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This week, I am joined by Leon Gussow, MD of the excellent blog: The Poison Review (TPR). TPR is my source for new toxicology articles; I highly recommend it as an incredible read. I got to meet Leon for a few beers a month ago; he is a great guy.

My Canadian pal, Ram, suggested calcium channel blocker OD as a podcast episode. Ram, here you go.

Calcium Channel Blocker OD

CCB Classes

Nifedipine and other dihydropyridines (amlodipine, felodipine, isradipine, nicardipine, nimodipine, nisoldipine) will cause profound hypotension without bradycardia, due to poor affinity for myocardial calcium channels.  This selectivity is not lost in overdose.  They may actually present with reflex tachycardia

How to tell CCB OD from B-Blocker

CCBs do not cause AMS

CCBs block receptor in B-Islet cells, preventing insulin release, so can see hyperglycemia as opposed to the normal-low sugar in B-Blockers

Presentation

Weak/Dizzy, mild confusion, bradycardia progressing to severe hypotension and shock

Selectivity is lost in overdose (except dihydropyridines)

Treatment

·        Activated Charcoal x 1

·        Whole bowel-Irrigation is not recommended by Leon's group

·        Frequent glucose and k checks

·        Atropine (can try it once, but it will limit gastric motility and probably won't work)

·        Calcium, 1 g of CaCl or 3 g of CaGluc.  Give slowly over 3 minutes for CaCl and 10 min for CaGluc.

·        Glucagon 5 mg bolus, probably won't do much, unlike in beta blocker OD

·        IVF

·       High Dose Insulin. Start with 1 unit/kg push followed by 0.5-1 unit/kg/hr. Fingersticks q30 minutes and adequate glucose replacement if needed. Check potassium; supplement if < 2.5. (Crit Care 2006;10:212) You can see our protocol on High-Dose Insulin Euglycemic Therapy (for informational purposes only, don't use clinically until approved by your P&T committee).

·        May need to use norepinephrine or dopamine (alternatively Epi). May need much higher doses of epi or norepi. Dopamine must be stopped at 20 mcg/kg/min, which is kind of a joke in this OD. Switch to one of the others if you get this high.

·        Levosimendan may have a role, but not available in the US.

·        IABP, CP Bypass

At this stage of the game, if your hospital is not offering hypothermia to out-of-hospital cardiac arrests, you are probably lagging behind optimal care. For shockable rhythms, you essentially double your patient's chances of leaving the hospital with good neurological outcome. However hypothermia can be tough, unless you have done a bunch. Learn from my mistakes in this lecture.

NCS 2010 Hypothermia Talk

I'd love to hear your comments and what you are doing at your hospital.

for more hypothermia resources, see my NYC Hypothermia Section

When I was a resident, every vent lecture either put me to sleep or left me dazed and bewildered. I gave a lecture of that ilk when I started working after fellowship. I had become part of the problem. I decided there must be a way to make vent management more understandable and if not interesting, at least bearable.

This lecture was up on the soon to be defunct EMCrit Lecture site. It offers a path to managing any patient on the ventilator in the ED. I have tried to simplify as much as possible while still maintaining an evidence-based approach.

This is Part II, it deals with the obstructive strategy. Last week, we spoke about the strategy for patients with  lung injury.

Your goal with these patients is to let them have adequate time to breathe out.

There are only 4 things you need to remember for an obstructive patient

Vt (Tidal Volume) = 8 ml/kg, don't mess with it

Flow Rate = 60-80 lpm, shortens insp times (this really doesn't do much good, and super-high IFRs should not be used. Increasing IFR will also increase peak pressure)

Resp Rate = Lung protection, start at 10 work your way down if necessary

FiO2/PEEP = Oxygenation, should need much O2 (40%)m I recommend PEEP of 0, but certainly keep it less than 5

First Print out this Handout

If you need just the audio [right or cntrl click here]

When I was a resident, every vent lecture either put me to sleep or left me dazed and bewildered. I gave a lecture of that ilk when I started working after fellowship. I had become part of the problem. I decided there must be a way to make vent management more understandable and if not interesting, at least bearable. Right now, the actual knowledge in most of EM on vents is dismal [PMIDs: 27330658 and 25497896]

This lecture was up on the soon to be defunct EMCrit Lecture site. It offers a path to managing any patient on the ventilator in the ED. I have tried to simplify as much as possible while still maintaining an evidence-based approach.

This is Part I, it deals with the lung injury strategy. Next week, we'll talk about the strategy for patients with obstructive lung disease.

There are only 4 things you need to remember for a lung injury patient:

Vt (Tidal Volume) = Lung Protection

Flow Rate = Patient Comfort

Resp Rate = Ventilation

FiO2/PEEP = Oxygenation

Read More

First, read my Ventilator Article [Managing-Initial-Vent-ED]

Then, print out this Handout

Audio Only

If you need just the audio [right or cntrl click here]

Updated Refs

* American Journal of Respiratory and Critical Care Medicine Vol. 195, No. 4 | Feb 15, 2017 Mechanical Ventilation to Minimize Progression of Lung Injury in Acute Respiratory Failure

* LOV-ED Low Ventilation Trial (Ann Emerg Med 2017;70:406)

* Low Tidal Volume in the ED decreases mortality: Lung-Protective Ventilation and Associated Outcomes and Costs Among Patients Receiving Invasive Mechanical Ventilation in the Emergency Department. Chest. 2020 Sep 20;S0012-3692(20)34522-0. doi: 10.1016/j.chest.2020.09.100.

 

Now on to the Vodcast...

This post is just to place the vent handout into itunes.

Even when we can't cure a patient, we can relieve suffering. On average, we kind of stink at pain control in the ED. One physician, Dr. Ed Gentile, has created a simple path to optimal acute pain control in the ED. I heard this lecture on the EM:RAP podcast and got permission from Drs. Gentile and Herbert to repost it here. This is not a critical care topic per se, but it is applicable to the critically ill, the non-critically ill--basically any patient who is in pain in the ED.

Patient Controlled Analgesia without the Pump

by Ed Gentile, MD

Need for an effective and efficient process is self evident .

Acute pain protocol for moderate/severe pain

* Administer morphine 0.1 mg/kg IVP (If pt is > 55 y/o, substitute morphine 0.05 mg/kg IVP for this 1st dose)

+ diphenhydramine 0.5 mg/kg IVP

* 7 minutes later the patient is asked, "Would you like more pain medicine?"

* If the answer is yes, give a 2nd dose of morphine 0.05 mg/kg IVP

* 7 minutes later, the patient is asked again, "Would you like more pain medicine?"

* If the answer is yes, give a 3rd dose of morphine 0.05 mg/kg IVP

* This continues every 7 minutes until the patient answers "no" to the question or the patient is asleep.

According to Dr. Gentile, "We don't want to use the minimum, but the optimum pain dose for all patients."

The protocol uses morphine because it has the longest half-life .

Diphenhydramine prevents antihistamine effects: nausea, vomiting, hypotension.

The protocol is unbiased and controlled by the patient!

Photo by Azarius

Update:

There finally is a study validating this process:

Efficacy of an Acute Pain Titration Protocol Driven by Patient Response to a Simple Query: Do You Want More Pain Medication?      (doi:10.1016/j.annemergmed.2015.04.035)

Hi folks, I received a bunch of emails asking how to get the old episodes into itunes. I expanded the RSS feed to include them, now you just need to bring them into itunes, this 40 second video shows you how.

We're still working on the Greater NY Sepsis Initiative. The next step towards making a non-invasive protocol possible is to teach folks how to use ultrasound of the IVC to assess fluid responsiveness. I developed this video to get ED & ICU docs up to speed. If you can do ANY ultrasound exam, you can do this one.

If you want to see the most recent version of the non-invasive protocol:

Non-Invasive Protocol

The invasive protocol that goes with it can be seen here:

Invasive Protocol

photo from wikipedia

Aggressive palliative care is just as important as aggressive critical care in the ED. Sometimes we will be the first physicians to talk to a family about end of life issues, even if their loved one is terminally ill. Now that is not how it should be, but it just means that we must be just as skilled at family palliative care discussions as we are at floating a transvenous pacer. In this podcast, I discuss my vision of how to handle palliative care issues in the ED.

Step I-Identify potential comfort care patients

Step II-Establish goals of care

Either aggressive curative or aggressive comfort. Sometimes, you will decide with the family to a "trial" of critical care

Step III-Sign the Paperwork

Step IV-Maximize comfort

start a fentanyl drip

consider glycopyrrolate or a scopolamine patch

Remember the concept of double effect

photo by P Nicholson

Updates:

Review-Palliative Care in the ED

Two listener questions answered in 5 minutes   From Dr. Ram Reddy of Canada: Great thought to intubate a patient in hemodynamic extremis using the awake approach. I can't tell you how many times I've given etomidate only to have to yell \start CPR\ immediately after( and i just started working). So this stuff about etomidate being HD stable is bullshit, when the pressure is super low. With Regard to awake intubation for the HD unstable patient. My worry is two fold 1) when you are looking to secure the airway of somebody with a systolic of 50, the time required to administer glyco, nebulize lido, gargle( if they can) and atomize is too lengthy 2) I'm also willing to wager that the scenario where you don't really get great topicalization is more common then maybe we think. now you have a patient gagging, bucking, fighting, making 1st pass success more difficult. if they get complete topicalization then i guess I would look heroic, but if it's partial, and they fight you or the muscular tone remains too high to visualize cords well, i think it could look like a gong show? then you are stuck with going back to a conventional RSI with the disadvantage of having manipulated the airway already. what do you think? how about a modified RSI, quick bolus of fluid, 500 of phenyl + half induction dose ketamine + succs + apologize later, if they live to remember that they were paralysed with some awareness. this is the typical induction for the anaesthetists when they need to do a trauma lap on a hypotensive patient at my institution. this question refers to Podcast 23 ------ from Dr. Ram Parekh of my shop: the copd-er had a pH 7.05 and pCO2 119 at the time I decided to intubate, despite NIV and nebs. I put him on NIV SIMV with a minimum rate of 18 (using EtCO2 as a guide) , tv 550, FiO2 100% to make sure he ventilates some while pushing the meds before intubating. Any thoughts? How are you optimizing your hypercarbic resp failure patients? this question refers back to Podcast 3 Great thought to intubate a patient in hemodynamic extremis using theawake approach. I can't tell you how many times I've given etomidateonly to have to yell \start CPR\ immediately after( and i just startedworking). So this stuff about etomidate being HD stable is bullshit,when the pressure is super low. With Regard to awake intubationfor the HD unstable patient. My worry is two fold 1) when youare looking to secure the airway of somebody with a systolic of 50,the time required to administer glyco, nebulize lido, gargle( if theycan) and atomize is too lengthy 2) I'm also willing to wager thatthe scenario where you don't really get great topicalization is morecommon then maybe we think. now you have a patient gagging,bucking, fighting, making 1st pass success more difficult. if theyget complete topicalization then i guess I would look heroic, but ifit's partial, and they fight you or the muscular tone remains too highto visualize cords well, i think it could look like a gong show?then you are stuck with going back to a conventional RSI with thedisadvantage of having manipulated the airway already. what do youthink?   how about a modified RSI, quick bolus of fluid, 500 of phenyl +half induction dose ketamine + succs + apologize later, if they liveto remember that they were paralysed with some awareness. this isthe typical induction for the anaesthetists when they need to do atrauma lap on a hypotensive patient at my institution.