FOAMed in 2012 focused on airway management, checklists, and optimizing resuscitation room performance. Key topics included new airway devices, using checklists to guide procedures like intubation, and approaches like the "Vortex" to manage difficult airways. FOAMed resources highlighted evidence-based practices and innovative techniques to improve patient care and guide the future of emergency medicine.
7. LMA in Cardiac Arrest
• Does the LMA decrease cerebral blood flow?
• Using FOAMed to challenge the science!
http://bit.ly/XGYcv9
8. LMA in Cardiac Arrest
• They didn’t buy it!
• Used MRI to show LMA doesn’t impede flow!
• Short paper response - rejected to letter form
• So they used FOAMed instead!
– Blog post, videocast&podcast discussion!
• LMA’s are safe in critically ill.
http://bit.ly/XGYcv9
9. The Man who made Sepsis Sexy!
NYC STOP Sepsis Collaborative
10. Sepsis in the ED
Lessons:
– Time sensitive disease - High mortality
– Needs early recognition
– AB’s & fluids within 1 hour
– Use lactate to find the cryptic cases
– Non invasive approach is effective
http://emcrit.org/severe-sepsis-resources/
12. Ketamine or KetaMinh
• What is it good for?
– Agitation/Aggression/Analgesia
– Procedural sedation
– Antidepressant
– Hypotensive patients
– Chronic pain
– The DSI approach
13. PCAs in the ED
• Review of 2 studies!
• Provide less-labor intensive analgesia
• Better pain scores
• Few more adverse events!
– Nausea, vomiting, pruritis
• Worth it in some painful conditions!
14. Critical Care Palliation
“When we can’t be aggressive with our
resuscitation – we need to be aggressive with
our palliation!”
http://emcrit.org/podcasts/critical-care-
palliation/
15. Critical Care Palliation
3 things never to say:
1. “Do you want us to do everything?”
2. “Do you want us to resuscitate her?”
3. “I am so sorry, there is nothing more we can
do”
http://emcrit.org/podcasts/critical-care-
palliation/
16. Tranexamic Acid
The FOAMed world ask why we aren’t using it?
– Its cheap!
– Its an old drug!
– But it works!
– ?prehospital drug
17. Pressure Poisoning
• Lung protective ventilation – Meta Analysis
• Not just in ARDS!
• Lower tidal volumes = better outcomes
20. High Flow Nasal O2
• Give ^60L/02/min
• Enable 100% 02, with 5/PEEP
• Humidified
• Great for NFI pts
• More comfortable NIV
• Use for DSI!
http://emupdates.com/2012/03/01/the-high-flow-
nasal-cannula-in-the-emergency-department/
21. PPI & Upper GI Bleeder!
• Face validity of using PPI’s
• 750 million per/yr USA
• Systematic R/V -Cochrane
• 2000 Pts
http://thesgem.com/2012/12/sgem-16-ho-ho-
hold-the-ppi/
22. PPI & the Upper GI Bleeder!
No difference in:
• Mortality, rebleeding, need for surgery!
http://thesgem.com/2012/12/sgem-16-ho-ho-
hold-the-ppi/
28. Combine Adenosine with the Flush
• Use 20ml syringe
• Draw up adenosine & flush together
• Administer by fast IV push
• Doesn’t reduce effectiveness!
http://academiclifeinem.blogspot.com.au/2012/12/trick-
of-trade-combine-adenosine-and.html
29. Nebulised Naloxone
• Worried about acute withdrawal with IV
naloxone?
• Still got some respiratory effort?
• Feel you need to do something?
• Gives “gentle & effective” reversal?
Try 2mg naloxone, 3mls saline in a neb!
http://www.thepoisonreview.com/2013/02/01/neb
ulized-naloxone-in-opiate-intoxication/
30. Stabilising Mandibular Fractures
• Splinting mandibular dislocation/fracture
• Easy as
• Putting them in a stiff neck collar!
http://academiclifeinem.blogspot.com.au/2012/05/trick-of-trade-stabilizing-mandibular.html
31. A Dose of Dex
• Casey been doing it for a while!
• Cochrane then decided to agree with him:
Benefits:
• Reduction of pain
• Early onset - 24hours
• Same Kids vs Adults
• No difference Bactvs Viral
http://broomedocs.com/2012/12/a-dose-of-dex/
33. Life, Limb & Sight Saving
Procedures
• Published in emj & Resus.Me
• Questions if we’re ready to perform:
– Time Critical Interventions
Highlights metacompetence:
• Ability to apply the intervention @ the right time!
http://resusme.em.extrememember.com/?p=6707
34. The Usual State of Readiness
• Being ready to act with life-saving maneuvers
• Managing your own catecholamine's
Being ready
1. Cognitively
2. Materially
http://emupdates.com/2012/09/26/the-usual-state-of-readiness/
35. The Usual State of Readiness
1.Cognitively
• Invisible simulation
• Develop & prepare plans/scenarios in your
mind!
• Knowing what you need to know
http://emupdates.com/2012/09/26/the-usual-state-of-readiness/
36. The Usual State of Readiness
2. Materially
• Equipment you need
• When you need it
• Where you need it
• Checking your equipment yourself!
http://emupdates.com/2012/09/26/the-usual-state-of-readiness/
37. Mind of the Resuscitationist
• Being at the sharpest end of EM
• Making things happen
• Controlling your environment
• Science of human persuasion
• Standing like a leader
38. Owning the Airway in 2012
Been dominated by:
• From DL to VL
• To Human Factors & CRM
• & Tools and Techniques
• Then LMAs, retrogrades, bougies, & airway aids –all
through to the surgical airway!
40. The Vortex
• “High stakes cognitive aid”
– Simple enough to be recalled
– Flexible enough to be use in any context
• Train staff in unanticipated difficult airway
• Using single, simple, universally applicable
template
http://www.vortexapproach.com/Vortex_Approach/Vortex.htm
l
46. In Summary
FOAMed in 2012 was all about:
• Airway management/devices
• Teaching us to use Checklist
• How to Rule the Resus Room
FOAMed showing how to practice medicine in
the future!
Unable to give credit or highlight them all but for more check out LITFL reviewThe big things that have changed practice
Both Andy and Jim didn’t buy the results of the study!
Over 10000 patients in this collarborative
Modified SIRS at triageSend lots of lactates- a high lactate means something you have do act on it Panic value of lactete of 4 or moreBroad spectrum Ab’s firstNot all need a central line
Excited delirium
Excited delirium
These have once been thought of the domain of the surgical ward
The ultimate ED critical care palliative care lecture by Ashley Shreves, when you cant be aggressive with resuscitation, be aggressive with your palliative care!
The ultimate ED critical care palliative care lecture by Ashley Shreves, when you cant be aggressive with resuscitation, be aggressive with your palliative care!
In the bleeding trauma patient!Its sad to say but We need a new patented drug for us the to start using it. 3 hour drug window, works best if given within 1st hour – better being given in prehospital environment
JAMA Article 2012 October Both featured on EMCRIT and ResusMeCheck Plateu pressures and titrate down
JAMA Article 2012 October Both featured on EMCRIT and ResusMeCheck Plateu pressures and titrate down
Allows patients to eat and drink, brilliant for the type 1 resp failures, pneumonia, smoke inhalation, burns ect
We know a lot of these patients bleed because of petic ulcers, makes sense to use a PPI
No evidence to support the routine use of these costly treatment in the emergency department.
Feeding NGT into the esophagus can sometime sometimes be hard, use the two finger technique. The two finger method works almost every time. When you feel the tube enter the nasopharynx on top of your fingertips, then use this to guide the tube down the esophagus
These patients often resistant to laxatives and enemas
The success of adensosine depends as much on the administration technique as it does the mechanism of action. While most drugs are metabolized in the liver, adenosine doesn’t even make it that far, being metabolised in the erythrocytes and vascular endothelial cells.Forget the stopcock, prevents fumbling, gets adenosine to the heart with seconds.
The flurry and excitement has been huge with some great post on how we manage and run the resus room.From great logistic strategies, being prepared and getting the most out of your staff in the resus room. The big 3 experts on this Cliff Reid, Rueben Strayer and Scott Weingart
Looks at training and procedual skilling for time critical interventions.
Knowing what you need to know Ie adrenaline in anaphylaxis, the rest you can look up
Don’t always rely on others check the equipment yourself
Human peursuaion getting the most out of your team and the people in the resus room.