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.

Thanks again for listening to the RAGE!

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:

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!

RAGE Session One

You’d be forgiven for thinking it was never going to happen… but it has… the first RAGE Session is finally here!

RAGE Session One is 71 min 7 sec long and includes:

  • Introduction, including the RAGE team ‘meet and greet’ (starts 00:00 min)
  • ‘What’s bubbling up?’ (starts 05:40 min) — shout outs and interesting discoveries from the world of FOAM and elsewhere featuring CO2 retention in COPD, the LINC trial, intraosseous blood transfusion, Rory Spiegel’s EM Nerd, the ‘quick look’ CT in ‘semi-stable’ trauma patients and fallen cycling legend Martyn Ashton
  • the RAGE team discussing ‘The post-TTM era: homeopathic hypothermia or aggressive normothermia?’ (starts 25:20 min)
  • the RAGE team’s discussion on ‘Septic and hypotensive: what next?’ (starts 39:06 min)
  • ‘A blast from the past’ on critical care deity Peter Safar, presented by Haney Mallemat (starts 63.57 min)
  • ‘Wise Words’ featuring Descartes and Diderot, presented by Michelle Johnston (starts 67.58 min)

It’s early days and we expect to incrementally improve the format, presentation and audio quality with each episode. To make this happen, we need your feedback — leave comments on this post or contact us here (especially if you want to appear on the show, correct us or respond to an episode in audio format).

The RAGE podcast has been submitted to iTunes , but is not yet available there  and is available here. The RAGE podcast audio feed is available here.

Read on for the ‘show note’ links for RAGE Session One…

Intro

What’s bubbling up?

The post-TTM era: homeopathic hypothermia or aggressive normothermia?

  • Nielsen N et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med Nov 17 2013 doi: 10.1056/NEJMoa1310519
  • Reports of therapeutic hypothermia’s death are greatly exaggerated (LITFL)
  • All in a lather over TTM (LITFL)
  • Post-arrest care: EMCrit interview with Stephen Bernard part 1 and  part 2
  • Dumas F, et al. Is hypothermia after cardiac arrest effective in both shockable and nonshockable patients?: insights from a large registry. Circulation. 2011 Mar 1;123(8):877-86. doi: 10.1161/CIRCULATIONAHA.110.987347. Epub 2011 Feb 14. PubMed PMID: 21321156. [Free Full Text]
  • Kim F et al. Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac ArrestA Randomized Clinical Trial. JAMA Nov 17 2013  doi:10.1001/jama.2013.282173
  • 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.
  • Nehme Z, Andrew E, Bernard SA, Smith K. Treatment of monitored out-of-hospital ventricular fibrillation and pulseless ventricular tachycardia utilising the precordial thump. Resuscitation. 2013 Dec;84(12):1691-6. doi: 10.1016/j.resuscitation.2013.08.011. Epub 2013 Aug 27. PubMed PMID: 23994203.

Septic and hypotensive: now what?

Blast from the Past

Thanks for listening to the RAGE!

Special thanks to Scott Weingart and Rob Orman for technical advice in making this happen — we will follow your advice more closely next time 😉