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
    • 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 279 – The Decision to use Ketamine – Disruptive and Dangerous with Reub Strayer

    EMCrit 279 – The Decision to use Ketamine – Disruptive and Dangerous with Reub Strayer

    I frequently see both residents and attendings inappropriately using ketamine for agitated patients. Inappropriately both by giving it when it is unecessary and giving it in poor fashion when it is indicated.

    Our guest today is Reub Strayer

    (@emupdates). He is the author of EMUpdates.com. His research and clinical interests include checklists and standardization, airway, legislative work on the treatment of opioid dependence, and an approach to opioid misuse in the ED.



     



    Reub breaks agitated patients down in to 3 groups:





    1. Agitated, but Cooperative

    Not a problem in the ED. Oral medications or non-pharm techniques.

    2. Disruptive without Danger

    Use standard anti-psychotics and sedatives, with the understanding that Haldol 5mg and Lorazepam 2 mg given IM will take a long time for full effect and even then, may not provide adequate sedation. There are better choices for this group:



    * Droperidol monotherapy 5-10 mg IM or 5 mg IV

    * Droperidol 5 mg + Midazolam 2mg IM or IV in the same syringe

    * Olanzapine 10 mg IM (Needs Resp Monitoring)

    * Olanzapine 5 mg + Midazolam 2 mg IM or IV  (Needs Resp Monitoring)

    * Haldol 5 mg + Midazolam 2 mg IM or IV (will be slower than the other choices)



    If using standard 5/2 (haldol and lorazepam IM), too much time for effect and impatience leads to the wrong subsequent choice, i.e. giving ketamine to this group.

    3. Disruptive and Dangerous



    * dangerous to staff, dangerous to self

    * danger is relative to the resources of the location



    Danger could be due to



    * The agitation itself or

    * An underlying condition that the agitation is preventing from being treated (and may be the cause of the agitation, e.g. tension pneumothorax)



    Dividing Line Question: Would you consider intubation to control the situation if ketamine was not available? Reub calls this the Ketamine Litmus Test.



    Ketamine takedown must be treated as Procedural Sedation (1:1 nursing observation)

    Intramuscular Medication Administration



    * Can go through clothes if you need to [Fleming et al.]

    * Reub states maximum volume of up to 20 mls per injection



    Ketamine Brain Continuum





    * See the EMUpdates post by Reub



    More on this Stuff



    * Podcast 060 On Human Bondage and the Art of the Chemical Takedown

    * Podcast 185  Disruption, Danger and Droperidol by Reub Strayer



    Now on to the Podcast...

    • 23 min
    • video
    EMCrit 278 – Labors of Trauma – Blunt Edition (Part 1)

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

    After reviewing many recordings of major trauma resuscitations, I have come to the conclusion that we are not training our learners on how to perform as a Trauma Team Leader (TTL). They are forced to extrapolate from ATLS, a course never designed for a team at a Level I trauma center. Trauma resuscitations as opposed to medical are a bounded reality. Both the time in the bay and the menu of options are limited--the complete list could be delineated and therefore available for novice TTLs. For a few weeks, I set out to do exactly that. I then sent it out to Chris Hicks (@humanfact0rz) for peer review. His feedback was so good, that I asked him to co-author this project with me. If the response to this project is positive, we will work on the penetrating edition as well.







    Blue=cognitive tasks for the TTL



    Red=TTL must assign to a subteam (operational)



    Solid=always happens in every trauma



    Dotted=May happen based on patient injuries or severity



     







    * Zero Point Survey

    * Team Leadership with Cliff Reid

    * EMCrit #230 - Resuscitation Communication

    * COMM CHECK: More On Resuscitation Communication



     







     







     







     







    * Rapid Infusion Catheter



     





    Revised Assessment of Bleeding and Transfusion (RABT)



    * Penetrating Trauma

    * Shock Index > 1.0

    * Pelvic Fracture

    * Positive Abdominal FAST



    >=2 had sensitivity of 84% and a specificity of 77%



    World J Surg 2018;42:3560



    5 Sites of Bleeding



    * Chest

    * Intra-Peritoneal

    * Retro-Peritoneal/Pelvis

    * Thigh

    * Street



     







    * Hemostatic Resuscitation by Richard Dutton, MD

    * EMCrit Podcast 30 Hemorrhagic Shock Resuscitation



     







     







     



    a href="https://emcrit.

    • 48 min
    EMCrit 277 – COVID Pulmonary Physiology with Martin Tobin

    EMCrit 277 – COVID Pulmonary Physiology with Martin Tobin

    Today on the podcast, I interview Martin Tobin on 3 papers he has recently written on COVID pulmonary physiology.

    Martin Tobin



    * Praise for Dr. Tobin

    * Bio Page



     

    Caution about Early Intubation in COVID-19

    p-SILI

    From 2 studies, 1 on sheep breathing with a human-equivalent Vt of 502 ml



    2nd study was observational with a questionable connection to Vt--it was confounded by a number of other factors

    Absence of Obtundation

     

    L vs. H Subtypes

     

    Physio Diversion - Looking for the Patient that needs more Inspiratory Flow



    * Tobin Vent Review in NEJM







     

    Basing Respiratory Management of COVID-19 on Physiological Principles

    Tachypnea in Isolation is Not an Indication for Intubation

    Not indicative of increased WOB

    Avoiding Intubation with NIPPV

    Correlation of saturation with a host of other evils, but it is possible that the saturation is merely a marker--similar to pH. Vicious cycle of shunt, low SvO2, encephalopathy, decreased resp. drive. COVID has been different, with decreased saturation without the horrible lung injury that normally accompanies it. We are also used to patient discomfort from the disease causing the hypoxemia. Retained good compliance. We have not seen the isolated hypoxemia of COVID in many situations before.



     

    The Baffling Case of Silent Hypoxemia

    Happy Hypoxemia vs. Silent Hypoxemia

    Dr. Tobin defines silent hypoxemia as PaO2 39 mmHg (as a PaCO2 39 mmHg [32539537]

    Definition of Hypoxemia

    Do we need to factor in FiO2? Dr. Tobin and I say no!



    I define by pulse ox or (PaO2), doesn't matter how much O2. e.g. "He is still hypoxemic despite being placed on NRB."

    When does Hypoxemia Become Dangerous?

     

    Pulse Ox Inaccuracy

     

    OxyHemoglobin Dissociation Curve Shifts

    Fever shifts to the right, Decreased CO2 shifts left

    Mechanism of Silent Hypoxemia

    ACE2 is expressed in the carotid body and may be partially to blame

    COVID breaks our Heuristics

    Heuristic representation of how bad their lung disease actually is. Projecting expected course...



    COVID first disease that unlinks it

    Now on to the Podcast...

    • 32 min
    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 hr 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

Customer Reviews

4.9 out of 5
1.6K Ratings

1.6K Ratings

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!

EllizaM ,

Great even when I’m drowning

I’m a Peds/occasional-Adult nurse, home care/hospital/clinic background. Most of the time with this podcast I’m in over my head. It doesn’t matter. I’m not taking this for credit, I’m not responsible to treat at the same level. I get to just learn, hear big picture and big concept material and can replay when I don’t get something or pause and look it up or let it go and get what I can contextually. The material gives me greater field context, and Dr. Weingart has a very relaxing, informative, often funny way of presenting material.

mmrhein ,

Almost perfect

Love the podcast BUT, small pet peeve that really only applies to the video cast and a few of the show notes over the years. I am one of those seemingly few people in the world who can not see color, so color coded charts make me crazy just label stuff particularly on a chart, go ahead and color it for the majority of society but for the few of us who are so maligned by nature and experience the world in a more visually subdued light please add a label it really helps

Thanks Scott and the whole emcrit team for all you do.

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