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

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 265 – ECPR 2.0 (ECMO CPR)

    EMCrit 265 – ECPR 2.0 (ECMO CPR)

    This ECPR interview was origianlly published on edecmo.org. The interview was conducted by my buddy, Zack Shinar. I wanted to expose a broader audience to the episode, so I am reposting it here:

    ECPR 2.0

    The Patient

    1. OOH Cardiac Arrest Patients are Different



    Cannulation

    2. Ultrasound-Guided Percutaneous Placement

    3. Wire choices

    4. Wire Location Verification

    5. Small arterial cannulae

    6. Simpler Circuits



    Post-Pump Critical Care

    7. Find the Injuries

    8. Mandatory leg perfusion

    9. Lower Anticoagulation Goals

    10. Lower Flow Goals

    11. Try to avoid venting – Truby et al. PMID:28422817, less is more

    12. Understanding Cardiac Prognostication / Stunning

    13. Understanding Neuro Prognostication

    14. Protection/Ownership

    15. In it for the Long Haul

    16. Lower Anticoagulation and Hb targets

    17. Parade your Successes to every person in the chain

    Now on to the Podcast...

    • 38 min
    EMCrit – Midlines Part 2-Explosion with Rory Spiegel

    EMCrit – Midlines Part 2-Explosion with Rory Spiegel

    Here is part 2 on midlines.



    See Part 1 for the shownotes and introduction. Also, go to part 1 to comment on midline stuff.

    Part 1-Primer on Midlines

    Now on to the Podcast...

    • 25 min
    EMCrit 264 – Case Discussion of Combined CCB and BB Overdose

    EMCrit 264 – Case Discussion of Combined CCB and BB Overdose

    Today, we discuss a case of a patient who 45 mintues prior to arrival took took 150 Labetalol 100mg and 70 Amlodipine 10mg.

    Hemodynamically Neutral Intubation



    * See this EMCrit Podcast



    3 Presentations for CCB or BB OD



    * Vasodilatory

    * Negative-Inotropy (& Chronotropy)

    * Combined Picture



    Vasopressor-Only Management

    For me this is only appropriate for primarily vasodilatory shock (PMID 23642908, Skoog et al., Levine et al.)

    Tum-E-Vac Commercial Device for Gastric Lavage

    If you believe in lavage...



    from manufacturer site

    Prior Post on Calcium Channel Blocker OD



    * EMCrit Podcast 27



    Tox & Hound on Mechanism of Insulin



    * Insulin for CCB/BB OD



    Now on to the Podcast...

    • 34 min
    EMCrit Podcast 263 – The Venous Side – Part 1 – VEXUS Score with Phillipe Rola

    EMCrit Podcast 263 – The Venous Side – Part 1 – VEXUS Score with Phillipe Rola

    Today, we discuss the VEXUS Score. One of the big philosophical mistakes of early EMCrit was my approach to fluids in sepsis. It is no excuse that I was in good company--as in most of the intensivists in the US. I've come to my senses in the past 8 years or so and now I am actively fighting to avoid the drowning of our patients. One of the stalwarts in that fight is my buddy Phillipe Rola. He is an intensivist in Montreal, EMCrit team member, and creator of the Thinking Critical Care Blog.



    He, along with Rory Spiegel and Korbin Haycock, has created the VEXUS score to evaluate your patient for fluid overload.

    VEXUS Score



    Hepatic Vein

    Look at the IVC in the sub-xiphoid



    Phased Array Probe may be easiest, but Curvilinear works as well



    S wave should be larger than D wave



    TR may be a confounder



    S just after QRS if you have ECG leads

    Portal Vein

    Mid-Ax Line on Right Side with probe longitiduinal or R Costal Margin



    Use curvilinear



    Flow should move towards probe (red)



    Normal is continuous flow



    If it becomes pulsatile, there is backpressure



    If it drops below baseline that is bad



    PF =0.5 (same thing as resistive index)



    may be abnormal in pts with low BMI

    Renal Artery

    Curvilinear with Abd preset



    Use color doppler to find vessels



    Pick a vessel and look at the PW wave



    RRI



    0.55-0.7 is normal



    Approaches 1 when there is an absence of diastolic flow



    IRVF



    Look for vein in parenchyma



     



    from JACC HF 2016;4(8):683



     

    Katie Wiskar Tutorial





    Katie's Slide of Confounding Factors

    Venous Excess Chapter from Phillipe's Book

    venous-congestion-chapter

    More from Phillipe on this Topic



    * EMCrit Podcast 240- Renal Compartment Syndrome It's all about the Venous Side and We've Been Fracking it up for Years

    * Posts on Thinking CC

    * Vexus Lite



    Literature



    * Tang Editorial JACCHF 2016



    Resus Crisis Manual



    Now on to the Podcast...

    • 24 min
    EMCrit 262 – Midlines – Part 1

    EMCrit 262 – Midlines – Part 1

    Today on the podcast, we discuss Midlines. This is the first of two parts. In a week, I will interview Rory Spiegel on the topic, so send me your thoughts and questions in anticipation of that episode.

    Our Article



    * Utility of Midlines in Ann Emerg Med 2020



    What the Heck is a Midline?

    a 8-25 cm catheter that is placed in the arm and doesn't extend past the shoulder

    Why Ultrasound-Guided IVs Suck?



    * They aren't long enough [30021833]

    * Nearly 1/2 of them are dislodged in 24 hrs [Ann Emerg Med 1999;34(6):711]

    * Another study demonstrating they do not last [AJEM 2010;28:1]

    * Vessel Depth and Catheter Depth are the key to longevity [AJEM 2011 Fields et al.]

    * Need 2.75 cm in the vessel for good reliability [https://doi.org/10.1016/j.annemergmed.2019.11.013]

    * Midlines are better for avoidance of infections



    Which Midlines Do We Use?

    10 cm Midline

    Bard Powerglide ST





    20 cm Midline

    Medcomp 20 cm 5F CT Midline







     



     



    I take no money from any of these folks

    Video of the Dual-Lumen Midline Placement

    Start at 7:10

    The Hospitalist & the Resuscitationist 2020

    Phillipe Rola and a panoply of rogues will be discussing amazing things in beautiful Montreal



    May 20-22, 2020



    * See the Poster

    * Check out the Conference



    Send Me ?s below or on Twitter

    Now on to the Podcast...

    • 24 min
    EMCrit 261 – Thrombolysis during Cardiac Arrest

    EMCrit 261 – Thrombolysis during Cardiac Arrest

    Do you administer thrombolytics during cardiac arrest? Or maybe you don't believe in thrombolytics, but are totally down with fibrinolytics during arrest. Who do you administer them to and which one do you use? I give you my own circuitous ramblings on the topic in this episode.

    Who Should Get Lysed?







    SR/MA



    * Wang et al.



    RCT Mentioned



    * TROICA (19092151)



    Studies not Included in that SR/MA









    * PEAPETT (27422214) (RebelM Review)

    * French Registry Trial (31381884)













    What Lytic?







    Full Dose Tenecteplase via Manufacturer Recs or 50 mg of Alteplase by IV Push over ~60 seconds (29880524)











    How Long Should You Keep Going?

















    * 30-60 minutes after lytic administration



    ===Ad from Friends===

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    Thanks again!Fred and JF



    Update

    Evidence on the lack of utility of the RV during arrest to dx PE

    Now on to the Podcast...

    • 21 min

Customer Reviews

chymotrpsin ,

Excellent

A bit over my head at times as someone who works primarily in a remote center, but still worth listening to.

_Qwegg ,

One of the Best EM Podcasts Around

Fantastic, succinct, high-level, topic-focused critical care podcast for emergency physicians and residents. Scott Weingart is a well-informed evidence-based educator who's not afraid to combine his critical appraisal of the literature with his anecdotal experience and medical knowledge. Thanks for the great content and pearls.

Habeas Barkus ,

Thank you for all your hard work.

Here's the thing: Scott Weingart can punch me in the face and you know what? I would thank him. He would then expertly assess any damages to my facia bruta and fix them masterfully. Amazing, informative, entertaining, and inspiring. On a somewhat serious note, my life has recently imploded, and keeping Weingart's voice in the background of my personal chaos has helped immensely. This calming voice, and yet there is an urgency, which makes sense….so many patients, many of them so very sick. Also, his voice reminds me of Dennis Miller (I hope you take this as a compliment), and I like to imagine him strolling the hallways of his hospital, and if something gets in his way, he retaliates with "Hey, I'm walkin' here, I'm walkin'!"

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