EMCrit Digest (2010)

[Tony Held]

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

Ep 23 - Awake Intubation for Trauma and Medical Patients - 3/26/10

Abstract
Expansive podcast on who to intubate and what to expect.

Take Home Points

• Consider intubating for the following reasons:
  Crash - apneic patient
  Can't Protect Airway - patients with pooling secretions or obtundation with vomiting
  Possible Loss of Airway - angioedema, anaphylaxis, neck trauma are all good reasons to intubate and early
  Expected Decline - if the patient is certainly going to be worse before they become better such as uncorrectable O2/CO2, intubate early instead of when they are apneic.
  Supply/Demand Imbalance - severe metabolic acidosis or shock resulting in the lungs becoming a huge metabolic demand with no supply should warrant early intubation.
• Who can be intubated awake? Everyone except the Crash category. They have to be breathing to be awake.
• If you suspect a difficult airway, temporize with non-invasive while topically anesthetizing. The LEMON rule is a great tool for predicting difficult airways.

Ep 22 - Non-Invasive Severe sepsis Care - 3/13/10

Abstract
Evaluates and interview the author of a study that evaluated ScvO2 monitoring vs. lactate clearance in severe sepsis management.

Take Home Points

• Lactate clearance of greater than or equal to 10% was found statistically equivalent to ScvO2 > 70.
  This means that if after following the initial fluid resuscitation guidelines given in early goal directed therapy, a serial lactate can be used in place of ScvO2 monitoring, potentially saving your patient from central line access.
• The above point is further extrapolated to mean that providers hesitant to place central lines in patients that don't look "that sick" have a different non-invasive assessment to appropriately predict clinical outcome.
• Ultrasound remains the go-to assessment tool for evaluating appropriate fluid resuscitation (inferior vena cava is > 1.5cm and collapses less than 30% with inspiration).

Ep 21 - A Bad Sedation Package Leaves Your Patient Trapped in a Nightmare - 2/26/10

Abstract
Elaborates on the pain-first paradigm of post-RSI sedation

Take Home Points

• The act of being intubated and also maintaining intubation is extremely painful and uncomfortable. Don't skimp on the pain relief.
• Patients should be calm and relaxed even without the sedation. Sedation is the bonus that lets them sleep/forget everything terrible that is happening to them.
• Special scenarios do exist that require alteration but not abandonment of this paradigm:
  Hypotensive medical patients should receive combination therapy of pressors and fentanyl/versed (or ketamine/versed if you're particularly forward thinking).
  Delerium tremens patients that have already been treated extensively with diazepam would benefit from an alternative approach from benzo-only including propofol/fentanyl or versed/fentanyl/phenobarbital.
  Neurocritically ill patients will benefit most from fentanyl/propofol. You may find that their blood pressure comes down after pain relief is achieved and anti-hypertensives may be unnecessary. Also adopt a low-threshold for intubation if transferring to a referral center.
  Hypotensive trauma patients assumed to be hypovolemic should receive 25mcg increments of fentanyl until MAP < 65, then switch to 10-15mg increments of ketamine until patient no longer cares about being intubated.

Ep 20 - The Crashing Atrial Fibrillation Patient - 2/12/10

Abstract
What do you do when ACLS fails your unstable rapid a-fib patient?

Take Home Points

• Start with cardioversion. Will it work? Maybe:
  Use your highest energy setting to give yourself the best chance of success.
  Give some analgesia but avoid inhibiting your mental status exam. Consider mixing a low dose of etomidate with a low dose of ketamine. Suggest 5-7mg and 10-15mg respectively.
• Screen for WPW - High heart rates above 250-300 are often due to a re-entry pathway. Electricity is your friend.
• Raise their blood pressure:
  Consider push-dose phenylephrine. You're only raising their pressure transiently so you can use another drug to slow them down. Remember you haven't fixed anything, you've just given yourself a little time.
• Slow them down with amiodarone (1) or diltiazem (2)
  (1) Give 150mg Amiodarone bolus and then maintain with a drip
  (2) Drip diltiazem at 2.5mg/min until heart rate drops below 100 OR you reach 50mg. Diltiazem is too aggressive on blood pressure and will chew up your push-dose pressor if given as a bolus.
• Still struggling?
  Consider magnesium, additional carioversion, a cardiology consult, different sources, or throw in the towel and let someone else take over.

Ep 19 - Non-Invasive Ventilation - 2/5/10

Abstract
Outlines the essential tenets of non-invasive ventilation.

Take Home Points

• Most respiratory patients fall into two categories: inadequate ventilation or inadequate oxygenation. Think about the disease process and choose the right path.
• PEEP, EPAP (expiratory pressure), and CPAP are all the same thing but may have a different name depending on its application or your device.
  This setting is titrated to oxygenation. Start at 5cm H20 and titrate as high as 15-17.
  Examples are atelectasis, pneumonia, and acute pulmonary edema.
• Pressure support (PSV) and IPAP are also the same thing.
  This setting is titrated to ventilation. Start at 5cm H20 and titrate as high as 15-17.
  Examples are asthma and COPD.
• FiO2 should be titrated to patient demand. Remember if your patient's oxygen saturation is 100%, their PaO2 could be anywhere between 100 and 500; if your patient's oxygen saturation is 95%, their PaO2 is near 95.
• Don't forget the role sedation can play during non-invasive ventilation. Your patient is already anxious and/or hypoxic. A little fentanyl or versed will relax them and may bring their respirations to a reasonable rate, but don't OVER sedate. You're trying NOT to intubate your patient.

Ep 17 - Reversal of Anti-coagulant and Anti-platelet Drugs in Head Bleeds - 1/12/10

Abstract
Provides guidelines for reversal of blood-thinning medications in the presence of head trauma as well as stressing the importance of a cautious stance on the treatment of head trauma with a negative CT in presence of these medications.

Take Home Points

• A combination of Vitamin K, Prothrombin Complex Concentrate, FFP, dDAVP, and platelets are the foundation for many medication reversals.
• Negative CT scans in the presence of head trauma and blood-thinner usage does not mean a bleed is not present. Depending on the severity of injury, extreme caution should be used in discharging patients too early without repeat scans.