RAGE Session Two

The wait is over, RAGE Session Two is here!

RAGE Session Two is 80 min 19 sec long and includes:

  • Introduction, including some bad news… (starts 00:00 min)
  • ‘What’s bubbling up?’ (starts 00:58 min) — shout outs and interesting discoveries from the world of FOAM and elsewhere featuring codeine in kids, post-intubation sedation, adenosine versus verapamil for SVT and how to do a good vagal manoeuvre, the ETM Twitter fiasco, the FOAMcc Google Plus Community and smaccGOLD.
  • the RAGE team discussing a case of submassive pulmonary embolism and the role of thrombolysis (starts 22:14  min)
  • the RAGE team’s discussion on ‘Humans in the resus room: ‘when your back-up gets your back up’’ (starts 51:50 min)
  • ‘A blast from the past’ on WW2 hero and chain-smoking legend Edgar Patz, the only man to complete an entire Masters degree unconscious!  (starts 73:00 min)
  • ‘Wise Words’ featuring the art of observation, the immortal John Hunter and the infinitely wise Sir William Osler (starts 77.55 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 Two:

What’s bubbling up?

 Submassive Pulmonary Embolus and Thrombolysis


Journal articles:

  • Dresden S,et al. Right ventricular dilatation on bedside echocardiography performed by emergency physicians AIDS in the diagnosis of pulmonary embolism.  Ann Emerg Med. 2014 Jan;63(1):16-24. doi: 10.1016/j.annemergmed.2013.08.016. Epub 2013 Sep 27. PubMed PMID: 24075286.
  • Kline JA, Steuerwald MT, Marchick MR, Hernandez-Nino J, Rose GA. Prospective evaluation of right ventricular function and functional status 6 months after acute submassive pulmonary embolism: frequency of persistent or subsequent elevation in estimated pulmonary artery pressure. Chest. 2009 Nov;136(5):1202-10. doi: 10.1378/chest.08-2988. Epub 2009 Jun 19. PubMed PMID: 19542256; PubMed Central PMCID: PMC2818852.
  • Howard LS. Thrombolytic therapy for submassive pulmonary embolus? PRO viewpoint. Thorax. 2014 Feb;69(2):103-5. doi: 10.1136/thoraxjnl-2013-203413. Epub 2013 Apr 26. PubMed PMID: 23624534.
  • Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W; Management Strategies and Prognosis of Pulmonary Embolism-3 Trial (MAPPET-3) Investigators. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med. 2002 Oct 10;347(15):1143-50. PubMed PMID: 12374874. [Free Full Text]
  • Sharifi M, et al; “MOPETT” Investigators. Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT” Trial). Am J Cardiol. 2013 Jan 15;111(2):273-7. doi: 10.1016/j.amjcard.2012.09.027. Epub 2012 Oct 24. PubMed PMID: 23102885.
  • Simpson AJ. Thrombolysis for acute submassive pulmonary embolism: CON viewpoint. Thorax. 2014 Feb;69(2):105-7. doi: 10.1136/thoraxjnl-2013-204193. Epub 2013 Sep 17. PubMed PMID:24046127.

Humans in the Resus Room: ‘When your Back-Up gets your Back Up’

Blast from the Past

Words of Wisdom

Thanks again for listening to the RAGE!

19 thoughts on “RAGE Session Two”

  1. Rage2-
    Excellent discussion. Might want to clue us folks that are less familiar with MOPPET etc into what they concluded. The playing field on this one is not very level (different folks have different familiarity with the literature). Thanks for a great discussion though.


    1. Thanks Mike

      It is tricky in a discussion like this to be all things to everyone. The intention was for us all to talk about what we do and why, trying to show the things that we consider in making the decision. In a 30 min segment it is impossible to include everything, and some building blocks are likely to get lost along the way. We also hope our discussion will stimulate others to learn more through FOAM, talking to colleagues and reading the primary literature.

      There are some useful links in the show notes above.

      Most RAGE episodes will have a link to the LITFL Critical Care Compendium, where I have summaries of critical care core topics and controversies, usually with extensive links to other resources and references. The Submassive PE and thrombolysis page is here: http://lifeinthefastlane.com/education/ccc/thrombolysis-submassive-pulmonary-embolus/ (a work in progress!)

      MOPPET (half dose thrombolysis for a ‘moderate’ PE – they didn’t use traditional definitions based on effects of the PE, but rather anatomical extent) found a 41% absolute risk reduction in longterm pulmonary hypertension.
      MOPPET is just a pilot study, but if you are going to thrombolyse giving a half dose with the option of giving more with monitoring with serial Echos seems reasonable.
      One of the criticisms of MOPPET was the high rate of pulmonary hypertension in the control arm (over 50%). This is higher than other other studies – though Kline, et al (2009) (see show notes for reference) also had high rates of pulmonary hypertension. The frequency of pulmonary hypertension probably depends on how hard you look for it! More recent studies seem to be taking this complication seriously and looking harder. Previously pulmonary hypertension rates of 2-4% had been quoted post-PE.

      EMCrit seemed to love MOPPET (http://emcrit.org/wee/mopett-trial/) – sorry, I originally left the link out of the show notes. The initial response on Medscape was more skeptical, especially about the rates of pulmonary hypertension (http://www.medscape.com/viewarticle/761062). Ryan Radecki at EM Lit of Note seems to be a fan (http://www.emlitofnote.com/2013/01/mopett-half-dose-tpa-for-pe.html).

      Hope that helps,

  2. The “Minh Le Cong rule” was enforced….
    I thought the MLC rule was :
    “Don’t worry….your penis will be the same length whoever does the airway….”

    Sorry, couldn’t resist… keep up the great work!

      1. You are quite right. I heard it on Scott’s podcast and thought Mihn said it and attributed it to him (it was over a year ago after all!). I like the idea of some more CR rules though, like “push that @#$*&$!! propofol and I’ll bite your @^s%#!! head off!”
        (paraphrasing) .

    1. Thank you. I have found it to be the most tactful yet helpfully persistent! Allows face saving for everyone! I have used it in communications with interns to consultants without offence.
      A lot of time is spent on team leader skills but effective negotiation when you are the hired gun coming down to a strange turf is a skill set as well!
      If it is badly done people are reluctant to call you until they are forced to, time is lost and the patient suffers.

  3. I need to make a correction. When I described Pete Sherren’s background I described him as a ‘UK based emergency physician, intensivist and HEMS doctor’. I mean to say anaesthetist rather than emergency physician. I doubt he cares.

  4. Pingback: RERN Kit - KI Doc
  5. Am getting huge amounts out of this all-star podcast.
    “The Humans in the Resus Room” section was especially fantastic and like Scott “EMCrit” Weingart I thought Michaela’s tips on how to be a helpful hired gun were excellent. Her illustrative story about the “stream of consciousness” team leader has only reinforced my own similar story that was also a seminal moment in my (ongoing) training. In my Eureka moment we were notified that we had a traumatic PEA inbound in 5 minutes and just before they arrived the team leader had the whole team pause their preparatory activities in the resus room to listen to the leader succinctly outline what they felt were the priorities in terms of treatment and likely outcome. It meant that when the patient arrived we all knew what had to be done and in what order almost without the leader having to repeat themselves. Then when we ended up with the negative outcome that the team leader had predicted I was left with the impression that everyone in the room felt that we had given that patient the best care possible. It also meant that the debrief was brief but there was no-one who I thought was likely to bring the issue up in tears 3 weeks later because of questions over whether enough had been done.
    Thanks again and keep up the good work.
    Andrew Perry
    ED Registrar

  6. RAGE Team,

    Great podcast as usual. I noticed there was no talk on Lactic Acid as a marker of mortality in PE on the podcast. Recently I found a study that evaluated patients with PE and serum lactate > 2 are at high risk for death, independent of shock/hypotension, RV dysfunction, or injury markers (17.3% vs 1.6%). Should we use this as a surrogate marker as well? http://www.ncbi.nlm.nih.gov/pubmed/23306454


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