427 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
    • 4.9 • 1.6K 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.

    EMCrit 289 – Ketamine Only Intubation Paper with Brian Driver

    EMCrit 289 – Ketamine Only Intubation Paper with Brian Driver

    Brian Driver, MD

    Dr. Brian Driver is the Director of Clinical Research in the Department of Emergency Medicine at Hennepin County Medical and an Assistant​ ​Professor​ ​of​ ​Emergency​ ​Medicine at the University of Minnesota Medical School. In 2016, his research was selected for Airway World’s Airway Article of the Year.



    Dr. Driver loves teaching, as it keeps his knowledge and skill-set fresh, and challenges him to think in new ways. He sees it as a good way to learn something new every day. His favorite moments are with students who are particularly curious, and eager to solve new problems. “It’s fun to work with them and break it down, and work through their knowledge gaps and figure out the best way to approach new scenarios.”



    In his free time, Dr. Driver likes to mountain bike, run, and during some parts of the year, can be found biking over a frozen lake on the way to work.

    The Two NEAR Database Papers on Ketamine Hemodynamics



    * Mohr et al.

    * April et al.



    A Flawed Analysis of the Papers (Terren--get in touch-this post is ungood)



    EMCrit Wee to Follow...

    The Driver Ketamine Paper



    * Driver Ketamine Only



    My Podcast on Ketamine Dissociated Intubation

     

    Now on to the Podcast...

    • 20 min
    EMCrit 288 – Neurogenic Shock & Should we be Using Vasopressors for Hemorrhagic Shock?

    EMCrit 288 – Neurogenic Shock & Should we be Using Vasopressors for Hemorrhagic Shock?

    Neurogenic Shock

    Neurogenic shock is on our differential for hypotension and hemodynamic instability in trauma patients. Today, we discuss this condition as well as the use of vasopressors for hemorrhagic shock.

    Neurogenic Shock is not Spinal Shock

    Spinal Shock is a loss of reflexes below the level of the injury

    What Level?

    Preganglionic sympathetic neurons originating in the hypothalamus, pons and medulla are located in the intermediolateral cell column of the spinal cord between the first thoracic (T1) and second lumbar (L2) vertebrae. Theoretically, any SCI within or above this could cause sympathetic disruption. Since sympathetic innervation of the heart only occurs from T1 to T5, it is often said that neurogenic shock can only occur when the lesion is above the mid-thoracic (T6) level. [ 27697845]

    Presentation



    * Doesn't necessarily happen instantly

    * Won't always have bradycardia

    * Move arms and legs during primary survey



    Fluids

    InoPressors



    * dopamine is bad--diuresis



    MAP Push



    * 85 for 7 days???

    * UPDATE: Recently published cohort trial supports this practice (but not great evidence here) [Journal of Trauma and Acute Care Surgery Issue: Volume 90(1), January 2021, p 97-106]



    More Reading



    * Deb Stein's ENLS on Spinal Cord Injury

    * Descriptive Reporting of Neurogenic Shock



    Should we be using Vasopressors in Hemorrhagic Shock?

    I listened to a thought-provoking episode of Traumacast today. It was an interview with Dr. Carrie Sims on the use of Vasopressin after Hemorrhagic Shock.



    The contention is that Vasopressin at the 0.03-0.04 unit/minute dose will not affect blood pressure unless the patient is actually vasopressin deficient.



    5th-10th Unit of blood, vasopressin levels begin to drop



    Are we diluting out our stress hormones?



    RCT by Carrie Sims et al. (PMID: 31461138)



    vasopressin (bolus 4 IU) and i.v. infusion of 200 mL/h (vasopressin 2.4 IU/h) for 5 h after pts who received 6 units of product



     



    Vasopressors are associated with worse otucome after blunt trauma shock (PMID: 18188092), but little can be taken from this study



    Spahn, D.R., Bouillon, B., Cerny, V. et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 23, 98 (2019). https://doi.org/10.1186/s13054-019-2347-3

    If they are warm, give them vasoconstriction

     



     

    • 20 min
    EMCrit 287 – Thoracotomy Masterclass with Dennis Kim

    EMCrit 287 – Thoracotomy Masterclass with Dennis Kim

    Today, we turn back to a topic near and dear to my heart (pun always intended), resuscitative thoracotomy. I covered the basics of this in my:

    Crack to Cure Lecture

    If you have not seen that one, you should watch it first. Then come back here to listen to the conversation I had with Dennis Kim.

    Dennis Kim, MD

    Dennis is a trauma surgeon and intensivist at Harbor-UCLA. He was born and raised in Toronto, Canada & attended medical school at McMaster University. Following his general surgery residency, he completed a critical care medicine fellowship at the University of Ottawa. He then completed a fellowship in trauma & surgical critical care at UC San Diego. His passion for surgical education led me to complete a Masters in Medical Education at the University of Dundee. I’ve been a trauma surgeon at Harbor-UCLA Medical Center in Torrance, CA, since 2012.

    He also runs the wonderful Trauma ICU Rounds podcast which you should check out ASAP if you are interested in Trauma and Surgical Critical Care.



    Today we run through the entire thoracotomy procedure with tips, tricks and pitfalls.

    Additional EMCrit Thoracotomy Stuff



    * Podcast 83 – Crack to Cure – ED Thoracotomy

    * The Abbreviated ED Thoracotomy Tray

    * John Hinds on Crack the Chest–Get Crucified

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

    * EMCrit Podcast 36 - Traumatic Arrest(Opens in a new browser tab)



    Now on to the Podcast...

    • 45 min
    EMCrit 286 – The Venous Side Matters Too with Phil Rola

    EMCrit 286 – The Venous Side Matters Too with Phil Rola

    We've spoken about the concepts of venous congestion being problematic beyond just pulmonary edema. I've had Phil Rola on in the past to discuss Venous-side issues such as Renal Compartment Syndrome, the Vexus score, and other issues of the under-respected side of the circulation.

    Prior Episodes



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

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



    Today we go further into these concepts, with some concentration on the micro-circulation. There may be quite deleterious effects from iatrogenic volume overload--especially when we are compelled by government regulation to go against our clinical gestalt.



     

    Journal Articles



    * Blood pressure deficits in acute kidney injury: not all about the mean arterial pressure?

    * Renal Perfusion Pressure 60 predisposes to kidney injury

    * There is individual variation on micro-circ from NorEpi

    * CVP affects Microcirc Flow (Editorial)

    * Physiology of the Microcirculation

    * Perioperative Blood Pressure

    * Sublingual Microcirculatory Microscopy

    * Hot off the Press: Relative Hypotension and Adverse Kidney-related Outcomes among Critically Ill Patients with Shock. A Multicenter, Prospective Cohort Study. Am J Respir Crit Care Med. 2020 Nov 15;202(10):1407-1418. doi: 10.1164/rccm.201912-2316OC.



    Special Mention to Ince on Microcirculatory Hemodynamic Coherence



    * Ince hemodynamic coherence





    Now on to the Podcast...

     

    • 17 min
    EMCrit 285 – More on Palliative Care Conversations in Resuscitation

    EMCrit 285 – More on Palliative Care Conversations in Resuscitation

    Rob Orman steers a conversation on skillful ways to discuss code status, comfort care, intubation, and whether or not dying debilitated patients should go to the ICU.



    For more of the amazing Rob Orman, check out the Stimulus Podcast.













    Pearls:



    * When family members have to make decisions for their loved ones, you can minimize their guilt by being clear what you think is medically inappropriate.





    * In an ideal world, a DNR order would only affect what you do when a patient’s heart stops.





    * When having a comfort care conversation, Scott uses the dichotomy of two goals:  curative care vs. dignity.



    ___________________________________________________________________________



    Tips and tricks for having a conversation with a patient and/or their family about plan of care:



    * If you don’t have time for the conversation, then reconsider having it.



    * You still must make the initial foray to find out if they have preexisting wishes and if the pt's condition is dire, then you have no choice.

    * Deferring the conversation to the ICU is an option.

    * A slapdash conversation is worse than no conversation at all.









    * Create a space where everyone feels comfortable.



    * Provide chairs so people can be seated.









    * Reassure the family that this is a discussion you have with EVERYBODY who enters the hospital system.





    * Feel out the situation and try to understand one another. 



    * Your job is to translate the medical realities in a way the family can understand.

    * The family’s job is to translate their wishes, desires, and belief structure to us in a way we can understand.

    * 5-10% of people are “vitalists”. They want anything done to bring back whatever form of life possible, no matter the predicted quality of that life. You’re not going to get what you feel is medically appropriate in those cases.









    * Pick your own philosophy that fits with your strategy and psyche in medicine.



    * Weingart has learned to be medically paternalistic and socially completely open.









    * Inquire:  has the family had prior end-of-life conversations with their loved one?



    * It makes everything easier if they have.

    * If they haven’t, ask them to put themselves in the mindset of their loved one. By asking the family to be a channeler of what their loved one would want, you minimize their guilt.









    * If you feel something is medically inappropriate, state it clearly.



    * This transfers guilt to yourself.

    * In many countries (ie. Canada, Australia, New Zealand), CPR is not offered if it’s felt to be medically unacceptable.









    * Avoid being manipulative when describing CPR.



    * Don’t tell them chest compressions might break ribs or cause organ damage.

    * Instead, concentrate on the end game and what you could get out of CPR.







    There are 3 tiers of care:  DNR (do not resuscitate), DNI (do not intubate), and comfort care.







    * DNR



    * In an ideal world, DNR would only apply when a patient’s heart is about to stop.





    * While DNR is not supposed to affect the rest of the care we provide, it often does.

    * Being DNR may have significant effects on the willingness of physicians to provide aggressive care,

    • 44 min
    EMCrit 284 – You are the Product – Delete Your Algorithmic Social Media

    EMCrit 284 – You are the Product – Delete Your Algorithmic Social Media

    Algorithmic social media is stealing your joy and may be making your life dramatically worse. If you haven't watched The Social Dilemma, you probably should sit down and give it a view, especially if you have kids.







    Advertising + Algorithm



    Misalignment of incentives



    Business model in which incentive is to find customers ready to pay to modify someone else's behavior



     





    The Algorithm

    Get you to the app and keep you there



    Movie Social Dilemma gets it Wrong



    Negative trumps positive



    Dopamine hit



    Addictive, but mostly shallow or perhaps b/c of shallowness

    Tribalism & Mob Behavior

    Magnification of Fringe Views



    Makes assholes more assholey



    Attention is the reward on social media, and assholery gets the most attention

    Loss of Objective Reality

     

    Individual Apps

    Facebook

    The Worst!!!



    A bunch of you are there so EMCrit has to announce new episodes there

    Instagram

    Just as evil

    Reddit

     

    Twitter

    Sponsored Tweets



    Built to inflict misery and turn people into assholes



    Reub--bring it to Reddit



    Twitter happiness feed

    Youtube

    Turn off "Up Next"

    TikTok

    Insanely addictive

    Netflix

    Algorithm with the right incentives

    The News

    Algorithm



    If you can't change it, don't regard it as important

    Google

    not just creating an echo chamber



    but actually sculpting Truth based on a political agenda



    * Switching over to Hey Email

    * DuckDuckGo



    RSS

    The way to have social media goodness come to you

    Turn off Notifications

    for any social media and for anything else possible

    Go Deep instead of Shallow

     

    If you have kids, avoid social media until ~16

    Jonathan Haidt





    More Stuff to Check Out



    * How to go from being an Ass-hole to an AYS-hole on Twitter

    * 7 Ways to be Insufferable on Facebook

    * How to Use RSS and Itunes to Maximize FOAM Podcasts

    * The Online Hierarchy of Needs - Social Media and FOAM



    Please ReRead 1984



    Now on to the Podcast...

    • 33 min

Customer Reviews

4.9 out of 5
1.6K Ratings

1.6K Ratings

je55722 ,

Great ER podcast! I look forward to episodes.

Dr. Weingart is amazing! He is talented in the way he delivers his information and teaches. I’m an ER trauma nurse and I have found this podcast so helpful and I look forward to listening to every episode.

Labors of blunt trauma is my favorite episode of all time! It’s a great review for highly experienced Trauma nurses and super beneficial for new trauma nurses. I’m waiting on the labors of penetrating trauma.

Mish Mash Mosh Maggs ,

Seek education!

Ed & trauma nurse here, I love this podcast. I work in a rural hospital with a busy ED, this podcast gives supplemental and pertinent information that has both improved the care I provide and helped me grow as a nurse. Relatable to many levels of health care providers, in many different fields and departments.
Have also seen much of this podcast implemented at work... even joking with my coworkers saying “Scott Winegart here” when suggesting something I learned on this podcast. Always gets a good laugh... because we ALL listen to this. 👍🏼
Thank you Scott! Keep it up, I love this stuff!

Art of more hair ,

Love his Passion

OMG! This Dr has high energy and is super passionate about saving lives and teaching us. LOVE IT!

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