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 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



    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]



    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===

    EZDrips APP

    “EZDrips is a non-profit application that facilitates the administration of medications in adult and pediatric resuscitation and critical care. You enter the patient’s weight and the app does the rest for you. We are not on the App Store so visit us at www.ezdrips.com. The first 200 subscribers at www.ezdrips.com/emcrit get the app for free, for life!”

    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
    EMCrit 260 – Thoughts on the NEJM Acute Upper Airway Obstruction Review

    EMCrit 260 – Thoughts on the NEJM Acute Upper Airway Obstruction Review

    NEJM recently published an interesting review article on upper airway obstruction. This podcast was spurred by a rantorial on twitter by Farkas regarding the article:



    https://twitter.com/PulmCrit/status/1195103809745440768?s=20



    I took a look--and it was indeed bad...

    Here is the Article:

    Eskander et al. Acute Upper Airway Obstruction

    Some Additional References

    Here is the review article on which some of the flawed messages of the NEJM piece are based:



    * Cricothyrotomy versus Trachetomy: An Otolaryngologist's Perspective. Laryngoscope. 1988 Feb;98(2):131-5.



    These two pieces from the ENT and OMFS literature correct these errors:



    * Cricothyrotomy: When, Why and Why Not: Am J Otolaryng 2000;21(3):195

    * Elective Surgical Cricothyroidotomy in Oral and Maxillofacial Surgery Br J Oral Max Surg 2013;51:779



    Updates:

    Best Practices for Emerg Surg Airway (Laryng Invest Otolaryng 2019;4:602)

    Now on to the Podcast...

     

    • 21 min
    EMCrit 259 – Cardiogenic Shock — The Next Level & Mechanical Circulatory Support with Jenelle Badulak

    EMCrit 259 – Cardiogenic Shock — The Next Level & Mechanical Circulatory Support with Jenelle Badulak

    Back on podcast 10, I discussed the basics of the initial approach to cardiogenic shock. Today, we bring the discussion to the next level...

    Our Special Guest

    Jenelle Badulak, MD



    Acting Assistant Professor of Emergency Medicine, UW Medicine



    Dr. Badulak is an emergency physician and intensivist caring for patients in the Cardiothoracic and Medical Intensive Care Units at the University of Washington Medical Center, and in the Trauma Surgical Intensive Care Unit and Emergency Department at Harborview Medical Center.



    @JenelleBadulak







    How do we know if a patient is in cardiogenic shock and how sick they are?

     



    How Should We Start Treatment in the ED

    We could center this discussion about the SCAI paper that came out (attached). A nice collaborative expert panel piece outlining a CS pyramid used quickly at the bedside in the ED, ICU, Cath Lab, etc to help us identify these patients and communicate how sick they are to quickly activate escalation of care. It’s gaining traction and it’s way more useful for us in the ED and ICU than INTERMACS.







    2) What are the temporary MCS devices out there and when do you decide to use them?:  We could talk through an example algorithm that we use at UW, and many other institutions have developed something similar (attached screen shots from my online textbook corECMO in development).

    Characterize the Type and Severity of the Cardiogenic Shock

    Evaluate for non-ventricular failure



    * Is this a acute valve issue?

    * Is this tamponade or another cause of obstructive shock?



    Pure Left ventricular vs. Bi-ventricular/RV Failure





    Decide on MCS Strategy



    Cardiogenic Shock Centers

    What is regionalized care for cardiogenic shock?:  This is a super hot topic now, especially with rapidly expanding use of temporary MCS, and needing to rapidly transport patients to centers capable of implanting MCS. Many cities are developing cardiogenic shock hub and spoke models to make it faster and easier to ship these patients to tertiary centers for rescue with temporary MCS and definitive care with comprehensive advanced heart failure therapies.  Often these patients are first recognized to be in bad CS in the ED and if your hospital has nothing but an IABP, I’d argue the best thing to do is ship them instead of admit them.



    Additional Resources











    * Cardiogenic shock classification Baran 2019

    * Cardiogenic shock management statement 2017 AHA

    * Cardiogenic Shock Centers Rab JACC 2018



    Now on to the Podcast...

     

    • 38 min
    EMCrit 258 – Should Andexxa be added to a Hospital’s Formulary?

    EMCrit 258 – Should Andexxa be added to a Hospital’s Formulary?

    The question of the use of Andexxa, a reversal agent for Factor Xa Inhibitors, has been batting around my brain for a few months now. We are in the unfortunate position of having a drug with very questionable evidentiary support but with an FDA labelled indication. I received an email from the lead author of paper just published in Neurocritical Care.



    * Peled et al. Key Points to Consider When Evaluating Andexxa for Formulary Addition. Neurocrit Care 10.1007/s12028-019-00866-6



    Dr. Harry Peled is the medical director of Cardiology and Critical Care at St Jude Medical Center in California. Relevantly, he is also chair of the Pharmacy an Therapeutics Committee.



    I would love to hear your thoughts on this issue--place them in the comments below.

    See Also



    * I Have Issues with Andexanet by K. Kipp, PharmD



    Now on to the Podcast...

    • 19 min

Top Podcasts In Medicine

Listeners Also Subscribed To