EMCrit Archives

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.

Ok, Ok, I promise this is the last airway episode for at least a little while. I am perhaps a bit obsessed. Had this show in the works for a while. The cric is the last barrier between a failed airway and death. EM docs need to be able to perform this procedure without hesitation. This requires training and practice until you can perform the procedure in

So after the intubation video went up on emrap tv, I got a flurry of emails telling me how cool the concept is, but questioning who this would actually be usable on.To answer that question, we first must discuss who actually requires intubation. If you wait until the patient is apneic, then of course you can't use awake intubation. The idea is to intubate before the patient stops breathing.

Dr. David Schriger gave a fantastic lecture on risk in emergency medicine at the ALL LA Conference. If you have not heard it, go and listen now; it is vitally important to our specialty. This is a brief EMCrit rant on some of my thoughts on the lecture.

Young patient, lactate of 5.2, pneumonia... You know what you're supposed to do--put in the central line and start early goal directed therapy. Problem is, most people can't see sticking a central line in a patient that does not need pressors and otherwise looks well. Yet these patient have an annoying habit of going on to decompensate and perish. Well now there may be another way. Thanks to an article just published in JAMA, we may have a path to non-invasive treatment of severe sepsis. In this EMCrit Podcast, I interview Dr. Alan E. Jones, author of the article, Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. Then I discuss how this article changes the game when it comes to caring for severe sepsis patients.

Pushing some ativan followed by vecuronium is no longer an acceptable strategy to manage post-intubation sedation. A good analgesia and sedation package is essential if you care about your patient's comfort and well-being. We need to move to PAIN-FIRST paradigm. Optimize analgesia and then add in sedative agents as a bonus. In this episode of the EMCrit Podcast, I expand on a previous rant to discuss the optimal way to handle routine post-intubation patients and some special scenarios you may encounter.

Your patient is pale and diaphoretic. Blood pressure is 70/50. Heart rate is 178. EKG shows atrial fibrillation... What are you going to do???Yeah, yeah the Pavlovian ACLS response--You cardiovert. Wonderful, except it didn't change a thing. Now what?In this episode, I discuss the crashing atrial fibrillation patient.

Intubation is a sexy procedure, there is no doubt about it.NIV does not have the glamour; it's not nearly as cinematic. But for the patient, to spend 30 minutes on a NIV mask is preferable to a couple of days on the ventilator. In this episode, I discuss some of the basic ideas and methods of NIV.

Emergency awake intubation in a patient with a difficult airway

So you have a patient with intracranial bleeding or you have a high pre-ct suspicion of intracranial bleeding and they are taking coumadin, aspirin, or clopidogrel. Should you reverse them? If so, how?

Hi folks,Sorry about the voice--got a cold off those damn ED keyboardsThanks to my friend Reuben, this week we'll talk about the asthmatic patient that codes while on the ventThe DOPE mnemonic gives you a path to figure out why a patient is desaturating(If anyone knows who created the DOPE mnemonic, please add a comment or send me an email.)If the pt is asthmatic, add an "S" to make DOPESThe "S" stands for Stacked Breaths--and it's the first thing to address.Address it by disconnecting the vent circuit. Don't think about it, don't dither, just disconnect the vent."E" is for equipment. Attach a BVM hooked up to O2 and you'll eliminate ventilator equipment failures."D" is for tube displacement. Verify the tube with ETCO2, either qualitative or quantitative."O" reminds you to check for obstruction of the tube. See if you can put a suction cath all the way down.If all of these don't fix the problem, then consider "P" for pneumothorax.Lung sounds are not always definitive. Throw on the UTS if you have the time.Otherwise perform bilateral finger thoracostomies. What the hell is that, you say?Listen to the podcast.Then you can read more about it in this articleC.D. Deakin, G. Davies and A. Wilson, Simple thoracostomy avoids chest drain insertion in prehospital trauma, J Trauma 39 (2) (1995), pp. 373–374. Tech Code (please ignore) YQAVYRPWGPHA

To PEEP or not to PEEP, that is the question...in the management of the severe asthmatic

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 ProtocolMR 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 pressureI 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 about1:1:1 transfusion PCC, Factor VIIa, Cryo Calcium IV Accesscoming up in the next few podcasts: Sedatives for Intubation, Trauma Airway Management, The Crashing A-fib patient