor response

Best verbal response: (V)

Smiles, oriented to sounds, follows objects, interacts.

Cries but consolable, inappropriate interactions.

Inconsistently inconsolable, moaning.

Inconsolable, agitated.

No verbal response.

Any combined score of less than eight represents a significant risk of mortality.

Articles Mentioned in the Episode

* Cerebral hemodynamic predictors of poor 6-month Glasgow Outcome Score in severe pediatric brain injury. J Neurotrauma 26(5):657-663, 2009.

* CPR for bradycardia with poor perfusion vs pulseless cardiac arrest. Pediatrics 124(6): 1541-1548, 2009.

* Osmolar therapy in pediatric  traumatic brain injury. Crit Care Med 40(1): 208-215, 2012.

The Trauma Professional's Blog

Want to read more of Dr. McGonigal's stuff; hell yeah you do. Go on over to the The Trauma Professional's Blog.

Now, on to the podcast...

Are we creating a blockage of blood flow to the brain?

This article has created quite a stir in the resuscitation community:

Impairment of carotid artery blood flow by supraglottic airway use in a swine model of cardiac arrest.  Segal N, Yannopoulos D, Mahoney BD, Frascone RJ, Matsuura T, Cowles CG, McKnite SH, Chase DG.  Resuscitation. 2012 Mar 28.

 

Are EGAs harming carotid blood flow during CPR and therefore making neurological outcomes worse? At least in pigs, this is worrisome. Human data to follow.

What am I going to do with this? At least for now, keep using LMAs (the device associated with the least problems), but now I will check cuff pressure to make sure it stays below 40 cm H20

Additional Reading:

Andy Neill has an amazing Anatomy for Emergency Medicine Post on this very issue

Now, on to the wee...

The 2nd EMCrit Live Show was so much fun!

Here are some of the things we discussed:

Should we be using the femoral route for central lines?

Minh Le Cong posed that question.

Seth (@mdaware) has a great post with a talk by Matt Pirotte

All of the evidence is there.

Who to lyse in submassive PE?

Casey Parker of Broome Docs fame asked this one.

Who needs Cath after Cardiac Arrest?

Karen from down under asked this one. Luckily I have a post just waiting to go with the answer.

Should we be using NIPPV for ARDS or Pneumonia?

Andy Buck (@edexam) chimed in with this one.

What should you do if your cath lab refuses to take therapeutic hypothermia patients?

Rebecca, a PA Student, wrote in with this question.

Alexander a prehospital and ED doc from Spain wrote and asked:

Should we be using CPAP or BiPAP for Preoxygenation?

and finally, the Rogue Medic wants to know why I don't talk about

Not needing to Intubate once DSI has been used?

The Recs:

 

* Use Hunt & Hess or WFN Scores

* Risk of early rebleeding is high – be quick and decisive in getting the aneurysm secured

* Still recommending LP if negative CT

* Get CTA if CT or LP is positive

* MRI may be useful if negative CT, but if negative you still need a LP

* Keep SBP < 160 until clip/coil

* If delay until clip/coil, use aminocaproic acid or TXA

* Give nimodipine to prevent delayed cerebral ischemia

* Need CSF drainage if acute, symptomatic hydrocephalus

* Consider anti-convulsants in acute SAH management

* Use isotonic fluids, keep fluid balance positive

* Keep patient Normothermic

* Control Hyperglycemia

from:

Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage

doi: 10.1161/?STR.0b013e3182587839

What is EMCrit drinking?

An insanely good aged sour ale: Rodenbach 2009 Vintage

 

Today we are joined by Benjamin Abella, MD to discuss who to cool after cardiac arrest.

Who is Ben Abella?

Dr. Benjamin Abella is an Assistant Professor of Emergency Medicine and the Clinical Research Director of the Center for Resuscitation Science at the Perelman School of Medicine of the University of Pennsylvania. His research focuses on the clinical care of cardiac arrest victims, with a special emphasis on methods to improve the quality and training of cardiopulmonary resuscitation (CPR). He also maintains an active research program in the use of therapeutic hypothermia to improve survival after resuscitation from cardiac arrest. He is the medical director for the nation's only therapeutic hypothermia intensive training and certification course, based at the University of Pennsylvania. Dr. Abella also serves on the Medical Advisory Board of the Sudden Cardiac Arrest Association.

Want More?

* See the EMCrit Hypothermia Deep Dive

* Center for Resuscitation Science

* The free course Ben mentioned is starting in July

Now on to the Podcast:

 

An anonymous EM Intensivist writes:

Scott,

I am writing to comment on a trend that I'm noticing among my residents, and I wonder if others are noticing a similar trend.  I am an emergency physician and an intensivist at the University of XXXXXXX, and I have a number of EM residents who avidly listen to your podcasts.

 

Over the course of the last year, most of our residents have made the transition to using rocuronium for RSI (mostly based on recommendations from your podcast, I think).  I use rocuronium preferentially as well, for many of the same reasons that you cite.

 

What has not accompanied the use of rocuronium, though, is an accompanying willingness to provide adequate sedation and pain control.  I find that this is especially true with trauma intubations.  I would say that the usual course of events goes something like this: etomidate and rocuronium for RSI, tube goes in, patient is hypotensive (trauma patient), so patient gets crystalloid or blood during emergent evaluation.  After 5-10 minutes, blood pressure and HR start to trend back up, and most everyone in the trauma bay is patting themselves on the back because they have resuscitated a hypotensive trauma patient.  They are going to CT.

 

In the old world order (the etomidate and sux days) -- which I do NOT think was better -- the clinical course would be the same ... except.  After 10-15 minutes, that hypotensive trauma patient would start coughing (with better vitals), then would sit up and give someone the finger while he was preparing to pull his endotracheal tube out.  The janitor would peer into the trauma bay and would recognize a trauma patient who needs sedation, and sedation would be provided.

 

Now, everyone is hesitant to give long-acting sedative medications to our patients immediately post-intubation, because pts are "sedated" and we're worried about hypotension.

 

I think that this is an unintended consequence to the transition of moving to rocuronium as a paralytic agent for RSI.  I think it's a great drug, but I think that when the tube goes through the cords, the intubator needs to announce to everyone in the room "I've given a paralytic drug that lasts for an hour, the sedative agent that I gave does not, so we are going to give ___ right now so that this guy does not wake up paralyzed."  Propofol infusion +/- fentanyl, bolus of midazolam and dilaudid -- I don't really care what people use, but I think that the way that people are starting to practice is to unintentionally use pain and awareness as a pressor, and I hate to see this happen.  I also think that people need to think to watch the vitals and respond with sedation as necessary.  I had one case of a SAH that started with intubation and ended with a resident using labetalol IVP for HTN that started about 20 minutes after intubation.  In many of these patients, propofol can be a very effective antihypertensive.

 

I have not done in depth analyses to see what our patients remember (perhaps we should), but I'm a little worried that someone out there is aware of their resuscitation while they are paralyzed because we are not rigorously applying the pharmacokinetics we know about the agents we are using.  I think that in some cases, their physiology would suggest that they might.

 

Thanks for all the good work you do for our community,

N.

 

This wee is my audio response. But to sum it up:

* If you are going to use roc, you better be starting sedation the second you are done securing the tube

* There is no patient so unstable that they do not deserve analgesia and sedation.

* For more see this previous