FOAMcastini – Undifferentiated Agitation and Cured Pork

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We cover pearls from smaccDUB (Social Media and Critical Care Conference in Dublin, Ireland), Day 2. We are here thanks to the Rosh Review.

Dr. Reuben Strayer (@emupdates) – “Disruption, Danger, and Droperidol: Emergency Management of the Agitated Patient”  

Dr. Strayer presented a brilliant talk on dealing with the quintessential Emergency Medicine patient – the undifferentiated acutely agitated patient. These patients are high risk and require emergent stabilization and resuscitation.  

Dr. Reuben Strayer's (@emupdates) algorithm for agitation in the ED
Dr. Reuben Strayer’s (@emupdates) algorithm for agitation in the ED
  • Oh, and, droperidol is not dangerous [1]. See this post on the controversial black box warning.

Dr. Haney Mallemat – “The PEA Paradox”

  • The typical way we think about PEA, the “H’s and T’s,” is overly complicated. Further, we are horrendous at pulse palpation (see this for more) [2,3], and so what we think is PEA may not actually be PEA.  Dr. Mallemat proposed something along the lines of the following the following.

Screen Shot 2016-06-15 at 6.43.52 PM

  • For some FOAM commentary on the limitations of this approach, see this post by Dr. Rory Spiegel [4].

Dr. Michele Dominico – “How Usual Resuscitative Maneuvers Can Kill Paediatric Cardiac Patients”

Interventions we jump to in sick patients – oxygenation, ventilation, vasopressors – these can kill pediatric patients with cardiac pathology. She gave examples of some high yield pearls in these already terrifying patients.

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EM Literature update by Drs. Ashley Shreves and Ryan Radecki

 Ridiculous Research Pearls from Drs. Ashley Shreves and Ryan Radecki

  • Perception of dyspnea and pulmonary function tests change with stress – and rollercoaster rides.  Rietveld S, van Beest I. Rollercoaster asthma: when positive emotional stress interferes with dyspnea perception. Behaviour research and therapy. 45(5):977-87. 2007. [pubmed]
  • Cured pork for epistaxis? Possibly. Researchers will try everything, especially if it involves bacon. Humphreys I, Saraiya S, Belenky W, Dworkin J. Nasal packing with strips of cured pork as treatment for uncontrollable epistaxis in a patient with Glanzmann thrombasthenia. The Annals of otology, rhinology, and laryngology. 120(11):732-6. 2011. [pubmed]

References:

  1. Calver L, Page CB, Downes MA et al. The Safety and Effectiveness of Droperidol for Sedation of Acute Behavioral Disturbance in the Emergency Department. Annals of Emergency Medicine. 66(3):230-238.e1. 2015. [article]
  2. Tibballs J, Weeranatna C. The influence of time on the accuracy of healthcare personnel to diagnose paediatric cardiac arrest by pulse palpation. Resuscitation. 81(6):671-5. 2010. [pubmed]
  3. Eberle B, Dick WF, Schneider T, Wisser G, Doetsch S, Tzanova I. Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation. 33(2):107-16. 1996. [pubmed]
  4. Bergum D, Skjeflo GW, Nordseth T. ECG patterns in early pulseless electrical activity-Associations with aetiology and survival of in-hospital cardiac arrest. Resuscitation. 104:34-9. 2016.

Foamcastini – Do We Make Saves?

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We are at SMACC in Dublin – thanks to the Rosh Review, an excellent board review question bank.

Do We Make Saves?

Dr. Mervyn Singer “Is Survival Predetermined in the Critically  Ill?”

  • Many critical care studies are negative, but in some cases this may be because critically ill patients don’t have a uniform prognosis.
  • Dr. Singer argues that some people may be “destined to die” and some may be “destined to live.”  Interventions may be harmful or futile in one group but beneficial in the other.  For example, Dr. Singer references the CORTICUS trial of steroids in septic shock [1]. This was a negative trial.  Dr. Singer asserts that some evidence (of not great quality), purports that the sickest patients could benefit from steroids, while this same intervention could be deleterious in the healthier ones.
  • Problem: many of the studies that go back and re-analyze these groups looking at the sickest or least sick patients? They perform subgroup analyses, a form of data dredging that must be taken with a huge grain of salt.

Favorite Pearls

Dr. Suzanne Mason – “Acute Care of the Elderly”

  • Hospital admission may not benefit geriatric patients – interdisciplinary interventions involving nurses, consultants, pharmacists, physical therapy may be best.
  • If there is a single, free intervention that providers can do it’s assessing for polypharmacy. Polypharmacy in the elderly is a huge problem.  Check the patient’s medication list and beware adding new medications that may not be absolutely necessary.

Dr. Victoria Brazil – “So You Think You’re a Resuscitationist?”

  • The Dunning-Kruger effect is real in medicine and this is why we MUST have and provide feedback.  A review of the Dunning-Kruger effect can be found here.  Essentially, people tend to overestimate what they know (i.e. overly confident in their knowledge). The exception?  Masters tend to underestimate their knowledge.

Screen Shot 2014-03-15 at 9.36.53 AM

  • Our perception of reality is very skewed so, again, feedback is crucial. For example, Cemalovic and colleagues found that intubators underestimated the time they took to intubate: they estimated 23.5 seconds on average vs the 45.5 seconds intubation actually took. Additionally, they thought 13% of their patients desaturated during intubation but 23% actually desaturated [2].

Also, there was an excellent tribute to the late Dr. John Hinds, a reminder that by living profoundly, you can impact people across the world.

References

  1. Sprung CL, Annane D, Keh D et al. Hydrocortisone Therapy for Patients with Septic Shock. N Engl J Med. 358(2):111-124. 2008. [article]
  2. Cemalovic N, Scoccimarro A, Arslan A, Fraser R, Kanter M, Caputo N. Human factors in the emergency department: Is physician perception of time to intubation and desaturation rate accurate? Emergency medicine Australasia : EMA. 28(3):295-9. 2016. [pubmed]
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FOAMcastini – SMACC

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FOAMcast will be back shortly with regular core content-cutting edge mash ups.  However, we would be remiss not to take a moment to focus on a conference that inadvertently created FOAMcast…and is coming to Chicago in June 2015.  SMACC – Chicago (#smaccUS) June 23-26, 2015.

The etiology:  FOAMcast was dreamed up whilst milling around the exhibition hall at SMACC, discussing how even core content and “basic” medicine seemed cutting edge and important here.  These projects can be dreamed up via Twitter or e-mail but I think there’s something special engendered by the propinquity of Free Open Access Medical education (FOAM) mixed with the physical conference. Our fate was sealed when Dr. Victoria Brazil happened to stop by to say “hi” while we were hyped up on “long blacks” and blabbering away about what we would call our project.  For better or worse, FOAMcast was born.

  • Note: Please do not blame Dr. Brazil for our off-beat humor or the podcast.  She had no idea what we were up to and does not endorse FOAMcast or Drs. Jeremy Faust and Lauren Westafer.

The talks at SMACC were unparalleled.  The speakers inspiring, the slides clean, the material relevant, and the audience questions thoughtful.  We learned from social workers (Liz Crowe’s hilarious talk), nurses, medics, and doctors from around the globe.  In fact, we became friends, even the pre-med university student.  We learned from them all.

The Core Content – There were a cornucopia of excellent core content talks; for example, Natalie May’s pediatric pearls, Aortic Catastrophes, and the Meaning of Acidosis by Dr. David Story.  There are too many to list and they’re all worth a listen and can be found on iTunes or via the Intensive Care Network.  Even the sonowars were brilliant.  For example, Drs. Matt Dawson and Mike Mallin taught us to visualize cardiac view using humans.  The awkward apical 4 chamber view for cardiac ultrasound:

Apical 4 Chamber View - Cardiac Ultrasound
Awkward (Apical) 4 Chamber View – Cardiac Ultrasound

In this episode, we only had time to hit just a few heavy hitters that haven’t made it onto our other podcasts.

Dr. Haney Mallemat – The Art and Science of Fluid Responsiveness

  • Dr. Mallemat beautifully describes various methods of assessing fluid responsiveness – from IVC ultrasound (used alone, approximately equal to CVP), stroke volume variation, to passive leg raise and more advance ultrasound techniques.
  • Use dynamic markers rather than static numbers, which seemed to be universally lousy.  Trend the patient’s response in order to give them “as much fluid as they need, and not one drop more.”

Dr. Scott Weingart – Sepsis in New York: Our First 15,000 Patients

  • Source control is key in sepsis.  If a patient has an infected gallbladder, obstructing kidney stone, etc – call surgery. Advocate for these patients.
  • ProCESS (and now ARISE) have demonstrated that protocols don’t necessarily have to be followed in order to reduce mortality in sepsis.  We have become increasingly good at identifying and treating sepsis since the original EGDT trial.  In his words – you don’t have to do sh*t, you just have to give a sh*t (Note: you still have to provide basic resuscitation, antibiotics, etc; you just don’t have to do the fancy stuff).
  • He had more pearls about lactate – such as in his collaborative, the number predicted badness but trends mattered less.

Dr. Cliff Reid – Resuscitation Dogmalysis

  • One cannot predict blood pressure based on the presence or absence of a pulse in various anatomic locales (i.e. if there’s a pulse at the radial artery, then their systolic blood pressure is at least >80 mmHg).  This myth was taught for years and still persists in some trauma bays; however, even the evidence and the two most recent iterations of ATLS agree with Dr. Reid [Deakin et al]

Dr. Rob Mac Sweeney – ARDS: An Evidence Based Update

  • The Berlin definition of ARDS [ARDS Definition Task Force]:
    • Acute worsening of respiratory failure (< 1 week)
    • Edema not solely due to hydrostatic pulmonary edema (i.e. should not be due to heart failure or fluid overload)
    • Bilateral infiltrates on CT/CXR *(subjective)
    • PaO2/FiO2 ratio <300 mmHg with at least 5 cm H20 of PEEP
  • The premise of Dr. Mac Sweeney’s talk; however, is that we ARDS is problematic because:
    • ARDS is a disease we can’t diagnose –  Many of the criteria, although seemingly helped by the Berlin definition, are still subjective (ex: CXR Sensitivity 0.73; specificity, 0.70 [Figueroa-Casas]
    • The diagnosis of ARDS is of limited clinical utility.  What he means by this is that the definition doesn’t really affect management and nearly all drugs targeted towards ARDS fail to show benefit consistently.  The ARDS care that does work, like lung protective ventilation and fluid balance, these are just good critical care.  Proning may work, but doesn’t seem to pan out in everyone [Guerin].  Dr. Mac Sweeney is also a little sweet on ECMO, awaiting future studies.
    • People don’t typically die from ARDS even though ARDS is associated with a 40-50% mortality rate.  Yet, only 10% of people with ARDS die of ARDS or respiratory failure. Most people with ARDS die because they’re super sick.
    • Most people with ARDS don’t have ARDS.  Autopsy studies have demonstrated that ~50% of people who met Berlin criteria for ARDS didn’t have the pathognomonic feature of ARDS, diffuse alveolar damage (DAD). The other half of the patients had pneumonia, abscesses, COPD, or other processes [Pinheiro et alThielle et al].
  • The crux of the ARDS issue per Dr. Mac Sweeney -It seems that ARDS is a fairly diverse spectrum with some subjectivity to the criteria.  If approximately half of the people diagnosed with ARDS don’t have ARDS, then it’s no surprise that the therapies don’t benefit them.  He leaves better identification in the hands of researchers.

Timing, Tribes, and STEMIs

  • In medicine we use teams or “tribes” to cope with stress, work together, and rally – Tribe Emergency Medicine, Tribe Anesthesiology, Tribe Surgery, etc.  While making snarky comments, if in jest, may boost the morale and confidence of our team, this may be detrimental to overall patient care
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