RAGE HEAD BANNER 2

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!

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10 thoughts on “RAGE SESSION THREE”

  1. Any comments on using THAM (tromethamine) to raise patient pH in a ventilated asthmatic patient? Great podcast. I always look forward to the next episode.
    Emergency Department Pharmacist
    University of Michigan

    1. Hi Mary
      I have no personal experience with THAM – though it might be a more sensible option than HCO3 as it won’t generate CO2 in the same way (which is, of course, why you’ve made he comment!)
      Anyone else used it for this?
      Chris

  2. As someone who only has to deal with the challenges of the OR, I admire the line of fire faced by EM types.

    Regarding lidocaine (lignocaine), I was struck by nearly-immediate, unanimous response by the panel regarding the (non)utility of this drug for severe bronchospasm. If the critique is that is has little advantage in the setting of maximal beta-stimulation, then what is the rationale for giving salbutamol (albuterol) if the patient is already maximally beta-stimulated?

    Based on my purely observational experience with this drug as a common part of many (most) anesthetic inductions, I have to ask the question: once the decision has been made to proceed to intubation, what is the downside of adding lignocaine/lidocaine to the induction mix? There are numerous reports regarding its potential to reduce airway reactivity; hemodynamically it is relatively benign.

    Having raised the point, I will acknowledge a caveat similar to the crapulence that Cliff Reid reported with ketamine: patients in extremis do not tolerate otherwise-benign drugs well, even lidocaine. A reduction in the dosage of all drugs (and an adjustment for any drugs added to the regimen) is probably worth considering.

    As one of my attendings used to say, they can tolerate 2 benign drugs in combination, but not 3.

    1. Great comment Greg
      People can argue either way for lignocaine – I don’t think there is a right or wrong answer and there is not value in being dogmatic about it
      Main drawbacks for me: only anecdotal evidence, adds complexity, potential for drug errors/ reactions/ toxicity, lack of familiarity in my setting
      Hence I choose not to use it – though I suspect I use agents with a similar level of evidence and biological plausibility!
      All the best
      Chris

      1. Hi Chris,

        Thanks for the 15 seconds of fame. One of the local EM docs listened to the RAGEback and asked if it was me. Had to own up.

        I don’t want to turn this into a micturation contest, but with all due respect, isn’t “lack of familiarity with a drug” exactly the space that #FOAM seeks to broach, rather than a convincing disqualifier?

        I am familiar with both the Maslow and Adamzik papers you cited. Two important differences are dose and timing. Maslow gave 1.5 mg/kg 3 min before intubation to patients who were instructed to forego their regular asthma medications on the day of surgery, whereas Adamzik gave 2 mg/kg 5 min after intubation, followed by another 0.5 mg/kg over 10 min to patients took their usual medications on the day of surgery. While Adamzik measured plasma lidocaine levels, Maslow did not, which may be relevant given lidocaine’s early half-life of 8-15 min.

        My conclusion based on these 2 studies would be: lidocaine in a dose of 1.5 mg/kg, when given 3-4 minutes before a challenging stimulus, is not a substitute for traditional bronchodilators in patients who have abstained from their normal asthma medications; while 2-2.5 mg/kg lidocaine produces a clinically significant lowering of airway resistance in patients receiving traditional bronchodilators.

        While it may be difficult to design a study to definitively answer the role of IV lidocaine for patients in asthmatic crisis, it seems reasonable to consider the universe of medications, especially when they work by different mechanisms with a limited downside. I will acknowledge that IV lidocaine has the potential to induce seizures; concomitant administration of midazolam, propofol, or other medications known to lower the seizure threshold should be considered. As I alluded to in the earlier post, that may significantly limit the utility of lidocaine as a pre-intubation “rescue drug”.

        1. Thanks again Greg
          As you suggest, The Maslow and Adamzik papers, apart from being contradictory, have limited to zero external validity when considering the patient with severe life-threatening asthma. I don’t have a problem with someone using it if they have experience with it, but – as discussed in the RAGEback – it’s not for me in this setting.
          Cheers
          Chris

  3. Have used verapamil for many years for SVT. Virtually Always works. Patients don’t fall back into SVT as with adenosine. BP risk overstated- have always used it with 250 ml bolus and calcium gluconate bolus pretreatment although I know it probably isn’t necessary.

  4. As far as I recall, a reminder of the evidence basis for special K in asthma- a procedure in the 70s where a kid was a bit blue beforehand, and did OK with K.
    http://journals.lww.com/anesthesia-analgesia/Citation/1971/05000/Use_of_Ketamine_in_an_Asthmatic_Child__A_Case.30.aspx

    External chest compressions- certainly seen a CO2 go from >100 to <60 with a minute of this (post intubation COPD arrest).
    Love the SHIT mnemonic.
    Ultrasound for pneumothorax 1st not holes in chest? But does the pleura move enough in these cases……

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