kane guthrie: foam in review

FOAM in Review Kane Guthrie

FOAM from 2012• The review:– 189 different EMCC blogs & podcasts

Crowdsourcing

The Big FOAMed Hit’s

Of 2012

The Popular OnesEMCrit DSI Best use of the Bougie

Thought Provokers

& Game Changers!

LMA in Cardiac Arrest • Does the LMA decrease cerebral blood

flow?

• Using FOAMed to challenge the science!

http://bit.ly/XGYcv9

LMA in Cardiac Arrest • They didn’t buy it!• Used MRI to show LMA doesn’t impede

flow!• Short paper response - rejected to

letter form• So they used FOAMed instead!– Blog post, videocast & podcast discussion!

http://bit.ly/XGYcv9

The Man who made Sepsis

NYC STOP Sepsis Collaborative

Sepsis in the EDLessons:– Time sensitive disease - High mortality– Needs early recognition– AB’s & fluids within 1 hour– Use lactate to find the cryptic cases– Non invasive approach is effective

http://emcrit.org/severe-sepsis-resources/

Ketamine or KetaMinh

Who’s using it more because of Minh?

Ketamine or KetaMinh• What is it good for?– Agitation/Aggression/Analgesia– Procedural sedation – Antidepressant– Hypotensive patients– Chronic pain – The DSI approach

PCAs in the ED• Review of 2 studies!• Provide less-labor intensive analgesia• Better pain scores• Few more adverse events!– Nausea, vomiting, pruritis

• Worth it in some painful conditions!

Critical Care Palliation

“When we can’t be aggressive with our resuscitation – we need to be aggressive with our palliation!”

http://emcrit.org/podcasts/critical-care-palliation/

Critical Care Palliation

3 things never to say:

• “Do you want us to do everything?”• “Do you want us to resuscitate her?”• “I am so sorry, there is nothing more

we can do”

http://emcrit.org/podcasts/critical-care-palliation/

Tranexamic AcidThe FOAMed world ask why we aren’t

using it?

– Its cheap! – Its an old drug!– But it works!– ?prehospital drug

Pressure Poisoning

• Lung protective ventilation – Meta Analysis

• Not just in ARDS!• Lower tidal volumes = better outcomes

Pressure PoisoningStart with:• 6-8ml/kg by IBW for all intubated ED

patients

And protect those lungs!

Hypoxic Patient?

Needs lots of O2?

Not for Intubation?

What to do?

High Flow Nasal O2

http://emupdates.com/2012/03/01/the-high-flow-nasal-cannula-in-the-emergency-department/

• Give ^60L/02/min• Enable 100% 02, with 5/

PEEP• Humidified• Great for NFI pts• More comfortable NIV• Use for DSI!

PPI & Upper GI Bleeder!• Face validity of using PPI’s• 750 million per/yr USA

• Systematic R/V -Cochrane• 2000 Pts

http://thesgem.com/2012/12/sgem-16-ho-ho-hold-the-ppi/

PPI & the Upper GI Bleeder!No difference in:• Mortality, rebleeding, need for

surgery!

http://thesgem.com/2012/12/sgem-16-ho-ho-hold-the-ppi/

The Best Tricks of the Trade!

Difficulty feeding the NGT tube?• Try the SCANCRIT manoeuvre!

http://www.scancrit.com/2012/05/30/scancrit-manoeuvre/

Opioid Induced Constipation = Naloxone

• Give 2mg Naloxone PO• Mix with lactulose/colonlytely• Doesn’t induce opioid withdrawal!

http://blog.ercast.org/2012/02/the-constipation-manifesto/

=

Superglue for CVCs• Need to secure that ART line or CVC

during a resus?Forget this: Try this:

http://bit.ly/Sf1sXY

Need to Chemically Cardiovert SVT?

Combine Adenosine with the • Use 20ml syringe• Draw up adenosine & flush together• Administer by fast IV push• Doesn’t reduce effectiveness!

http://academiclifeinem.blogspot.com.au/2012/12/trick-of-trade-combine-adenosine-and.html

Nebulised Naloxone • Worried about acute withdrawal with IV

naloxone?• Still got some respiratory effort?• Feel you need to do something?• Gives “gentle & effective” reversal?

Try 2mg naloxone, 3mls saline in a neb!

http://www.thepoisonreview.com/2013/02/01/nebulized-naloxone-in-opiate-intoxication/

Stabilising Mandibular Fractures

• Splinting mandibular dislocation/fracture

• Easy as

• Putting them in a stiff neck collar!

http://academiclifeinem.blogspot.com.au/2012/05/trick-of-trade-stabilizing-mandibular.html

A Dose of Dex• Casey been doing it for a while!• Cochrane then decided to agree with

him:Benefits: • Reduction of pain• Early onset - 24hours• Same Kids vs Adults• No difference Bact vs Viral

http://broomedocs.com/2012/12/a-dose-of-dex/

Ruling & Managing the

RESUS ROOM

Life, Limb & Sight SavingProcedures

• Published in emj & Resus.Me• Questions if we’re ready to perform:– Time Critical Interventions

Highlights metacompetence:• Ability to apply the intervention @ the right

time!http://resusme.em.extrememember.com/?p=6707

The Usual State of Readiness• Being ready to act with life-saving

maneuvers• Managing your own catecholamine's

Being ready • Cognitively• Materially

http://emupdates.com/2012/09/26/the-usual-state-of-readiness/

The Usual State of Readiness1.Cognitively• Invisible simulation • Develop & prepare plans/scenarios in

your mind!• Knowing what you need to know

http://emupdates.com/2012/09/26/the-usual-state-of-readiness/

The Usual State of Readiness2. Materially • Equipment you need• When you need it• Where you need it

• Checking your equipment yourself!

http://emupdates.com/2012/09/26/the-usual-state-of-readiness/

Mind of the Resuscitationist• Being at the sharpest end of EM• Making things happen• Controlling your environment• Science of human persuasion • Standing like a leader

Owning the Airway in 2012Been dominated by:

• From DL to VL• To Human Factors & CRM• & Tools and Techniques• Then LMAs, retrogrades, bougies, & airway

aids –all through to the surgical airway!

The Vortex

Changing the way we approach the difficult airway

The Vortex• “High stakes cognitive aid”– Simple enough to be recalled– Flexible enough to be use in any context

• Train staff in unanticipated difficult airway

• Using single, simple, universally applicable template

http://www.vortexapproach.com/Vortex_Approach/Vortex.html

The FOAM Checklists

EMCrit Intubation

EM Updates Intubation

EMCrit Post-Intubation

EM Updates Asthma

In SummaryFOAMed in 2012 was all about:• Airway management/devices• Teaching us to use Checklist• How to Rule the Resus Room

FOAMed showing how to practice medicine in the future!

Questions

Thank-you

May the FOAM be with you!