ECG in deWinter...

Here's probably something new to your terminology - deWinter waves on an ECG!
For fans of diagnosing Wellen's syndrome, this will give you more reason to glance down at those seemingly normal ECGs.
I won't ruin the surprise and let Dr Amal Mattu do the stuff he does best.



For more of his vids or older cases, go to www.ekg.umem.org

Fast Reliable and Safe

Learn a few techniques. This is one nice and gentle one than may help you skip the sedation.



And check out the literature on pubmed:
http://www.ncbi.nlm.nih.gov/m/pubmed/19952238/

Have fun.

Do Not Terminate Resus Based on Bedside Cardiac US


Blyth L, et al. Bedside focused echocardiography as predictor of survival in cardiac arrest patients a systematic review.Acad Emerg Med. 2012:1119-26.

Objective
o Determine if focused transthoracic echo can be used during resuscitation to predict cardiac arrest outcomes

Method
o Literature search of diagnostic accuracy studies using traditional medical search engines
o A hand search of references was performed and experts in the field were contacted
o Included studies for further appraisal and analysis only if the selection criteria and standards were met

o Appraised and scored by two independent reviewers using a modified quality assessment tool for diagnostic
accuracy studies (QUADAS) to select the papers included in the meta-analysis

Results
o Initial search had 2,538 unique papers
o 11 were determined to be relevant after screening criteria were applied by two independent researchers
o One additional study was identified after the initial search for a total of 12 papers
o Total number of patients was 568; all had echo during resuscitation to determine the presence or absence of kinetic cardiac activity and were followed up to determine ROSC
o Meta-analysis of the data showed as a predictor of ROSC during cardiac arrest;
- Echo had a pooled sensitivity of 91.6% (95% confidence interval [CI] = 84.6% to 96.1%)
- Echo had a pooled specificity of 80.0% (95% CI = 76.1% to 83.6%)
- Positive likelihood ratio for ROSC was 4.26 (95% CI = 2.63 to 6.92)
- Negative likelihood ratio was 0.18 (95% CI = 0.10 to 0.31)
- Heterogeneity of the results (sensitivity) was nonsignificant

Conclusion
o Echocardiography performed during cardiac arrest that demonstrates an absence of cardiac activity harbors a significantly lower (but not zero) likelihood that a patient will experience ROSC
o In other words if we look with a probe and see no activity, we can use it as an additional piece of information that makes it less likely to be ROSC
o In selected patients with a higher likelihood of survival from cardiac arrest at presentation, based on
established predictors of survival, echo should not be the sole basis for a decision to end resuscitative efforts
o Echo should continue to be used only as an adjunct to clinical assessment in predicting the outcome of resuscitation for cardiac arrest.

Should We Be Using Less Normal Saline


Yunos NM et al. The association between a chloride-liberal versus a chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA 2012 Oct 17; 308:1566-72.

Objective
o Assess association of chloride-liberal versus chloride-restrictive IV fluid strategy in the critically ill

Design
o Prospective, open label, sequential pilot study in a university affiliated hospital in Melbourne, Australia
o 760 patients admitted to the ICU during the control period compared to 773 patients admitted consecutively
during the intervention period
o During control period, patients received the standard IV fluids, then a six month phase out period occurred
followed by an intervention period
o Chloride-liberal IV fluids: normal saline, 4% succinylated gelatin solution or 4% albumin solution
o Chloride-restrictive IV fluids: Lactated Ringer’s, Hartman’s solutions, Plasmalyte, and chloride poor 20% albumin

Outcome measures
o Primary
- Increase from baseline to peak creatinine levels in the ICU
- Actual incidence in AKI according to the RIFLE (risk injury failure loss end stage) classification

o Secondary
-The need for dialysis
- ICU and hospital stay

Results
o Control versus intervention
- Chloride administration decrease from 694 to 496 mmol/patient
- Mean serum creatinine increased while in the ICU (22.6 vs. 14.8 micromol/liter)
-AKI injury rate was 14% vs. 8.4
- Renal replacement or dialysis rate was 10% vs. 6.3%

o After adjusting for co-variance
- Association remained for AKI (OR 0.52)
- Use of renal replacement therapy OR 0.52
- No difference in length of hospital/ICU stay or need for renal replacement therapy after discharge

Conclusion
o Implementation of a chloride restrictive strategy in a tertiary ICU was associated with a significance decrease in AKI and use of renal replacement therapy
o First must know initial kidney function, and if risk of AKI, should consider chloride restrictive strategies
o May consider starting with lactate ringers to avoid hyperchloremic metabolic acidosis

Open Thoracotomy

Dr Larry Mellick's videos are well made, spontaneous and optimum for teaching. This one is no different. A rare thing in most emergency departments worldwide but not so if you are in a geographical location where penetrating trauma is common. None the less, this is a skill that all Emergency professionals and trainees need to know and have on tap if and when the need arises. So know the indications to and refresh, refresh, refresh.




Subscribe to Dr Mellick's stream here.

Webucation 26/3/13

This week's browsing has a bit for everyone. From tech to airway to old practices that should go away.

  1. Forget Chovstek? - med students have been memorising this for decades. Is it time to let go?
  2. New otitis media guidelines - updates  and a good revision paper.
  3. Extubation in the ED - short and sweet checklist for those who are getting more and more patients in their EDs who don't need the "tube" anymore. 
  4. Ketofol lovin - some love and some will get to love it. Here's a play by play on how to use this combo of Propfol and Ketamine. We endorse it too in our ED when deeper sedation is required.
  5. Star Trek not far away with Google glasses  - a look into the future on how tech serves the forces of good.
  6. Enough with the Belladonna already... - here at Emergence Phenomena, we like all things Ketamine so here's a timely reminder from our own folks at KK Children's Hospital in Singapore on how we should dispense with mixology in our practice.
As usual, remember to spread the education and support the original authors.

History of prehospital care




Great summary and sliedshow of the history of prehospital care. Those in retrieval will especially appreciate this. We only see so far because we stand on the shoulders of giants. You can also follow Dr Andersen on twitter

SMACC day 3 and summary



A little delay while I enjoy my holiday but here it is.

How does a critical care expert think? What exactly goes through his mind? That's the topic given to Scott Weingart as he did "Mind of the resuscitationist". One thing I am with : Preparation is all important, you can never over-prepare. Had a hood laugh over the slide "when do you call for a consult" Answer: "There are only 2 reasons to call for a consult: ask for a bed or ask for a procedure you can't do." Because really, you've not fully prepared yourself as a resuscitationist if you start asking for advice. But I will digress, cause everyone need to know when to call for help and I personally don't mind asking for advice nor dishing it. Real resuscitationists will sweat buckets, as Scott alluded to the fact, cos it's hard work and pretty involving too.

"How to be a hero" by Cliff Reid was as much personal as it was inspirational. Difficult to put in words such a great talk. The theme revolves around doing the right thing for the patient at hand. And often times it takes great courage, no personal gain and maybe even personal retribution to stand up for what is right.

The term meta-cognition was mentioned much during this conference. Chris Nickson explained it all in "All Doctors are Jackasses". This talk is really about the cognitive processes in critical thinking; namely the dual process theory (which I talked about in a previous post). All are encouraged to read up on the writings of Pat Croskerry. Luv this topic, and Chris did a good job of summarizing system 1 and 2 thinking. The analogy using Star Trek's Kirk and Spock as system 1 and 2 respectively was really hilarious. Will remember it always.

Are we diagnosticians? Many of us ED folk might think so, but according to Simon Carley in "Wrestling with Risk", we are more probabiliticians. Chasing that diagnosis can sometimes lead to more harm and I agree that the language we use as physicians need to reflect that uncertainty principle to the patients we treat.

Did you know, that the 10% chance of cross reactivity between penicillins and ceftriaxone is a - MYTH! Studies had shown that patients allergic to penicillin are also pretty much MORE allergic to anything. Pre-1980s manufacturers make penicillin and cephalosporins using the same mold and thus resulting in cross-contamination but not so anymore. AND it is not the b-lactam ring that've the culprit. That's not all, speaker Gerard Fennessy even did a Kermit the Frog in life threatening anaphylaxis song (actually Elmo, masquerading as Kermit turned red from allergy). 

Again, SIMWARS was the highlight of the 3rd and final day. It was totally amazing and I have never seen simulation done in such competitive manner. Who could have imagined; fully dressed and equipped Sydney HEMS team members rappelling from the ceiling as an entrance? 3 teams competed in the final and Simon Carly's team from St Emlyn's came out tops. They were really cool under fire, though they had no clue as to how to treat a snake bite victim with obvious systemic envenomation. It was funny to watch, and yes, no snakes in Manchester is probably a good excuse.

Summary
SMACC was totally worth it. A lot of thought went into the plenaries, it's not difficult to see why; the crème de la crème of crit care bloggers & podcasters are also professionals at the top of their field. This conference is a wonderful expression of how tacit knowledge is shared amongst the thinkers and doers in the field of crit care, and the benefits are really for the rest of us. Be sure to check out emcrit, LIFTL, ICN etc for the podcasts to follow.

It's Brisbane March 17-19 for SMACC 2014. See you there.

Webucation 17/3/13

Here's some great reads from the WWW.

·         Why guidelines work – the rationale for forming and auditing 
·         Paediatric back pain – as important as the adult one
·         How to refer patients – good one for juniors when talking to “upstairs”
·         Voltages and battery fluid – great ECG case you will remember
·         Poisoning kids with IV panadol – anything IV has the ability to go wrong
·         Central line goes really really badly wrong – I mean REALLY wrong

Remember to spread the education and support the original authors.

Voltages and battery fluid

Dr Amal Mattu lets you know all about low voltages and "classic" signs.



For more of his vids or older cases, go to www.ekg.umem.org

Gotye medical rant

Hilarious and intellectually satisfying at the same time. Kudos to James McCormack for this.

SMACC Day 2 highlights


The second day was as good, if not better. "Path to Insanity" was one of the plenary talks by Scott Weingart. Now this talk totally blew my mind, you know, it just resonates with my inner being. It is about the road to excellence, how this road is less travelled by most. Using the Dreyfus model, most of us would stop at being a competent doctor, but the few who dare to achieve excellence will strive for more, literally walking the path of insanity. It is hard work to become the expert master of one's field! Scott pores through 60 journals a month to become the Crit care expert that he is. That is insane. But that is also the path I found myself on a few years ago, when Dr Andy Jagoda, a pillar in emergency medicine, came through my little department and left me with an unforgettable impression. That we can be good. That knowledge is on our side if we choose to imbibe. Because the literature and stuff is out there, what the cardiologists are reading, what the neurologists are reading, we can well read it ourselves.

Joe Lex was the perfect man for his talk; teaching an old dog new tricks. Did you know, he started out as an army medic, he served in Vietnam, was an ER nurse before starting med school? And the American Academy of Emergency Medicine named the educator of the year award after him? The anecdotes that he shared was just priceless. The drive and fervor that he has now as a senior educator in emergency medicine is just absolutely amazing.

SONOWARS was the highlight event of the day. They got 2 teams in the final competing for ultrasound honors. There were great clips, and sono education mixed in with a good amount of entertainment. Those who are ultrasound naive may be intimidated by the amount of sonographic details that whiz by and get lost. Not to worry, all the material should be uploaded onto the online space (GMEP I believe) in due time.

Stay tuned for day 3 highlights.
Ash

Paeds for dummies

Colin Parker is a former mentor of mine and here he gives quite possibly the best paediatric talk you're gonna hear for a while. Bite sized with a pearl in every bite. Go to his site to get more paediatric EM goodness.


PEM for Dummies from Social Media and Critical Care on Vimeo.

SMACC Day One highlights

Here I am at SMACC, second day and enjoying every minute. To those who still do not know about SMACC, check it out at SMACC.net.au for possibly the bestest and coolest Crit care conference to date. Also check out your favorite blogs for posts on SMACC.

Day One highlights
Coolest  opening sequence for a conference ever. An amazing skit followed by a cinematic quality opening video clip. Scott Weingart was in top form, delivering possibly one of the best opening talks I've heard him give. Upstairs care downstairs has been his mantra for some time, but I like his new one - maximally aggressive care always - maximally aggressive curative care and maximally aggressive palliative care.

John Myburgh followed with a great talk about catecholamines in resuscitation. MSFP; wonder what that is? Ask the hemodynamicists out there, it's certainly not a new concept, but I gotta read up on Guyton. I will also mention 2 great articles in Jan 2013 issue of Crit Care Med on hemodynamic physiology : go read! John gave another great talk on fluid resuscitation later on. I fully agree with his take on fluids; if you don't see the fluid loss, the patient is likely not benefitting from the excess drip. In my opinion, a limited fluid strategy is probably the way forward in sepsis resuscitation. I'll stand by USCOM and hemodynamic guided therapy.

Anthony Delaney shared a little bit on the ARISE trial - can't wait for the results of that one. Good talk on the goal posts of EGDT.

But John Myburgh summed it all up nicely - see the patient, not some number!

The afternoon was deep. The full panel of online greats got down and dirty talking about the nitty gritty of social media, FOAMed and issues pertaining. What an eye opener. Next, Joe Lex did his best as usual, giving up his treasure trove of quotes from Hippocrates to Osler.

Last but not least, Simon Carly was all James Bond cool Brit and all. I like it. Wish you were here RG! Did you know, the cogs of SMACC and FOAM started turning way back in ICEM, Dublin, over some Irish stout surely?! I remembered a certain train ride from Dublin to Cork...


“No army can withstand the strength of an idea whose time has come.” Victor Hugo



Bleeding in the uremic patient

We recently discussed treatment of Haemophilia in one of our department education sessions. The role of DDAVP or demopressin was discussed in treating mild cases of bleeding.
Here's details on something that I talked abt - ie role of desmopressin in BGIT - mx of massive bleeding in uremic pts

Management of Penetrating Neck Trauma

Forget about ATLS & Zone I, II, III...
Just see if the platysma is breached;
a.  If hemodynamically unstable = Operative Mx
b.  If hemodynamically stable = CT angio kiv non-operative mx

Read - http://tinyurl.com/bux96gv

Propofol for Refractory Migraine

Propofol for refractory migraine - 10mg @ 5 mins
- http://www.intjem.com/content/pdf/1865-1380-5-19.pdf

SMACC talk

There is a sea change in the ED community with THIS conference.
Not only are new concepts or info delivery being debated, the way the debate is framed and transmitted itself has changed.
If you aren't lucky enough to get down under - get the apps. Also available here.
That's the beauty of FOAMEd.

Paediatric ECG

Quite a superb teaching case at Dr Smith's ECG blog. Covers aspects which we don't see often:

  • Kids' ECGs
  • Trauma ECG abnormalities

So head on over to this link and spread the word:
Paediatric trauma ECG

Not the bees' knees

This x-ray fascinated us for a while. You don't really expect to see that much calcium where its not supposed to be! A lady presented with knee pain and a hx consistent with osteoarthritis. What could this be?