EMCrit Podcast - Emergency Critical Care

Chris Nickson is an Aussie, oops Kiwi, who is a lead author of a great blog: lifeinthefastlane.com and tweets under the moniker @precordialthump; check him out, he's doing really good stuff. He wrote a comment about the last podcast-- Hey Scott, Great to hear your views and approach to EGDT. I agree with the need for aggressive resuscitation of the septic patient – with fluid, antibiotics, vasopressors (we’re a ‘norad/ norepi shop’ too) and adequate oxygen delivery being the mainstays – and, if nothing else, the Rivers paper deserves credit for bringing this into the spotlight. However, the Rivers study itself is still a cause of concern for me – a single center study that has never been repeated as an RCT, with a very high mortality in the control arm (mid-40s%), and more recently the WSJ allegations about about methodological ‘dodginess’ behind the scenes and concerns about conflicting financial interests (of which I’m not sure what to make). Most ICUs in Australia don’t use CV02 monitoring, yet our mortality rates are substantially better than the Rivers study (ICU sepsis mortality around 20% these days, down from 34% in 1997) – different populations or something else? I’m also uneasy about the blood transfusion phase of the Rivers protocol. Hopefully trials like ARISE and ProCESS will help clear up what actually works. In the mean time, I heed your call to resuscitate! Cheers, Chris Nickson ED/ICU Registrar, Perth So in this brief aside, I respond to Chris' comments and tell you a bit about the EMCrit Podcast EBM philosophy. Here are the links mentioned: Henry Ford Hospital Reply to WSJ - 10.27.2008 New MSSM ED Crit Care Sepsis Protocol MR of Early Quantitative Therapies for Sepsis

In this episode I rant and rave about why for the most part Emergency Medicine has disappointed me by not doing something about our sick septic patients. If you are offering aggressive (Early Goal Directed) therapy in the ED, then good on you.

On this podcast, I recap from last show, especially the concept of bare minimum normotension (called erroneously permissive hypotension by just about everyone else) and why we should keep the MAP higher if there is suspected elevations in intracranial pressure I then talk about massive transfusion. This is probably the best strategy for a patient that will require greater than 8-10 units of PRBCs. What may be the best review of the topic is by Spinella and Holcomb: (Blood Reviews 2009;23:231-240) I talk about 1:1:1 transfusion PCC, Factor VIIa, Cryo Calcium IV Access coming up in the next few podcasts: Sedatives for Intubation, Trauma Airway Management, The Crashing A-fib patient

Thought we'd talk about some trauma stuff, specifically the resuscitation of the critically ill hemorrhagic shock patient. There is much to discuss, so this will be a multi-episode affair. Today, we'll concentrate on the Lethal Triad and BP Goals. Lethal Triad The picture says it all. Bleeding causes acidosis, hypothermia, and coagulopathy. Then the cycle begins as they all beget each other. If this continues for too long, it is irreversible. We can iatrogenically make things worse by keeping our patients exposed and infusing ice cold fluids and products. By diluting their existing clotting factors and platelets with too much fluid and red cells. And by not ensuring adeqaute perfusion to counter acidosis. BP Goals Your goal is a MAP of 65. This is not hypotensive resus, which is still not proven. It is normotensive resuscitation; beyond 65, no additional benefts will be seen, but you do risk increased bleeding and dilutional coagulopathy. If MAP 65 - check perfusion there are monitors for this such as NIRS measurement of thenar eminence, but at this stage, I recommend using the presence of a nice strong pulse and warm hands. MAP > 65 & Good Perfusion-stand tight MAP > 65 & Bad Perfusion-give fentanyl 20-25 mcg why fentanyl? b/c taking away pain and fear will limit endogenous catecholamines and the pt's bp will drop slightly from vasodilation. Now give fluids/products to take the MAP to > 65. Here are the articles resus of crit ill trauma patients damage_control_anesthesia Next Time: Massive Transfusion Protocols

The management of severe ETOH withdrawal and Delirium Tremens

Mohamed, a listener from Sudan, emailed asking about the treatment of acute pulmonary edema in patients with low blood pressure. This is in distinction to SCAPE patients (see podcast 1). If the patients have pulmonary edema and low BP from a cardiac cause, then they are in cardiogenic shock. First, consider the etiology: Rate-related Valve Disorder Ischemic (Right sided infarct, STEMI, NSTEMI) Cardiomyopathy Toxicologic At the same time, you are treating the patient with: Inotropes (dobutamine, milrinone, calcium) Pressors to achieve a MAP > 65 (allows coronary perfusion) Oxygenation support, most likely with intubation Optimize O2 carrying capacity (Hb>10)

Does the EM ban on letting sick patients go to CT scan make sense? Listen to the podcast and then register your opinion.

This week's podcast is on the management of a the patient with SAH. It's not a complete review, just some tips and reminders. Best article for EM that I've found, comes out of Columbia For more reviews on mostly ICU issues see here and here. 1. Get a neuro exam before you intubate 2. Intubation Give pretreatment, now just lidocaine and fentanyl Etomidate or propofol; plus sux. Most experienced intubater should perform laryngoscopy 3. Treat Pain and if intubated, give sedation 4. Treat Vasospasm give nimodipine 60 mg PO or NGT 5. BP Control place a-line treat pain first Give Labetalol or Nicardipine to achieve the patient's baseline BP if the patient has good mental status if they are obtunded, be a bit more conservative until ICP monitoring is in place If MAP is below 80, give fluids, pressors, and inotropes 6. Anti-seizure prophylaxis Load with phenytoin or fosphenytoin 7. Anti-fibrinolytics Amicar is the main one these days; ask your neurosurgeon/neurointensivist on a case-by-case basis see ehced.org for drip sheets 8. Reverse Coagulopathy 9. Think Heart these patients can get EKG changes, dysrhythmias, LV stunning, and frank infarcts from their SAH 10. ICP ASAP get the neurosurgeons to get the EVD (external ventricular drain) aka IVC (intraventricular catheter) in place as soon as possible keep ICP 55-60 Please Subscribe and Please Comment! .

Hi folks, this podcast is really brief--I gave a lecture at Jacobi last week (thanks for having me Jacobites!), and in response to a question I gave this rant on my vision of sedation after intubation.

Finally a non-intubation topic! Bolus dose pressors and inotropes have been used by the anesthesiologists for decades, but they have not penetrated into standard emergency medicine practice. I don’t know why. They are the perfect solution to short-lived hypotension, e.g. post-intubation or during sedation. They also can act as a bridge to drip pressors while they are being mixed or while a central line is being placed. Click Here for printable sheet with mixing instructions Ephedrine I don’t use this one much anymore, listen to the podcast to hear why. Onset-Near Instant Duration-1 hour Mixing Instructions: Take a 10 ml syringe with 9 ml of normal saline Into this syringe, draw up 1 ml of ephedrine from the vial (vial contains Ephedrine 50 mg/ml) Now you have 10 mls of Ephedrine 5 mg/ml Dose: 1-2 ml every 2-5 minutes (5-10 mg) No extravasation worries! Epinephrine Do not give cardiac arrest doses (1 mg) to patients with a pulse Has alpha and beta-1/2 effects so it is an inopressor Onset-1 minute Duration-5-10 minutes Mixing Instructions: Take a 10 ml syringe with 9 ml of normal saline Into this syringe, draw up 1 ml of epinephrine from the cardiac amp (amp contains Epinephrine 100 mcg/ml) Now you have 10 mls of Epinephrine 10 mcg/ml Dose: 0.5-2 ml every 2-5 minutes (5-20  mcg) No extravasation worries! Mixing Video: Phenylephrine Phenyl as a bolus dose is just the best! It is clean, quick, and never causes trouble. It is pure alpha, so no intrinsic inotropy, but increases in heart perfusion can improve cardiac output. Onset-1 minute Duration- 20 minutes Mixing Instructions: Take a 3 ml syringe and draw up 1 ml of phenylephrine from the vial (vial contains phenylephrine 10 mg/ml) Inject this into a 100 ml bag of NS Now you have 100 mls of phenylephrine 100 mcg/ml Draw up some into a syringe; each ml in the syringe is 100 mcg Dose: 0.5-2 ml every 2-5 minutes (50-200 mcg) No extravasation worries! Please send me any comments or questions Mixing Video:

We've had a  few gruesome airways in patients with GI bleeds and bellies full of coffee ground emesis. This is a top 10 list encompassing my approach to this difficult situation: 1. Empty the Stomach Place a salem sump and suck out all of the stomach contents. Varices are not a contraindication (see: Digest Dis 1973;18(12):1032 and Anesth Analg 1988;67:283) Administer Metoclopramide 10 mg IVSS 2. Intubate the Patient with HOB at 45° Semi-Fowler's position will keep the gastric contents from moving up the esophagus 3. Preoxygenate like mad You do not want to bag these patients, give yourself a preox cushion 4. Intubation Meds Use a sedative that is BP stable, use reduced doses. These patients NEED paralytics. You need to optimize first pass success. Paralytic agents actually increase the lower esophageal sphincter tone (Br J Anaesth 1984;56:37). 5. Gather your equipment to optimize first pass Use fiberoptic laryngoscopy if you have it (e.g. Glidescope) At the bedside, have a bougie, an LMA, a meconium aspirator (more below), and 2 suction set-ups Wear eye protection! 6. If you need to bag after a failed attempt... Bag gently and slowly (10 times a minute) Consider placing an LMA if you need to bag. 7. If the patient vomits: Trendelenberg This potentially keeps the emesis out of the lungs 8. Meconium Aspirator If the normal suction is too slow, attach the meconium aspirator to your ET tube. See this post on a novel ETT suction set-up for the full description. 9. No ABX for Aspiration Aspiration in the initial phases is a chemical pneumonitis, not a bacterial pneumonia See Marik's article (NEJM 2001;344(9):665) 10. SIRS Expect a sepsis-like syndrome from the aspiration. This folks may need pressors and tons of additional fluid

The video for this lecture is up at this link. Awake intubation can save your butt. It requires forethought and humility--you must be able to say to yourself, "I am not sure I will be able to successfully intubate this patient." However, the payoff for this thought process is enormous. You can try an intubation in the ED with very few downsides. If you get it, you look like a star, if you don't you have not made the situation worse. Two of my critical care resident specialists, Raghu Seethala and Xun Zhong, volunteered to intubate each other awake. The purpose of this was to let them gain experience, understand what their patients would feel during the procedure, and to prove that awake intubation can be done without complicated nerve block injections or fragile equipment, such as a bronchoscope. Here is the procedure for ED Awake Intubation--EMCrit Style: DRY THEM OUT (Do All) If you can give it early 10-15 min before topicalizing, it will be most effective. Glycopyrolate: 0.2 mg IVP (No central effects – does not cross BBB. You can use atropine, but more side effects are possible) Suction and then pad mouth dry with gauze – you want the mouth very dry! TOPICALIZE (Do All) 5 cc of 4% lidocaine nebulized @ 5 liters per min Gargle with viscous lidocaine (4% best, 2% ok). Place a blob (~3 cc) on a tongue depressor, put it in the back of the throat and have the patient gargle and then spit Spray the epiglottis, cords, and trachea with 4% lidocaine (3 cc) in a Mucosal Atomizer Device (MAD). The patient will cough during this spraying, wear eye/face protection Have another syringe loaded with 4% lidocaine to spray with during the procedure Note: the systemic and pulmonary absorption from this method is quite low. The only place to watch out is spraying the trachea. I would not spray more than 2-3 cc down the ol' windpipe. SEDATE (Choose one!) Ketamine and propofol in the same syringe makes Ketofol. The classic mix is 50 mg of ketamine to make 5 cc and 50 mg of propofol to make 5 cc. Put these both in a 10 cc syringe and shake. Depending on the patient's hemodynamics, I sometimes will use more ketamine (75% instead of 50%). Give 1-2 cc every minute until you have the patient relaxed, but still breathing and arousable. Ketamine alone also works just fine. Start with 20 mg and give 10 mg every minute or so. If you have it, Dexmedetomidine also works very well as long as your patient is not bradycardic. If you have neither of these 2 mg of midazolam will do just fine. Preoxygenate with NRB Optimally position (ear to sternal notch) with the head tilted all the way back Restrain both arms with soft restraints to prevent the "grabbies" Switch to nasal cannula INTUBATE with Fiberoptic laryngoscope and bougie If the patient coughs or is uncomfortable after placing the bougie through the cords, push the remainder of the ketofol syringe. Thread  the tube over the bougie with the laryngoscope still in the mouth Confirm tube placement That's all for this week For more info on awake ED intubation, you can view a complete lecture here Thanks to Raghu and Xun for risking their singing careers and to Jimmy & Anita for technical support. * The opinions on this site and in the video represent the author's and not the opinions or policies of the Mount Sinai School of Medicine or Elmhurst Hospital Center. It is not my intention to provide specific medical advice for any individual patient. Please confirm anything on this video with your own clinical judgment and the policies and procedures of your institution. This video is for education purposes only; it does not represent a standard of care or clinical advice.

Sorry about the voice--blame the swine flu. Case Thanks to Joe Chiang Severe DKA; Obtunded with pH 6.65, PaCO2 18, Bicarb 5 Pt’s mental status is worsening The decision is made to intubate Should you give NaBicarb? Probably won’t help as patient is already breathing at their maximum. Unless they blow off the Bicarb-generated CO2, they won’t increase their pH significantly. What you need Properly fitted NIV mask Ventilator, not a NIV machine Someone who knows how to work the vent Normal intubation stuff If available, Quantitative ETCO2 Procedure Place pt on pseudo-NIV Settings are Mode Volume SIMV Vt 550 ml FiO2 100% Flow Rate 30 lpm PSV 5-10 PEEP 5 RR 0 Attach ETCO2 and observe value Push the RSI Meds Turn the Resp Rate to 12 Perform jaw thrust Wait 45 seconds This violates the tenets of RSI, but keeping the pt alive is probably more crucial right now. Most experienced operator should intubate the patient Attach the ventilator Confirm tube placement by observing ETCO2 Immediately increase Respiratory Rate to 30 Change Vt to 8 cc/kg predicted IBW Change Flow Rate to 60 lpm, this si the normal setting for intubated patients (forgot to mention this in the audio) Why 30 BPM? Listen to the podcast. Make sure ETCO2 is at least as low as it was when you started Check ABG Pat yourself on the back

I did a spot on ETCO2 for Amal Mattu's podcast a couple of weeks ago. I try to clear up some of the myths on the use of ETCO2. Of course the most pervasive and potentially dangerous myth is that ETCO2=PaCO2. Long story short, in our patients, it doesn't. Listen to the podcast for more...

Here it is, the 1st EMCrit podcast. It's on the topic of Sympathetic Crashing Acute Pulmonary Edema (SCAPE). To boil it down to 10 seconds: Start patient on Non-invasive ventilation with a PEEP of 6-8; quickly titrate to a PEEP of 10-12. Start the patient on a nitroglycerin drip. Administer a loading dose of 4oo mcg/min for 2 minutes (120 ml/hour on the pump for 2 minutes with the standard nitro concentration of 200 mcg/ml.) Then drop the dose to 100 mcg/min and titrate it up from there as needed. By 10 minutes, your patient should be out of the water. See crashingpatient.com for the references.   Here is some info from a handout from a lecture I gave on the topic: High Dose Nitroglycerin Homeopathic nitroglycerin does not work so well Start at 50-100 mcg/min, you can rapidly titrate to 200-400 mcg/min. You must stand at the bedside to use these doses. Need >120 mcg/min to get sig decreased Pulm Cap Wedge Pressure (Am J Cardio 2004;93:237) But even this strategy is not as effective as the … Nitro Bolus First Can give 400-800 mcg over 1-2 minutes = 400 mcg/min for 1-2 minutes. (Annals EM 1997, 30:382) How to do it Standard nitro mix is 200 mcg/ml. VERIFY YOUR HOSPITAL’S MIX BEFORE USING THESE RECS In order to give the 400 mcg/min for 2 minutes, set the pump to Rate: 120 cc/hr Volume to be Infused: 4 ml (This will deliver 400 mcg/min for 2 minutes and then stop) Or Draw up 4 ml of the nitro and 6 ml of NS and give over 2 minutes After the bolus, I drop the drip to 100 mcg/min and titrate up from there to effect When the patient gets better, you need to sharply decrease this drip rate Some folks have gone even further High dose nitroglycerin for severe decompensated heart failure—2 mg at a time (Ann Emerg Med 2007;50:144) Cotter gave isosorbide 3 mg q 5 minutes with good results in his study. This is equivalent to nitro 600 mcg/min. (Lancet 1998 351:9100, 389-393) Update 6-10-12 Piyush Mallick did an amazing study on nitro-bolus to avert intubation