Critical Care

Expert Commentary: Troubleshooting Hypoxia on the Vent

In emergency medicine education, we tend to focus on establishing the airway but spend less time discussing the aftercare and managing the ventilator.  While we have spent more time on this recently, thanks to Brian Fuller and his research on the importance of low tidal volume ventilation in the ER (see EM Journal club summary and podcast from February 2014),  most of us are still more comfortable putting the ET tube in than managing the vent.

Luckily for us, here at WashU we have some EM-Critical Care wise guys who can teach us a thing or two, and today we share with you Brian Fuller's method for trouble-shooting hypoxia on the vent, forwarded to us by PGY-3 Brendan Fitzpatrick:

>>From: Fitzpatrick, Brendan
>>To: Fuller, Brian
>>Subject: vent desats

Dr. Fuller,

Good working with you last night. I was trying to recall how you broke down desats on the vent last night, but somewhere between little sleep and my kids' halloween parade, I've lost the finer points.

In all your free time, would you mind jotting down what you told me so I can review it?

thanks,

Brendan

 

>From: "Fuller, Brian"
>To: "Fitzpatrick, Brendan"
>Subject: RE: vent desats


For the purposes of acute deterioration (in the form of hypoxia) on the ventilator, we are gonna talk about two airway pressures: peak pressure and plateau pressure. As an aside, mean airway pressure is the average pressure over one cycle of inspiration and expiration. It is largely governed by PEEP and I:E ratio. It really governs oxygenation- higher it is, more you open up stiff alveoli in sick vented patients.


Peak pressure is the summation of pressure generated from: 1) tidal volume and compliance; 2) resistance and peak inspiratory flow; and 3) PEEP
 

Plateau pressure is a reflection of compliance. Think "how stiff the lungs are"; or "how much transalveolar stretch is occurring".
Compliance is ∆ volume/∆pressure. Specifically, tidal volume/(plateau pressure - PEEP)




So the first thing I do when somebody becomes acutely hypoxic on the ventilator is to look at their peak airway pressure:

1. If decreased: you have an air leak or the patient is hyperventilating/tugging hard and therefore pulling the airway pressures down. Air leak would be something like: bronchopleural fistula, the chest tube you just put in has a leak in the system, your ETT has migrated or cuff has a leak and air is escaping.

2. If increased: see above- this could either be primarily a compliance or resistance problem. So your next step is to look at the plateau pressure to figure out where the problem lies.

If no change in plateau, you therefore have a bigger difference between the peak pressure and the plateau pressure than existed before the hypoxic event. See above for what governs these pressures, so you can tell that this is therefore a resistance problem. Think: airway obstruction from bronchospasm, clogging of the ETT with secretions, kinking of the ETT.


If plateau pressure is also increased, you now have a situation where the peak and plateau pressures both increased. See above for what governs these pressures, so you can tell that this is therefore a compliance problem. Think: pulmonary edema, abdominal distention, pneumothorax, atelectasis, etc.

3. If no change: think "Something made my patient hypoxic but didn't change my airway pressures." Not a lot of stuff does that. Think: pulmonary embolism, PFO.

Sometimes it is difficult to figure out "Is the ventilator and my ventilator settings the problem, or is this a patient problem?" If you remove the patient from the ventilator, and therefore take that out of the equation, bag them and they get better, it is probably a ventilator problem. If you bag them and they stay bad, it is probably a patient problem.

Hope this helps. Hit me back with questions PRN.

Feel free to share with others.

Be good man.
B



For those of you who like pictures, here is a visual representation of the algorithm:

Want to do a little more reading or watching about this? Life in the Fast Lane had a nice review of Pulmonary Mechanics.  I recommend the second Eric Strong video on pulmonary pressures as a supplement to understanding the above material (and hell, it only takes 9 minutes to watch).

Expert Commentary by Brian Fuller
Visual aids by Maia Dorsett (@maiadorsett), PGY-3 
Expert inquiry, sharing skills and parenting by Brendan Fitzpatrick, PGY-3.

@WUSTL_EM FOAMed Digest #7: Best of the Best of the Best Sir! ...With Honors

To build on my “Intro to FOAMed” lecture from Tuesday, I thought I would use the Digest this week to highlight some of the highest-quality resources out there for those of you just dipping your toes into the FOAMy goodness. You can’t go wrong adding these to your Feedly. Well-referenced, expert review, open discussion with prompt response – they’re really setting the bar for the FOAMed world.

And don’t worry – in the spirit of FOAMed the lecture and slides will be posted as soon as the video editing is done.

Now come on in, the water’s fine!

Three Stars:

1. Academic Life in EM (ALiEM) continues to be one of the paragons of the FOAMed community. Check out this “Diagnose on Sight” case from this week – don’t want to give it away, but you will see it time and time again during your Children’s shifts. Make note of the reference list and pre-publication review from a practicing clinician. Supremely high quality.

2. I must credit my inspiration for this FOAMed Digest – the LITFL Review from Life in the Fast Lane. Curated by some of the sharpest tacks around, it’s a great way to get familiar with the variety of resources out there. Lots of good stuff this time around, including links to Amal Mattu’s EKG video review of QT prolongation, the latest edition of FOAMCast (all about the spleen!), and the St. Emlyn’s view of the new NICE guidelines for managing acute heart failure.
EXTRA CREDIT: If you need help keeping up with the EM primary literature, the Research & Reviews in the Fastlane segment is a great place to start!

3. EM Lyceum takes the “flipped classroom” concept to the next level. Every month or so, they publish a series of clinical questions focused on a particular topic. This time, it was trauma. The point is to ponder those questions, discuss them in a group, and maybe even do your own research. The EM Lyceum group then publishes the best evidence-based answers they could find in an exceptionally well-referenced summary. Pearl from this month: Bust out the PCC for ICH on warfarin, but no good evidence for PCC in your “average” coagulopathic trauma patient.  





Oldie But Goodie:

This post isn’t actually that old, but it’s about older patients, so we’re gonna count it. On the heels of Dr. Galante’s lecture from last month, Ken Milne at the Skeptics’ Guide to Emergency Medicine takes on Chris Carpenter’s systematic review of ED tool to predict fall risk ingeriatric patients from this months Annals.
This is a can’t-miss episode, as it is the initial installment of the “Hot Off The Press” series. You can watch in real-time as the FOAMed and published-journal worlds start to merge. Each episode of this series will feature a critical analysis and interview with an author of a paper just published in Annals or CJEM. The audience (i.e., everyone) will have a chance to respond with their own post-publication peer review via social media outlets. The top responses will be featured in a future publication in each journal. Knowledge translation and crowdsourced feedback at the speed of social media!

F(FN)OAMed:

If you’re going to pick one podcast to listen to religiously, that podcast should probably be EM:RAP. This month, be sure to check out the segment on IV contrast myths.
Take-home points: Iodine is not an allergen. Seafood allergy does not increase risk of anaphylaxis to IV contrast any more than any other given allergy, although previous reaction to IV contrast or past history of atopy does increase risk. And most notably – premedication with steroids has not been shown to decrease the number of severe reactions.

The Gunner Files:

1. Check out Scott Weingart’s interview with Dr. John Hinds regarding his approach to the patient with blunt traumatic arrest.
In Dr. Hinds’ shop, before they do anything else they: 1) intubate, 2) perform bilateral finger thoracostamies, 3) place a pelvic binder, 4) reduce any gross long-bone deformities, 5) start uncrossmatched transfusion. Only then do they start a formalized assessment. Really interesting stuff.

2. Similar to the R&R from the Fastlane mentioned above, Ryan Radecki’s EM Lit of Note blog is another excellent version of a curated primary literature review. Here is his critical appraisal summary of a systematic review and meta-analysis comparing trauma “pan scan” with more selective imaging.

3. The most recent installment of the EM BASIC podcast is your panic-free look at what we know about Ebola – screening, clinical signs & symptoms, diagnosis, isolation, and treatment.

4. The ultimate skeptic, Rory Spiegel of EM Nerd, turns his nihilistic eye towards the cash cow of cardiac interventionalists everywhere – PCI. Turns out, there’s not a lot of evidence to support its use outside the realm of emergent intervention for STEMI.

5. In the most recent podcast on Emergency Medicine Cases, an EM sports medicine specialist and an orthopedic surgeon help you to avoid falling prey to the “Commonly Missed (Uncommon) Orthopedic Injuries.” Want to know how not to miss a DRUJ? Lisfranc? Perilunate? Tune in.


Never stop learning,


C. Sam Smith, PGY-3

Expert Commentary: ARISE and ED Sepsis Resuscitation

As we discussed on our last Paper Trail post, the results of the ARISE and ProCESS trials seem to indicate that the most meaningful interventions for a patient in severe sepsis/septic shock are early antibiotics & source control and aggressive resuscitation in an appropriately-monitored environment. 

At our shop, we're currently working on analyzing our own sepsis response data and designing new protocols. In these discussions, some have expressed concern over the potential for giving too much fluid to these patients. The concepts of "fluid responsiveness" and "fluid tolerance" are the subject of much debate in the FOAMed critical care world these days. 
(See the discussions between Drs. Marik and Weingart over at EMCrit for reference.)

Our own ED Critical Care guru, Dr. Christopher Holthaus, stepped up to the plate and offered his views on fluid resuscitation of septic patients in the ED:




"The fluid issue can be challenging. Although some studies suggest that an early restrictive fluid strategy potentially may bear a signal [toward improved outcomes], the preponderance of current ED-based RCTs involving patients with severe sepsis and septic shock will have up-front ED volumes of 4-6L and are showing the best mortalities to date (approx. 18%). [See comparative table below delineating up front/early fluid volumes PROCESS vs ARISE -- Ed.] 

"Although any patient is at risk for volume overload during a resuscitation, patients in these studies appear to have tolerated these volumes relatively well with low adverse events as far as acute pulmonary edema (< 0.02%). We know patients do worse if they are dry and get placed on pressors. Somewhere in between probably lies the truth. Perhaps better exact timing of fluid administration when the heart is truly volume-responsive (i.e., on the ascending portion of the Starling curve) will be the way to go. It remains to be seen, but this approach hypothetically may also show the same overall total volume in the end...     

"Nevertheless, perhaps in the meantime a more judicious rule of thumb is to discriminate "early vs. late" in the resuscitation, and to acknowledge that patients with distributive shock from sepsis generally have trouble maintaining intravascular volume and/or blood pressure during SIRS-related events. Unfortunately we don’t have any great immediate fixes for that yet besides giving volume (or pressors), treating the source, and supportive care. 

"Providers dealing with these patients early in their presentation (i.e., first 6-8 hours) are supported in administering total fluid volumes of 4-6 L (Rivers’ EGDT, PROCESS, ARISE). The RCT using an ED early restrictive fluid strategy for these patients does not exist yet. In current practice, most providers will bolus the first 1-2 L on presentation and perhaps another 500-1000 mL "PRN" based on various factors -- fluid tolerance, tachycardia, hypotension, urine output. The argument for a maintenance rate in these patients is supported by Figure S2 from the PROCESS trial [shown below - Ed.] which used maintenance rates of 250-500 mL/hr once a SBP > 100 or Shock Index < 0.8 were achieved with boluses. This point alone was perhaps one of the best contributions from PROCESS in regards to demonstrating a proven objective alternate fluid administration strategy which went beyond the original use of CVP for quantitative resuscitations. 

"Because the ED currently does not have a go-to gold standard outcome study for gauging volume responsiveness via dynamic changes in stroke volume in these patients, we are left with the fluid volume quantity and rates which stands as the current best available evidence (i.e., 4-6 L in first 6-8 hrs parsed between boluses and maintenance rates).

"In the end, of course one size does not fit all and clinical judgment individualized to the patient is always warranted."

Adopted from ARISE & ProCESS data by Holthaus CV.




Protocol for Standard Therapy arm of ProCESS trial (Supplmental Figure S2)


What do you think? Is fluid overload from ED resuscitation in the "early" phase of sepsis a legitimate concern? When do you pull the trigger and start pressors? Let us know what you think!


Submitted by Christopher V. Holthaus MD.
Copy editing C. Sam Smith, PGY-3.



FOAMed Digest #6 Update: The Paper Trail

Today, we'd like to introduce a new section to the Everyday EBM FOAMed Digest, which will be published as a standalone post. It may seem a bit counterintuitive, but each week we're going to draw your attention to some of the latest-and-greatest papers from the primary EM literature. Most of these will not be open-access, but we hope you can still access them via the medical library at your institution. A lot of the discussion in the FOAMed world centers around recently-published papers from EM journals. The EM trainee should view FOAMed as a tool to assist with understanding and analysis of this literature, as a forum for discussion and further discovery -- not as a replacement for reading the papers for his/her self. We'll provide you a very short summary here and link you to relevant FOAMed resources if applicable.




1) This week, it's impossible to hold any discussion of EM literature this week and not start with the ARISE trial. Hot on the heels of ProCESS, the results of this trial appear to confirm what resuscitationists have long suspected: in terms of sepsis care, you don't have to do a lot of s***, you just have to give a s*** (H/t Dr. Weingart).

Briefly, this multi-center RCT enrolled over 1600 patients from 51 hospitals (mostly in Australia & New Zealand) who presented to an ED with suspected infection, 2+ SIRS criteria, and refractory hypotension (low SBP after 1L IVF) and/or hypoperfusion (lactate >4). These patients were randomized to receive EGDT (as ensured by a dedicated sepsis response team) or "usual care," which allowed for treatment at the physicians' discretion except that ScvO2 measurement was not permitted within the first 6 hours of therapy. There was no difference in the primary outcome, mortality at 90 days.

Needless to say, this publication has got the FOAMed world all atwitter (pun intended).

- The best high-yield summary with all the relevant info can be found on The Bottom Line. Also includes links to other FOAM resources, and excellent tables comparing the Rivers trial to the "holy trinity" of modern sepsis studies -- ProCESS, ARISE, and ProMISe.
- EM Lit of Note also published a short piece.
- Scott Weingart of course has an excellent summary on his latest EMCrit podcast, which has the added bonus of including references to two other recently published papers. The TRISS trial from NEJM found no differences in clinical outcomes when using transfusion goals of 9 g/dL vs. 7 g/dL. A retrospective study by Ferrer et al published in Critical Care this month again demonstrates that delayed time to antibiotics for patients with severe sepsis/septic shock increases mortality in a near-linear fashion. (The Bottom Line summary of the Ferrer study here).
- The European Society of Intensive Care Medicine posted an interview and a presentation by the lead author of ARISE, Dr. Sandra Peake.


The ARISE trial is probably more than enough to keep you busy, but a few more items for your perusal:

2) The Dalai Lama of PE diagnosis in the ED, Dr. Jeffrey Kline, is back at it again, this time with a systematic review and meta-analysis of pregnant patients undergoing investigation for PE in the ED. Seventeen studies including over 25,000 patients were analyzed, and Dr. Kline's team found a lower rate of VTE among pregnant patients compared with nonpregnant patients, with a pooled risk ratio of 0.60 (95% CI 0.41-0.87). Dr. Kline cautions, "We do not interpret these data to indicate that pregnant patients have a lower risk of PE when compared to healthy nonpregnant patients. Instead, we believe that our data illustrate that clinicians order testing at a low test threshold among pregnant patients." Well worth a read.
- Our own Captain Cranium, Dr. Chris Carpenter provided a commentary to this piece, astutely summarizing the controversy of PE overdiagnosis.
- Sarah Sanders, a 4th year medical student (!) posted an excellent summary of this paper and other current research to the EM Curious blog.

3) While this next paper is perhaps not of the most relevance to the EM trainee, its publication should be a source of pride for all of us here at Wash U. The results from the Contraception CHOICE Project, conducted entirely here in St. Louis by the Washington University OB/Gyn Department, were published in the NEJM this week. Through private funding, the investigators were able to provide young women enrolling in the study their choice of birth control method, with special emphasis on Long-Acting Reversible Contraception (LARC) such as implants or IUDs. Without cost as a barrier, 72% of the women enrolled chose a LARC method. Women utilizing LARC methods reported unintended pregnancy at a far lower rate than the national average, especially for those age 15-19 years. Really great work.

Never stop learning,
Sam Smith, PGY-3

#FOAMed Digest No. 6: Ain't Nobody Got Time For That

Welcome back, FOAMheads! My apologies for the delay this week. I ended up being a bit busier than I expected, which not coincidentally brings me to the theme for today's entry.

Sometimes you have a lot on your plate and may not be able to set aside a large chunk of time to watch/listen to a 30-minute-plus podcast. But that doesn't mean you don't have time to get your learn on! This time around, we'll highlight some of the best FOAMed sources of short-and-sweet educational pearls. Easily digestible for the highly-distractible mind of the EM trainee.

There is no moment like the present -- let's get started!




Three Stars:

1. The Glasgow Coma Scale was first introduced 40 years ago. It's past time we started assessing it properly. "GCS 12" doesn't cut it any more. What are the deficits? How do you score for eye-opening if the patient's eyes are swollen shut from trauma? What does "abnormal flexion" even mean, anyway? Ian Miller at TheNursePath provides us an excellent infographic-style breakdown of the "new" GCS.

2. The EMS 12-Lead blog, edited by EMT-P and prehospital resuscitationist extraordinaire Tom Bouthillet, is an excellent resource of EKG cases. This week's case provides an excellent example of why a resuscitationist must always treat the patient, not the monitor. Review the EKG and develop your interpretation first, then read the conclusion.

3. I don't know that a FOAMed segment has ever been more appropriately titled. "Positively Painful Private Parts" is a four-part series published by Brad Sobolewski on his PEM Blog, focusing on the evaluation of acute testicular and scrotal pain. There is a pediatric focus, not surprising given the nature of the blog, but Dr. Sobolewski does include information on "adult" diagnoses like epididymitis as well. Each part is succinct and high yield.
Part 1: Focused H&P
Part 2: Testicular torsion
Part 3: Pathology of the appendix testis
Part 4: Epididymitis

Oldie But Goodie:

An excellent case from The Blunt Dissection, in which Dr. Chris Partyka lays out everything you need to know when you must intubate a crashing neonate.

F(FN)OAMed:

Via your EMRA membership, you now have access to all of the resources from the EMedHome website. Go to the site and explore for yourself the wealth of resources available -- everything from taped lectures from prior EM conferences, the EMCast podcast hosted by Amal Mattu, weekly clinical and radiology pearls, and other vodcasts and presentations.

This week, check out the clinical pearl describing some of the changes in the new 2014 AHA/ACC guidelines for management of patients with NSTEMI.  Ryan Radecki at EM Lit of Note also published his take on the new guidelines this week; well worth the quick read.

(As always, if you need help getting access to any of these resources, please contact your friendly neighborhood Social Media Committee member.)

The Gunner Files:

1. Reinforce the take-home points from the EM Lyceum piece on DKA management with this bullet-pointed breakdown by Adaira Landry on emDocs.

2. In case you've been off the grid for the past week, ebola is here. Triage and isolation protocols are coming to an ED near you any day now. Luckily for all of us Daniel Cabrera at the Mayo EM Blog published for your review the CDC infographic Algorithm for Evaluation of the Returned Traveler.

3. So the latest installment of the Skeptic's Guide to Emergency Medicine will take you about half an hour to listen to, but it's well worth the time. Drs. Milne and Swaninathan analyze the Ottawa Aggressive Protocol for ED cardioversion and discharge of patients presenting with AFib.
This piece really highlights the interconnectedness of the FOAMed world, as it references back to last week's FOAMCast on AFib (as seen in FOAMed Digest #5), and a recently-published research letter (containing data from the largest-ever study on this topic) in JAMA calling into question the safety of cardioverting AFib patients presenting with >12 hours of symptoms.
This research letter was analyzed in depth by Rob Orman on the latest episode of his ERCast.
We're all in this together, folks.

4. I don't want to think too hard about having a cricket or other insect lodged in my ear canal, but it is probably in our best interest to know what to do if we're presented with it. Mitchell Li at ALiEM has us covered. (Great tip for getting out plastic beads, too!)

5. When you do get a little extra time, don't miss the September installment of the Annals of Emergency Medicine podcast. Covered topics include pigtail catheters for pneumothorax, acute stroke care, age-adjusted D-dimer cutoffs, and the HINTS exam (authored by our very own Dr. Brian Cohn!) You can download the podcast directly here.
(And be sure to check out Cohn's paper!)

Never stop learning,
Sam Smith, PGY-3

#FOAMed Digest No.5: But This One Goes to 11

Time once again for your mid-week blast of FOAMy goodness from around the interwebs. There’s no particular subject today; instead we’re going to highlight some of the better podcasts/vodcasts that updated this week. Podcasts are great. They break up the monotony of reading (and the monotony of mundane things like laundry, grocery shopping, training for this damn marathon…). For the more distractible among us, they usually come in easily-digestible 20-30 minute morsels. They expose you to different presentation styles, and allow you to match a face and a voice with the big names in FOAMed. Most of them also feature written show notes with references as well, which allows you both to reinforce the things you learned while listening, and also to dig deeper into topics you’re interested in.

Fun for the whole family!

Three Stars:

1. I think FOAMcast, authored by residents and EM social media savants Jeremy Faust and Lauren Westafer, might be the first example of “metaFOAM.” They peruse the FOAM world for interesting recent posts, then integrate that information with relevant material from the most popular EM textbooks (i.e., “Rosenalli”), other relevant blogs/podcasts, primary literature, and even Rosh Review questions. This week they use a post from ALiEM on calcium channel blockers vs beta blockers for A-Fib as a jumping-off point for a discussion on ED management of A-Fib and A-Flutter. There’s links to vodcasts from Scott Weingart and Amal Mattu on narrow-complex tachydysrhythmias, and plenty of cited references from the primary literature (including one from our own Brian Cohn!). It’s good stuff.

2. Speaking of the Godfather of ED EKG, Dr. Mattu has two quick cases for you to ponder. Remember: T-wave inversion does not always mean cardiac ischemia!
Remember: Gotta think tox in a seemingly unprovoked wide complex tachycardia!

3. Steve Carroll at EM Basic provides an excellent analysis of the ED management of asymptomatic hypertension, including references to the relevant ACEP Clinical Policy document and other FOAMed resources.


Oldie But Goodie:

Chris Nickson, creator and administrator of Life in the Fast Lane, gave an excellent talk at the original SMACC conference in March 2013 with the confidence-inspiring title, “All Doctors are Jackasses.” Why are we jackasses? Because we don’t do enough to understand how we think and how we make decisions, and this leads us to make errors. Watch Nickson’s lecture and begin to understand how to remedy this situation.
(EXTRA CREDIT: Links in the show notes to the other SMACC talks in the “Mind of the Resuscitationist” plenary by Weingart, Cliff Reid, and Simon Carley.)

F(FN)OAMed:

By this point you guys all know how awesome EM:RAP is, but this week is particularly relevant because Herbert & Co. just released an “EM:RAP Mini” segment about the newly-published “Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis” trial in the New England Journal. For those of you that aren’t familiar, this was a study in which we participated, and our own Drs. Aubin and Griffey are authors on the paper! An excellent summary of this paper is found on the Emergency Medicine Ireland blog, with a link to download the EM:RAP Mini segment in the show notes.

The Gunner Files:

1. Time to synthesize the knowledge you gained about non-surgical management of pediatric appendicitis at Journal Club last month. Dr. Cohn is back with another excellent EMJClub podcast along with Drs. Trehan and Horst, summarizing the primary literature.

2. EMin5 is back at it with a review of the four types of shock, in a little over four minutes.

3. From the Maryland Critical Care Project, an excellent lecture from Neuro Critical Care and ED intensivist Dr. Wendy Chang describing the ED management of status epilepticus. She covers the gamut from first-line benzos to second-line AEDs and third-line agents for initiation of therapeutic coma.

4. The good people at the All NYC EM blog posted a lecture given during their conference day by the FOAMed superstar Dr. Haney Mallemat. He covers all the basics of ultrasound evaluation of pericardial effusion and tamponade, even ultrasound-guided pericardiocentesis.

5. In case you’re not familiar, US Air Force Pararescuemen, a.k.a. “PJs,” are the ultimate badasses. Just look at it this way: think becoming a SEAL is tough? PJ training has an even higher failure rate. But I digress.
Former PJ and critical care flight retrieval medic Mike Lauria is now in medical school, and is making a bit of a splash in the FOAMed community as an expert on training, thinking, and operating in high-stress environments. Scott Weingart recently interviewed him on EMCrit about the concept of “mental toughness,” how that translates from the combat realm to the ED, and how to incorporate it into physician training. Really interesting stuff.


That Others May Live,

Sam Smith, PGY-3

#FOAMed Digest No. 4: Butter My Biscuit, Baby

Welcome back, to the brand new edition of the WUEMR FOAMed Digest. Get out your Tintinalli’s and strap in, because we’re going back to basics today. It’s all about the bread and butter. The things any PGY-2 setting off to an overnight Saturday shift in the Deuce should have down cold…yet us seniors still screw up on the daily.

FOAMed…ENGAGE!

Three Stars:

1. If my last shift at Children’s is any indication, the season is upon us – pharyngitis in every exam room. Casey Parker over at Broome Docs (a blog authored by EPs & GPs practicing in rural Australia), presents a magnificent summary of the data surrounding rapid strep swabs, antibiotic use for symptom relief, and antibiotic use for preventing secondary complications of strep. As always, be sure to check out the original literature for yourself. And don’t miss Minh Le Cong’s excellent counterpoint in the comments, which is also well-referenced.

2. What’s your record for most C-collars cleared in one shift? (When you hit double-digits, then we can talk.) The best tools in our arsenal for clearing C-spine in low-risk patients remain the Canadian C-spine and NEXUS instruments. But which one should you use? Do you even remember which criteria belong in each rule, or do you find yourself trying to apply the “Canadi-EXUS” criteria, like I do? Luckily for us, Alayna Hawling at BoringEM authored an excellent rundown and comparison – with a pretty flowchart!

3. As much as you want to start the fist-pumping and beer-chugging as soon as you drop that tube past the cords, your work with the intubated patient is not done, my friend! We’ve already touched on our persistently poor rates of achieving adequate analgesia & sedation in the intubated patient. Another part of quality post-intubation care is knowing what to do if your ventilated patient acutely decompensates. Check out Chris Cresswell’s summary of the DOTTS mnemonic over at EM Tutorials.
(EXTRA CREDIT: He also included a link to Scott Weingart’s notes regarding care of the crashing ventilated patient, which are well worth a look.)

Oldie But Goodie:

There’s been some e-mail discussion lately among our attendings regarding the best way to clean lacs prior to closure. Back in February, Ken Milne at the Skeptic’s Guide (along with Eve Purdy, a rockstar med student and creator of the excellent Manu et Corde blog) published a piece dedicated to breaking down the dogma of management of simple lacerations. Tap water vs sterile water, sterile gloves vs clean gloves, to sew or not to sew…it’s all covered here. Plus there’s links to other excellent FOAMed resources regarding wound care dogma.

F(FN)OAMed:

The good folks over at EB Medicine recently published a stem-to-stern guide to UTI diagnosis and management in the ED, all based on best available evidence. A bit lengthier than your average blog post, but incredibly high-yield and well worth your time. It’s a bit difficult for me to place a direct link here, but you can find it simply by logging into your account at EBMedicine, following the link to browse issues of Emergency Medicine Practice, and opening the July 2014 issue on UTI.
(As always, contact your friendly neighborhood Social Media Committee member if you need help obtaining access to EB Medicine resources.)

The Gunner Files:

1. Hard to get through a Deuce shift without breaking out the prochlorperazine at least once. We’ve all seen patients get jittery, agitated, or downright whacky following its use. Does Benadryl help? A PharmD expert at ALiEM has a good lit review of the topic.

2. Short and sweet: some diabetic medications are more likely to cause harmful hypoglycemia after overdose than others. Quick table-based rundown over at ALiEM.

3. It is asthma season, and you may find yourself in the worst-case-asthma-scenario of impending need for intubation. Check out this post from The Kings of County regarding care for the sick asthmatic, including intubation and mechanical ventilation issues.

4. FOAMed is taking the world by storm! Does the UK College of Emergency Medicine launching a dedicated FOAMed site mean it’s officially gone mainstream? Don’t worry – we were all into FOAMed before it was cool. But seriously, check out this vodcast on diagnostics in EM, and not feel quite so much increase in sphincter tone when Carpenter or Cohn pimp you on likelihood ratios or Bayesian analysis.

5. Another classic from the Skeptic’s Guide, this time addressing another oh-so-common ED complaint: renal colic. Fluids? Flomax? Any good evidence for either? In news that will surprise no one, Ken Milne is skeptical.


Never stop learning,

Sam Smith, PGY-3

#FOAMed Digest No. 3: You Need Me On That Wall

Emergency Medicine physicians practice in a unique environment. We must synthesize plans for  diagnosis, management, and disposition while utilizing input from almost every subspecialty, and the ED is the ultimate proving ground for diagnostic tests and treatment modalities of every sort. Unsurprisingly, a fair deal of controversy and debate exists regarding the optimum management of patients. (For reference, see any Trauma Case Conference featuring Drs. Schuerer and Aubin.) The “best evidence” is often poor evidence. We in Emergency Medicine retain the rebellious spirit of our founders, and are always looking for new and innovative techniques. Some physicians are too quick to jump on the bandwagon, and others lag behind the curve when it comes to adopting new practices.

The selections this time around are not meant to tell you the best way to do things. The algorithms and practice patterns suggested are not universally adopted, written in textbooks, or taught as part of any standard curriculum. They are meant to promote thought, to prompt you to read the primary literature for yourself, to encourage you to seek the opinions of other experts on the subject, and to form your own conclusions. Hopefully they will inspire you to suggest new ideas to your seniors and attendings during your next shift – or even question ideas you think are unsound. Maybe, just maybe, they will even inspire a new research or QI project. FOAMed is by design perfectly adapted to assist you in this quest.

Ramblers, let’s get ramblin’.

Three Stars:

1. Ken Milne at the Skeptic’s Guide to Emergency Medicine pretty much sets the bar when it comes to FOAMed of the latest EBM topics. He asks his clinical questions in the PICO format, he applies a rigorous quality checklist when analyzing the available literature, and includes in his discussion other FOAMed experts (including on occasion our very own Chris R. Carpenter, a.k.a. “Captain Cranium”). This episode he turns his skeptical eye to a topic sure to generate heated discussions for years to come: tPA for stroke.

2. If there’s anyone that looms larger in the ED Critical Care world than Weingart, it’s Resuscitationist Extraordinaire Cliff Reid. His lecture from the SMACC Gold conference hit resuscitation dogma like an A-bomb, leaving irradiated bits of unfounded practice patterns strewn about the Outback countryside.
(EXTRA CREDIT: Reid’s talk from the original SMACC conference, “Making Things Happen,” should be required viewing for anyone wanting to be a Trauma Senior someday.)

3. If pediatric surgeons have come to accept ultrasound as a stand-alone diagnostic method for appendicitis, maybe there’s hope that someday ultrasound can also be used as a radiation-sparing technique for diagnosis of small bowel obstruction. Academic Life in EM has an excellent run-down of the technique and comparative research studies.
(EXTRA CREDIT: The book Evidence-Based Emergency Care, authored in part by our own Captain Cranium Chris R. Carpenter, has a chapter dedicated to the inferiority of plain films for SBO diagnosis. You can read it for free online via Becker Library.)

Oldie But Goodie:

I think here in a few more years this will reach “accepted standard practice” level, and maybe even “textbook” level, but it’s not there yet. It should be: there’s good evidence to show kayexelate doesn’t work, and may even cause harm. Let Weingart and the PaperChase fellows from EM:RAP give you the ammunition you need to stand up to any pesky floor seniors.

F(FN)OAMed:

In a very enlightening segment from this month’s EM:RAP, Rob Orman interviews a community ED practitioner, Dr. Cameron Berg, regarding his hospital’s new Accelerated Diagnostic Protocol for low-risk chest pain. While his exact algorithm hasn’t been externally validated and probably isn’t ready for prime-time at our shop, the evidence-based and pragmatic approach is certainly worth considering. And he provides links to almost all of his references in the show notes!

The Gunner Files:

1. The “Research & Reviews” segment on Life in the Fast Lane is worth checking out every week. A group of some of the brightest minds in the FOAMed world get together and spoon-feed us summaries some of the most relevant, practice-changing, or downright strangest papers in the EM literature.

2. Josh Farkas over at PulmCrit wrote an excellent piece laying out his argument for super-high-flow NC (think 30-45L!) as an acceptable method of preoxygenation before RSI. It’s also got a good rundown of apneic oxygenation using NC (which we all should be doing every time), and an enlightening counterpoint from the grand maester of ED Critical Care, Scott Weingart.

3. Pediatric EM expert Sean Fox provides an excellent summary of the neonatal ALTE on his blog Pediatric EM Morsels.

4. Two EM airway heavyweights, Rich Levitan and Reuben Strayer, slug it out in the ultimate Direct Laryngoscopy vs Video Laryngoscopy debate, posted to the Prehospital and Retrieval Medicine podcast hosted by Minh Le Cong.

5. All of us will be the bearer of the -07 phone at some point, and that means you better have your act together when discussing decision-making capacity. Bill Johnston, EMT-P and author of the excellent blog Prehospital Wisdom, shares his fundamentally sound and no-bullshit method for determining capacity in the field.

In the words of Ken Milne: “Meet ‘em, greet ‘em, treat ‘em, and street ‘em!”

Sam Smith, PGY-3

#FOAMed Digest No. 2: Breathless Love

Welcome back! Fresh new FOAMy goodness for you, this time with an emphasis on airway and pulmonary care. Let’s do it!

Three Stars:

1. No way around it: “Delayed Sequence Intubation” is the new hotness. If you want to be one of the cool kids, you better get on board. I’ll let the more graphically-minded folks at EMCurious lay it all out for you with a prototypical case. Don’t miss the links – more excellent FOAMed resources on DSI.
(And Weingart’s seminal paper on the subject is required reading at this point.)
(And, oh yeah, ketamine does NOT increase ICP. Let’s use these two systematic reviews 1 & 2 to stop the foolishness already.)

2. Someday you will need to perform a cricothyrotomy. Accept it as reality, and do everything you can to prepare for it. Start here, with Weingart’s lecture on the surgical airway delivered at the SMACC Gold conference last fall. This page from the EMCrit blog has compiled all sorts of great surgical airway resources from around the FOAMed world all in one spot, including can’t-miss stuff about the scalpel-finger-bougie technique and Weingart’s pre-intubation checklist. You should probably add it to your favorites list now.

3. Wouldn’t be a FOAMed Digest without getting a little off-topic, and Rick Body’s recent contributions over at St. Elmyn’s regarding ACS & “low-risk” chest pain in the ED are too good to pass up. Great post analyzing his recent paper, which concluded ED physicians simply aren’t capable of ruling out ACS in chest pain patients with an acceptable accuracy using only the clinical exam. Dr. Body also gives you a run-down of how to properly utilize high-sensitivity troponin in his talk from SMACC Gold.
(Link to Body's paper here.)

Oldie But Goodie:

By the end of our Ultrasound rotation, we can all diagnose pneumothorax with ultrasound at the bedside. It’s time to take it next-level. A-lines, B-lines, pneumonia vs edema…the experts at the Ultrasound Podcast help you figure it all out in a two-part 1 & 2 podcast.

F(FN)OAMed:

Sanjay Arora and Mike Menchine, hosts of the PaperChase segment on EM:RAP, summarize the current literature about how terrible we are at adequately sedating patients after RSI. Roc lasts longer than Sux – the patients won’t be able to tell us they need sedation!
(Links to relevant papers in the show notes.)

The Gunner Files:

1. Brett Sweeny at EMDocs provides an exhaustive review of FOAMed resources regarding permissive hypotension in trauma. Great lectures and podcasts from some of the brightest minds in EM & trauma surgery.

2. We’re seeing it already – asthma cases are starting to pile up over on the SLCH side. Luckiliy for you, Pediatric EM rockstar Andy Sloas just published an excellent podcast on the evaluation and management of asthma in the Peds ED.

3. Next time you’re consulting Ortho or Plastics for a hand injury, sound like you know what you’re talking about. The folks over at EMin5 hit you with the quick rundown on the neuro exam of the hand.

4. Last week, St. Elmyn’s helped the rooks get up to speed when it came to dealing with the dyspneic patient in the ED (and I bet the seniors learned a thing or two as well). This time, get your mind right when faced with a syncopal patient.

5. Who doesn’t love infographics? And if they actually help us learn something about managing septic patients, that’s just a bonus! Very well done by EMCurious, with embedded links to the relevant studies!

6. New podcast from R.E.B.E.L.EM, summarizing the results of a meta-analysis just published this month in Annals which concluded prehospital application of NIPPV in patients with severe respiratory distress regardless of cause reduced need for intubation (NNT 8) and in-hospital mortality (NNT 18). 
w00t prehospital medicine!
(Original pub here.)

That’s all, folks! Go get your learn on!

Sam Smith, PGY-3

#FOAMed Digest No. 1: Total Eclipse of the Heart

Welcome to the very first edition of the WUEMR FOAMed Digest! The Social Media Committee hopes with this segment to parse out from the overwhelming FOAMed universe a few of the most high-yield pieces of highest relevance to the general EM trainee. We hope to deliver this in an easily digestible format that you can realistically work through over a week – even if you’re stuck in an ICU.

Each post will contain several sections:

1. Three Stars: Three of the best-of-the-best from the FOAMed world published in the past week or so.

2. Oldie But Goodie: The FOAMed universe has been around long enough that there’s already a good number of very well-done and highly informative blog posts and podcasts.

3. Free (For Now) Open Access Med Ed: F(FN)OAMed for short. There are some great resources out there that are not free to the vast majority of EM practitioners but, due to your EMRA membership being graciously covered via the residency and MoCEP, you have access to them. Most notably, your EMRA membership allows you subscription to the EM:RAP podcast and the EB Medicine resources – EM Practice, EM Critical Care, etc. You should take advantage of this opportunity while you can, and this section will help you do so. (Contact your friendly local Social Media Committee member if you need help setting up your access.)

4. The Gunner Files: The Social Media Committee recognizes that, with this being Wash U and all, some of you will always be overachieving. So we’ll include a few extra selections for those of you that have a more insatiable FOAMed appetite.

Without further ado, let’s kick the tires and light the fires.
This week, “Total Eclipse of the Heart,” will focus on care of various cardiac conditions.

Three Stars:

1. Ever heard of Wellens’ Syndrome? If you have any hope of passing your boards one day, you should. Not mention that whole “you shouldn’t miss a critical EKG finding that portends certain doom” thing. Never fear, Salim Reazie, author of the excellent R.E.B.E.L.-EM blog, has you covered
(Don’t miss the links list at the bottom that highlights posts from other top-notch FOAMed resources!)

2. Syncope is one of those presenting complaints that really must be approached in a systematic manner. The grandmaster of EM EKG interpretation, Amal Mattu, reviews the differential while highlighting the characteristic EKG findings of a can’t-miss diagnosis.

3. Okay, so DKA isn’t exactly a “cardiac” condition – but the worst-case-scenario is still hemodynamic collapse, right? It counts. The EBM gurus over at Anand Swaminathan’s blog EMLyceum give you the latest & greatest when it comes to evidence-based care of DKA.

Oldie But Goodie:

So you’ve achieved the nigh-impossible – achieved sustained ROSC in an OHCA patient. Now what? The reigning American Idol of EM Critical Care, Scott Weingart, tells you what in an excellent two-part interview with one of the lead authors of the TTM trial, Stephen Bernard.

F(FN)OAM:

Worst-case scenario #137: Running ACLS on a patient brought in with PEA arrest. As CPR continues, the staff looks to you. “Uhhhhhh…more Epi?” Like all things resus, you need a systematic approach. The smart dudes over at EM:RAP, along with EM cardiology expert Amal Mattu, review a newly published paper that will help you do just that in the August 2014 edition.
PubMed link to the paper itself here.
(Once again, contact the Social Media Committee if you need helping subscribing to EM:RAP.)

The Gunner Files:

1. Excellent review article from the journal Emergency Medicine Australasia covering that bane of the overnight Deuce shift. No, not vaginal discharge – dental pain.

2. EMLyceum deals in pearls once again when addressing ocular emergencies.

3. Ryan Radecki over at EMLitofNote looks at a very interesting paper just published in JAMA regarding the use of pulse oximetry and dispo of bronchiolitis patients
(And as always, be sure to read the original paper for yourself!)

4. My FOAMed man-crush, Rory Spiegel of EMNerd, tackles the C-spine injury algorithm debate.

5. The Aussies over at St. Elmyn’s get you straightened out when dealing with the breathless patient in the ED. Incredibly high-yield for new ‘terns, but useful for docs of all ages.

Now get to FOAMing! 
As always, comments/concerns/criticisms are appreciated!



C. Sam Smith, PGY-3