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The Future of CPR

I got to interview two cutting edge researchers on what CPR will look like in the next decade; their answers were fascinating.

Flow-Enhanced CPR

They discuss the use of the impedance threshold device and the active-compression/decompression device to augment flow during CPR. See the results of the ResQ trial listed below to see what this does in cardiac arrest patients.

Note: Dr. Lurie is the founder, chief medical officer, and a major shareholder of the company that manufactures these two devices. Dr. Yannopoulos has no conflicts of interest.

Reperfusion Injury Protection

Stutter CPR is giving 3 cycles of 20 seconds of compressions/ventilations, 20 seconds of pause. In pigs, this has markedly reduced the reperfusion injury when resuscitating a patient with prolonged arrest.

New Medications

Sodium nitroprusside (in addition to small doses of epi and flow-enhanced CPR) increases flow to the heart and the brain. May also blunt reperfusion injury to heart and brain. In addition adenosine and cyclosporine A may have a role as well.

Note: None of this is ready for clinical use--this may be the future, it is not the present

Want More?

* A presentation on the topic by Dr. Yannopoulos

* Read the ResQ Trial (Lancet  2011;377(9762):301–311)

Supplemental Audio

More on the ROC-Primed Trial and the ResQ Trial (MP3 File--Right Click and choose Save As)

More on Dosing and Intra-Arrest Hypothermia and Cath (MP3 File--Right Click and choose Save As)

Update

* Recent 15-minute pig cardiac arrest study provides continued evidence of ischemic post-conditioning (Resuscitation  Volume 84, Issue 8, August 2013, Pages 1143–1149)

* Review article on the physiology of CPR

This podcast is eligible for EMCrit CME

And Now to the Podcast...

 

From Minh's Interview, I stole this five minute piece for an EMCrit Wee.

Cliff Reid discusses some tips for occasional intubators.

Welcome to the first episode of Practical Evidence, a podcast about the evidence you NEED to know but may not have time to read.

This month we discuss the Eastern Association for the Surgery of Trauma’s (EAST) guidelines on the management of penetrating trauma.

What’s EMCrit Drinking?

This month, I’m drinking a Mary’s Maple Porter from Brooklyn Brewery

Please visit our bandwidth sponsor:

Please check out our bandwidth sponsor EB Medicine for great offers exclusively for our listeners.

This is a recording of the first EMCrit Live episode. Hope you enjoy.

Please check out the new EMCrit CME Site!

Crash 2 and Tranexamic Acid

One of the most exciting and underutilized therapies for trauma is tranexamic acid (txa). TXA inhibits the breakdown of clot--it is an anti-fibrinolytic. Is there evidence for using this in trauma patients?

First came the Crash 2 Trial (Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; 376: 23–32),

then the subgroup reanalysis (Lancet. 2011 Mar 26;377(9771):1096) showing the benefit of treatment as early as possible.

Recently, the MATTERS trial (Arch Surg. 2012; 147:113-119) was published demonstrating the benefits of TXA in military situations, particularly massive transfusion.

How about an incredible review from the J Trauma (2011; 71(1) Supplement S9)

Then there is this paper describing current military protocol rationale.

To discuss TXA in Trauma, I got to interview Dr. Tim Coats, one of the primary authors of Crash 2.

Here is a List of Resources from the Crash 2 Investigators

This is the official resource page from Crash 2

 

We also discussed the concept of the pragmatic trial...

Future Research in Emergency Medicine: Explanation or Pragmatism

(Emerg Med J 2011;28(12):1004)

Listen to the podcast excerpt on pragmatic trials (mp3--right click the link and choose save-as if you want to download)

In an amazing demonstration of synchronicity, Jeff Guy of the ICU Rounds Podcast put out a tranexamic acid episode on the same day.

Minh Le Cong provided this prehospital protocol for TXA use.

An incredible review article can be found at this citation (Journal of TRAUMA 2011;71(1) July Supplement)

Update...

This article published in J Trauma (74(6), May 2013, p 1587–1598) gives an excellent summary of the current evidence as of 5/2013

Summary: What Do We Know?

* TXA is associated with a 1.5% reduction in 28-day all-cause mortality in adult trauma patients with signs of bleeding (SBP < 90 mm Hg, heart rate > 110 beats per minute, or both, within 8 hours of injury) in a large pragmatic prospective randomized placebo-controlled trial.

* What is critical is the modest effect on the overall population: All-cause mortality was “significantly” reduced from 16.0% to 14·5% (NNT, 67). The risk of death caused by bleeding overall was “significantly” reduced from 5.7% to 4·9% (NNT, 121).

* TXA signal for benefit was in the most severe shock group (admission SBP <= 75 mm Hg), 28-day all-cause mortality of 30.6% for the TXA group versus 35.1% for the placebo group (RR, 0.87; 99% CI 0.76–0.99).

* 1,063 deaths (35%) were caused by bleeding in the CRASH-2 Trial.

* TXA had greatest impact on reduction of death caused by bleeding in the severe shock group (SBP <= 75 mm Hg) (14.9% vs. 18.

If you want to understand this post you probably need to listen to the episode on c-spine imaging approach and the follow-up regarding the evidence behind it.

 

Mike Wells from Scotland Writes:

Hi Scott,

Your two excellent podcasts on C spine imaging really got me thinking.

I work in the UK where resource constraints within our public

healthcare system mean that even if I wanted to, I would not be able

to obtain CTs as the first imaging port of call for all my neck trauma

patients. I can however argue individual cases with the radiology

department and therefore effectively need to try to choose high risk

patients.

I pulled the Canadian C spine and NEXUS studies and looked back

through their methodology and results. In both studies ordering a neck

CT was at the discretion of the treating physicians - but most

patients only got plain C spine films (in CCspine 436 patients got CTs

= 7% of total patients who were imaged; for NEXUS I could find data to

allow me to make this calculation). I also went through the further

NEXUS study looking at missed fractures - another way of looking at

their data is that in the 581 patients with technically adequate C

spine films, only 3 unstable fractures were missed - giving a

sensitivity of 99.4% for the unstable injuries which I am most scared

of missing.

I absolutely agree with you though that very often plain films are

technically inadequate and that their sensitivity is therefore much

lower.

However I would argue that the real sensitivity we are interested in

is not that of C spine films alone, but rather than the sensitivity of

the combination of plain C spine films and clinical examination and

acumen. CTs in the NEXUS and Canadian studies were after all ordered

at clinician discretion. It's possible that fractures were missed in

the patients who weren't scanned but both studies did seem to attempt

follow up (NEXUS in particular checked local 'event logs' although I'm

not clear on what these are).

So I think over here in the NHS I would argue that in 'minor' trauma

patients failing the CCspine rule I am still obliged to use plain C

spine films as my first imaging step. On the basis of what you have

said I'll will set the bar higher in terms of making sure films are

technically adequate (over here we still use Swimmer's views, which I

detest). However for patients with adequate films and the roughly 3%

prevalence of fractures in the group failing Canadian C spine, I would

hope that my clinical exam would then identify those patients with

normal films but underlying injuries.

Utimately I think from my view what this is about is not the

sensitivity of plain films on their own - which I agree is

unacceptably low - but about the sensitivity of plain films + clinical

skills.

Please feel free to put this in your comments section if you wish!

Thanks again for your fantastic podcast and blog.

Best wishes

Mike Wells

Here is my response to Mike and the others who voiced similar questions about what to do when CT is not easily obtained...

The Lewis Lead (S5)

How to place the electrodes for the Lewis Lead (S5)

from Christopher Watford's blog My Variables Only Have 6 Letters...

S5 Lead: You can produce this using many variations of the electrodes, however, for simplicity's sake we will stick with Kelly's description:

* Place the Right Arm electrode on the patient's manubrium.

* Place the Left Arm electrode on the 5th intercostal space, right sternal border.

* Place the Left Leg electrode on the right lower costal margin.

* Monitor Lead I.

Image from Paramedic Watford

Lewis Lead Enhances Atrial Activity Detection in Wide QRS Tachycardia

The Lewis Lead - Making Recognition of P Waves Easy During Wide QRS Complex Tachycardia

Christopher's ideal path to learning ECGs if he had to do it all again

1. Structured Learning: Garcia and Holtz "12-Lead ECG: The Art of Interpretation"

2. Depth of Knowledge: skip Dubin, get Chou's/Goldman's/Marriott's (something with meat)

3. Deliberate Practice: read 1000's of ECGs. Brady & Mattu "ECGs for the Emergency Physician", Marriott's "Challenging ECGs", Harvard's WaveMaven

4. Participate!

* Dr. Smith's ECG Blog

* The EKG Club

* EMS 12-Lead Blog

Structured Learning/Depth of Knowledge links:

http://library.med.utah.edu/kw/ecg/ (Alan E. Lindsay's ECG Learning Center)

http://lifeinthefastlane.com/ecg-library/

 CCTMC Conference

The Air Medical Physician Association is co-sponsoring an upcoming conference called CCTMC: Critical Care Transport Medicine Conference—info and brochure available here.

It’s 4.2.12 through 4.4.12 in Nashville.

This year’s opening talk at the conference, is “Upstairs Care Outside: Top Ten Tricks of the Trade for Bringing ICU-Level Care to the Transport Environment.”

And now on to the wee...

It is winter and that means cardiac arrests coming in with extremely low body temperatures after environmental exposure. How do you treat these patients? How do you rewarm if you don't have bypass?

BVM Ventilation

Today I want to talk about proper ventilation with a Bag-Valve-Mask, aka the BVM. I am joined by my friend Reuben Strayer, MD of EM Updates. You'll see Reub's talk from this year's EMCrit ED Critical Care Conference and hear some of my thoughts as well.

After Reuben's lecture, I made a few points of my own:

* Anesthesiologists can't do one hand BVM as well as they think, at least according to this article: (Anesthesiology 2010; 113:873-9)

* How about the best article on how to manipulate the jaw for optimal BVMing

* Here is a link to an article where I discuss Vent as a Bag and here is the video as well.

need an audio-only version, (right click here and choose save-as), otherwise

Updates:

Please use the Ultimate BVM

* Pressure Gauge

* One-Way Exhalation Port

* PEEP Valve

* ETCO2

Head Rotation for BVM

* ResusME

Or Consider the Oxylator

* The Oxylator Podcast

More on BVM Use

* Kovacs from AIME

* How to Grade Quality of BVM Vent

* Why to Bag during Apneic Period1

And now to the Vodcast...

1.

Casey J, Janz D, Russell D, et al. Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2019;380(9):811-821. [PubMed]

Today I had the pleasure to interview Dr. Paul Marik, Professor and Division Chief of Pulmonary Critical Care at Eastern Virginia Medical Center. We got to speak on the topic of fluid responsiveness--one of the toughest questions in critical care.

Fluid Responsiveness

The definition we are using for fluid responsiveness is an increase of stroke volume of 10-15% after the patient receives 500 ml of crystalloid over 10-15 minutes

Dr. Marik's Path through the Morass

this is a modification of the algorithm from Dr. Marik's upcoming paper

* if using passive leg raise, give a 500 ml bolus if the response is positive

What is Passive Leg Raising?

For a brief period of time, a bolus of fluid is sent to the heart, allowing you to test fluid responsiveness without doing anything permanent to the patient's fluid status.

What is the Monitor that Dr. Marik mentioned?

The NICOM Monitor by Cheetah Med uses bio-reactance to yield cardiac output/stroke volume non-invasively. I have been trialing the monitor and have been very impressed so far. It is inexpensive and correlates with my echocardiograms.

Articles of Interest

* This systematic review basically was the end of using CVP in the ICU for fluid responsiveness: Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares

* Marik's review of hemodynamic parameters to guide fluid therapy

* An even better review by Dr. Marik will be published in the journal Resuscitation, as soon as it is published, I'll put it up on the site

* If using Pulse Pressure Variation, probably only helpful if <9 or >13: Assessing the diagnostic accuracy of pulse pressure variations for the prediction of fluid responsiveness: a "gray zone" approach. by Maxime Cannesson (Anesthesiology. 2011 Aug;115(2):231-41.)

Neither Dr. Marik nor I have any Conflicts of Interest!

Update 6-10-12

Here is an amazing review article by Dr. Marik on this topic

and Now to the Podcast...