438 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

    • Health & Fitness
    • 4.9 • 1.7K 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 300 – Airway Continuous Quality Improvement and the Resus Airway Bundle

    EMCrit 300 – Airway Continuous Quality Improvement and the Resus Airway Bundle

    Create a Goal

    Safe First Pass Success (sFPS)



    DASH-1A



    An Airway Quality Assurance Program Improves First Pass Success without Desaturation







    * What is good FPS



    * Emerg Med Australas 2017;29:40



    * Research published in the last 16 years shows a mean ED FPS rate of 84.1%. This represents the best available published data that can be used to benchmark emergency airway performance.





    * 60% of ED Intubations deemed difficult Acad Emerg Med 2013;20:71











    Creation of an Airway Lead

    One attending was assigned to oversee airway management quality and empowered to enact changes to maximize success. (2020 DOI: 10.1016/j.bja.2020.04.053)











    * Watches every intubation

    * Conducts CQI / Reviews every Intubation that went Awry

    * Training

    * Lit Watch











     

    Development of a Debrief Form

    This form allowed a review and quality improvement process for every intubation.

    Development of an Airway Database

    If you are not measuring, I promise you, you are not doing well

    Checklist

    A call-and-response checklist was used for all non-crashing intubations. The nurse-leader of the resuscitation would read through each item of the checklist (see on-line materials) and a member of the intubating team would affirm or stop to remedy the missed item.

    Use of a Validated Failed Airway Algorithm

    A three pass maximum airway algorithm was adopted as standard practice (2009 DOI: 10.1213/ane.0b013e3181ad87b0; 2011 DOI: 10.1097/ALN.0b013e318201c42e)

    Development of an Airway Note

    Key aspects of management: CL, story behind the airway

    Standard Operating Procedure

    No everyone cannot have their own way of doing things

    Perfect Preox and Preintubation Optimization

    We changed the allowable preoxygenation techniques to allow full denitrogenations. ETO2 monitoring was added to allow monitoring of success. Positioning of the patient for intubation was standardized

    Midline Approach

    Some attendings were teaching a right-sided mouth entry with aggressive tongue sweep. Video review demonstrated that often with this approach, key structures were missed and the esophagus was entered. A switch to mandatory midline approach with progressive visualization of uvula and epiglottis avoided this issue.

    VL for all First Passes

    At the beginning of the intervention, there was wide variance on techniques and choice of intubating equipment between the attending staff of our department. This was viewed as a primary source of poor first-pass performance and decreased the teaching potential for residents. Video laryngoscopy allows for real-time teaching during airway management and allows salvage of poor performance during the first pass.



    * Maximize FPS

    * Maximize Learning

    * Maximize Teamwork

    * Maximize Reflection



    Standard Geometry Video Laryngoscopy as Standard

    Unless intubating a patient with cervical spinal precautions, a CMAC macintosh standard geometry blade was made the standard for all first-pass intubation attempts. Based on the impediments noted on the first laryngoscopy, in some cases a switch to a hyper-angulated blade was indicated for subsequent passes.

    Recordings and Videographic Review of All Intubations

    • 22 min
    • video
    EMCrit 299 – Bougie Masterclass with George Kovacs

    EMCrit 299 – Bougie Masterclass with George Kovacs

    If you are not using the bougie for your intubations then you are leaving first pass success on the table. Today, George Kovacs on how to use the bougie, aka the tracheal tube introducer. This is a remix of two lectures from Georges amazing AIME Airway Project. If you want to hear the full version, click on over to George's Youtube (Part 1 & Part 2).



    George discusses when to use the bougie, how to use the bougie, and the part that I liked best, advanced bougie techniques.

    More Bougie on EMCrit



    * EMCrit Guest Post – Bougie Lessons from the Literature and Experience by George Kovacs

    * EMCrit Guest Post – Drawing Circles for Bougie Hangup by Neil Dasgupta

    * EMCrit Podcast 226 - Airway Update - Bougie and Positioning



    Now on to the Vodcast...

    • 42 min
    EMCrit 298 – Calcium in Exsanguinating Patients with Ricky Ditzel and Jeffrey Siegler

    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.

    Ricky Ditzel

    Prior Special Operations Combat Medic and current Premed Postbacc Student at Columbia trying to go to medical school

    Jeffrey Siegler

    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



    * MilMed

    * Citrate in Cirrhotics

    * Hypocalcemia during MTP

    * mass trans

    * Ionised-calcium-levels-in-major-trauma-patients-who-received-blood-in-the-emergency-department

    * 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.

    * Retrospective Study



    Related EMCrit Stuff



    * Hypocalcemia

    * 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...

    • 18 min
    EMCrit 297 – EVARs, TEVARs, and Endoleaks – Oh My! with Ani Aydin

    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.

    Ani Aydin, MD

    Dr. Aydin is an assistant professor of emergency medicine at Yale EM. She received her medical degree from Stony Brook Medicine, did EM residency at Bellevue/NYU, and then completed a fellowship in surgical critical care at the Shock Trauma Center (we bleed pink, yay!!). She is the medical director of the Yale critical care transport service. Her academic work includes projects ranging from mechanical ventilation to endovascular emergencies.

    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

    Endoleaks

    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!!!!

    Review Article



    * Aortic graft emergencies



    Other Great FOAM



    * EM Docs on EVAR Complications



    Now on to the Podcast...

    • 18 min
    EMCrit 296 – The French Connection, Part 1 – Resuscitation Geography, Logistics, & Ergonomics

    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,

    • 56 min
    EMCrit 295 – Resuscitation Room Readiness

    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.

    Philosophy

    Instantly Ready



    but no need to put things away



    EM Docs are good at prep bad at breaking down



    Reliability

    BVM

    from Precision Medical





    Airway Cart

    Flex Tip Bougie, Intubation Stylet for Hyperangulated Blade

    Airway Supplies

    Orange Tackle Boxes

    Igel 4, Scalpel, Bougie, DuCanto Suction

    SCRAM Resus Bag

    Coming Soon...

    Suction

    Needs to be Set-Up

    Intubation Meds

    Maryland Boxes



    SCRAM Rx Lite

    Vascular Access

    I/O



    Crash Big-Bore



     

    Defib with Pads

     

    Epi

     

    Art Line Set-Up

     

    Trauma

    Scalpel



    Hemostats



    Mayo

    Blood

    PCC



    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

    go to



    www.Bringmebacktolife.ca and use the password "Le show" for a $100 discount

    Now on to the Podcast...

    • 22 min

Customer Reviews

4.9 out of 5
1.7K Ratings

1.7K Ratings

Anshshs ,

Love the lecture by Dr Sara Crager!

Love the lecture by Dr Sara Crager on RV failure! Best Lecture I’ve heard on RV failure.

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!

Top Podcasts In Health & Fitness

Listeners Also Subscribed To