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.

What a great job!

Indispensable RAGE team member Cliff Reid was a keynote speaker at the ACEM Annual Scientific Meeting in 2013.

He was tasked with delivering a talk titled ‘What a great job!’

… and, of course, he well and truly delivered.

Hopefully this tides you over until the next RAGE session and inspires you as much as it inspires us.

Special thanks to ACEM for allowing the audio to be released as FOAM on the RAGE Podcast.

RAGE on…

Thanks again for listening to the RAGE!

RAGE smaccGOLD Edition

As promised in SMACCGOLD IS ALL THE RAGE here is the smaccGOLD edition of the RAGE podcast.

This podcast represents the first time all the RAGE podcasters have been together in person. In addition to the RAGE team we had a bunch of friends helping us out:

RAGE at smaccGOLD
Photo via @markhwilson

From left to right:

Unfortunately, missing from the photo is my great friend and SMACC co-conspirator Oli Flower (@oliflower). Also, the third founder of SMACC, the ‘SMACC Big Cheese’ Roger Harris (@RogerRDHarris)  wasn’t included because we’d just have to bleep  out everything he’d say anyway… Sorry Rog!

The audio quality is a tad marginal in places, but that’s what you get with an impromptu recording of 10 slightly manic people in a room with one mic. All the same, we hope it is an engaging audio experience and gives a good insight into the SMACC experience and what to look out for as the talks are released online. Thanks to Haney for helping me get this audio into the best shape possible.

This is ’17 minutes’, the amazing video by Tamara Hills and family mentioned in the podcast (nearly 7,000 views and counting):

Look out for all the talks being released on the SMACC podcast and the affiliated FOAM websites in the coming months. Follow the @smaccteam on Twitter for updates.

For other accounts of smaccGOLD (based on a list originally made by Alan Batt), check out:

Thanks again for listening to the RAGE!

RAGEback: Weingart and co on Asthma

This RAGEback includes commentary and reaction to the RAGE Session Three discussion of severe life-threatening acute asthma. It features comments from Mary Shue on THAM, Greg Miller on lignocaine and someone called Scott Weingart (anyone heard of him?) on non-invasive ventilation.

Here’s some stuff on lignocaine (a fairly evidence free zone!):

  • BestBets: Lignocaine as a pretreatment to Rapid Sequence Induction of patients with Status Asthmaticus 
  • Maslow AD, Regan MM, Israel E, Darvish A, Mehrez M, Boughton R, Loring SH. Inhaled albuterol, but not intravenous lidocaine, protects against intubation-induced bronchoconstriction in asthma. Anesthesiology. 2000 Nov;93(5):1198-204. PubMed PMID: 11046206. [Free Full Text]
  • More recently though, this paper suggested some beneficial effects on bronchoconstriction post-intubation:
    Adamzik M, Groeben H, Farahani R, Lehmann N, Peters J. Intravenous lidocaine after tracheal intubation mitigates bronchoconstriction in patients with asthma. Anesth Analg. 2007 Jan;104(1):168-72. PubMed PMID: 17179265.

Some stuff by Scott Weingart on Emcrit.org relevant to this discussion:

Finally, some useful links from the LITFL Critical Care Compendium:

Thanks again for listening to the RAGE!

smaccGOLD is all the RAGE

The entire RAGE team were at smaccGOLD, and we loved every minute of it.

Of course, Cliff Reid stole the show as per usual with his talk on ‘When should resuscitation stop?” (look out for it on the SMACC podcast in the coming months) but all the RAGE team made huge contributions to the critical care conference of the millennium.

Photo courtesy of SMACC
Photo courtesy of SMACC

This was the first time the entire RAGE team were in one place at the same time – rather than connected via Skype over the Internet – so we took the chance to record some audio. We managed to include a few friends too… Though, as always, the best bits will probably have to be edited out 😉

Look out for the next RAGE podcast featuring these SMACCers:

RAGE at smaccGOLD
Photo via @markhwilson

From left to right:

Unfortunately Oli Flower (@oliflower) is missing from the photo, but he’ll be in the next podcast too.

PS. Hat tip to @alittlemedic for inspiring the post title

RAGE SESSION THREE

Just in time for smaccGOLD, RAGE Session Three is here!

It is 67 min 53 sec long and includes:

  • Introduction, including an ERCAST shout out and apologies from Haney… (starts 00:00 min)
  • ‘What’s bubbling up?’ (starts 01:30 min) — shout outs and interesting discoveries from the world of FOAM and elsewhere featuring pre-hospital spinal immobilisation, astronaut Chris Hadfield, ‘Mistakes were made’, EMA’s 25th anniversary edition and the need to tailor blood pressure targets to the individual.
  • the RAGE team discussing acute  life-threatening asthma (starts 15:52  min)
  • the RAGE team discussing ‘Medical Reversal’ (starts 52:52 min)
  • ‘A blast from the past’ by Karel Habig on ‘Ether Day’ and the origins of general anaesthesia (starts 63:42 min)
  • ‘Words of Wisdom’ featuring a quote from Cliff Reid’s role model, and some other guy (starts 66:32 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 Three:

Introduction

What’s bubbling up?

Life-threatening severe asthma

Medical reversal

  • Medical Reversal (LITFL CCC)
  • Mac Sweeney’s Top Ten Critical Care Papers for 2013 (LITFL)
  • Prasad V, et al. A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices. Mayo Clin Proc. 2013 Jul 12. doi:pii: S0025-6196(13)00405-9. 10.1016/j.mayocp.2013.05.012. [Epub ahead of print] PubMed PMID: 23871230. [Free Full Text] (includes a video commentary by the lead author)
  • Walters BC, Hadley MN, Hurlbert RJ, Aarabi B, Dhall SS, Gelb DE, Harrigan MR, Rozelle CJ, Ryken TC, Theodore N. Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery. 2013 Aug;60 Suppl 1:82-91. doi: 10.1227/01.neu.0000430319.32247.7f. PubMed PMID: 23839357. [Free Full Text articles]
  • The Nobel Prize in Physiology or Medicine 2005 — Barry J. Marshall, J. Robin Warren (NobelPrize.org)
  • Chesnut RM,  et al; Global Neurotrauma Research Group. A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med. 2012 Dec 27;367(26):2471-81. doi: 10.1056/NEJMoa1207363. Epub 2012 Dec 12. Erratum in: N Engl J Med. 2013 Dec 19;369(25):2465. PubMed PMID: 23234472; PubMed Central PMCID: PMC3565432.
  • Bellomo R, Chapman M, Finfer S, Hickling K, Myburgh J. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group. Lancet. 2000 Dec 23-30;356(9248):2139-43. PubMed PMID: 11191541.
  • Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation. 2011 Sep;82(9):1138-43. doi: 10.1016/j.resuscitation.2011.06.029. Epub 2011 Jul 2. PubMed PMID: 21745533.
  • Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R; SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004 May 27;350(22):2247-56. PubMed PMID: 15163774.
  • Stroke Thrombolysis (LITFL CCC)

Blast from the Past

Words of Wisdom

Dreams save us

Addendum 30 March 2014:

Thanks again for listening to the RAGE!

How we train is how we fight

The RAGE team’s sphincters are progressively tightening as the pressure to perform at smaccGOLD mounts… the conference is just a couple of weeks away.

Sydney HEMS submitted a fantastic SimWars GOLD video entry — featuring quotations from HEMS speakers at the first SMACC conference, including RAGE’s Karel Habig and Cliff Reid.

Watch and be inspired…

Be inspired to train harder…

Be inspired to fight harder to save lives.

RAGEback: Minh Le Cong, Verapamil and SVT

The discussion of verapamil as an option for the treatment of supraventricular tachycardia (SVT) in RAGE Session Two went off like a fire cracker in the FOAM world.

In this RAGEback, Minh Le Cong from the PHARM podcast explains why the RAGE discussion is not going to change his practice, which is to use adenosine as a first line agent.

This is followed by a response by RAGErs Karel and Cliff.

You — the listener — are left to make up your own mind about which patients (if any) you’ll consider verapamil as an option.

References and Links

Minh cites these references (in the order they were mentioned):

  • Leitner RP, Hawker RE, Celermajer JM. Intravenous verapamil in the treatment of paroxysmal supraventricular tachycardia in children. Aust Paediatr J. 1983 Mar;19(1):40-4. PubMed PMID: 6870700.
  • Delaney B, Loy J, Kelly AM. The relative efficacy of adenosine versus verapamil for the treatment of stable paroxysmal supraventricular tachycardia in adults: a meta-analysis. Eur J Emerg Med. 2011 Jun;18(3):148-52. doi: 10.1097/MEJ.0b013e3283400ba2. Review. PubMed PMID: 20926952.
  • Hood MA, Smith WM. Adenosine versus verapamil in the treatment of supraventricular tachycardia: a randomized double-crossover trial. Am Heart J. 1992 Jun;123(6):1543-9. PubMed PMID: 1595533.
  • Anugwom C, Sulangi S, Dachs R. Adenosine vs. calcium channel blockers for supraventricular tachycardia. Am Fam Physician. 2007 Jun 1;75(11):1653-4. Review. PubMed PMID: 17575655. [Free Full Text]
  • Brady WJ Jr, DeBehnke DJ, Wickman LL, Lindbeck G. Treatment of out-of-hospital supraventricular tachycardia: adenosine vs verapamil. Acad Emerg Med. 1996 Jun;3(6):574-85. PubMed PMID: 8727628.

Karel and Cliff added these to the mix:

  • Holdgate A, Foo A. WITHDRAWN: Adenosine versus intravenous calcium channel antagonists for the treatment of supraventricular tachycardia in adults. Cochrane Database Syst Rev. 2012 Feb 15;2:CD005154. doi: 10.1002/14651858.CD005154.pub3. Review. PubMed PMID: 22336809. [Free Full Text] (note: withdrawn by the author due to lack of time and resources to update)
  • Miyagawa K, Dohi Y, Ogihara M, Sato K. Administration of intravenous calcium before verapamil to prevent hypotension in elderly patients with paroxysmal supraventricular tachycardia. J Cardiovasc Pharmacol. 1993 Aug;22(2):273-9. PubMed PMID: 7692169.
  • Riaz R, Mishra J, Hussain S, Sinha LM. Adenosine Versus Verapamil for the Treatment of Supra-ventricular Tachycardia: Randomized Comparative Trial. Pakistan J Med & Health Sci. 2012 Jul-Sept [Free Full Text]
  • Lapage MJ, Bradley DJ, Dick M 2nd. Verapamil in infants: an exaggerated fear? Pediatr Cardiol. 2013 Oct;34(7):1532-4. doi: 10.1007/s00246-013-0739-8. Epub 2013 Jun 26. PubMed PMID: 23800976.

Roie Tal’s Prezi journal club presentation on the Lapage et al 2013 article:

The links mentioned at the end are:

Thanks again for listening to the RAGE!