300 episodes

Help me fill in the blanks of the practice of ED Critical Care. In this podcast, we discuss all things related to the crashing, critically ill patient in the Emergency Department. Find the show notes at emcrit.org.

EMCrit Podcast - Critical Care and Resuscitation Scott D. Weingart, MD FCCM

    • Medicine
    • 5.0, 2 Ratings

Help me fill in the blanks of the practice of ED Critical Care. In this podcast, we discuss all things related to the crashing, critically ill patient in the Emergency Department. Find the show notes at emcrit.org.

    • video
    EMCrit 278 – Labors of Trauma – Blunt Edition (Part 1)

    EMCrit 278 – Labors of Trauma – Blunt Edition (Part 1)

    After reviewing many recordings of major trauma resuscitations, I have come to the conclusion that we are not training our learners on how to perform as a Trauma Team Leader (TTL). They are forced to extrapolate from ATLS, a course never designed for a team at a Level I trauma center. Trauma resuscitations as opposed to medical are a bounded reality. Both the time in the bay and the menu of options are limited--the complete list could be delineated and therefore available for novice TTLs. For a few weeks, I set out to do exactly that. I then sent it out to Chris Hicks (@humanfact0rz) for peer review. His feedback was so good, that I asked him to co-author this project with me. If the response to this project is positive, we will work on the penetrating edition as well.







    Blue=cognitive tasks for the TTL



    Red=TTL must assign to a subteam (operational)



    Solid=always happens in every trauma



    Dotted=May happen based on patient injuries or severity



     







    * Zero Point Survey

    * Team Leadership with Cliff Reid

    * EMCrit #230 - Resuscitation Communication



     







     







     







     







    * Rapid Infusion Catheter



     





    Revised Assessment of Bleeding and Transfusion (RABT)



    * Penetrating Trauma

    * Shock Index > 1.0

    * Pelvic Fracture

    * Positive Abdominal FAST



    >=2 had sensitivity of 84% and a specificity of 77%



    World J Surg 2018;42:3560



    5 Sites of Bleeding



    * Chest

    * Intra-Peritoneal

    * Retro-Peritoneal/Pelvis

    * Thigh

    * Street



     







    * Hemostatic Resuscitation by Richard Dutton, MD

    * EMCrit Podcast 30 Hemorrhagic Shock Resuscitation



     







     







     







     







    * a href="https://emcrit.

    • 48 min
    EMCrit 277 – COVID Pulmonary Physiology with Martin Tobin

    EMCrit 277 – COVID Pulmonary Physiology with Martin Tobin

    Today on the podcast, I interview Martin Tobin on 3 papers he has recently written on COVID pulmonary physiology.

    Martin Tobin



    * Praise for Dr. Tobin

    * Bio Page



     

    Caution about Early Intubation in COVID-19

    p-SILI

    From 2 studies, 1 on sheep breathing with a human-equivalent Vt of 502 ml



    2nd study was observational with a questionable connection to Vt--it was confounded by a number of other factors

    Absence of Obtundation

     

    L vs. H Subtypes

     

    Physio Diversion - Looking for the Patient that needs more Inspiratory Flow



    * Tobin Vent Review in NEJM







     

    Basing Respiratory Management of COVID-19 on Physiological Principles

    Tachypnea in Isolation is Not an Indication for Intubation

    Not indicative of increased WOB

    Avoiding Intubation with NIPPV

    Correlation of saturation with a host of other evils, but it is possible that the saturation is merely a marker--similar to pH. Vicious cycle of shunt, low SvO2, encephalopathy, decreased resp. drive. COVID has been different, with decreased saturation without the horrible lung injury that normally accompanies it. We are also used to patient discomfort from the disease causing the hypoxemia. Retained good compliance. We have not seen the isolated hypoxemia of COVID in many situations before.



     

    The Baffling Case of Silent Hypoxemia

    Happy Hypoxemia vs. Silent Hypoxemia

    Dr. Tobin defines silent hypoxemia as PaO2 39 mmHg (as a PaCO2 39 mmHg [32539537]

    Definition of Hypoxemia

    Do we need to factor in FiO2? Dr. Tobin and I say no!



    I define by pulse ox or (PaO2), doesn't matter how much O2. e.g. "He is still hypoxemic despite being placed on NRB."

    When does Hypoxemia Become Dangerous?

     

    Pulse Ox Inaccuracy

     

    OxyHemoglobin Dissociation Curve Shifts

    Fever shifts to the right, Decreased CO2 shifts left

    Mechanism of Silent Hypoxemia

    ACE2 is expressed in the carotid body and may be partially to blame

    COVID breaks our Heuristics

    Heuristic representation of how bad their lung disease actually is. Projecting expected course...



    COVID first disease that unlinks it

    Now on to the Podcast...

    • 32 min
    EMCrit 276 – The Rapid Code Status Conversation with Kei Ouchi

    EMCrit 276 – The Rapid Code Status Conversation with Kei Ouchi

    Today, I am joined by Kei Ouchi to disucss rapid code status discussions in Emergency Medicine and Critical Care. I came across Kei after he put up an amazing post on ALIEM with his co-author Naomi George. Conversation is the essence of palliative care--we need to be experts at them.

    Kei Ouchi, MD

    Kei Ouchi is an assistant professor of emergency medicine at the Brigham and Women's Hospital in Boston. He splits his time between EM and palliative care research. [@KeiO97]

    Kei's and Naomi George's Guide to Rapid Code Status Conversations



    More to Read



    * ALIEM Post

    * Prognosis after intubation study by Kei

    * Long-term prognosis after MV (Kei's new study)

    * Functional trajectories of older adults after critical illness

    * Worse than dying

    * How patients experience LTACH

    * Median survival is 8 months if older adults are transferred to LTACH



     

    How Kei Trained in Palliative Care Conversations

    Scott, I realized I’ve never told you anything about how I trained in palliative care communications skills. I keep a record of difficult communication cases from my practice, and I regularly hire actors/role play the encounters with Susan Block (mentor) to get coaching since 2014. She is a master communicator and has been teaching this internationally for the last 35 years. I also completed the following courses and now teach Vital Talk to our trainees with palliative care folks.



    * Vital Talk

    * Harvard Pall Care Course



    Vital Talk is adapted to EM by Corita Grudzen, who is now running a large, national study to see if this makes a difference in patient outcomes.



    My ED code status conversation guide is an adaptation of the original Serious Illness Conversation Guide created by Susan Block:



     







     





    Now on to the Podcast:

    • 34 min
    EMCrit 275 – NeuroCritical Care with Neha Dangayach

    EMCrit 275 – NeuroCritical Care with Neha Dangayach

    Today on the podcast, we discuss Neuro-Emergencies and NeuroCritical Care with Neha Dangayach. This is a wide-ranging conversation that you will truly enjoy.

    Neha Dangayach

    Neha is joining the EMCrit team!!!!!!



    Neha S. Dangayach MD, MSCR is an Assistant Professor of Neurology and Neurosurgery. Dr. Dangayach serves as the Director of Neuroemergencies Management and Transfers (NEMAT) for the Mount Sinai Health System, Neurocritical Care Fellowship Director and Research Co-Director for the Institute for Critical Care Medicine (ICCM). She is also a Co-Director of the Mount Sinai Hospital’s busy NSICU and collaborates with a compassionate team to provide world-class patient-centered Neurocritical Care. She leads the Mount Sinai Critical Care Resilience Program (MSCCRP), a multidisciplinary program including intensivists, nursing, social workers, physical, occupation and speech therapists, chaplains, nutritionists among others. Several projects under this program seek to help patients and families cope with ICU recovery. Her research focuses on resilience, spirituality and recovery in critical care; inter-hospital transfers for neuroemergencies and social media in medicine.

    Topics of Discussion with Time Stamps



    Neha's Slides



    * Neurocrit Care Stony Brook Grand Rounds



    Neuro-Emergency Management and Transfer (NEMAT) Service





     

    Tele-Stroke

    Video the CT with phone



    2 person job



    scroll through every image of axial head ct q 2 seconds



    Scroll through CTA MIPs, axial and coronal (sag is a bonus)



     

    ICH

    Blood Pressure

    Specify how often to cycle BP cuff



    Ischemic Stroke

     

    Who to Intubate and Neuroprotective Intubation



    * LAMW: The Neurocritical Care Intubation



     

    Which Osmotic Agent for ICP



    * Recently Published Guidelines



    Platelet Reversal

    Recent paper shows no benefit from PLTs or dDAVP in non-neurosurg bleeds [10.1097/CCM.0000000000004348]

    Status Epilepticus

    Choice of 2nd Line Agent

    Keppra 60mg/kg (1/2 the dose in ESRD)

    General Anesthetic of Choice is Midazolam

    0.2 mg/kg bolus



    start infusion 0.2 mg/kg/hr



    titrate up every 5 minutes



    max 2.9 mg/kg/hr



    when getting close to 1mg/kg/hr, give ketamine 1mg/kg followed by 1 mg/kg/hr



    Cirrhotics, get propofol

    Now on to the Podcast...

    • 1 hr 14 min
    EMCrit 274 – Team Leadership with Cliff Reid

    EMCrit 274 – Team Leadership with Cliff Reid

    Team leadership is hard [duh]. Teaching it to our trainees is even tougher. When you work in a team of true experts with established implicit communication, things just flow--giving the the team leader the impression that they actually know what the hell they are doing. The mark of a good team leader is how they handle a less than ideal team. I found a true master to interview on the topic of team leadership--friend of the show, Cliff Reid.

    Attitudinal Choices



    * Authoritative vs. empowering

    * Be Aware that many of us are helped or hurt by implicit biases



    Gender bias paper



    * Ju et al. Effect of Professional Background and Gender on Residents’ Perceptions of Leadership. Academic Medicine. 2019 Nov;94:S42–7.



    Prep and Prebrief



    * Relational Coordination by Purdy et al.



    from Purdy et al.

    Where to Stand



    * Foot of the bed in the opinion of Cliff and me



    Zero Point Survey (ZPS)



    * Cliff's Video on ZPS

    * Perform STEP at the beginning then UP for team recaps



    Recap / SitRep / Updates-Priorities



    * What am I missing here?



    How to Lead from the Follower Slot



    * Presupposition

    * Pacing and Leading

    * Play to their ego





    Drive by Voice / Fly by Voice



    * Commentary Driving



    Eyes On / Eyes Off





    Sydney HEMS Team Communication Videos

    More from Cliff on EMCrit



    * How to Be a Hero with Cliff Reid

    * Making Things Happen with Cliff Reid

    * Mind of the Resuscitationist with Cliff Reid

    * Cliff Reid's Own the Resus Room



    Additional Reading



    * Resus Communication

    * Hicks Human Factors for Teams Summary from Simulcast

    * Hicks Fog of War

    * Another of those duh studies, but it had to be done -- No difference between EM and surgery resident team leading for trauma

    * ABCs of Team Leadership from Regions

    * Brindley on followership



    Post Publication Peer Review from Iain Beardsell

    Chaps,

    • 51 min
    • video
    EMCrit Wee – A Theoretical Model of the Pathophysiology of COVID-19 with Farid Jalali (Not a Single Thing Verified–Pure Musings)

    EMCrit Wee – A Theoretical Model of the Pathophysiology of COVID-19 with Farid Jalali (Not a Single Thing Verified–Pure Musings)

    Today on the podcast, my guest lays out a theoretical framework for the pathophysiology of the lung effects of COVID-19.

    Farid Jalali

    Dr. Farid Jalali received his Medical Degree from West Virginia University School of Medicine in 2012. He completed his postgraduate training in Gastroenterology at the University of California, Irvine Medical Center in 2018. Dr. Jalali has had extensive training and experience in diagnosing and treating a broad spectrum of GI and Liver disorders. He has a special focus on cancer prevention and spends a great deal of time educating and helping patients on how to prevent cancers in the GI tract and Liver. [@farid__jalali]



    Pathophysiology



    Potential Treatments



     

    Slides from the Presentation



    * Farid Jalali COVID-19 Pathophys



    Take Home Points from the Talk



    * Early endothelial stabilization, before hypoxia sets in, is key to prevent SARS-CoV-2 induced, excess Angiotensin II mediated, intense alveolar capillary vasoconstriction as well as the concomitant pro-inflammatory, pro-thrombotic endothelial milieu, all of which form the basis of lung

    injury in COVID19.

    * Once hypoxia sets in, supportive care should include early and aggressive endothelial stabilization interventions, properly dosed anticoagulation to prevent lung microvascular thrombi, HFNC, and awake prone position to redistribute flow away from the forming dorsal-predominant intrapulmonary shunts.

    * Alveolar capillary microvascular thrombi are not a pre-requisite for the severe lung injury in COVID19, but are a clear step in the wrong direction if allowed to be formed.

    * Lung's natural and physiologic protective response to SARS-CoV-2 induced alveolar capillary vasoconstriction and dead-space ventilation is characterized by alveolar hypocapnic bronchoconstriction at the level of the alveolar ducts to reduce a harmful alveolar expansion in these affected capillaries.

    * Naturally, unaffected capillaries and corresponding alveoli will have a higher redistribution of ventilation, will exchange more CO2 into alveolar space, and will therefore have hypercapnic bronchodilation.

    * This redistribution keeps the lung compliance preserved in the initial lung injury characterized mainly by dead-space ventilation, forming intrapulmonary shunts, without significant interstitial or alveolar edema.

    * Compensatory lower inspiratory volumes characterize the patient's response, associated with higher respiratory rate, and "shallow rapid breaths" without distress. [this has not been my experience--EMCrit]

    * This lower inspiratory volume is needed to prevent expansion of alveoli in the affected vasculopathic areas, as inappropriate expansion compounds the vasoconstriction in these affected alveolar capillaries.

    * This will result in a compensatory tendency to develop hypocapnea on blood gas analysis, often concomitant with hypoxia as intrapulmonary shunts also begin to form as lung injury progress.

    * Higher lung volumes, and positive pressure ventilation, disturb the fine balance maintained physiologically in the ventilatory redistribution pattern of the COVID1 9 lung, between high V/Q mismatch areas (poor perfusion, compensatory reduced ventilation to protect against the vasculopathy) and the compensating lower V /Q areas that safely receive higher ventilation in return.

    * Therefore, mechanical ventilation may result in worsening of dead-space ventilation by constricting alveolar cap...

    • 55 min

Customer Reviews

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2 Ratings

Saleel77 ,

Brilliant

Scott is fantastic. Thank you soo much for this podcast. Keep up the good work.

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