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 298 – Calcium in Exsanguinating Patients with Ricky Ditzel and Jeffrey Siegler
Something I have been preaching for a decade has finally gotten the attention and research it deserves. On this episode, I get two of the authors from the Lethal Diamond Paper to discuss hypocalcemia in the bleeding patient.
Prior Special Operations Combat Medic and current Premed Postbacc Student at Columbia trying to go to medical school
EM Doc & EMS Physician at Wash U in St. Louis
Read the Lethal Diamond Paper
* Official JTACS Lethal Diamond
Here is a powerpoint from Ricky
The Lethal Triad Should be the Lethal Diamond
Calcium is an independent part of the death spiral, but it is also intertwined with the other three factors as this diagram demonstrates:
Calcium in Clotting
from @MikeEMPharmD data from: Giancarelli A, Birrer K, Alban R, Hobbs B, Liu-DeRyke X. Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res. 2016;202(1):182-187. [PubMed]
What to Do
* Give calcium with your first unit of blood in trauma (and TXA)
* Consider giving 1g for every 2-4 products you administer during large transfusion
* Send and Respond to Icals
Read these Papers
* Citrate in Cirrhotics
* Hypocalcemia during MTP
* mass trans
* Howland WS, Schweizer O, Carlon GC, Goldiner PL. The cardiovascular effects of low levels of ionized calcium during massive transfusion. Surg Gynecol Obstet 1977; 145:581.
* Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res. 2016;202(1):182-187.
Related EMCrit Stuff
* EMCrit 278 – Labors of Trauma – Blunt Edition (Part 1)
* EMCrit Podcast 13 – Trauma Resus II: Massive Transfusion
* Massive Transfusion Protocol (MTP)
Now on to the Podcast...
EMCrit 297 – EVARs, TEVARs, and Endoleaks – Oh My! with Ani Aydin
EndoVascular Aortic Repairs are a game changer in patients with AAAs. Add a T and you get a TEVAR for the treatment of aortic dissections. Despite the amazing advances that these devices represent, they are not without problems.
Recently Done Operation
Look at the Access Site in the groin. These devices require enormous access in the femoral vessels. Search for pseudoaneurysms, dissection, thrombosis, or bleeding.
Kidney injury both from operation and all of the imaging that goes along with it
Leaks through or around the graft into the original aneurysm.
Get imaging. Don't get ad hoc imaging. They need specialized CT angiography of the chest and abdomen with both arterial phase and delayed venous phase. You really want to work the scan parameters out ahead of time with your radiologists.
* Type 1: Failure of complete apposition to vessel wall (1a is proximal, 1b is distal)
* Type 2: Retroleak - Back flow through a vessel
* Type 3: Graft torn or ruptured
* Type 4: Porosity of the graft
* Type 5: Unclassified/Who Knows?
from UW Emerg Radiology
Type 1 and Type 3 needs immediate surgical intervention
for the others, Aortic dp/dt control just like a dissection until you get in touch with Vascular
Thrombosis and Embolus
These pts can through clots to their distal vessels
Look for arterial clots and for mesenteric ischemia
Reach out to the Patient's Vascular Surgeon
anytime someone has any issue with their EVAR, call early!!!!
Other Great FOAM
* EM Docs on EVAR Complications
Now on to the Podcast...
EMCrit 296 – The French Connection, Part 1 – Resuscitation Geography, Logistics, & Ergonomics
After my recent Resus Room Readiness post, my buddy James got in touch with me wanting to do this episode. I said frack that, we can't do an episode, there is too much goodness in the French brain, we need a series. This is the first episode in a new series with an amazing Emergency Medicine Doc and Innovator, James French.
James French, MD
Dr. James French was born to a father that was an incredible engineer and tenacious inventor. James’ earliest memories were working with his dad restoring vintage motorcycles which sparked his fascination with fixing things. When James was 5 years old he went to watch the film “Superman” with his dad. It turned out they knew Christopher Reeves from the flying club that they went to, so they actually knew superman while he was learning to fly. James attended many Emergency Departments in the years after as it turns out that no matter how hard he believe you can fly or whatever machine he invented, gravity always won.
Whilst studying for a science degree he realised that training in martial arts was a partial antidote to not being able to sit still or focus on one task and has trained in martial arts throughout the majority of his life.
In 1995 James started medical school in Southampton, England. In 1997 at a local kung-fu club he met a guy called Dr. Cliff Reid who was a resident or registrar in Emergency Medicine. They immediately became friends. Whilst at medical school James would shadow Dr. Reid when he worked in the ED, particularly at weekends . They constantly exchanged ideas about resuscitation, psychology, meditation and of course martial arts. Cliff later stated openly on social media that James saved him from a residency system that was breaking him. To outsiders it was obvious that the “saving” was a two way street. James’ passion for resuscitation and education comes from Cliff.
James graduated medical school in 1999. Whilst driving to work as an intern in 2000 he was first on scene at a fatal road traffic collision. Trying to render aid to multiple trapped and dying casualties, with no formal training in prehospital care was a formative experience. He started working with the Magpas Air Ambulance System (www.magpas.org.uk) as a volunteer in 2003. The training course featured multiple days of simulation based medical education, a competency based curriculum and was probably a decade ahead of its time and was lead by the legend that is Dr. Rod Mackenzie. Influenced heavily by the aviation industry and the military Rod and James invented the first RSI kit dump and RSI checklist in about 2006. James continued to work with Magpas in PHEM until 2012.
In 2009 James started working as an attending in Addenbrookes Hospital, Cambridge and was given the task of selecting and purchasing all of the clinical equipment and for a new Trauma Center. Influenced heavily by a very strong department of clinical engineers lead by Prof Paul White, James realised the necessity of applying principles of from EMS, ergonomics, lean and clinical engineering to resuscitation practice.
In 2012 James moved to Canada to work in Saint John, New Brunswick. Whilst in New Brunswick he chaired the trauma research subcommittee and lead an interprofessional team to establish a province wide simulation system for trauma education. In 2017 James met Dr. David Elias, who is an Emergency Physician and highly successful medical entrepreneur,
EMCrit 295 – Resuscitation Room Readiness
We need to be able to respond instantly to the sickest patients rolling into the resus bay--sometimes with no warning at all.
but no need to put things away
EM Docs are good at prep bad at breaking down
from Precision Medical
Flex Tip Bougie, Intubation Stylet for Hyperangulated Blade
Orange Tackle Boxes
Igel 4, Scalpel, Bougie, DuCanto Suction
SCRAM Resus Bag
Needs to be Set-Up
SCRAM Rx Lite
Defib with Pads
Art Line Set-Up
Two Great Virtual Conferences
Essentials of EM
Go Here for early bird discount before April 5th: Register for EEM
Bring Me Back to Life: Le Show
www.Bringmebacktolife.ca and use the password "Le show" for a $100 discount
Now on to the Podcast...
EMCrit 294 – Acute Crit Care Grand Rounds with Josh Farkas
Anyone who reads EMCrit knows PulmCrit and therefore its creator, Josh Farkas. We had him for virtual grand rounds at Stony Brook EM recently. This is the 1 hr GR--and it was fantastic!!!
See the Video Version
Here is the Audio-Only Version
EMCrit 293 – The Jerk & Check, Functional Heuristics in Resuscitation Project (MotR)
What is a Heuristic?
A short cut to extended, analytical thinking that when functional provides a solution that may not be optimal but will be sufficient. When based on cognitive biases, heuristics may be dysfunctional. Wikipedia has a fairly good discussion of heuristics.
Thinking Fast and Slow
System 1 vs. System 2
Our interview with Gary Klein
ERADs are the Action Version of Functional Heuristics
Emergency Reflex Action Drills from Lauria
Jerk & Check
Never immediately act on a heuristic. Have your kneejerk response and then use System 2 to Check
Functional Heuristics in Resuscitation
Flank Pain in Elderly is AAA until the Ultrasound
Severe Bradycardia/Heart Block = Hyperkalemia until you see the K
Slovis' Hypokalemia = Hypomagnesemia (Hypok=HypoMAG)
Unexplained Hypotension gets antibiotics
Hypotension and Abdominal Pain in Child-Bearing Age Female is Ectopic
Chest Pain Plus
Tamponade is dissection until it is not
Old stay, young go
Err towards Young D/C and Old Stay and then check
Think LP/do LP
The diagnoses of costochondritis and gastroenteritis do not exist
What is going to kill this patient? (Pre-Mortem)
a adaption of Gary Klein's idea
Ad Spot: Butterfly IQ+
Read about and watch Mike Stone demonstrate BiPlane
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Note: Butterfly provided a probe for testing to Metasin LLC
Now on to the Podcast...
Also for emergency nurses
Love it, love it, love it.....