July 22, 2019
REBEL Cast Ep 68: Rebellion in EM Day 2 Speaker Summaries with Andy Little
This is a special edition REBEL Cast done by my good friend Andy Little, DO (Twitter: @andylittle). As I was busy running the 2nd annual Rebellion in EM clinical conference, Andy was able to sit down with the speakers to summarize their main take away messages from each of their talks. This post is a summary of day 2.
REBEL Cast Episode 68: Rebellion in EM Day 2 Speaker Summaries with Andy Little
Chris Hicks – TEG and ROTEM in Resus
- Trauma coagulopathy effects ¼ of severely injured trauma patients, 4x increase in mortality
- Trauma coagulopathy is due to a series of things, factor consumption, fibrinogen deficit, the only way to distinguish is to use point of care testing. Then tailor your resus based on those findings.
- TEG and ROTEM give you the information you need for the coagulopathy so you can tailor the resus to your specific needs
Haney Mallemat – Epi in Cardiac Arrest
- Paramedic 2 trialshowed that epi was harmful in terms of neuro outcome. Might be helpful in lower doses but still unsure.
- Maybe all types of cardiac arrest should not all be bundled together; some subtypes will benefit with epi while others may not.
- Only way to be sure of what type of cardiac arrest is to do an arterial line and use ultrasound.
George Willis – Steroids in Sepsis
- Big picture view of studies with steroids for sepsis were flawed but generally speaking steroids did not show mortality benefit.
- Patient centered outcomes like length of stay in ICU, days on vent, pressor free days steroids did show improvement
- Don’t use steroids on all septic patients, wait till your maxed out on 1 pressor and about to use another and add on steroids at that time
Rob Bryant – 3 Changes to the way I intubate
- Always have bed of the bed elevated during pre-oxygenation and intubation phase
- Use Bougie as first look with video laryngoscope
- Be less of a jerk and use team factor management and good communication during resuscitation
Chris Hicks – Prehospital Airway Management
- Use what your familiar with and comfortable with for your airway management
- Resuscitation economics – when picking a strategy for management, if you’re doing one thing then you can’t be doing something else. Example, intubating hypotensive patient in field vs getting them to ER faster for definitive management.
- Airways 2 trial – Supraglottic device vs Intubation, essentially no difference between the two in survival to hospital discharge and neuro intact at 30 days. PARTS study focused more on mortality at 72 hours as laryngeal tube vs intubation as initial strategy, showed laryngeal tube had mortality benefit.
Ashley Voss-Liebig – Vascular Access
- Size matters in terms of length and diameter
- Consider best condition for patient and best access for them
- IO is safe, effective and fast
Patrick Bafuma – Major Delays to Second Dose of Antibiotics
- >25% delay is associated with increased mortality
- Pay attention to boarders, set timer or talk to IT people to build in automatic second dose
- Bolus + continuous infusion has been shown to decrease mortality with APACHE II score >20
Ashley Voss-Liebig – Arterial Line Pressure Monitoring
- Trouble shooting from patient site, checking patency, position and pressure
- Zeroing at phlebostatic axis point
- Understanding waveforms with underdampened and overdampened
George Willis – Hyperoxia in Critically Ill
- Several studies with hyperoxia on ischemic patients showed no improved benefits, normoxic is ok
- Too much oxygen is harmful. ICU oxygen trial liberal vs conservative, liberal (too much) had increased badness occur. IOTA trial conferred increased mortality with liberal oxygen.
- Normoxia is good, hypoxia is bad & hyperoxia is not good either
Scott Wieters – So you Can’t and Don’t and you Won’t Stop
- Literature shows significant pauses added when ultrasound applied to a code. Counting down and making sure US and pulse checkers are ready before the pause
- Limit US to less than 10 seconds during pulse check and check images after pulse check
- Don’t review US while performing check, review images once pause complete
Jenny Beck-Esmay – First Trimester Vaginal Bleeding
- Most of these patients can get gentle and cautious reassurance when discharging, if intrauterine pregnancy then majority will be normal pregnancy
- Do a better job when we don’t find live IUP, deliver a better message
- Some studies show pelvic exam is equivocal in medical decision making though those are small, still recommend doing them because may find unexpected pathology.
Patrick Bafuma – Epidural Abscess
- Patients with immunocompromised state need to be considered for deep space infection.
- Think about it in drug users, indwelling port, foley catheter and hemodialysis port.
- Also consider in recurrently ill patient.
Jamie Hope – Pregnancy Related Emergencies
- In case of resuscitative hysterotomy most difficult choice is to do it in the first place, needs to be done within 4 minutes of mom losing vitals.
- Postpartum hemorrhage is the leading cause of maternal mortality worldwide and in the United States. 80% of the time its uterine atony
- Most medications for resuscitation are the same as regular resuscitation doses.
Jenny Beck-Esmay – Emergency care for the lactating patient
- Avoiding pump and dump strategy as much as possible, use these online sources to help LactMed & Infant Risk for patients
- Better care of these patients in the holistic sense, if they’re breast feeding then try to facilitate that
- Mastitis treated with NSAID and Warm compresses and remember mother needs to continue breastfeeding.
Shownotes Written By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)
Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)