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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FOAM Eye-Catchers 7: SMACC GOLD Highlights

Having recently returned from the FOAM-ite mecca, SMACC GOLD, in this edition I take a look at just a few of the many highlights.  Given there were frequently 3 speakers on at the same time, there were many talks that I missed so this is not an all inclusive list by any means. Continue reading

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FOAM Eye-Catchers 6

This is what has caught my eye in the FOAM world lately:

Nicholas Chrimes the co-creator of the much vaunted Vortex approach to the unanticipated difficult airway, released an excellent post on clinicalcred regarding the choice of preoxygenation device in the ED before intubation. Whether you agree with his conclusion that the Mapleson B device is the preferred option, it is an excellent discussion of the relevant considerations that need to be taken into account. Scott Weingart of emcrit then released a response podcast debating the conclusions of Chrimes. This was in very much a continuation of a debate that started in the comments section on our Bite-Sized Basics post on Preoxygenation.

The whole debate is worth following from the start to finish although I doubt this will be the end of it as the two come together for Airway discussions at SMACC this week.

Ryan Radecki from emlitofnote released a key post discussing a recent article in Nature that describes the abuse and misinterpretation of the p-value that has become endemic in the scientific community. Essentially we are putting far too much stock in p values without paying enough attention to the probability context in which the data is generated. Not all p values are equal and they should be considered more like likelihood ratios rather than exact estimations of truth or fiction. This is a must read and the full article is currently available for free here.

– Anand Swaminathan from emdocs reviews Frusemide in the treatment of Acute Pulmonary Oedema (APO). He looks at the evidence for harm and benefit and concludes there’s no clear evidence of benefit and some suggestion of harm so it really has no role in APO. The focus should be on early NIV (Non-invasive Ventilation) and nitroglycerine. I think there are different types of APO and for most I agree the role for frusemide is quite uncertain but the iatrogenic APO patient that a ward doctor may encounter who has been overloaded with IV fluids would probably find benefit from frusemide.

Do we really need them and if so when – find out in this review of the literature by Andrew Grock from ALIEM.

REBEL EM takes a look at the utility of the pelvic exam in the ED – perhaps may not be as useful as we thought.

This topic received an interesting update in a recent emcrit podcast suggesting an analgesia first, minimal sedation technique reduces delirium and improves outcomes. It was later further discussed and summarised by emdocs.

Seth Truger released an excellent screencast on Awake Intubation via laryngoscope published on PHARM – provides a stepwise approach to the procedure with handy tips and tricks.

The next FOAM Eye-Catchers will likely provide some highlights from SMACC that starts tomorrow. I’ll also likely tweet tit-bits on the fly from @drsenthi.

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FOAM Eye-Catchers 5: ACEP says fasting is not required for procedural sedation in ED

HOT OFF THE PRESS: ACEP has just published a new Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department, in the February edition of Annals of Emergency Medicine. After reviewing the relevant literature they have made several important recommendations including:

1. Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Pre procedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia [Level B]

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FOAM Eye-Catchers 4

Time for a Rethink on IV Fluids in Sepsis?

Earlier this year in March, I was fortunate enough to pilgrimage to the inaugural FOAMite mecca – SMACC (Social Media And Critical Care) Conference in Sydney. Quite frankly, it was the best conference I’ve ever attended. Some of the highlights included talks by Prof John Myburgh, in particular one on IV fluids in Sepsis, available for free via SMACC talk archive.

Recently Emcrit released a paradigm shifting lecture by Dr Paul Marik on fluids in sepsis that builds on some of the theme’s of Prof Myburgh’s talk. Not long after, Scott Weingart released his response to Dr Marik’s lecture.

All 3 talks are well worth listening to in full. However I’ve summarised some of the key concepts below as well as the FEAST study which is a landmark study discussed in both talks: Continue reading

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