FOAM Eye-Catchers 13: Mental Training for Resuscitaiton

Despite resuscitation teams operating in extremely high stress environments and such stress being known to substantially impair optimal performance, historically very little attention has been paid to preparing these teams to mentally function at their best. Recently strategies taken from other high stress environments such as armed “special forces” teams and high performance athletes have been applied to critical care with some impressive demonstrated and potential benefits.

Several excellent critical care podcasts (links provided below at the end) by Jason Brooks, Chris Hicks, Mike Mallin & Scott Weingart provide an excellent insight into how we can specifically train our minds for the rigours of the resuscitation room, using psychological techniques from “stress inoculation training” or “stress exposure training”. Note, while this post focuses on the resus room, these techniques could be applied to other stressful situations at work or in your personal life. Continue reading

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FOAM Eye-Catchers 12: Lead aVL – overlooked but crucial in diagnosing STEMI

Several pieces of gold in the FOAM world from doctors Stephen Smith and Amal Mattu have highlighted the importance of ST changes in ECG lead aVL for diagnosing and excluding inferior and lateral STEMIs.

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FOAM Eye Catchers 11: C spine collars dumped

Much has happened of late as several organisations have one by one abandoned the hard C spine collar.

Last year scancrit reported that a major pre hospital service in Norway ceased the use of hard cervical collars.

Following this in October 2014, PHARM reported that the entire Queensland Ambulance Service (QAS) would in 2015 be ceasing the use of hard cervical collars.This was confirmed, when in December QAS released their rationale for the change, explaining why they would be replacing hard collars with soft collars. Their cervical collar procedures policy, released in February, is provided here. They are following the lead of their state-wide tertiary referral centre for spinal injuries, the Princess Alexandra Hospital, who abandoned hard collars in 2009 and have had no adverse outcomes as a result with an attendant significant reduction in complications.

This is a very significant change in practice in a large state of Australia.

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FOAM Eye-Catchers 10: Apnoeic Oxygenation – new trial questions value of NODESAT

A new RCT called the FELLOW trial examining the benefits of NODESAT (Nasal Oxygenation During Attempts at Larngoscopy) has been published online and Emcrit has just released a podcast interviewing the leader author. There is also a brief review of this paper at emlitofnote.

This is a RCT in a single medical ICU randomising patients to NODESAT or usual care. Surprisingly it found no benefit in the primary outcome – the lowest measured arterial oxygen saturation.

However there was some key aspects of this trial that seriously affect its generalisability to ED and operating room patients: Continue reading

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FOAM Eye-Catchers 9: Early Goal Directed Therapy is Dead

Apologies for the recent hiatus in FOAM Eye-Catchers – have had my head down in fellowship exam study.

The big news of late is that the 3rd episode in the trilogy of multi-centre trials evaluating Early Goal Directed Therapy (EGDT) for septic shock has been released.

First we had PROCESS from the US, then came ARISE from Australia/NZ and now we have PROMISE from the UK.

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Fluids in Sepsis: Less is More

I presented this talk at the ACEM Annual Scientific Meeting 2014 – Wednesday 10/12/14Fluids in Sepsis ASM cover page

 

Evidence FOR fluid resus

Carcillo JA, Davis AL, Zaritsky A. Role of early fluid resuscitation in pediatric septic shock. Jama. 1991;266(9):1242-5.

Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-77.

Evidence AGAINST fluid resus

Alsous F, Khamiees M, DeGirolamo A, Amoateng-Adjepong Y, Manthous CA. Negative fluid balance predicts survival in patients with septic shock: a retrospective pilot study. Chest. 2000;117(6):1749-54.

Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, et al. Sepsis in European intensive care units: results of the SOAP study. Crit Care Med. 2006;34(2):344-53.

Rosenberg AL, Dechert RE, Park PK, Bartlett RH. Review of a large clinical series: association of cumulative fluid balance on outcome in acute lung injury: a retrospective review of the ARDSnet tidal volume study cohort. J Intensive Care Med. 2009;24(1):35-46.

Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med. 2011;39(2):259-65.

Micek ST, McEvoy C, McKenzie M, Hampton N, Doherty JA, Kollef MH. Fluid balance and cardiac function in septic shock as predictors of hospital mortality. Crit Care. 2013;17(5):R246.

Brandt S, Regueira T, Bracht H, Porta F, Djafarzadeh S, Takala J, et al. Effect of fluid resuscitation on mortality and organ function in experimental sepsis models. Crit Care. 2009;13(6):R186.

including FEAST trial 2011:

Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364(26):2483-95.

and FEAST re-analysis 2013 and accompanying editorial:

Maitland K, George EC, Evans JA, Kiguli S, Olupot-Olupot P, Akech SO, et al. Exploring mechanisms of excess mortality with early fluid resuscitation: insights from the FEAST trial. BMC Med. 2013;11:68.

Myburgh J, Finfer S. Causes of death after fluid bolus resuscitation: new insights from FEAST. BMC Med. 2013;11:67.

Trilogy of Trials Debunking Early Goal Directed Therapy

PROCESS: Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA, Pike F, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683-93.

ARISE: Peake SL, Delaney A, Bailey M, Bellomo R, Cameron PA, Cooper DJ, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371(16):1496-506.

PROMISE: Mouncey PR, Osborn TM, Power GS, Harrison DA, Sadique MZ, Grieve RD, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372(14):1301-11.

Endothelial Glycocalyx

See this great LITFL post which includes an excellent 6 minute video I highly recommend. Also this PulmCCM overview is most informative.

Central v Peripheral Lines

Ricard JD, Salomon L, Boyer A, Thiery G, Meybeck A, Roy C, et al. Central or peripheral catheters for initial venous access of ICU patients: a randomized controlled trial. Crit Care Med. 2013;41(9):2108-15.

– note the benign outcomes for the 19 cases of extravasation was confirmed in personal correspondence from the author to Dr Scott Weingart. More on this topic on emcrit

Loubani & Green. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care. 2015 Jun;30(3):653.e9-17

– 97% of reported episodes of tissue injury from extravasation in peripheral catheters occurred in infusions of > 4 hour duration, and 85% occurred in sites distal to the antecubital and popliteal fossa.

Noradrenaline’s beneficial effects in septic shock

Bellomo R, Giantomasso DD. Noradrenaline and the kidney: friends or foes? Crit Care. 2001;5(6):294-8.

Hamzaoui O, Ksouri H, Richard C, Teboul JL. Effect of norepinephrine on cardiac output and preload in septic shock patients. Crit Care. 2007;11(Suppl 2):P37.

Hamzaoui O, Georger JF, Monnet X, Ksouri H, Maizel J, Richard C, et al. Early administration of norepinephrine increases cardiac preload and cardiac output in septic patients with life-threatening hypotension. Crit Care. 2010;14(4):R142.

Persichini R, Silva S, Teboul JL, Jozwiak M, Chemla D, Richard C, et al. Effects of norepinephrine on mean systemic pressure and venous return in human septic shock. Crit Care Med. 2012;40(12):3146-53.

Bai X, Yu W, Ji W, Lin Z, Tan S, Duan K, et al. Early versus delayed administration of norepinephrine in patients with septic shock. Crit Care. 2014;18(5):532.

Marik Sepsis Review Article

Marik PE. Early management of severe sepsis: concepts and controversies. Chest. 2014;145(6):1407-18.

More from Paul Marik at emcrit

Addendum 9/8/15: I’ve added 2 references above that were not included in the original talk but have been released since and are quite relevant to it.

– The PROMISE trial (NEJM 2015): the 3rd in the trilogy of trials debunking EGDT.

– Bai et al (Crit Care 2014): demonstrating a mortality benefit of starting noradrenaline early in septic shock (as beneficial as early antibiotics)

– Loubani & Green (J Crit Care 2015) demonstrating that 97% of reports in the literature of tissue injury from peripheral vasopressor extravasation occurred with infusions of > 4 hours duration.

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PE: A New Approach to Low Risk Patients

I presented this talk at the ACEM Annual Scientific Meeting 2014 – Monday 8/12/14

PE Talk ACEM ASM cover page

 

 

Mortality of Untreated PE

Calder KK, Herbert M, Henderson SO. The mortality of untreated pulmonary embolism in emergency department patients. Ann Emerg Med. 2005;45(3):302-10.

Stein PD, Hull RD, Raskob GE. Withholding treatment in patients with acute pulmonary embolism who have a high risk of bleeding and negative serial noninvasive leg tests. Am J Med. 2000;109(4):301-6.

Benefit of Treatment

Barritt DW, Jordan SC. Anticoagulant drugs in the treatment of pulmonary embolism. A controlled trial. Lancet. 1960;1(7138):1309-12.

Nielsen HK, Husted SE, Krusell LR, Fasting H, Charles P, Hansen HH. Silent pulmonary embolism in patients with deep venous thrombosis. Incidence and fate in a randomized, controlled trial of anticoagulation versus no anticoagulation. J Intern Med. 1994;235(5):457-61.

Risk of Treatment

Carrier M, Le Gal G, Wells PS, Rodger MA. Systematic review: case-fatality rates of recurrent venous thromboembolism and major bleeding events among patients treated for venous thromboembolism. Ann Intern Med. 2010;152(9):578-89.

Risk of Contrast

Mitchell AM, Jones AE, Tumlin JA, Kline JA. Incidence of contrast-induced nephropathy after contrast-enhanced computed tomography in the outpatient setting. Clin J Am Soc Nephrol. 2010;5(1):4-9.

Newhouse JH, RoyChoudhury A. Quantitating contrast medium-induced nephropathy: controlling the controls. Radiology. 2013;267(1):4-8.

McDonald JS, McDonald RJ, Comin J, Williamson EE, Katzberg RW, Murad MH, et al. Frequency of acute kidney injury following intravenous contrast medium administration: a systematic review and meta-analysis. Radiology. 2013;267(1):119-28.

McDonald RJ, McDonald JS, Bida JP, Carter RE, Fleming CJ, Misra S, et al. Intravenous contrast material-induced nephropathy: causal or coincident phenomenon? Radiology. 2013;267(1):106-18.

Davenport MS, Khalatbari S, Dillman JR, Cohan RH, Caoili EM, Ellis JH. Contrast material-induced nephrotoxicity and intravenous low-osmolality iodinated contrast material. Radiology. 2013;267(1):94-105.

Accuracy of CTPA

Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, et al. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators. Am J Med. 2006;119(12):1048-55.

Test Threshold

Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004;2(8):1247-55.

Lessler AL PJ. In Reply Ann Emerg Med 2010;56(5):587.

Summarising Risks v Harms of Testing 

Newman DH, Schriger DL. Rethinking testing for pulmonary embolism: less is more. Ann Emerg Med. 2011;57(6):622-7 e3.

PERC Rule

Singh B, Mommer SK, Erwin PJ, Mascarenhas SS, Parsaik AK. Pulmonary embolism rule-out criteria (PERC) in pulmonary embolism–revisited: a systematic review and meta-analysis. Emerg Med J. 2013;30(9):701-6.

Fesmire FM, Brown MD, Espinosa JA, Shih RD, Silvers SM, Wolf SJ, et al. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med. 2011;57(6):628-52 e75.

Clinical Prediction Rule Meta-analayses

Ceriani E, Combescure C, Le Gal G, Nendaz M, Perneger T, Bounameaux H, et al. Clinical prediction rules for pulmonary embolism: a systematic review and meta-analysis. J Thromb Haemost. 2010;8(5):957-70.

Lucassen W, Geersing GJ, Erkens PM, Reitsma JB, Moons KG, Buller H, et al. Clinical decision rules for excluding pulmonary embolism: a meta-analysis. Ann Intern Med. 2011;155(7):448-60.

Patient Risk Tolerance

Davis MA, Keerbs A, Hoffman JR, Baraff LJ. Admission decisions in emergency department chest pain patients at low risk for myocardial infarction: patient versus physician preferences. Ann Emerg Med. 1996;28(6):606-11.

Flynn D, Knoedler MA, Hess EP, Murad MH, Erwin PJ, Montori VM, et al. Engaging patients in health care decisions in the emergency department through shared decision-making: a systematic review. Acad Emerg Med. 2012;19(8):959-67.

Geyer BC, Xu M, Kabrhel C. Patient preferences for testing for pulmonary embolism in the ED using a shared decision-making model. Am J Emerg Med. 2013.
10. Hess EP, Knoedler MA, Shah ND, Kline JA, Breslin M, Branda ME, et al. The chest pain choice decision aid: a randomized trial. Circ Cardiovasc Qual Outcomes. 2012;5(3):251-9.

Hess EP, Knoedler MA, Shah ND, Kline JA, Breslin M, Branda ME, et al. The chest pain choice decision aid: a randomized trial. Circ Cardiovasc Qual Outcomes. 2012;5(3):251-9.

Kramer MS, Etezadi-Amoli J, Ciampi A, Tange SM, Drummond KN, Mills EL, et al. Parents’ versus physicians’ values for clinical outcomes in young febrile children. Pediatrics. 1994;93(5):697-702.

 

 

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