RAGEback: Swami on Adrenaline in Cardiac Arrest

Anand ‘Swami’ Swaminathan is an Emergency Physician in New York. He is one of the co-creators of EM Lyceum, and a major contributor to Lifeinthefastlane.com, primarily through R&R in the Fastlane and The LITFL Review, as well as other FOAM resources.

Swami is a skeptic of the benefit of adrenaline in cardiac arrest. This is his brief response to Scott Weingart’s Cutting Edge Intra-Arrest Care at smaccGOLD and Weingart’s subsequent discussion about intra-arrest meds with Rob Mac Sweeney on EMCrit.

For a summary of the articles discussed check out Swami’s ‘Epinephrine in Cardiac Arrest‘ post on emdocs.net, which includes links to all of the relevant studies. Scott Weingart also has another relevant discussion in EMCrit Podcast 130 – Hemodynamic-Directed Dosing of Epinephrine for Cardiac Arrest.

Bubbles in the Wilderness

There have been many discussions and debates about the role of FOAM (free open-access meducation) in medical education, the pros, the cons and whether or not it really is useful.

It may not be for everyone, yet for some individuals – especially those who are remote or isolated – FOAM has transformed how they learn, engage and enjoy medicine. A great example of this — one the RAGE team recommends you read — is Natasha Pirie-Burley’s account, Bubbles in the Wilderness: All about FOAM, published on the Adventure Medic blog.

“In 2007 I struggled to find my passion or heroes within my workplace. I listened to closed minds and wondered why everyone was, “just getting through it”. It was un-inspiring and at times depressing. I resigned from my job in the UK and headed to the wilderness of America, New Zealand, Nepal, and Australia. I was searching for heroes and inspiration relevant to my life. Then last year, by chance, I found that Mawson’s bravery, Shackleton’s leadership, Dean Potter’s composure and the family Robinson’s ingenuity were right here at my fingertips and living in these medical pioneers of FOAM.”
— excerpt from Bubbles in the Wilderness: All about FOAM by Natasha Pirie-Burley

Vive la FOAM!

Punk Rock, Top Gun and the Resus Room

Some time back I wrote about the amazing career of Deniz Tek in Top Gun and Punk Rock in the ER. So it was a real thrill when I contacted Deniz and he agreed to present at smaccGOLD.

Deniz gave an engaging talk titled ‘Punk Rock, Top Gun and the Resus Room’, one that he is uniquely qualified to give. He talked about the parallels between combat aviation complexity and care of the critically ill. He highlighted the importance of checklists (not just for the routine, but even more so for emergencies), communication, teamwork and being prepared to do what is necessary, when it is necessary.  Indeed, a recurring theme at smaccGOLD was that it is, paradoxically, the ‘unsexy’ stuff that matters.

What about the parallels with ‘punk rock’?… Listen to the talk to find out! Here is the audio (download mp3):

Deniz also inspired this creative description of the smaccGOLD conference itself by Jesse Spur on Injectible Orange:

“SMACCGOLD 2014 on the Gold Coast was like punk rock. Subversive, political, honest, rough at the edges and committed to thrashing out the issues that matter. Ironically, on further reflection, the second installation of Social Media and Critical Care Conference struck me as having parallels with one of my favourite speakers of the program, Deniz Tek himself – older and wiser than the Radio Birdman days, more accessible to the mainstream, less likely to punch you for disagreeing, but still able to excite, destroy unfounded dogma and put on a world class show.”

Jesse also had this footage of Deniz on stage in the SMACC lounge:

To listen to all the smaccGOLD talks as they are released subscribe to the SMACC podcast on iTunes or Libsyn. See you in Chicago — SMACC Chicago 23-26 June 2015.

 

References and links

Submassive PE on EMCrit

Back in RAGE Session Two we discussed ‘Thrombolysis for Submassive Pulmonary Embolus’. This was actually just before the PEITHO trial was published, though we were able to anticipate many of the findings thanks to the wonders of the web.

A great follow up to our discussion is EMCrit Podcast 128 – Pulmonary Embolism Treatment Options and the PEAC Team with Oren Friedman. This discussion reiterates many of the conclusions the RAGE team came to, with additional discussions about catheter-directed thrombolysis and reduced dose thrombolysis.

Meanwhile, the NEJM has just published correspondence in response to the PEITHO trial -it  includes a comment about half-dose thrombolysis by Rory Spiegel, myself and Ryan Radecki.

Cases from the Races

The RAGE team’s John Hinds gives the medical perspective on high speed motorcycle racing on closed private roads in Ireland at smaccGOLD. Of note, is the use of rapid response motorcycle medics to get to the scene fast, in the first few seconds of the dying process, to save lives.

This talk stole the show at SMACC, you are about to find out why.

Here is the audio (download mp3):

Here are the amazing slides:

To listen to all the smaccGOLD talks as they are released subscribe to the SMACC podcast on iTunes or Libsyn.

Resuscitation Dogmalysis

Just when you thought there could not possibly be anymore Cliff Reid to go round, the SMACC podcast has released another of his great talks from smaccGOLD.

This time Cliff takes on resuscitation myths, mistruths and misunderstandings – many of which are widely practiced. Do you agree? Are these pseudoaxioms? Do we need to stamp them out?

Here is the audio (download the mp3 directly here):

For the references and slides, go to Cliff’s page here on Resus.ME.

Here is the video:

Reid, Cliff — Resuscitation Dogmalysis from Social Media and Critical Care on Vimeo.

To listen to all the smaccGOLD talks as they are released subscribe to the SMACC podcast on iTunes.

miniRAGE: The ProCESS Trial

Relax, we didn’t really delete the discussion of The ProCESS Trial from RAGE Session Four… We just chopped it out to be published separately as a miniRAGE.

This is what we’re talking about:

ProCESS Investigators, Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA, Pike F, Terndrup T, Wang HE, Hou PC, LoVecchio F, Filbin MR, Shapiro NI, Angus DC. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014 May 1;370(18):1683-93. doi: 10.1056/NEJMoa1401602. Epub 2014 Mar 18. PubMed PMID: 24635773. [Full Text] [Supplement]

So, following on from Haney’s comments on the Surviving Sepsis Campaign response to ProCESS, here is the RAGE team talking about what it all means for the management of septic shock.

Learn more here:

Thanks again for listening to the RAGE!

RAGE Session Four

RAGE Session Four is here! (at last…. you say)

It is 61  min 46 sec long and includes:

  • Introduction, including a welcome to new RAGE team recruit John Hinds and apologies from Cliff… (starts 00:00 min)
  • ‘What’s bubbling up?’ (starts 01:16 min) — shout outs and interesting discoveries from the world of FOAM and elsewhere featuring regional anaesthesia, the GoodSam app, the Surviving Sepsis Campaign response to the ProCESS Trial, Brain Impact Apnoea and the ‘Tamiflu’ debacle.
  • the RAGE team discussing ‘Getting The Right Side Right: RV infarction and RV failure’ (starts 13:39  min)
  • the RAGE team discussing another ‘Humans in the Resus Room’ topic: ‘I Want to Stop, But Someone Else Doesn’t’ (starts 37:03 min)
  • ‘A blast from the past’ by me (Chris Nickson) on ‘Jack Barnes and the Irukandji Enigma’ (starts 55:07 min)
  • ‘Words of Wisdom’ from motorcycle legend Guy Martin via John Hinds (starts 59:14 min)

The RAGE podcast is on  iTunes here and the RAGE podcast audio feed is available here.

Here are the show notes for RAGE Session Four:

Introduction

What’s bubbling up?

Regional Anaesthesia

  • Beaudoin FL, Haran JP, Liebmann O. A comparison of ultrasound-guided three-in-one femoral nerve block versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: a randomized controlled trial. Acad Emerg Med. 2013 Jun;20(6):584-91. doi: 10.1111/acem.12154. PubMed PMID: 23758305.
  • Black KJ, Bevan CA, Murphy NG, Howard JJ. Nerve blocks for initial pain management of femoral fractures in children. Cochrane Database Syst Rev. 2013 Dec 17;12:CD009587. doi: 10.1002/14651858.CD009587.pub2. Review. PubMed PMID: 24343768.
  • De Buck F, Devroe S, Missant C, Van de Velde M. Regional anesthesia outside the operating room: indications and techniques. Curr Opin Anaesthesiol. 2012 Aug;25(4):501-7. doi: 10.1097/ACO.0b013e3283556f58. Review. PubMed PMID: 22673788.
  • Gadsen J. Regional Anesthesia in Trauma: A Case-Based Approach. Cambridge University Press; 1 edition (November 12, 2012) (website)
  • Wu JJ, Lollo L, Grabinsky A. Regional anesthesia in trauma medicine. Anesthesiol Res Pract. 2011;2011:713281. doi: 10.1155/2011/713281. Epub 2011 Nov 21. PubMed PMID: 22162684; PubMed Central PMCID: PMC3227428.
  • Mike Stone’s video showing how to perform a fascia iliaca block with ultrasound:

FICB Refresher from Mike Stone on Vimeo.

Other topics ‘bubbling up':

Getting The Right Side Right: RV Infarction and RV failure

  • The ‘OH CRAP’ mnemonic for optimising oxygen delivery and haemodynamics: Oxygen, Haemoglobin, Contractility, Rate & rhythm, Afterload and Preload (for both the right and the left heart – need to do different things for each!)
  • Inohara T, Kohsaka S, Fukuda K, Menon V. The challenges in the management of right ventricular infarction. Eur Heart J Acute Cardiovasc Care. 2013 Sep;2(3):226-34. doi: 10.1177/2048872613490122. Review. PubMed PMID: 24222834; PubMed Central PMCID: PMC3821821.
  • Vandenheuvel MA, Bouchez S, Wouters PF, De Hert SG. A pathophysiological approach towards right ventricular function and failure. Eur J Anaesthesiol. 2013 Jul;30(7):386-94. doi: 10.1097/EJA.0b013e3283607a2d. Review. PubMed PMID: 23571479.
  • Right ventricular infarction (LITFL ECG Library)
  • Right Ventricular Failure (LITFL CCC)
  • Right Ventricular Function and Haemodynamic Assessment (LITFL CCC)
  • Pulmonary Artery Catheters (LITFL CCC)
  • Pulmonary Hypertension (LITFL CCC)

Humans in the Resus Room: I Want To Stop, But Someone Else Doesn’t

Blast from the Past

Words of Wisdom

Thanks again for listening to the RAGE!

When should resuscitation stop?

RAGE Session Four is fully edited and soon to be released. Unfortunately, as you’ll soon find out, Cliff wasn’t able to make the session.

To make up for it, we’ll be featuring a few different Cliff Reid talks in the next week or two. We’ll start with this controversial and inspiring talk from smaccGOLD which left more than a few resuscitationists feeling conflicted.

Listen to it yourself and make up your own mind.

Cliff was asked to speak on the topic of ‘When should we stop resuscitation?’ instead – as he is wont – he turns the talk on its head and asks ‘When should we NOT stop resuscitation?’

Here is the audio (download the mp3 directly here):

Here is the video:

Cliff Reid – When Should Resuscitation Stop from Social Media and Critical Care on Vimeo.

 

To listen to all the smaccGOLD talks as they are released subscribe to the SMACC podcast on iTunes.

Neurosurgery for Everyone!

You’ll remember Mark Wilson (@markhwilson) from RAGE: The smaccGOLD Edition. Mark is an amazing mix of neurosurgeon and prehospital physician… We’ve already got him to promise to come on RAGE for a neuro-focused RAGE Session in the next few months.

Check out Mark’s talk on ‘Neurosurgery for Everyone!’ from smaccGOLD.

Mark Wilson Neurosurgery for Everyone from Social Media and Critical Care on Vimeo.

To listen to all the smaccGOLD talks as they are released subscribe to the SMACC podcast on iTunes.