Category: Critical Care

Podcast #260: Preoxygenation

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Author: David Rosenberg, M.D.

Educational Pearls

  • Preoxygenation is done before rapid sequence intubation, and should be done even if SaO2 is at 100%.
  • Preoxygenation is done to fill the lungs with oxygen rather than ambient air, which is only 20% O2. While the patient is paralyzed, the O2-filled lungs will continue to oxygenate venous blood, buying you more time for intubation.  
  • BiPAP is an effective tool for pre-oxygenation.

References: https://lifeinthefastlane.com/ccc/preoxygenation/

Podcast #258: REBOA

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Author: Dylan Luyten, M.D.

Educational Pearls

  • Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA).
  • Exsanguination is a major cause of mortality in trauma
  • One temporizing technique to buy time to definitive hemorrhage control is to occlude the aorta thereby shunting blood away from pelvis and lower extremities, increasing cardiac afterload to increase myocardial and brain perfusion.
  • Rather than perform a thoracotomy to cross clamp aorta, a REBOA catheter may be introduced into the aorta via the common femoral artery and a balloon inflated in the descending aorta to occlude it.
  • The indications for REBOA include PEA arrest of brief duration attributable to exsanguination for sub-diaphragmatic source in a young, healthy patient, or severe hypovolemic shock or those in an agonal state due to non-compressible hemorrhage not responding to volume and in whom obstructive cause of shock has been ruled out.
  • Contraindicated in prolonged arrest, suspected proximal aortic injury, advanced age/comorbidities.
  • Controversies and evidence: 
    • High quality evidence is lacking – as it is for much of what we do and even consider standard of care in trauma. It has not been shown to improve survival, which is hard to demonstrate.
    • Role in remote settings vs trauma centers unclear.
    • Further refinements of indication for use are likely to occur with time and experience.
  • Summarize – REBOA is a promising relatively new technology that may have potential to improve outcomes in the sickest of trauma patients.

Reference: https://lifeinthefastlane.com/ccc/resuscitative-endovascular-balloon-occlusion-aorta-reboa/

Podcast #254: Myths About Antibiotic Course Length

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Author: Chris Holmes, M.D.

Educational Pearls

  • There’s little/no data about the necessary length of an antibiotic course, nor has it proven that stopping a course of antibiotics early selects for the most resistant bugs.
  • There’s little incentive for drug companies to fund this type of study.
  • Pro-calcitonin levels have been used in some settings to distinguish if an infection has resolved or not, but this may not be feasible in an outpatient setting.

References: Llewelyn, Martin J et al. The antibiotic course has had its day. 2017. BMJ

Podcast #249: Detecting Pulses

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Author:  Jared Scott, M.D.

Educational Pearls

  • Overall, medical providers are bad at detecting pulses.
  • However, only 2% of patients do not have a detectable DP pulse.
  • In one study, for patients with limb claudication, there was only about 50% agreement on the presence of a DP pulse.

References: Brearley et al. Peripheral pulse palpation: an unreliable physical sign. Annals of the Royal College of Surgeons of England. 1992

Podcast #248: Family Presence During Resuscitation

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Author: Aaron Lessen, M.D.

Educational Pearls

  • Traditionally the family is removed from the room during procedures and codes, but recent research shows that family presence may be beneficial.
  • 50% patients want family present during a code.
  • Family-related outcomes were improved with presence.
  • There was no change in medical outcomes, and no increased incidence of medicolegal issues.

References: Jabre et al. Family Presence during Cardiopulmonary Resuscitation. NEJM. 2013.

Podcast #236: Ultrasound in Cardiac Arrest

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Author: Aaron Lessen M.D.

Educational Pearls

  • Ultrasound  is helpful in the setting of cardiac arrest for finding a cause like cardiac tamponade or PE, but also for predicting outcomes for non-shockable rhythms.
  • One study showed that in those that presented with asystole or PEA and cardiac activity on US had a 4% survival rate, while those without cardiac activity had almost no chance.

References:  Philip Salen, Larry Melniker, Carolyn Chooljian, John S. Rose, Janet Alteveer, James Reed, Michael Heller, Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients?, The American Journal of Emergency Medicine, Volume 23, Issue 4, 2005, Pages 459-462, ISSN 0735-6757, http://dx.doi.org/10.1016/j.ajem.2004.11.007.

Podcast #235: Peripheral IJ Access

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Author: Nick Hatch, M.D.

Educational Pearls

  • When peripheral or central IV access is difficult, sometimes providers will try to use a peripheral IV setup at an IJ site using US guidance.
  • Case studies have shown that this method is often successful, with the most common complication being the loss of access.

References: Ash AJ, Raio C. Seldinger Technique for Placement of “Peripheral” Internal Jugular Line: Novel Approach for Emergent Vascular Access. Western Journal of Emergency Medicine. 2016;17(1):81-83. doi:10.5811/westjem.2015.11.28726.

Podcast #227: CPR-Induced Consciousness

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Author: Nick Hatch, M.D.

Educational Pearls

  • CPR-induced consciousness is a phenomenon that occurs when someone who was previously unconscious and is undergoing CPR regains consciousness and makes purposeful movements.
  • Studies have shown that this phenomenon is increasing, likely because of increased quality of CPR.
  • Many people use a sedative such as ketamine  to keep patients unconscious to reduce the psychologic trauma of CPR.
  • 39% of people who survive CPR with good neurologic details remember the process of CPR.

References:

Joshua Pound, P. Richard Verbeek, and Sheldon Cheske. CPR Induced Consciousness During Out-of-Hospital Cardiac Arrest: A Case Report on an Emerging Phenomenon. 2017. Prehospital Emergency Care Vol. 21.

Podcast #205: Post Cardiac Arrest Temperature Control

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Author: Michael Hunt, M.D.

Educational Pearls:

  • Research has shown that the higher temperatures post-cardiac arrests may lead to poorer outcomes.
  • Initially, 33 deg C was the target temp. However, more research is being done to find therapeutic temperature levels.
  • New studies have shown that the cooling protocol differs for inpatient cardiac arrests vs. outpatient cardiac arrests.   The results show that it may not be necessary to cool inpatient cardiac arrests.

References: http://www.hopkinsmedicine.org/healthlibrary/test_procedures/cardiovascular/therapeutic_hypothermia_after_cardiac_arrest_135,393/

 

Podcast #204: Thoracotomy

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Author: Aaron Lessen M.D.

Educational Pearls:

 

  • Thoracotomy is a potentially life-saving procedure. However, outcomes are often poor and the procedure itself poses many risks to provider and patient.
  • Chance of surviving a thoracotomy when there is no cardiac activity on ultrasound is 0%.
  • Performing a thoracotomy is unlikely to benefit patients with no cardiac activity on ultrasound or patients that lost vital signs greater than 10 minutes before starting the procedure.
  • A thoracotomy is maximally beneficial in patients with a penetrating chest injury that occurred less than 10 minutes before the procedure.

 

References: K. Inaba et al, “FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy: A Prospective Evaluation” Ann. of Surgery, 2015. https://www.ncbi.nlm.nih.gov/pubmed/26258320