Critical Care Updates: Resuscitation Sequence Intubation – Hypoxemia Kills (Part 2 of 3)

Resuscitation Sequence Intubation - Hypoxemia Kills

This blog post is the second part of a series of 3, on a recent lecture I was asked to give  on Critical Care Updates: Resuscitation Sequence Intubation. This talk was mostly derived from a podcast by Scott Weingart (Twitter: @EMCrit) where he talked about the physiologic killers during preintubation and perintubation. In this podcast, Scott mentions the HOp killers: Hypotension, Hypoxemia, and Metabolic Acidosis (pH) as the physiologic causes of pre-intubation/peri-intubation morbidity and mortality. Taking care of these critically ill patients that require intubation can be a high stress situation, with little room for error.  In part two of this series we will discuss some useful strategies at the bedside to help us reduce pre-intubation/peri-intubation hypoxemia.
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Critical Care Updates: Resuscitation Sequence Intubation – Hypotension Kills (Part 1 of 3)

Resuscitation Sequence Intubation - Hypotension Kills

This blog post is the first part of a series of 3, on a recent lecture I was asked to give  on Critical Care Updates: Resuscitation Sequence Intubation. This talk was mostly derived from a podcast by Scott Weingart (Twitter: @EMCrit) where he talked about the physiologic killers during preintubation and perintubation. In this podcast, Scott mentions the HOp killers: Hypotension, Hypoxemia, and Metabolic Acidosis (pH) as the physiologic causes of pre-intubation/peri-intubation morbidity and mortality. Taking care of these critically ill patients that require intubation can be a high stress situation, with little room for error.  In part one of this series we will discuss some useful strategies at the bedside to help us reduce pre-intubation/peri-intubation hypotension.
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Beyond ACLS: Cognitively Offloading During a Cardiac Arrest

Beyond ACLSToday I am giving a talk at the 25th National Emergency Medicine Symposium by Kaiser Permanente in Maui, HI.  The focus of this talk was on how to cognitively offload our minds as we are running a resuscitation. ACLS provides us with a framework in treating adult victims of Cardiac Arrest (CA) or other cardiopulmonary emergencies. This helps get providers who don’t commonly deal with CA, to improve things, such as the quality of CPR, minimizing interruptions during CPR for pulse checks, and the timing/dosing of epinephrine. Emergency Medicine (EM) and the prehospital world are different than many environments in medicine. We get minimal information at the time of patient arrival while at the same time the disease process that is taking place has not quite defined itself.  We are constantly expected to acutely manage and resuscitate anyone who comes in our doors 24-7-365, many times without crucial information. Our job therefore should be to ensure coronary and cerebral perfusion are at their highest quality, but also simultaneously putting the pieces of the puzzle together to figure out why our patient is in CA. It can be very difficult to do both and many times we sacrifice one for the other. It is therefore important to cognitively offload ourselves during the resuscitation of our patients in CA and focus our attention on why they are in CA. As a disclosure for this lecture I did state that some of the recommendations made have evidence to support them and others are more theoretical and certainly up for discussion. Continue reading

September 2016 REBEL Cast: Refractory Ventricular Fibrillation

Refractory Ventricular FibrillationBackground: Welcome back to the September 2016 REBEL Cast. We are back with another episode and I am super excited about this episode because we are going to talk about two papers just published in the Resuscitation Journal on management of refractory ventricular fibrillation. It is a well known fact that the cornerstones for survival from Out-Of-Hospital Cardiac Arrest (OHCA) have always been early, high quality CPR and early defibrillation in patients with shockable rhythms (i.e. Ventricular Fibrillation/Ventricular Tachycardia). Some patients with shockable rhythms may be refractory to standard defibrillation therapy (i.e. refractory VF). Even more frustrating, there is truly a dearth of data on what to do with these patients. One strategy that has been reported more and more in the literature is double sequential defibrillation (DSD).

Another issue in cardiac arrest patients is we frequently give boluses of 1mg epinephrine every 3 – 5 minutes as is outlined in the ACLS guidelines.  When patients have minimal cardiac output, the buildup of catecholamines may potentially cause refractory ventricular fibrillation (RVF).  This could be due to an increase myocardial oxygen consumption causing an increase in myocardial ischemia, and ultimately more difficulty in successful defibrillation.  But maybe by blocking the beta-adrenergic receptors in the myocardium, we can block the beta effects of the catecholamines and potentially increase the chances of successful sustained ROSC.

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Upcoming Conferences Presented By The Teaching Institute

The Teaching Institute LogoThis year has been an exciting year for us at The Teaching Institute (TTI).  We have had some great medical education conferences at some pretty amazing places, including Cape Town, South Africa and Melbourne, Australia.  The rest of 2016 and 2017 promise to be just as exciting if not more so.  TTI is dedicated to helping others learn how to be better educators and committed to creativity and innovation.  Our motto is simple: better educators equals better patient care. If you haven’t been able to participate in any of our courses, it’s not too late.  You can still sign up for several of our courses that are coming up. Continue reading