EMCrit Podcast

Hmm… he’s tasty, but he just needs a little salt! In this podcast, I discuss the management of hyponatremia in the ED.

My favorite ED things for 2010...the EMCrit dirty dozen.

Pushing some ativan followed by vecuronium is no longer an acceptable strategy to manage post-intubation sedation. A good analgesia and sedation package is essential if you care about your patient's comfort and well-being. We need to move to PAIN-FIRST paradigm. Optimize analgesia and then add in sedative agents as a bonus. In this episode of the EMCrit Podcast, I expand on a previous rant to discuss the optimal way to handle routine post-intubation patients and some special scenarios you may encounter.

Your patient is pale and diaphoretic. Blood pressure is 70/50. Heart rate is 178. EKG shows atrial fibrillation... What are you going to do??? Yeah, yeah the Pavlovian ACLS response--You cardiovert. Wonderful, except it didn't change a thing. Now what? In this episode, I discuss the crashing atrial fibrillation patient.

Intubation is a sexy procedure, there is no doubt about it. NIV does not have the glamour; it's not nearly as cinematic. But for the patient, to spend 30 minutes on a NIV mask is preferable to a couple of days on the ventilator. In this episode, I discuss some of the basic ideas and methods of NIV.

So you have a patient with intracranial bleeding or you have a high pre-ct suspicion of intracranial bleeding and they are taking coumadin, aspirin, or clopidogrel. Should you reverse them? If so, how?

Hi folks, Sorry about the voice--got a cold off those damn ED keyboards Thanks to my friend Reuben, this week we'll talk about the asthmatic patient that codes while on the vent The DOPE mnemonic gives you a path to figure out why a patient is desaturating (If anyone knows who created the DOPE mnemonic, please add a comment or send me an email. An EMCrit listener solved the mystery) If the pt is asthmatic, add an "S" to make DOPES The "S" stands for Stacked Breaths--and it's the first thing to address. Address it by disconnecting the vent circuit. Don't think about it, don't dither, just disconnect the vent. "E" is for equipment. Attach a BVM hooked up to O2 and you'll eliminate ventilator equipment failures. "D" is for tube displacement. Verify the tube with ETCO2, either qualitative or quantitative. "O" reminds you to check for obstruction of the tube. See if you can put a suction cath all the way down. If all of these don't fix the problem, then consider "P" for pneumothorax. Lung sounds are not always definitive. Throw on the UTS if you have the time. Otherwise perform bilateral finger thoracostomies. What the hell is that, you say? Listen to the podcast. Then you can read more about it in this article C.D. Deakin, G. Davies and A. Wilson, Simple thoracostomy avoids chest drain insertion in prehospital trauma, J Trauma 39 (2) (1995), pp. 373–374. Update: Is the tube mainstem, is there a ball-valve obstruction? Consider reintubation Consider Bronchoscopy Finger Thoracostomy BET Emerg Med J 2017;34:417-418.

To PEEP or not to PEEP, that is the question...in the management of the severe asthmatic

Chris Nickson is an Aussie, oops Kiwi, who is a lead author of a great blog: lifeinthefastlane.com and tweets under the moniker @precordialthump; check him out, he's doing really good stuff. He wrote a comment about the last podcast-- Hey Scott, Great to hear your views and approach to EGDT. I agree with the need for aggressive resuscitation of the septic patient – with fluid, antibiotics, vasopressors (we’re a ‘norad/ norepi shop’ too) and adequate oxygen delivery being the mainstays – and, if nothing else, the Rivers paper deserves credit for bringing this into the spotlight. However, the Rivers study itself is still a cause of concern for me – a single center study that has never been repeated as an RCT, with a very high mortality in the control arm (mid-40s%), and more recently the WSJ allegations about about methodological ‘dodginess’ behind the scenes and concerns about conflicting financial interests (of which I’m not sure what to make). Most ICUs in Australia don’t use CV02 monitoring, yet our mortality rates are substantially better than the Rivers study (ICU sepsis mortality around 20% these days, down from 34% in 1997) – different populations or something else? I’m also uneasy about the blood transfusion phase of the Rivers protocol. Hopefully trials like ARISE and ProCESS will help clear up what actually works. In the mean time, I heed your call to resuscitate! Cheers, Chris Nickson ED/ICU Registrar, Perth So in this brief aside, I respond to Chris' comments and tell you a bit about the EMCrit Podcast EBM philosophy. Here are the links mentioned: Henry Ford Hospital Reply to WSJ - 10.27.2008 New MSSM ED Crit Care Sepsis Protocol MR of Early Quantitative Therapies for Sepsis

In this episode I rant and rave about why for the most part Emergency Medicine has disappointed me by not doing something about our sick septic patients. If you are offering aggressive (Early Goal Directed) therapy in the ED, then good on you.