Resus Now

The second part of my interview with Dr. Kenji Oyasu.Dr. Oyasu is an Emergency Room Physician and also runs ModernMed Recovery.https://www.modernmedrecovery.com/

I promised you content and I finally delivered! Dr. Kenji Oyasu joins me for this fascinating look into the world of addiction medicine.Dr. Oyasu is an Emergency Room Physician and also runs ModernMed Recovery.https://www.modernmedrecovery.com/

Just a quick update on what's going on with the show. New episodes coming soon!

On this episode, We discuss some contraindications, controversies, data analysis of different clinical trials of TXA, and much more! Please see links below for referenced articles in the show.http://www.emra.org/emresident/article/critcare-alert-crash3/https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-020-04623-5https://emcrit.org/pulmcrit/crash3/https://first10em.com/halt-it-trial/https://www.thebottomline.org.uk/summaries/icm/tich-2/https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31033-X/fulltexthttps://www.bmj.com/content/343/bmj.d3795https://rebelem.com/crash-3-txa-for-ich/

In this 5 minute bit, we describe the mechanism of action of tranexamic acid and its many indications as it applies to emergency conditions. Please see below for articles and evidence related to the show.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7023891/https://pubmed.ncbi.nlm.nih.gov/23477634/

https://emcrit.org/rush-exam/original-rush-article/https://emcrit.org/wp-content/uploads/2011/03/New-RUSH-Review-Article1.pdfhttps://emcrit.org/wp-content/uploads/2011/03/new-rush-study.pdfhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3485910/

https://emcrit.org/rush-exam/original-rush-article/https://emcrit.org/wp-content/uploads/2011/03/New-RUSH-Review-Article1.pdfhttps://emcrit.org/wp-content/uploads/2011/03/new-rush-study.pdfhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3485910/

In this 5 minute bit, we discuss scenario based pressor selection, vasopressors to choose in the face of RV failure or pulmonary hypertension, and peripheral vasopressors. Below you will find evidence related articles on vasopressin and dobutamine effect on pulmonary vascular resistance, safety profile of peripheral pressors and an interesting article about using midline catheters as an alternative to central lines for vasopressor administration (not prime time yet). https://pubmed.ncbi.nlm.nih.gov/12682485/http://www.emdocs.net/the-crashing-pulmonary-hypertension-patient/https://emcrit.org/emcrit/peripheral-vasopressors-extravasation/https://pubmed.ncbi.nlm.nih.gov/26014852/http://www.emdocs.net/r-e-b-e-l-em-peripheral-pressors-6-pearls-to-not-fk-up-the-arm/https://journals.lww.com/ccmjournal/fulltext/2020/01001/1276__safety_and_efficacy_of_vasopressor.1232.aspxhttps://first10em.com/peripheralperssors/https://www.acep.org/how-we-serve/sections/critical-care-medicine/news/july-2017/peripherally-versus-centrally-administered-potent-vasopressors-in-the-icu/https://journals.lww.com/anesthesia-analgesia/fulltext/2002/02000/vasopressin_effect_on_pulmonary_arterial_pressure.59.aspx

In this 5 minute bit we discuss Phenylephrine, Angiotensin II, Dobutamine and Milrinone. Please see attached evidence related to our topic:*Just to clarify, dobutamine and milrinone can both be used for right ventricular systolic failure but there is some evidence that milrinone may provide better pulmonary vascular afterload reduction than dobutamine. NO MILRINONE IN RENAL FAILURE. MILRINONE IS LONG ACTING. *Just to clarify, Angiotensin II data was not solely tested against placebo. The actual randomized trial had both groups on high dose norepinephrine and one group had placebo as a second agent and the other group had angiotensin II as a second agent. The point of the trial was to demonstrate Angiotensin II efficacy in a patient that was failing high dose norepinephrine alone (or equivalent dose of another vasopressor). So the trial was not really Angiotensin II against just placebo as both groups were also on high dose catecholamine.https://ccforum.biomedcentral.com/articles/10.1186/s13054-014-0534-9https://www.nejm.org/doi/full/10.1056/NEJMoa1704154https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764562/https://www.ncbi.nlm.nih.gov/books/NBK470431/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4691094/https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-14/Treatment-of-right-heart-failure-is-there-a-solution-to-the-problem

In this episode, 2 Intensivists Dr. Srinivasan and Dr. Patel visit Resus Now to discuss todays approach on taking care of patients with COVID 19 illness. Please see below articles for evidence related to todays topic.Dexamethasone article:https://www.nejm.org/doi/full/10.1056/NEJMoa2021436Tocilizumab article:https://www.nejm.org/doi/full/10.1056/NEJMoa2028836Vitamin C article:https://link.springer.com/article/10.1007/s43440-020-00176-1Reading about zinc:https://www.covid19treatmentguidelines.nih.gov/adjunctive-therapy/zinc/Reading about melatonin:https://consultqd.clevelandclinic.org/melatonin-a-promising-candidate-for-prevention-and-treatment-of-covid-19/Remdesivir article:https://www.nejm.org/doi/full/10.1056/NEJMoa2007764Pepcid reading:https://hartfordhealthcare.org/about-us/news-press/news-detail?articleid=28305&publicId=395Anticoagulation in COVID:https://www.universityhealthsystem.com/~/media/files/pdf/covid-19/guidelines-for-anticoagulation-in-hospitalized-covid-19-patients.pdf?la=enAnticoagulation in COVID:https://www.uptodate.com/contents/image?imageKey=HEME/128045Heparin resistance in COVID:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7242778/Anticoagulation in COVID:https://www.nejm.org/doi/full/10.1056/NEJMclde2028217

Review the below articles thoroughly before placing a temporary dialysis catheter. Remember RIJ is site of choice followed by femoral. LIJ not ideal and avoid subclavian. Enjoy and thank you for all of your support for Resus Now!https://www.ncbi.nlm.nih.gov/books/NBK539856/http://maryland.ccproject.com/2014/03/11/vascular-access-renal-replacement-therapy/

IT'S THE HALLOWEEN SPECIAL, PART TWO! Ralph & Dr. Barker are joined by Dr. Daniel Liesen, who is here to discuss thoracotomies in the emergency department. Remember:1. Know your indications and contraindications and ensure back up is available and on their way.2. Prepare your equipment3. Incise and gain entry also intubate right mainstem and know how to use your spreaders!4. LOOK!!! 5. Control hemorrhage that is visible and open pericardium-control direct cardiac bleeding6. Clamp the aorta above the diaphragm- Time is ticking.....7. Open cardiac massage/defibrillation8. Avoid further air embolism if any present9. Got ROSC and adequate vital signs————-> To the OR10. Always be careful please!Below are some great instructional links and evidence based articles. https://emj.bmj.com/content/22/1/22https://www.facs.org/-/media/files/quality-programs/trauma/publications/thoracotomy.ashxhttps://litfl.com/resuscitative-thoracotomy/https://www.east.org/education/practice-management-guidelines/emergency-department-thoracotomyhttps://rebelem.com/if-youre-going-to-do-the-thoracotomydo-a-clamshell/https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiHnNHUzdvsAhWriK0KHcJ_B-UQwqsBMAF6BAgFEAM&url=https%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3D924t8kpW-p4&usg=AOvVaw170N7m070KxjSCUWwAJRKYhttps://www.uptodate.com/contents/resuscitative-thoracotomy-techniquehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6802990/

IT'S THE (EARLY) HALLOWEEN SPECIAL, PART ONE! Ralph & Dr. Barker are joined by Dr. Daniel Liesen, who is here to discuss thoracotomies in the emergency department.Remember:1. Know your indications and contraindications and ensure back up is available and on their way.2. Prepare your equipment3. Incise and gain entry also intubate right mainstem and know how to use your spreaders!4. LOOK!!! 5. Control hemorrhage that is visible and open pericardium-control direct cardiac bleeding6. Clamp the aorta above the diaphragm- Time is ticking.....7. Open cardiac massage/defibrillation8. Avoid further air embolism if any present9. Got ROSC and adequate vital signs————-> To the OR10. Always be careful please!Below are some great instructional links and evidence based articles. https://emj.bmj.com/content/22/1/22https://www.facs.org/-/media/files/quality-programs/trauma/publications/thoracotomy.ashxhttps://litfl.com/resuscitative-thoracotomy/https://www.east.org/education/practice-management-guidelines/emergency-department-thoracotomyhttps://rebelem.com/if-youre-going-to-do-the-thoracotomydo-a-clamshell/https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiHnNHUzdvsAhWriK0KHcJ_B-UQwqsBMAF6BAgFEAM&url=https%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3D924t8kpW-p4&usg=AOvVaw170N7m070KxjSCUWwAJRKYhttps://www.uptodate.com/contents/resuscitative-thoracotomy-techniquehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6802990/

In this 5 minute bit, we talk about treatment and chest tube size options for the simple pneumothorax. Please see below for evidence related articles:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5334075/http://jtd.amegroups.com/article/view/8006/html https://www.cookmedical.com/critical-care/in-favor-of-small-bore-the-efficacy-of-pigtail-catheters-for-pleural-and-pericardial-drainage/

In this 5 minute bit, we discuss the emergency treatment of the tension pneumothorax using the finger thoracostomy. Please see attached evidence based articles associated with the episode. https://pubmed.ncbi.nlm.nih.gov/22987168/

In this episode Ralph goes over the use of the arterial line in cardiac arrest. Please see below evidence related articles to supplement this 5 minute bit. https://pubmed.ncbi.nlm.nih.gov/4064112/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4087068/pdf/nihms-598128.pdfhttps://emcrit.org/wp-content/uploads/2018/07/DBP-vs-ETCO2.pdfBelow is an excellent blog post and podcast done by Scott Weingart of EMCrit. This clears up where your diastolic value is during mechanical CPR. https://emcrit.org/emcrit/dbp-cpr/https://emottawablog.com/2020/04/nurse-led-acls/

Ralph is joined by Dr. Kelly Wren in a discussion about an anhydrous ammonia spill and the aftermath in the Emergency Department.

Ralph is joined by Dr. Brock Franklin, who presents an interesting airway case.

A 5 minute bit on a tracheostomy emergency that deserves some attention. Ralph describes this emergency, the etiology, the recognition, the management steps and prognosis. Please see evidence related articles and sites regarding this topic.https://www.ncbi.nlm.nih.gov/books/NBK482505/ https://emergencymedicinecases.com/tracheo-innominate-fistula/http://www.downstatesurgery.org/files/cases/tif.pdf

Emergent treatment of rapid atrial fib/flutter with Dr. Dave Zull. Please see below for Evidence based annotated articles Arrigo M. New Onset Atrial Fibrillation in critically ill patients and it’sassociation with mortality. Int J Cardiol 266:95-99, Sept 2018Bosch, NA, et al. Atrial Fibrillation in the ICU CHEST 154:1424-1434. Dec 2018Nice review of A fib in the critically ill patient. Emphasis first on correcting precipitants like sympathomimetics, electrolytes, volume and intercurrent illness. Esmolol implied to be best rate control drugDeSouza IA, et al. Pharmacologic Cardioversion of recent onset Atrial Fibrillation and Flutter in the Emergency Department. Ann Emerg Med 76:14-30. July 2020Looking at 360 patients with acute a fib. Ibutilide converted 50% of A fib and 75% of A flutter patients. Two patients had VT as a complication, but none received Magnesium prophylaxis.Nikki, AHA, et al. Early or Delayed Cardioversion in recent onset Atrial Fibrillation. N Engl J Med 380:1499-1508, Apr 2019Oral H, et al. Facilitating Transthoracic Cardioversion of atrial Fibrillation with Ibutilide pretreatment. N Engl J Med 340:1849, Jun 199972% converted to NSR with electrical cardioversion without pretreatment whereas 100% converted with Ibutilide pretreatment before electicityPatsilinakos S, et al. Effect of high doses of Magnesium on converting Ibutilide to a safe and more effective agent. Am J Cardiol 106:673, Sept 2010Magnesium sulfate 4-5 gm infused over one hour before Ibutilide prevents TorsadesSleeswijk ME, et al. Efficacy of Magnesium-Amiodarone step-up scheme in critically ill patients with new onset atrial fibrillation. J Intensive Care Med 23:61, Jan/Feb 2008Magesium infusion followed by Amiodarone infusion in A fib with RVR in the ICU. Half had acceptable rate or rhythm control with Mag alone. At the end of 24 hours 90% of patients converted to NSR.Stiell, Ian, et al. Electrical vs Pharmacologic cardioversion for emergency department patients with acute Atrial Fibrillation. RAFF2 Lancet 395:339-349, Feb 2020Canada’s aggressive protocol for conversion of acute A fib in the ER. IV Procoinamide infusion converted 50% to NSR. Electrical cardioversion worked in 92%. Only 3% of new A fib patients required admissionTercius AJ, et al. Intravenous Magnesium sulfate enhances the ability of intravenous Ibutilide to successfully convert atrial fibrillation or flutter. Pacing Clin Electrophysiol 30:1331, Nov 2007Vinson DR, et al. Ibutilide effectiveness and safety in the Cardioversion of atrial fibrillation and flutter in the community emergency department. Ann EmergMed71:96, Jan 2018Wyse DG, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation (AFFIRM trial). N Engl J Med 247:1825-33, Dec 2002Internists and cardiologist love to quote the AFFIRM trial as proof that attempts to convert are fruitless and we stick to rate control only. These patient were all in chronic a fib and of course we would never convert these patients unless there is life threat. This study has NO application to acute a fib less than 48 hoursZimetbaum P. Atrial Fibrillation. Annal Intern Med. March 2017Everything you ever wanted to know about atrial fibrillation

A 5 minute bit that discusses the feared complication of inadvertent arterial placement of central lines. We discuss some strategies to avoid this and other complications. We use ultrasound for needle insertion (even for subclavian lines), tube manometry, guidewire localization with ultrasound, and the agitated saline test using POC echo at the bedside. Please see below evidence based articles, blogs and pictures associated with the show.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296410/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4613416/https://pubmed.ncbi.nlm.nih.gov/26256713/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3040432/https://www.ejves.com/article/S1078-5884(09)00441-9/pdfhttps://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.aliem.com%2Ftrick-of-trade-use-angiocatheter-for%2F&psig=AOvVaw2_x647g9uR__qk7eZWPvFj&ust=1599256051066000&source=images&cd=vfe&ved=0CAIQjRxqFwoTCMDTt6H7zesCFQAAAAAdAAAAABADhttps://emcrit.org/wp-content/uploads/2015/08/bubble-confirm-of-central-lines.pdf

Dean Ferrera MD, Interventional Cardiologist visits Resus Now to discuss which post arrest ROSC patients without a STEMI on the EKG should go to the cath lab. Please see below for evidence related articles related to the show.https://www.nejm.org/doi/full/10.1056/https://wikem.org/wiki/STEMI_equivalents

In this 5 minute bit, Ralph discusses some methods of managing a patient with a bleeding AV fistula.Sorry, we ran way over 5 minutes........Hopefully it’s worth it.aShow Notes:Suture required is usually 5.0-6.0 prolene with a non cutting needle. Don’t forget local anesthesia. https://www.acepnow.com/article/dialysis-access-emergencies/https://emblog.mayo.edu/2015/04/27/how-to-stop-a-post-dialysis-site-bleeding/https://i1.wp.com/rushemergencymedicine.org/wp-content/uploads/2019/03/Cutting-vs.-Non-cutting-needles.jpg?w=638&ssl=1https://i1.wp.com/rushemergencymedicine.org/wp-content/uploads/2019/03/Purse-string.jpeg?resize=177%2C140&ssl=1https://img1.wsimg.com/isteam/ip/98c1f477-09ba-4d4d-87bc-8ed1076615eb/fistula3.png/:/cr=t:0%25,l:0%25,w:100%25,h:100%25/rs=w:1280

https://link.springer.com/article/10.1007/s12028-013-9950-yhttps://pubmed.ncbi.nlm.nih.gov/24996763/

In this episode, Ralph & Dr. Barker discuss the different drugs available for RSI.Evidence based articles related to our topics, click links below:https://coreem.net/core/parenteral-benzodiazepines/https://link.springer.com/article/10.1007/s12028-013-9950-yhttps://pubmed.ncbi.nlm.nih.gov/24515638/https://www.uptodate.com/contents/induction-agents-for-rapid-sequence-intubation-in-adults-outside-the-operating-roomhttps://emj.bmj.com/content/22/6/456https://emedicine.medscape.com/article/80222-periprocedurehttps://www.nejm.org/doi/full/10.1056/nejmoa1005372