EmCrit Digest (2009)

[Tony Held]

Please find below a brief digest of the EmCrit Podcast (2009). All content courtesy of Dr. Scott Weingart.

Ep 16 - Coding Asthmatic, DOPES, and Finger Thoracostomy - 12/23/09

Abstract
As a request regarding the prior podcast, Scott describes what to do if your severe asthmatic patient codes.

Take Home Points

• The DOPES mnemonic is your friend when it comes to the coding asthmatic, but consider tackling it out of order SEDOP (see below):
  Displacement - Verify placement with waveform capnography
  Obstruction - Insert a suction catheter down the tube (beware of mucus plugs that are easily displaced but reobstruct).
  Pneumothorax - Needle decompress or bilateral finger thoracostomies (see later).
  Equipment - If you've eliminated stacked breaths first and initiated BVM ventilations, you've already eliminated equipment failure from the equation.
  Stacked breaths - Remove your patient from the ventilator IMMEDIATELY to eliminate trapped air.
• Ultrasound is one of the most definitive tools for diagnosing a pneumothorax
• The finger thoracostomy procedure involves making an incision in the mid-axillary site, separating the intercostal muscles with a kelly forcep, and inserting the finger alone into the pleural space. This is suggested to be more efficient than needle decompression in that it does not induce pneumothorax if provider is mistaken on diagnosis, it is rapid and atraumatic to the lung tissue, and it is absolute in confirming presence of hemo or pneumothorax.
• Finger thoracostomy is also suggested to be relevant in traumatic arrests and worsening pneumothorax during diagnostic procedure such as CT.
• Severe asthmatics are often severely dehydrated due to exhaustion and may require aggressive fluid resuscitation and push-dose pressors to prevent arrest.

Ep 15 - The Severe Asthmatic - 12/8/09

Abstract
Outlines treatment of the severe asthmatic patient and the significance of avoiding intubation.

Take Home Points

• Intubating an asthma patient doesn't solve anything; steer clear if you can.
• Try non-invasive ventilation first especially with in-line beta agonists.
• Initiate steroid treatment and magnesium sulfate (if you believe in it, check out the 3MG trial).
• Try Ketamine for its dissociative properties as it will likely be the safest route to reduce anxiety.
• If your patient was unlucky enough to end up on the ventilator, ensure plateau pressures are below 30 and/or the flow graph shows that flow has stopped before the next breath.

Ep 14.5 - A Bit More on EGDT - 11/23/09

Abstract
Scott discusses a response to his prior podcast from Chris Nickson of Life In The Fast Lane.

Take Home Points

• Several studies are discussed as well as their limitations.

Ep 14 - EGDT Tirade - 11/20/09

Abstract
Early Goal Directed Therapy (EGDT) must be integrated in the care of septic patients seen at the ER.

Take Home Points

• Screen all patients at risk for sepsis.
• Initiate aggressive management early even they don't look "that sick".

Ep 13 - Trauma Resus: Part 2 - 10/31/09

Abstract
Reinforces "bare minimum normotension" and highlights what products and medications should be infused.

Take Home Points

• Permissive hypotension suggests intentionally propagating shock as opposed to reestablishing perfusion while mitigating unwanted additional bleeding.
• Rapid transfusion should utilize 1:1:1 product ratio.

Ep 12 - Trauma Resus: Part 1 - 10/13/09

Abstract
Outlines the lethal triad of bleeding patients and makes a very general guide of resuscitation management by MAP.

Take Home Points

• Lethal Triad of Bleeding: Acidosis, Hypothermia, Coagulopathy
• Treatment often feeds this triad including exposure, cold fluids, inappropriate BP management, incorrect product replacement, and not ensuring adequate perfusion to counteract acidosis.
• Blood pressure goals:
  MAP < 65 = Infuse products
  MAP > 65 = Hold products + Check perfusion
  If perfusion adequate (radial pulse/warm hands), hold tight
  If perfusion inadequate, give fentanyl in small doses until catecholamine release is relieved, THEN infuse products until MAP > 60

Ep 11 - Delirium Tremens - 9/29/09

Abstract
Promotes aggressive management of seizure activity in the DT patient in the ER.

Take Home Points

• DT patients can require unusually high amounts of diazepam.

Ep 10 - Cardiogenic Shock - 9/16/09

Abstract
Compares the differences in management and cause if cardiogenic shock vs the aforementioned SCAPE patient.

Take Home Points

• In cardiogenic shock, you are not necessarily fighting the sympathetic nervous system.
• Identifying the cause is of utmost priority, otherwise this patient cannot get better. Consider acute heart valve failure, right sided infarct, STEMI/NSTEMI, cardiomyopathy, and toxins.
• While finding cause, treat with inotropes and pressors, maximize oxygen availability with airway management and appropriate hemoglobin levels.

Ep 9 - Can you take sick patients to CT? - 8/31/09

Abstract
Though focused on critically ill ED patients, the point is reiterated, focus on what your patient truly needs: definitive management. In this case, this means definitive diagnostic by any means necessary.

Take Home Points

• Stresses the importance of early diagnostic testing and provides tactics for overcoming logistic difficulties encountered in achieving that diagnostic.

Ep 8 - Subarachnoid Hemorrhage - 8/16/09

Abstract
Outlines key differences in the management of subarachnoid hemorrhage to prevent rebleeding.

Take Home Points

• Perform a neuro exam prior to intubation. This doesn't need to be anything more than a standard GCS but ensure components are individually scored and available to neuro team.
• Treat pain as the stress response is likely to contribute to rebleeding.
  Be prepared for seizures.
• Ensure patient's heart is not experiencing reflex dysrhythmias or infarct.

Ep 7 - Sedation Tirade - 7/23/09

Abstract
Discusses the significance of post-RSI sedation

Take Home Points

• All intubated patients should receive some amount of post-intubation sedation regardless of paralytic use. Many patients will even be managed well without continued paralytics.
• Fentanyl drip is commonly preferred to maintain sedation as it requires less frequent intervention than bolus medications.

Ep 6 - Push-Dose Pressors - 7/10/09

Abstract
Discusses cases in which push-dose pressors are appropriate and also how to prepare them

Take Home Points

• Volume depleted patients are poor candidates for pressors in the first place so use caution when considering these medications.
• Epinephrine can easily be prepared as a 10mcg/ml concentration (1:100,000) and is extremely useful to boost MAP when you anticipate a short duration of hypotension or while preparing a drip.
• Epinephrine is an alpha and beta 1/2 agonist. This makes it an inotropic pressor but will also increase cardiac workload and oxygen consumption.
• Phenylephrine is an alpha selective agonist causing systemic vasoconstriction. Think the opposite of hydralazine. As a byproduct of increased afterload, coronary perfusion MAY increase and reduce cardiac workload.

Ep 5 - Intubating the Critical GI Bleeder - 6/21/09

Abstract
Outlines several key steps to maximize success when intubating a known GI bleed

Take Home Points

• Empty stomach
• Intubate semifowler
• Avoid bagging if possible
• Use a meconium aspirator to suction under laryngoscopy and also intubate when able to visualize cords

Ep 3 - Laryngoscope as a Murder Weapon - 5/22/09

Abstract
Details several challenging patients to perform intubation as their disease process grossly complicates standard procedure

Take Home Points

• Complex medical patients truly require first pass intubation success. Set yourself up for success instead of winging it.
• DKA patients require aggressive pre oxygenation and minimal time spent intubating.

Ep 2 - EtCO2 - 5/4/09

Abstract
Discussed unique uses for capnography as well as its limitations especially as it correlates to PaCO2

Take Home Points

• EtCO2 only equates to PaCO2 if cardiac output is at full capacity and all tissues are adequately perfused. The more appropriate assumption is that PaCO2 is always AT LEAST the EtCO2 value.
• Patients with severe metabolic acidosis (i. e. DKA) compensate with respiratory alkalosis (hyperventilation). If taking airway control of these patients, make every attempt to ensure EtCO2 does not rise (which may mean maintaining at 15mmHg)

Ep 1 - Sympathetic Acute Crashing Pulmonary Edema (SCAPE) - 4/25/09

Abstract
Describes the management of pulmonary edema in the presence of profound hypertension

Take Home Points

• The origin of pulmonary edema in these patients is no longer important in the acute sense as the massive increase in afterload due to sympathetic response is now the enemy.
• High dose nitro and non invasive pressure ventilation used in an aggressive manner can rapidly reverse this presentation.