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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

    • Medizin
    • 5.0, 33 Bewertungen

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 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 Std. 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.
    EMCrit 273 – Inhaled Pulmonary Vasodilators & Q&A with Sara Crager

    EMCrit 273 – Inhaled Pulmonary Vasodilators & Q&A with Sara Crager

    This episode continues on from last time's talk by Sara Crager on Right Ventricular Failure. This is a Q&A session with a focus on inhaled pulmonary vasodilators.

    Nitric Oxide

    Sara likes it through ETT or Hi-Flo NC (can also be done through BIPAP)

    Start at 20 ppm

    See results within 5-10 minutes

    Monitor with CVP

    Additional Resources



    * PulmCrit- Inhaled NO for submassive PE: iNOPE or iYEP?

    * Review Article on Inhaled NO



     

    Epoprostenol (Flolan)

    May be more complicated to set-up



    go back to marker 5



    Epoprostenol @ 0.05 mcg/kg/min



    Must have filters on the circuit



    * Review Article on Inhaled EpoProst



     

    Milrinone

    Get the vial, you want 1 mg/ml with 15 mls in vial



    5 ml (5 mg) q 6 hours (According to Dr. Crager--may be more frequent if symptoms rebound (down to q 3 hrs))



    Ideally use ultrasonic nebulizer



    onset ~15 minutes



    Must have filters on circuit



    LVOTO & RVOTO contraindication for the milrinone



     



    respigard!!!



    aeroneb pro



    must have filters on vent



    from Andre Denault Lecture

    Additional Resources



    * Inhaled Pulmonary Vasodilator Therapy for Management of Right Ventricular Dysfunction after Left Ventricular Assist Device Placement and Cardiac Transplantation









    * A multicentre randomized-controlled trial of inhaled milrinone in high-risk cardiac surgical patients







     

    Intratracheal Milrinone Bolus for a Crashing Patient

    50-80 mcg/kg or 5 mg (1/2 a bolus is also used by some)



    onset 4-5 minutes



    from the amazing Hospitalist & the Resuscitationist Lecture 2019 by Andre Denault



     

    Nitro

    Need conc. of 1 mg/ml (standard bottle is 200 mcg/ml)



    Doses in studies range from 2.5-25 mcg/kg/min for 10 minutes or 50 ug/kg total given over 8 minutes (perhaps easiest to put 4-5 mg in neb and let it run)



    * PulmCrit- Nebulized nitroglycerin: The stealth pulmonary vasodilator hiding under your nose?







    Photo by Valeriia Bugaiova on Unsplash

    Now on to the Podcast...

    • 26 Min.
    EMCrit 272 – Right Heart Failure with Sara Crager

    EMCrit 272 – Right Heart Failure with Sara Crager

    We did an amazing episode on EMCrit with Susan Wilcox on Right Heart Failure. However, this oft neglected ventricle deserves even more coverage giving how pesky it can be when it fails. So we brought Sara Crager, MD to Stony Brook to give Grand Rounds. You are going to love this lecture. Part 2 is a Q&A and will be released as a separate episode.



     



    This is an embedded Microsoft Office presentation, powered by Office.



     

    Now on to the Podcast...

    • 1 Std. 4 Min.

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33 Bewertungen

Luhvugvugvugv ,

Bester medizinisischer Podcast

Wahnsinns Podcast! Super informativ!

MaximumCrash ,

Bester Podcast im Bereich Notfallmedizin

Top Podcast!

Calenmobuser ,

Super!

Großartiger Podcast! Muss man unterstützen !

Top‑Podcasts in Medizin

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