Pearls from ResusX Rewired 2020

From Oct 6^th – 8^th, 2020, Haney Mallemat (@CriticalCareNow) and his team put on an absolutely amazing online critical care conference called ResusX Rewired.  ResusX is a conference designed by resuscitationists to provide clinicians with the most up to date skills and knowledge to help make a difference in your patients’ lives.  Haney and his crew made a combination of short-format, high-yield lectures, and completely customizable small group sessions with procedural demos seem easy.  There were so many high-quality speakers and pearls that I learned from this conference that I wanted to archive them here in one post for reference and to share with our readers/followers.

Treatment of Calcium Channel Blocker Toxicity

• High Dose Insulin (1U/kg bolus –> 1 to 10 U/kg/hr) + D10 at 0.25g/kg/hr
• Norepinephrine 2 to 20 mcg/min
• Epinephrine 2 to 20mcg/min
• CaCl 1 to 2g IV over 3min OR CaGluc 3 – 6g over 10min
• Glucagon 5mg IV
• 20% Lipid Emulsion Therapy (1.5mL/kg bolus –> 0.25mL/kg/min)
• ECMO

DKA Management via @SaraCrager

• It’s not about the sugar, it’s about the ketoacidosis
• Find the driver of the DKA (i.e. physiologic stressors)
• Normal glucose can still be DKA (i.e. euglycemic DKA)
• Normal bicarbonate + Normal pH can still be DKA (i.e. profuse vomiting)
• Intubation is a bad idea in DKA (RSI = Apnea = Worsening Acidosis = Potential Cardiac Arrest)
• Think BiPAP instead (give anti-emetics ahead of time
• Follow and replete K+
• Follow and replete Mg2+
• Bicarbonate fixes acidemia transiently and should not be routinely used
• Restore intravascular volume with balanced crystalloids
• REBEL EM Post: DKA Myths
• REBEL EM Post: Euglycemic DKA – It’s Not a Myth

Elevated Intracranial Pressure in Severe TBI via @4shikaJain

• Hypertonic Saline > Mannitol
• Mannitol
  • Bolus Only
  • Onset 30min
  • Lasts 6hrs
  • Causes Osmotic Diuresis
  • Dose 0.25 – 2g/kg over 30 to 60min
• HTS (3%)
  • Bolus or Drip
  • Onset 5min
  • Lasts 12hrs
  • No Diuretic Effect
  • Dose 300mL over 1hr

The Crashing Asthmatic via @EMSwami

• If usual care not working consider…
• Mg2+ 2g IV over 15min in 1st hour, then 2g IV/hr
• Epinephrine 5 to 10 mcg IVP then infusion at 1 to 20mcg/min
• Also consider Ketamine 0.3mg/kg bolus over 15min then 0.05 to 0.4mg/kghr
• REBEL Cast Ep11: The Crashing Asthmatic

TXA for Everything that Bleeds, an Update from 2019

• ICH (CRASH-3 + Pre-Hospital Study)
  • No benefit in severe TBI (GCS ≤8)
  • +/- benefit in moderate TBI (GCS 9 to 12)
  • No benefit in mild TBI (GCS 13 to 15)
• GIB (HALT-IT)
  • Exact timing of GIB hard to know
  • No benefit + potential harms
• REBEL EM Post: CRASH-3 – TXA for ICH?
• REBEL EM Post: Out-of-Hospital TXA for TBI
• REBEL Cast Ep85: The HALT-IT Trial – TXA in Acute GI Bleeds

CRASH-3: GCS 9 – 12 with Biggest Potential Benefit

CRASH-3 found a potential benefit in intermediate severity GCS, but pre-hospital study did not divide up patients

Clinical Probability Adjusted D-Dimer

• Acceptable miss rate = 1.8%
• YEARS trial missed 0.6% VTE at 90d and 0.2% death
• PEGeD trial missed 0% of VTE
• Both trials reduced ed imaging by 13 to 18%)
• Excluded cancer and pregnant pts
• Clinical adjusted d-dimer is ready for primetime
• REBEL EM Post: The YEARS Study – Simplified Diagnostic Approach to PE
• REBEL EM Post: PEGeD Study – Is it Safe to Adjust the D-Dimer Threshold for Clinical Probability?

YEARS Protocol

PEGeD Protocol

Metabolic Cocktail in Septic Shock…Maybe Not

• 5/6 RCTs with a negative primary outcome (ORANGES changed primary outcome after data collected)
• Arbitrary start point of ED arrival does not make sense as a stopwatch in a heterogenous disease that develops over time
• 5/6 RCTs showed no difference in mortality
• 5/6 RCTs showed no difference in time of pressors
• 5/5 RCTS have shown steroids alone decrease time off pressors
• REBEL Cast Ep74: Is it all About the VITAMINS in Sepsis?
• REBEL EM Post: Let’s get our ACTS Together – The Metabolic Cocktail and Septic Shock Again
• REBEL EM Post: CITRIS-ALI – Vitamin C in Patients with Sepsis and Severe Acute Respiratory Failure
• REBEL EM Post: The HYVCTTSSS Trial – The “Metabolic Cocktail” in Another RCT
• REBEL EM Post: The ORANGES Trial – Why You Can’t Just Read the Abstract

The Magical Lewis Lead to Differentiate SVT-AC vs VT via @amalmattu

• Lewis lead shows atrial activity
  • RA –> Suprasternal notch
  • LA –> Rt 5th ICS next to sternum
  • LL –> Rt lower costal margin

Terrible T’s of ACS via @amalmattu

• “The T wave is the underdog of ECGs”
• Hyperacute T waves = T wave out of proportion to QRS
  • Concerting for Occlusion MI
  • Repeat ECGs
• New upright T wave in V1
  • T wave in V1 bigger than T wave in V6
  • Type of hyper acute T wave
  • Get Serial ECGs
  • Normal Variants = Misplaced leads, LBBB, LVH

Bougie-Assisted Cricothyrotomy

• Simple and rapid
• No special equipment required
• High success and low complication rates
• Toughest part of procedure is decision to cut
• Know your anatomy
• Only need your finger, 10 blade scalpel, bougie, and a 6-0 ETT
• Betadine nice if available
• Don’t feed ETT too far (usually 1 to 2 cm after ETT ballon disappears)
• Practice, practice, practice

ACS in Presence of LBBB via @amalmattu

• Modified Sgarbossa Criteria (Only need in 1 lead)
  • Concordant STE ≥1mm
  • Concordant STD >1mm in V1 to V3
  • ST/S Ratio ≤-0.25
• REBEL EM Post: Modified Sgarbossa Criteria – Ready for Primetime?
• REBEL EM Post: The Modified Sgarbossa Criteria – Part Deux

Peripheral Pressors: 6 Pearls to Not F*#k up the Arm

• Use proximal veins
• Use a longer catheter (4.78cm or 6.35cm)
• Run for only 2 to 4 hours
• Dilute + small volume (i.e. norepinephrine 4mg in 250mL NS)
• Have an observation protocol (Look at IV site every 15 to 20min)
• Have an extravasation protocol (Phentolamine, terbutaline, Nitropaste, warm compress, and elevation)
• REBEL EM Blog Post: Peripheral Pressors – 6 Pearls to Not F*#k up the Arm

VExUS Score to Quantify Systemic Congestion via @EMNerd_

• POCUS
  • IVC
  • Hepatic Vein
  • Portal Vein
  • Intra-Renal Vein

Image from POCUS101.com [Link is HERE]