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.

Cutting Edge Intra-Arrest Care

The RAGE team owe a lot to Mr EMCrit Scott Weingart. Together with Rob Orman of ERCast, he was instrumental in helping us get the technical aspects of podcasting in order as we found our podcasting feet.

Here is Weingart in action at smaccGOLD. His talk on ‘Cutting Edge Intra-Arrest Care’ is unequivocally essential listening for anyone who follows the RAGE podcast.

It is controversial.

He calls for resuscitationists to go beyond ACLS and function on the bleeding edge of critical care.

Critics will argue that early adoption is intensely dangerous. I am sure that some of the things Scott talks about will prove to be false in the fullness of time (I just can’t see vasopressin-epi-steroids being validated by bigger multi-center trials, for instance).  Nevertheless, this is a masterful talk by a master resuscitationist.

If you resuscitate, you must listen to this talk!

This is the audio: (direct download mp3 here):

These are the slides:

This is the video:

Cricoid: To Press or Not to Press?

Just in case you still thought cricoid pressure was a good idea, listen to the RAGE team’s newest member John Hinds at smaccGOLD. Hinds is an anaesthetist, intensivist and a motorcycle-riding prehospital resuscitationist based in Northern Ireland. In this debate he will tell you about ‘cricolol’.

What?

John parodies cricoid pressure by encouraging us to imagine that this procedure is a drug… Yep, might as well use it as a suppository.

Would you give it?

RAGE listeners have already heard Scott Weingart in RAGE: smaccGOLD edition call this the ‘most brilliant cutting away at the knees of an opponent…”

Listen to the talk below (John starts about halfway through at 12min 55sec if you’re impatient).

Here are the slides to flick through as you listen:

Or why not go straight to the video:

BTW, big ups to Brent May for valiantly putting forward the case for cricoid pressure… An unenviable task.

Learn more here:

Otherwise check out John’s references:

  1. Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet 1961;2:404-6.
  2. Koziol CA, Cuddeford JD, Moos DD. Assessing the force generated with application of cricoid pressure. AORN journal 2000;72:1018-28, 30.
  3. Smith KJ, Dobranowski J, Yip G, Dauphin A, Choi PT. Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging. Anesthesiology 2003;99:60-4.
  4. Hartsilver EL, Vanner RG. Airway obstruction with cricoid pressure. Anaesthesia 2000;55:208-11.
  5. Allman KG. The effect of cricoid pressure application on airway patency. Journal of clinical anesthesia 1995;7:197-9.
  6. Levitan RM, Kinkle WC, Levin WJ, Everett WW. Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy. Annals of emergency medicine 2006;47:548-55.
  7. Garrard A, Campbell AE, Turley A, Hall JE. The effect of mechanically-induced cricoid force on lower oesophageal sphincter pressure in anaesthetised patients. Anaesthesia 2004;59:435-9.
  8. Chassard D, Tournadre JP, Berrada KR, Bouletreau P. Cricoid pressure decreases lower oesophageal sphincter tone in anaesthetized pigs. Canadian journal of anaesthesia = Journal canadien d’anesthesie 1996;43:414-7.
  9. Heath KJ, Palmer M, Fletcher SJ. Fracture of the cricoid cartilage after Sellick’s manoeuvre. British journal of anaesthesia 1996;76:877-8.
  10. Ralph SJ, Wareham CA. Rupture of the oesophagus during cricoid pressure. Anaesthesia 1991;46:40-1.

The Art and Science of Fluid Responsiveness

Unavoidable delays mean you’ll have to wait a bit longer for RAGE Session 4… But it is in the works, we promise!

In the meantime check out this masterful smaccGOLD presentation by the RAGE team’s very own Haney Mallemat: ‘The Art and Science of Fluid Responsiveness’.

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

Here is the video:

Learn more about related topics via the LITFL CCC:

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