October 10, 2020

Pearls from ResusX Rewired 2020

From Oct 6th – 8th, 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

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

YEARS Protocol

PEGeD Protocol

Metabolic Cocktail in Septic Shock…Maybe Not

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

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

Cite this article as: Salim Rezaie, "Pearls from ResusX Rewired 2020", REBEL EM blog, October 10, 2020. Available at: https://rebelem.com/pearls-from-resusx-rewired-2020/.
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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of REBEL EM

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