Podcasts about anesth analg

Un nouvel épisode du Pharmascope est disponible! Dans ce 154e épisode à saveur psychoactive, Nicolas, Isabelle et Olivier reçoivent un nouvel invité pour discuter de cannabis. Cette première partie est consacrée à discuter des composantes du cannabis, des différents cannabinoïdes pharmaceutiques et de leur efficacité en douleur neuropathique.  Les objectifs pour cet épisode sont les suivants: Discuter des composantes du cannabis et des cannabinoïdes pharmaceutiques Discuter de l'efficacité des cannabinoïdes dans le traitement de la douleur neuropathique Comparer les données d'efficacité et d'innocuité des cannabinoïdes en douleur neuropathique Ressources pertinentes en lien avec l'épisode  Mücke M, Phillips T, Radbruch L, Petzke F, Häuser W. Cannabis-based medicines for chronic neuropathic pain in adults. Cochrane Database Syst Rev. 2018 Mar 7;3(3):CD012182. Hansen JS et coll. Cannabis-Based Medicine for Neuropathic Pain and Spasticity-A Multicenter, Randomized, Double-Blinded, Placebo-Controlled Trial. Pharmaceuticals (Basel). 2023 Jul 28;16(8):1079. Ware MA, Fitzcharles MA, Joseph L, Shir Y. The effects of nabilone on sleep in fibromyalgia: results of a randomized controlled trial. Anesth Analg. 2010 Feb 1;110(2):604-10. Skrabek RQ, Galimova L, Ethans K, Perry D. Nabilone for the treatment of pain in fibromyalgia. J Pain. 2008 Feb;9(2):164-73. Bell AD et coll. Clinical Practice Guidelines for Cannabis and Cannabinoid-Based Medicines in the Management of Chronic Pain and Co-Occurring Conditions. Cannabis Cannabinoid Res. 2024 Apr;9(2):669-687. Busse JW et coll. Medical cannabis or cannabinoids for chronic pain: a clinical practice guideline. BMJ. 2021 Sep 8;374:n2040. Wang L et coll. Medical cannabis or cannabinoids for chronic non-cancer and cancer related pain: a systematic review and meta-analysis of randomised clinical trials. BMJ. 2021 Sep 8;374:n1034. Allan GM et coll. Simplified guideline for prescribing medical cannabinoids in primary care. Can Fam Physician. 2018 Feb;64(2):111-120. Allan GM et coll. Systematic review of systematic reviews for medical cannabinoids: Pain, nausea and vomiting, spasticity, and harms. Can Fam Physician. 2018 Feb;64(2):e78-e94.

Send us a textEs wird laut: Wir besprechen die Arbeit von Gagné et al. zum Einfluss von Lärm auf das Management von Zwischenfällen:Gagné JF, Dababneh S, Bélanger MÈ, Georgescu M, Drolet P, Richebé P, Issa R, Tanoubi I. Examining the Impact of High-Decibel Environment on Anesthesiologists' Crisis Situation Management. Anesth Analg. 2025 Feb 3. doi: 10.1213/ANE.0000000000007439. Epub ahead of print. PMID: 39899456.Im Studio mit dabei: Anna Hafner, wissenschaftliche Mitarbeiterin der Klinik für Anästhesiologie am UKHD

Contributor: Aaron Lessen MD Educational Pearls: Pregnant patients at high risk of cardiac arrest, in cardiac arrest, or in extremis require special care A useful mnemonic to recall the appropriate management of critically ill pregnant patients is TOLDD T: Tilt the patient to the left lateral decubitus position This position relieves pressure exerted from the uterus onto the inferior vena cava, which reduces cardiac preload If the patient is receiving CPR, an assistant should displace the uterus manually from the IVC towards the patient's left side O: Administer high-flow adjunctive oxygen  L: Lines should be placed above the diaphragm Lines below the diaphragm are ineffective due to uterine compression of the IVC May consider humeral interosseous line vs. internal jugular or subclavian central line D: Dates should be estimated > 20 weeks, can consider a resuscitative hysterotomy (previously known as perimortem c-section) to improve chances of survival The uterus is palpable at the umbilicus at 20 weeks and 1 cm superior to the umbilicus for every week thereafter D: Call the labor and delivery unit for additional help References ACOG Practice Bulletin No. 211 Summary: Critical Care in Pregnancy. Obstetrics & Gynecology. 2019;133(5) Fujita N, Higuchi H, Sakuma S, Takagi S, Latif MAHM, Ozaki M. Effect of Right-Lateral Versus Left-Lateral Tilt Position on Compression of the Inferior Vena Cava in Pregnant Women Determined by Magnetic Resonance Imaging. Anesth Analg. 2019;128(6):1217-1222. doi:10.1213/ANE.0000000000004166 Jeejeebhoy FM, Zelop CM, Lipman S, et al. Cardiac Arrest in Pregnancy. Circulation. 2015;132(18):1747-1773. doi:doi:10.1161/CIR.0000000000000300 Singh, Ajay; Dhir, Ankita; Jain, Kajal; Trikha, Anjan1. Role of High Flow Nasal Cannula (HFNC) for Pre-Oxygenation Among Pregnant Patients: Current Evidence and Review of Literature. Journal of Obstetric Anaesthesia and Critical Care 12(2):p 99-104, Jul–Dec 2022. | DOI: 10.4103/JOACC.JOACC_18_22  Summarized & Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

In this episode, we explore the critical role nurses play in advancing health equity within the ICU. Jennifer Adamski, president of the American Association of Critical-Care Nurses, shares insights on how nurses can make a difference at the bedside and the challenges they face. We also discuss strategies for empowering nurses and fostering a culture of equity in critical care.This episode is sponsored by Medtronic.Areia C, King E, Ede J, Young L, Tarassenko L, Watkinson P, Vollam S. Experiences of current vital signs monitoring practices and views of wearable monitoring: A qualitative study in patients and nurses. Journal of advanced nursing. 2022 Mar;78(3):810-22Williams EC, Polito V. Meditation in the Workplace: Does Mindfulness Reduce Bias and Increase Organisational Citizenship Behaviours? Front Psychol. 2022 Apr 11;13:747983. doi: 10.3389/fpsyg.2022.747983. PMID: 35478759; PMCID: PMC9035788.Lewis CL, Yan A, Williams MY, Apen LV, Crawford CL, Morse L, Valdez AM, Alexander GR, Grant E, Valderama-Wallace C, Beatty D. Health equity: A concept analysis. Nurs Outlook. 2023 Sep-Oct;71(5):102032. doi: 10.1016/j.outlook.2023.102032. Epub 2023 Sep 6. PMID: 37683597.Bhavani SV, Wiley Z, Verhoef PA, Coopersmith CM, Ofotokun I. Racial Differences in Detection of Fever Using Temporal vs Oral Temperature Measurements in Hospitalized Patients. JAMA. 2022;328(9):885–886. doi:10.1001/jama.2022.12290P Malhotra, L Shaw, J Barnett, E Hayter, N Hill, P Stockton. St Helens and Knowsley. P179 Patient safety alert: a prospective study on 100 patients highlighting inaccuracy of pulse oximeter finger probes used on ear lobes. Teaching Hospitals NHS Trust, Prescot, UK. 10.1136/thorax-2018-212555.336Torp KD, Modi P, Pollard EJ, Simon LV. Pulse Oximetry. 2023 Jul 30. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 29262014Nitzan M, Romem A, Koppel R. Pulse oximetry: fundamentals and technology update. Med Devices (Auckl). 2014 Jul 8;7:231-9. doi: 10.2147/MDER.S47319. PMID: 25031547; PMCID: PMC4099100Giuliano KK, Bilkovski RN, Beard J, Lamminmäki S. Comparative analysis of signal accuracy of three SpO2 monitors during motion and low perfusion conditions. J Clin Monit Comput. 2023 Dec;37(6):1451-1461. doi: 10.1007/s10877-023-01029-x. Epub 2023 Jun 2. PMID: 37266709; PMCID: PMC10651546Gudelunas MK, Lipnick M, Hendrickson C, et al. Low Perfusion and Missed Diagnosis of Hypoxemia by Pulse Oximetry in Darkly Pigmented Skin: A Prospective Study. Anesth Analg. 2024;138(3):552-561. doi:10.1213/ANE.0000000000006755

Matthew A. Borgman, M.D. is a Professor of Pediatrics in the Division of Pediatric Critical Care at the University of Texas Southwestern.  Dr. Borgman graduated from Uniformed Services University (USU), he completed Pediatric Residency at Brooke Army Medical Center in 2007, followed by a fellowship in Critical Care at Boston Children's Hospital.  He is a prolific author in pediatric trauma management which has helped redefine the care of injured children. He is also the former national chair of the Pediatric Trauma Society Research Committee and has co-authored the 2022 Pediatric Traumatic Hemorrhagic Shock Consensus Conference Recommendations. Learning Objectives:By the end of this podcast, listeners should be able to:Define pediatric hemorrhagic shock and massive transfusion.Develop a guideline-based clinical approach to managing a child with hemorrhagic shock.Explore an expert's approach to managing a child with hemorrhagic shock where the evidence might not be clear. References:Russell et al. Pediatric traumatic hemorrhagic shock consensus conference recommendations. J Trauma Acute Care Surg. 2023 Jan 1;94(1S Suppl 1):S2-S10. Spinella et al. Transfusion Ratios and Deficits in Injured Children With Life-Threatening Bleeding. Pediatr Crit Care Med. 2022 Apr 1;23(4):235-244. Gaines et al. Low Titer Group O Whole Blood In Injured Children Requiring Massive Transfusion. Ann Surg. 2023 Apr 1;277(4):e919-e924. Moore et al. Fibrinolysis Shutdown in Trauma: Historical Review and Clinical Implications. Anesth Analg. 2019 Sep;129(3):762-773.Roberts et al. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess. 2013 Mar;17(10):1-79. Dewan et al. CRASH-3 - tranexamic acid for the treatment of significant traumatic brain injury: study protocol for an international randomized, double-blind, placebo-controlled trial. Trials. 2012 Jun 21;13:87.Spinella et al. Survey of transfusion policies at US and Canadian children's hospitals in 2008 and 2009. Transfusion. 2010 Nov;50(11):2328-35.Whitton TP, Healy WJ. Clinical Use and Interpretation of Thromboelastography. ATS Sch. 2023 Jan 9;4(1):96-97. MATIC-2: Questions, comments or feedback? Please send us a message at this link (leave email address if you would like us to relpy) Thanks! -Alice & ZacSupport the showHow to support PedsCrit:Please complete our Listener Feedback SurveyPlease rate and review on Spotify and Apple Podcasts!Donations are appreciated @PedsCrit on Venmo , you can also support us by becoming a patron on Patreon. 100% of funds go to supporting the show. Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.com for detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.

This episode of the Ketamine Startup Podcast, comes from a presentation Sam gave at the American College of Emergency Physicians Scientific Assembly on October 1, 2024. Discover the journey of opening a ketamine clinic, the efficacy of IV ketamine for depression, anxiety, PTSD, and chronic pain, and the mechanism behind its success. You will learn about the growing mental health crisis, high burnout rates among emergency physicians, and why ketamine therapy can be a rewarding alternative career path. Sam also shares the emotional and financial realities of running a ketamine clinic, emphasizing the importance of motivation, purpose, and personal fulfillment. Hear powerful testimonials from patients and gain practical advice for starting your own clinic. Don't miss this comprehensive guide filled with scientific studies, real-life experiences, and expert insights.What You'll Learn In This Episode:• Career Transition: Discover how emergency physicians can pivot into running ketamine clinics and find greater autonomy and purpose.• Clinical Evidence: Explore key studies supporting the use of ketamine therapy for depression, anxiety, PTSD, and chronic pain.• Overcoming Challenges: Understand the financial and emotional challenges of running a ketamine clinic and how to stay motivated by focusing on your "why."Episode 22 show notes:00:00 Teaser - The Swimming Pool Dilemma00:35 Introduction01:10 Sam's Journey and Niche in Ketamine Therapy03:12 The Mental Health Crisis05:05 Challenges Faced by Emergency Physicians06:13 Scientific Studies on IV Ketamine Therapy08:45 Ketamine for Anxiety and PTSD10:47 Ketamine for Chronic Pain12:13 How Does Ketamine Work?12:17 Ketamine's Impact on Neurotransmitters13:11 Ketamine and Chronic Stress14:06 Hallucinogenic Effects of Ketamine14:57 Emergency Medicine and Ketamine16:16 Starting a Ketamine Clinic17:19 The Importance of Your 'Why'18:33 Challenges and Rewards of a Ketamine Clinic20:12 Patient Testimonials and Impact21:34 ConclusionThanks for listening

Send us a Text Message.Diese Woche beschäftigen wir uns mit einem klassischen AINS-Thema: PONV. Konkret geht es um die Arbeit von Sprung et al., die sich mit dem Effekt von Propofol auf PONV während einer balancierten Anästhesie mit volatilen Anästhetika beschäftigt haben:Sprung J, Deljou A, Schroeder DR, Warner DO, Weingarten TN. Effect of Propofol Infusion on Need for Rescue Antiemetics in Postanesthesia Care Unit After Volatile Anesthesia: A Retrospective Cohort Study. Anesth Analg. 2024;139(1):26-34. doi:10.1213/ANE.0000000000006906Mit im Studio dabei: Stefanie Petzold, wissenschaftliche Mitarbeiterin der Klinik für Anästhesiologie am UKHD.

Welcome to Episode 36 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 36 of “The 2 View” – Marijuana as a schedule III drug, treating sunburns and other skin problems, pulse oximetry and racial bias, and diagnosing lower UTIs. Marijuana as a schedule III drug Burton KW. The DEA Plans to Reschedule Marijuana: What Happens Next? Medscape: Emergency Medicine. Published May 2, 2024. Accessed May 10, 2024. https://www.medscape.com/viewarticle/dea-plans-reschedule-marijuana-what-happens-next-2024a10008ka?ecd=wnledittpal_etid6489685&uac=106964SV&impID=6489685 Dea.gov. DEA: United States Drug Enforcement Administration. Accessed May 10, 2024. https://www.dea.gov/drug-information/drug-scheduling Treating sunburns and other skin problems 12 Summer Skin Problems You Can Prevent. Aad.org. American Academy of Dermatology Association. Accessed May 10, 2024. https://www.aad.org/public/everyday-care/skin-care-secrets/routine/prevent-summer-skin-problems Benedetti J. Sunburn. Merck Manual Professional Edition. Reviewed/Revised Oct 2023. Accessed May 10, 2024. https://www.merckmanuals.com/professional/dermatologic-disorders/reactions-to-sunlight/sunburn Faurschou A, Wulf HC. Topical corticosteroids in the treatment of acute sunburn: A randomized, double-blind clinical trial. Arch Dermatol. PubMed. NIH: National Library of Medicine: National Center for Biotechnology Information. Published May 2008. Accessed May 10, 2024. https://pubmed.ncbi.nlm.nih.gov/18490588/ How to Treat Sunburn. Aad.org. American Academy of Dermatology Association. Accessed May 10, 2024. https://www.aad.org/public/everyday-care/injured-skin/burns/treat-sunburn Skowrońska W, Bazylko A. The Potential of Medicinal Plants and Natural Products in the Treatment of Burns and Sunburn—A Review. Pharmaceutics. PMC: PubMed Central. NIH: National Library of Medicine: National Center for Biotechnology Information. Published February 2023. Accessed May 10, 2024. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9958865/ Pulse oximetry and racial bias Gudelunas MK, Lipnick M, Hendrickson C, et al. Low Perfusion and Missed Diagnosis of Hypoxemia by Pulse Oximetry in Darkly Pigmented Skin: A Prospective Study. Anesth Analg. PubMed. NIH: National Library of Medicine: National Center for Biotechnology Information. Published March 1, 2024. Accessed May 10, 2024. https://pubmed.ncbi.nlm.nih.gov/38109495/ Valbuena VSM, Seelye S, Sjoding MW, et al. Racial bias and reproducibility in pulse oximetry among medical and surgical inpatients in general care in the Veterans Health Administration 2013-19: multicenter, retrospective cohort study. BMJ. Published July 6, 2022. Accessed May 10, 2024. https://www.bmj.com/content/378/bmj-2021-069775.long Diagnosing Lower UTIs Aydemir B, Overton D. Diagnosing Lower Urinary Tract Infections. ACEP Now: The Official Voice of Emergency Medicine. Published May 10, 2024. Accessed May 10, 2024. https://www.acepnow.com/article/diagnosing-lower-urinary-tract-infections/ Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to. Be sure to listen in and see what we have to share!

Travis Reece-Nguyen, MD, MPH, FAAP, and OpenAnesthesia Associate Editor Elisha Peterson, MD, MEd, FAAP, FASA, discuss perioperative care of transgender and gender diverse pediatric patients. Resources: OA Summary: Transgender and Gender-Diverse Patients: Anesthetic Considerations  van Rooyen, C., Aquino, N.J., Tollinche, L.E. et al. Perioperative Considerations for Gender-Affirming Surgery. Curr Anesthesiol Rep 13, 90–98 (2023). Link Sanchez K, Tollinche L, Reece-Nguyen T. Anesthesia for gender-affirming surgery: a practical review. Curr Opin Anaesthesiol. 2024;37(3):292-298. PubMed TRANSformed Anesthesia: Examining a Novel ERAS Pathway for Gender-Affirming Chest Reconstruction Surgery Link Sanchez KJ, Sanchez RA, Ben Khallouq B, Ellis DB. Perioperative Care of Transgender and Gender-Diverse Patients: A Biopsychosocial Approach. Anesth Analg. 2023;137(1):234-246. PubMed Reece-Nguyen T, Afonso AM, Vinson AE. Burnout, Mental Health, and Workplace Discrimination in Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersex, and Asexual Anesthesiologists. Anesthesiol Clin. 2022;40(2):245-255. Link

https://www.cursotdc.com.br/antibiotico/lead/

Calcium administration to trauma patients has become a hot topic with the rise of the “Lethal Diamond."  While evidence exists regarding the association between hypocalcemia and mortality, it remains unclear whether hypocalcemia is the problem or simply a finding secondary to critical injury.  In this podcast, Dr. Lauria reviews the evidence behind calcium administration in trauma and identifies which patients, given the available evidence, might benefit from calcium administration. Don't miss another FlightBridgeED Podcast feature episode of the MDCast! So much good stuff! Please like, subscribe, and leave any questions or comments. References for the use of Calcium in Severe Trauma Chanthima P, Yuwapattanawong K, Thamjamrassri T, et al. Association Between Ionized Calcium Concentrations During Hemostatic Transfusion and Calcium Treatment With Mortality in Major Trauma. Anesth Analg. Jun 1 2021;132(6):1684-1691. doi:10.1213/ANE.0000000000005431 D B. Prehospital administration of calcium in trauma J Paramed Prac. 2022; DeBot M, Sauaia A, Schaid T, Moore EE. Trauma-induced hypocalcemia. Transfusion. Aug 2022;62 Suppl 1:S274-S280. doi:10.1111/trf.16959 Ditzel RM, Jr., Anderson JL, Eisenhart WJ, et al. A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond? J Trauma Acute Care Surg. Mar 2020;88(3):434-439. doi:10.1097/TA.0000000000002570 Giancarelli A, Birrer KL, Alban RF, Hobbs BP, Liu-DeRyke X. Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res. May 1 2016;202(1):182-7. doi:10.1016/j.jss.2015.12.036 Kronstedt S, Roberts N, Ditzel R, et al. Hypocalcemia as a predictor of mortality and transfusion. A scoping review of hypocalcemia in trauma and hemostatic resuscitation. Transfusion. Aug 2022;62 Suppl 1(Suppl 1):S158-S166. doi:10.1111/trf.16965 Leech C, Clarke E. Pre-hospital blood products and calcium replacement protocols in UK critical care services: A survey of current practice. Resusc Plus. Sep 2022;11:100282. doi:10.1016/j.resplu.2022.100282 Messias Hirano Padrao E, Bustos B, Mahesh A, et al. Calcium use during cardiac arrest: A systematic review. Resusc Plus. Dec 2022;12:100315. doi:10.1016/j.resplu.2022.100315 Moore HB, Tessmer MT, Moore EE, et al. Forgot calcium? Admission ionized-calcium in two civilian randomized controlled trials of prehospital plasma for traumatic hemorrhagic shock. J Trauma Acute Care Surg. May 2020;88(5):588-596. doi:10.1097/TA.0000000000002614 Savioli G, Ceresa IF, Caneva L, Gerosa S, Ricevuti G. Trauma-Induced Coagulopathy: Overview of an Emerging Medical Problem from Pathophysiology to Outcomes. Medicines (Basel). Mar 24 2021;8(4)doi:10.3390/medicines8040016 Steele T, Kolamunnage-Dona R, Downey C, Toh CH, Welters I. Assessment and clinical course of hypocalcemia in critical illness. Crit Care. Jun 4 2013;17(3):R106. doi:10.1186/cc12756 Stueven H, Thompson BM, Aprahamian C, Darin JC. Use of calcium in prehospital cardiac arrest. Ann Emerg Med. Mar 1983;12(3):136-9. doi:10.1016/s0196-0644(83)80551-4 Vallentin MF, Granfeldt A, Meilandt C, et al. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. Dec 14 2021;326(22):2268-2276. doi:10.1001/jama.2021.20929 Vallentin MF, Povlsen AL, Granfeldt A, Terkelsen CJ, Andersen LW. Effect of calcium in patients with pulseless electrical activity and electrocardiographic characteristics potentially associated with hyperkalemia and ischemia-sub-study of the Calcium for Out-of-hospital Cardiac Arrest (COCA) trial. Resuscitation. Dec 2022;181:150-157. doi:10.1016/j.resuscitation.2022.11.006 Vasudeva M, Mathew JK, Groombridge C, et al. Hypocalcemia in trauma patients: A systematic review. J Trauma Acute Care Surg. Feb 1 2021;90(2):396-402. doi:10.1097/TA.0000000000003027 Vettorello M, Altomare M, Spota A, et al. Early Hypocalcemia in Severe Trauma: An Independent Risk Factor for Coagulopathy and Massive Transfusion. J Pers Med. Dec 28 2022;13(1)doi:10.3390/jpm13010063 Wray JP, Bridwell RE, Schauer SG, et al. The diamond of death: Hypocalcemia in trauma and resuscitation. Am J Emerg Med. Mar 2021;41:104-109. doi:10.1016/j.ajem.2020.12.065 Zhang Z, Xu X, Ni H, Deng H. Predictive value of ionized calcium in critically ill patients: an analysis of a large clinical database MIMIC II. PLoS One. 2014;9(4):e95204. doi:10.1371/journal.pone.0095204 See omnystudio.com/listener for privacy information.

Is Gabapentin the new Tramadol? We see quite a many post on Veterinary Anesthesia Nerds discussing the use of Gabapentin for acute post surgical pain..but what does the evidence say? Here Stephen breaks down how this drug works, why acute pain may not be the best use of gabapentin and what you should reach for instead. Resources mentioned in this episode: Pypendop B, Siao K, Lkiw J. Thermal antinociceptive effect of orally administered gabapentin in healthy cats. Am J Vet Res. 2010;71(9). doi:10.2460/AJVR.71.9.1027 Reid P, Pypendop B, Ilkiw J. The effects of intravenous gabapentin administration on the minimum alveolar concentration of isoflurane in cats. Anesth Analg. 2010;111(3). doi:10.1213/ANE.0B013E3181E51245 Johnson B, Aarnes T, Wanstrath A, et al. Effect of oral administration of gabapentin on the minimum alveolar concentration of isoflurane in dogs. Am J Vet Res. 2019;80(11). doi:10.2460/AJVR.80.11.1007

Dr. Chris Di Capua and Dr. Bryan Glezerson (@BryanGlezerson) join the show to discuss the literature around the risk of aspiration with LMAs compared to ETTs. This is an episode produced from the Depth of Anesthesia Podcast Elective that's available to MGH anesthesia residents. Special thanks to Dr. Saddawi-Konefka for supporting the initiative. Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts and consider helping us offset the costs of production by donating through our Patreon at https://bit.ly/3n0sklh. — Follow us on Instagram @DepthofAnesthesia and on Twitter @DepthAnesthesia for podcast and literature updates. Email us at depthofanesthesia@gmail.com with episode ideas or if you'd like to join our team. Music by Stephen Campbell, MD. — References Keller C, Sparr HJ, Luger TJ, Brimacombe J. Patient outcomes with positive pressure versus spontaneous ventilation in non-paralysed adults with the laryngeal mask. Can J Anaesth. 1998 Jun;45(6):564-7. doi: 10.1007/BF03012709. PMID: 9669012. Bernardini A, Natalini G. Risk of pulmonary aspiration with laryngeal mask airway and tracheal tube: analysis on 65 712 procedures with positive pressure ventilation. Anaesthesia. 2009 Dec;64(12):1289-94. doi: 10.1111/j.1365-2044.2009.06140.x. Epub 2009 Oct 23. PMID: 19860753. Qamarul Hoda M, Samad K, Ullah H. ProSeal versus Classic laryngeal mask airway (LMA) for positive pressure ventilation in adults undergoing elective surgery. Cochrane Database Syst Rev. 2017;7(7):CD009026. Published 2017 Jul 20. doi:10.1002/14651858.CD009026.pub2 Maltby JR, Beriault MT, Watson NC, Fick GH. Gastric distension and ventilation during laparoscopic cholecystectomy: LMA-Classic vs. tracheal intubation. Can J Anaesth. 2000 Jul;47(7):622-6. doi: 10.1007/BF03018993. PMID: 10930200. Kim D, Park S, Kim JM, Choi GS, Kim GS. Second generation laryngeal mask airway during laparoscopic living liver donor hepatectomy: a randomized controlled trial. Nature. 2021 Feb 11;11(1):3532. doi: 10.1038/s41598-021-83173-5. PMID: 33574495; PMCID: PMC7878811. Parikh SS, Parekh SB, Doshi C, Vyas V. ProSeal Laryngeal Mask Airway versus Cuffed Endotracheal Tube for Laparoscopic Surgical Procedures under General Anesthesia: A Random Comparative Study. Anesth Essays Res. 2017;11(4):958-963. doi:10.4103/aer.AER_97_17 Park SK, Ko G, Choi GJ, Ahn EJ, Kang H. Comparison between supraglottic airway devices and endotracheal tubes in patients undergoing laparoscopic surgery: A systematic review and meta-analysis. Medicine (Baltimore). 2016 Aug;95(33):e4598. doi: 10.1097/MD.0000000000004598. PMID: 27537593; PMCID: PMC5370819. White LD, Thang C, Hodsdon A, Melhuish TM, Barron FA, Godsall MG, Vlok R. Comparison of Supraglottic Airway Devices With Endotracheal Intubation in Low-Risk Patients for Cesarean Delivery: Systematic Review and Meta-analysis. Anesth Analg. 2020 Oct;131(4):1092-1101. doi: 10.1213/ANE.0000000000004618. PMID: 32925330. Halaseh BK, Sukkar ZF, Hassan LH, Sia AT, Bushnaq WA, Adarbeh H. The use of ProSeal laryngeal mask airway in caesarean section--experience in 3000 cases. Anaesth Intensive Care. 2010 Nov;38(6):1023-8. doi: 10.1177/0310057X1003800610. PMID: 21226432. Nicholson A, Cook TM, Smith AF, Lewis SR, Reed SS. Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients. Cochrane Database Syst Rev. 2013 Sep 9;(9):CD010105. doi: 10.1002/14651858.CD010105.pub2. PMID: 24014230.

In this episode, I speak about a little bit about my experience in CODA 22 in Melbourne followed by airway techniques that can be used in the daily practice of an emergency physician. You can go through the following papers - 1. Mosier JM, Joshi R, Hypes C, Pacheco G, Valenzuela T, Sakles JC. The Physiologically Difficult Airway. West J Emerg Med. 2015 Dec;16(7):1109-17. doi: 10.5811/westjem.2015.8.27467. Epub 2015 Dec 8. PMID: 26759664; PMCID: PMC4703154. 2. Perbet S, De Jong A, Delmas J, Futier E, Pereira B, Jaber S, Constantin JM. Incidence of and risk factors for severe cardiovascular collapse after endotracheal intubation in the ICU: a multicenter observational study. Crit Care. 2015 Jun 18;19(1):257. doi: 10.1186/s13054-015-0975-9. PMID: 26084896; PMCID: PMC4495680. 3. Mort TC. The incidence and risk factors for cardiac arrest during emergency tracheal intubation: a justification for incorporating the ASA Guidelines in the remote location. J Clin Anesth. 2004 Nov;16(7):508-16. doi: 10.1016/j.jclinane.2004.01.007. PMID: 15590254. 4. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012 Mar;59(3):165-75.e1. doi: 10.1016/j.annemergmed.2011.10.002. Epub 2011 Nov 3. PMID: 22050948. 5. Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS. Delayed sequence intubation: a prospective observational study. Ann Emerg Med. 2015 Apr;65(4):349-55. doi: 10.1016/j.annemergmed.2014.09.025. Epub 2014 Oct 23. PMID: 25447559. 6. Schwenk ES, Viscusi ER, Buvanendran A, Hurley RW, Wasan AD, Narouze S, Bhatia A, Davis FN, Hooten WM, Cohen SP. Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018 Jul;43(5):456-466. doi: 10.1097/AAP.0000000000000806. PMID: 29870457; PMCID: PMC6023582. 7. Green SM, Roback MG, Kennedy RM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. Ann Emerg Med. 2011 May;57(5):449-61. doi: 10.1016/j.annemergmed.2010.11.030. Epub 2011 Jan 21. PMID: 21256625. 8. Sehdev RS, Symmons DA, Kindl K. Ketamine for rapid sequence induction in patients with head injury in the emergency department. Emerg Med Australas. 2006 Feb;18(1):37-44. doi: 10.1111/j.1742-6723.2006.00802.x. PMID: 16454773. 9. Zeiler FA, Teitelbaum J, West M, Gillman LM. The ketamine effect on ICP in traumatic brain injury. Neurocrit Care. 2014 Aug;21(1):163-73. doi: 10.1007/s12028-013-9950-y. PMID: 24515638. 10. Tsan et al. Comparison of Macintosh Laryngoscopy in Bed-up-Head-Elevated Position With GlideScope Laryngoscopy: A Randomized, Controlled, Noninferiority Trial. Anesth Analg. PMID: 31348051.

Dr. Chris Di Capua and Dr. Bryan Glezerson (@BryanGlezerson) join the show to discuss the literature around the risk of aspiration with LMAs compared to ETTs. This is part I of a two-part series on LMAs. In part II, we discuss the safety of LMAs in specific patient populations including patients receiving positive pressure ventilation, patients undergoing laparoscopic surgery, obese patients, and pregnant patients. This is an episode produced from the Depth of Anesthesia Podcast Elective that's available to MGH anesthesia residents. Special thanks to Dr. Saddawi-Konefka for supporting the initiative. Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts and consider helping us offset the costs of production by donating through our Patreon at https://bit.ly/3n0sklh. — Follow us on Instagram @DepthofAnesthesia and on Twitter @DepthAnesthesia for podcast and literature updates. Email us at depthofanesthesia@gmail.com with episode ideas or if you'd like to join our team. Music by Stephen Campbell, MD. — References Barker P, Langton JA, Murphy PJ, Rowbotham DJ: Regurgitation of gastric contents during general anesthesia using the laryngeal mask airway. Br J Anaesth 1992; 69:314-5. Rabey PG, Murphy PJ, Langton JA, Barker P, Rowbotham DJ. Effect of the laryngeal mask airway on lower oesophage al sphincter pressure in patients during general anaesthesia. Br J Anaesth. 1992 Oct;69(4):346-8. doi: 10.1093/bja/69.4.346. PMID: 1419440. Owens TM, Robertson P, Twomey C, Doyle M, McDonald N, McShane AJ. The incidence of gastroesophageal reflux with the laryngeal mask: a comparison with the face mask using esophageal lumen pH electrodes. Anesth Analg. 1995 May;80(5):980-4. doi: 10.1097/00000539-199505000-00022. PMID: 7726443. Bercker S, Schmidbauer W, Volk T, Bogusch G, Bubser HP, Hensel M, Kerner T. A comparison of seal in seven supraglottic airway devices using a cadaver model of elevated esophageal pressure. Anesth Analg. 2008 Feb;106(2):445-8, table of contents. doi: 10.1213/ane.0b013e3181602ae1. PMID: 18227299. Brimacombe JR, Berry A. The incidence of aspiration associated with the laryngeal mask airway: a meta-analysis of published literature. J Clin Anesth. 1995 Jun;7(4):297-305. doi: 10.1016/0952-8180(95)00026-e. PMID: 7546756. Xu R, Lian Y, Li WX. Airway Complications during and after General Anesthesia: A Comparison, Systematic Review and Meta-Analysis of Using Flexible Laryngeal Mask Airways and Endotracheal Tubes. PLoS One. 2016 Jul 14;11(7):e0158137. doi: 10.1371/journal.pone.0158137. PMID: 27414807; PMCID: PMC4944923.

What an academic feast organized by the SEMI-WB on the weekend of 16-17th July 2022 for the academic residents of emergency medicine. I start of the episode by talking about the EZECON. Also the 24th Annual Conference of SEMI is happening in Kerala from 23-27th November. Do register for it. In this episode I give an insight towards dealing with acid base disorders using the modified stewart's approach. Following are the references you can go through to understand more and change your practice - 1. https://emcrit.org/wp-content/uploads/acid_base_sheet_2-2011.pdf 2. Story DA. Stewart Acid-Base: A Simplified Bedside Approach. Anesth Analg. 2016 Aug;123(2):511-5. doi: 10.1213/ANE.0000000000001261. PMID: 27140683. 3. Jones NL. A quantitative physicochemical approach to acid-base physiology. Clin Biochem. 1990 Jun;23(3):189-95. doi: 10.1016/0009-9120(90)90588-l. PMID: 2115411. 4. Mallat J, Michel D, Salaun P, Thevenin D, Tronchon L. Defining metabolic acidosis in patients with septic shock using Stewart approach. Am J Emerg Med. 2012 Mar;30(3):391-8. doi: 10.1016/j.ajem.2010.11.039. Epub 2011 Jan 28. PMID: 21277142. 5. Morgan TJ. The Stewart approach--one clinician's perspective. Clin Biochem Rev. 2009 May;30(2):41-54. PMID: 19565024; PMCID: PMC2702213. 6.Kaplan LJ, Kellum JA. Initial pH, base deficit, lactate, anion gap, strong ion difference, and strong ion gap predict outcome from major vascular injury. Crit Care Med. 2004 May;32(5):1120-4. doi: 10.1097/01.ccm.0000125517.28517.74. PMID: 15190960. 7. Malatesha G, Singh NK, Bharija A, Rehani B, Goel A. Comparison of arterial and venous pH, bicarbonate, PCO2 and PO2 in initial emergency department assessment. Emerg Med J. 2007 Aug;24(8):569-71. doi: 10.1136/emj.2007.046979. PMID: 17652681; PMCID: PMC2660085. 8. Kelly AM, McAlpine R, Kyle E. Venous pH can safely replace arterial pH in the initial evaluation of patients in the emergency department. Emerg Med J. 2001 Sep;18(5):340-2. doi: 10.1136/emj.18.5.340. PMID: 11559602; PMCID: PMC1725689. 9. Byrne AL, Bennett M, Chatterji R, Symons R, Pace NL, Thomas PS. Peripheral venous and arterial blood gas analysis in adults: are they comparable? A systematic review and meta-analysis. Respirology. 2014 Feb;19(2):168-175. doi: 10.1111/resp.12225. Epub 2014 Jan 3. PMID: 24383789.

A very Happy Doctors' Day to you all! In this episode I discuss some salient points regarding the physiologically difficult airway. There are many physicians I know who are still not aware regarding this concept that can kill patients as soon as we try and save them. Also - EZECON is being organised in Kolkata from 16-17th July,22 and it is going to be an academic feast for the residents. So do register for it. The references for reading up more on the physiologically difficult airways are as follows - 1. Mosier JM, Joshi R, Hypes C, Pacheco G, Valenzuela T, Sakles JC. The Physiologically Difficult Airway. West J Emerg Med. 2015 Dec;16(7):1109-17. doi: 10.5811/westjem.2015.8.27467. Epub 2015 Dec 8. PMID: 26759664; PMCID: PMC4703154. 2. Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS. Delayed sequence intubation: a prospective observational study. Ann Emerg Med. 2015 Apr;65(4):349-55. doi: 10.1016/j.annemergmed.2014.09.025. Epub 2014 Oct 23. PMID: 25447559. 3. https://www.acepnow.com/article/crash-a-mnemonic-for-the-physiological-difficult-airway/ 4. Myatra SN, Divatia JV, Brewster DJ. The physiologically difficult airway: an emerging concept. Curr Opin Anaesthesiol. 2022 Apr 1;35(2):115-121. doi: 10.1097/ACO.0000000000001102. PMID: 35165233. 5. Cai SR, Sandhu MRS, Gruenbaum SE, Rosenblatt WH, Gruenbaum BF. Airway Management in an Anatomically and Physiologically Difficult Airway. Cureus. 2020 Sep 24;12(9):e10638. doi: 10.7759/cureus.10638. PMID: 33123451; PMCID: PMC7584327. 6. Kornas RL, Owyang CG, Sakles JC, Foley LJ, Mosier JM; Society for Airway Management's Special Projects Committee. Evaluation and Management of the Physiologically Difficult Airway: Consensus Recommendations From Society for Airway Management. Anesth Analg. 2021 Feb 1;132(2):395-405. doi: 10.1213/ANE.0000000000005233. PMID: 33060492. 7. Mosier, Jarrod M. “Physiologically Difficult Airway in Critically Ill Patients: Winning the Race between Haemoglobin Desaturation and Tracheal Intubation.” British Journal of Anaesthesia 125, no. 1 (July 2020): e1–4. https://doi.org/10.1016/j.bja.2019.12.001. 8. Scott Weingart, MD FCCM. EMCrit 325 – The Hypoxemic Difficult Airway and Preox Discussion with Jarrod Mosier. EMCrit Blog. Published on June 5, 2022. Accessed on June 30th 2022. Available at [https://emcrit.org/emcrit/hypoxemic-difficult-airway/ ]. 9. Salim Rezaie, "An Emergency Difficult Airway Predictor Would be From HEAVEN", REBEL EM blog, January 31, 2018. Available at: https://rebelem.com/emergency-difficult-airway-predictor-heaven/. 10. Salim Rezaie, "Critical Care Updates: Resuscitation Sequence Intubation – Hypotension Kills (Part 1 of 3)", REBEL EM blog, September 26, 2016. Available at: https://rebelem.com/critical-care-updates-resuscitation-sequence-intubation-hypotension-kills-part-1-of-3/. 11. Salim Rezaie, "Critical Care Updates: Resuscitation Sequence Intubation – pH Kills (Part 3 of 3)", REBEL EM blog, October 3, 2016. Available at: https://rebelem.com/critical-care-updates-resuscitation-sequence-intubation-ph-kills-part-3-of-3/.

En este nuevo episodio hablo del Diamante letal en trauma. Pasamos de la triada letal con la acidosis, coagulopatía e hipotermia y añadimos hipocalcemia en el manejo al paciente con trauma grave. Espero que os guste. Bibliografía consultada: - Ditzel, Ricky, Anderson, Justin, Eisenhart, William, Rankin, Cody, DeFeo, Devin, Oak, Sangki, et al. (2020). A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond?. Journal of Trauma and Acute Care Surgery, 88, 434-439. https://doi.org/10.1097/TA.0000000000002570 - Bjerkvig CK, Strandenes G, Eliassen HS, Spinella PC, Fosse TK, Cap AP, Ward KR. "Blood failure" time to view blood as an organ: how oxygen debt contributes to blood failure and its implications for remote damage control resuscitation. Transfusion. 2016;56(Suppl 2):S182-S189. - Dyer M, Neal MD. Defining the lethal triad. In: Pape HC, Peitzman A, Rotondo M, Giannoudis P, eds. Damage Control Management in the Polytrauma Patient. Cham, Switzerland: Springer; 2017:41-53. - Dobson GP, Letson HL, Sharma R, Sheppart FR, Cap AP. Mechanisms of early trauma-induced coagulopathy: the clot thickens or not? J Trauma. 2015;79(2):301-309. - Eddy VA, Morris JA Jr., Cullinane DC. Hypothermia, coagulopathy, and acidosis. Surg Clin North Am. 2000;80(3):845-854. - Niles SE, McLaughlin DF, Perkins JG, Wade CE, Li Y, Spinella PC, Holcomb JB. Increased mortality associated with the early coagulopathy of trauma in combat casualties. J Trauma. 2008;64(6):1459-1465. - Martini WZ, Holcomb JB. Acidosis and coagulopathy: the differential effects on fibrinogen synthesis and breakdown in pigs. Ann Surg. 2007;246(5):831-835. - Armand R, Hess JR. Treating coagulopathy in trauma patients. Transfus Med Rev. 2003;17(3):223-231. - Hastbacka J, Pettila V. Prevalence and predictive value of ionized hypocalcemia among critically ill patients. Acta Anaesthesiol Scand. 2003;47:1264-1269. - Cherry RA, Bradburn E, Carney DE, Shaffer ML, Gabbay RA, Cooney RN. Do early ionized calcium levels really matter in trauma patients? J Trauma. 2006;64(4):774-779. - Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma. 2007;62(2):307-310. - Lier H, Krep H, Schroeder S, Stuber F. Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia on functional hemostasis in trauma. J Trauma. 2008;65(4):951-960. - Hoffman M, Monroe DM. Coagulation 2006: a modern view of hemostasis. Hematol Oncol Clin North Am. 2007;21:1-11. - Hoffman M. A cell-based model of coagulation and the role of factor VIIa. Blood Rev. 2003;17(suppl 1):S1-S5. - Ho KM, Leonard AD. Concentration-dependent effect of hypocalcaemia on mortality of patients with critical bleeding requiring massive transfusion: a cohort study. Anaesth Intensive Care. 2011;39(1):46-54. - Magnotti LJ, Bradburn EH, Webb DL, Berry SD, Fischer PE, Zarzaur BL, Schroeppel TJ, Fabian TC, Croce MA. Admission ionized calcium levels predict the need for multiple transfusions: a prospective study of 591 critically ill trauma patients. J Trauma. 2011;70(2):391-397. - Kornblith LZ, Howard BM, Cheung CK, et al. The whole is greater than the sum of its parts: hemostatic profiles of whole blood variants. J Trauma Acute Care Surg. 2014;77(6):818-827. - Li K, Xu Y. Citrate metabolism in blood transfusions and its relationship due to metabolic alkalosis and respiratory acidosis. Int J Clin Exp Med. 2015;8(4):6578-6584. - Giancarelli A, Liu-Deryke X, Birrer K, Hobbs B, Alban R. Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res. 2016;202:182-187. - Webster S, Todd S, Redhead J, Wright C. Ionised calcium levels in major trauma patients who received blood in the emergency department. Emerg Med J. 2016;33(8):569-572. - Kyle T, Greaves I, Beynon A, Whittaker V, Brewer M, Smith J. Ionised calcium levels in major trauma patients who received blood en route to a military medical treatment facility. Emerg Med J. 2017;35(3):176-179. - MacKay EJ, Stubna MD, Holena DN, Reilly PM, Seamon MJ, Smith BP, Kaplan LJ, Cannon JW. Abnormal calcium levels during trauma resuscitation are associated with increased mortality, increased blood product use, and greater hospital resource consumption: a pilot investigation. Anesth Analg. 2017;125(3):895-901. - Shackelford SA, Del Junco DJ, Powell-Dunford N, Mazuchowski EL, Howard JT, Kotwal RS, Gurney J, Butler FK Jr., Gross K, Stockinger ZT. Association of prehospital blood product transfusion during medical evacuation of combat casualties in Afghanistan with acute and 30-day survival. JAMA. 2017;318(16):1581-1591. - DailyMed - Teruflex blood bag system anticoagulant citrate phosphate dextrose adenine (CPDA-1) - anticoagulant citrate phosphate dextrose adenine (cpda-1) solution. US National Library of Medicine. 2012. - Cap AP, Gurney J, Spinella PC, et al. Damage Control Resuscitation (CPG ID:18). Joint Trauma Service Clinical Practice Guideline. Joint Trauma System, the Department of Defense Center of Excellence for Trauma. 2019. - Pedersen KO. Binding of calcium to serum albumin. II. Effect of pH via competitive hydrogen and calcium ion binding to the imidazole groups of albumin. Scand J Clin Lab Invest. 1972;29(1):75-83. - Maxwell MJ, Wilson MJ. Complications of blood transfusion. BJA Educ. 2006;6(6):225-229. - Lang RM, Fellner SK, Neumann A, Bushinsky DA, Borow KM. Left ventricular contractility varies directly with blood ionized calcium. Ann Intern Med. 1988;108(4):524-529.

Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC, Robinson M, Scott LJ, Smartt H, South A, Stokes EA, Taylor J, Thomas M, Voss S, Wordsworth S, Rogers CA. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. JAMA. 2018 Aug 28;320(8):779-791. doi: 10.1001/jama.2018.11597. PMID: 30167701; PMCID: PMC6142999. Bernhard M, Becker TK, Gries A, Knapp J, Wenzel V. The First Shot Is Often the Best Shot: First-Pass Intubation Success in Emergency Airway Management. Anesth Analg. 2015 Nov;121(5):1389-93. doi: 10.1213/ANE.0000000000000891. PMID: 26484464. Culbreth RE, Gardenhire DS. Manual bag valve mask ventilation performance among respiratory therapists. Heart Lung. 2021 May-Jun;50(3):471-475. doi: 10.1016/j.hrtlng.2020.10.012. Epub 2020 Nov 1. PMID: 33138977; PMCID: PMC7604178. Ioannidis JP. Effectiveness of antidepressants: an evidence myth constructed from a thousand randomized trials?. Philos Ethics Humanit Med. 2008;3:14. Published 2008 May 27. doi:10.1186/1747-5341-3-14 Sackles, et. al. (2013). The importance of first pass success when performing orotracheal intubation in the ED. Acad Emerg Med, 20(1). Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, Herren H, Hansen M, Richmond NJ, Puyana JCJ, Aufderheide TP, Gray RE, Gray PC, Verkest M, Owens PC, Brienza AM, Sternig KJ, May SJ, Sopko GR, Weisfeldt ML, Nichol G. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2018 Aug 28;320(8):769-778. doi: 10.1001/jama.2018.7044. PMID: 30167699; PMCID: PMC6583103. This podcast is hosted by ZenCast.fm

James clarifies what the process of permissive hypotension is and how and why to use it as a temporary management strategy.    Top 3 tips:   1.    Try not to think about a specific number in these patients but look at the bigger picture. Assess for multiple signs of shock when deciding how to treat these patients.  2.    Think about the patient's journey - how far do they need to go, how you are going to get there and how long will it take? Patient's requiring a longer journey may require more resuscitation that those undergoing a shorter journey. 3.    Think carefully before giving large amounts of crystalloid to these patients, it may be the only option in some patients but there are negative effects to its use.   Biography:     James is an anaesthetic registrar based in Edinburgh. He has worked for a number of pre-hospital organisations around the UK and is currently a fellow with the Emergency Medical Retrieval Service in Glasgow. He has completed sub-speciality training in Pre-hospital Emergency Medicine (PHEM) and holds the Fellowship in Immediate Medical Care (FIMC). His main interests inside medicine include trauma, from scene to theatre, and retrieval medicine. Outside of work he spends most of his time baking bread, enjoying mountains and looking after his 3 children.   Links and resources:      RCT comparing immediate vs delayed fluid resuscitation for patients with penetrating torso trauma.  Bickell WH, Wall MJ, Pepe PE, Martin RR, Ginger VF, Allen MK, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. New England Journal of Medicine 1994;331(17):1105-9.     Cochrane Review relating to timing and volume of fluid resuscitation in patients with bleeding.  Kwan I, Bunn F, Chinnock P, Roberts I. Timing and volume of fluid administration for patients with bleeding. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD002245. DOI: 10.1002/14651858.CD002245.pub2.     Systematic Review of animal trials regarding fluid strategies in trauma.  Mapstone J, Roberts I, Evans P. Fluid resuscitation strategies: a system- atic review of animal trials. J Trauma. 2003;55:571–589.      Correlation of SBP and pulse location in hypovolaemic shock.  Charles D Deakin, J Lorraine Low. Accuracy of the advanced trauma life support guidelines for predicting systolic blood pressure using carotid, femoral, and radial pulses: observational study. BMJ 2000;321:673–4.      Rat model of TBI and Haemorrhage comparing no fluid vs fluid.  Talmor D, Merkind V, Artru AA, et al. Treatment to support blood pressure increases bleeding and/or decreases survival in a rat model of closed head trauma combined with uncontrolled hemorrhage. Anesth Analg. 1999;89:950–956.      Secondary analysis of PAMPER trial showing benefit of FFP over crystalloid in TBI.  Danielle S. Gruen, Francis X. Guyette, Joshua B. Brown et al. Association of Prehospital Plasma With Survival in Patients With Traumatic Brain InjuryA Secondary Analysis of the PAMPer Cluster Randomized Clinical Trial. JAMA Netw Open. 2020;3(10):e2016869. doi:10.1001/jamanetworkopen.2020.16869.  

In this episode, Dr. Ross Kennedy and Dr. Cas Woinarski join us to discuss the evidence on whether low-flow anesthesia with sevoflurane is safe. We discuss Compound A generation and nephrotoxicity. Thanks for listening! If you enjoy our content, consider helping us offset the costs of production by donating through our Patreon at https://bit.ly/3n0sklh. — Follow us on Instagram @DepthofAnesthesia and on Twitter @DepthAnesthesia for podcast updates and new literature updates. Email us at depthofanesthesia@gmail.com. Music by Stephen Campbell, MD. — References Ebert TJ, Frink EJ Jr, Kharasch ED. Absence of biochemical evidence for renal and hepatic dysfunction after 8 hours of 1.25 minimum alveolar concentration sevoflurane anesthesia in volunteers. Anesthesiology. 1998 Mar;88(3):601-10. doi: 10.1097/00000542-199803000-00008. PMID: 9523801. Ebert TJ, Messana LD, Uhrich TD, Staacke TS. Absence of renal and hepatic toxicity after four hours of 1.25 minimum alveolar anesthetic concentration sevoflurane anesthesia in volunteers. Anesth Analg. 1998 Mar;86(3):662-7. doi: 10.1097/00000539-199803000-00042. PMID: 9495434. Eger EI 2nd. Compound A: does it matter? Can J Anaesth. 2001 May;48(5):427-30. doi: 10.1007/BF03028302. PMID: 11394507. Eger EI 2nd, Gong D, Koblin DD, Bowland T, Ionescu P, Laster MJ, Weiskopf RB. Dose-related biochemical markers of renal injury after sevoflurane versus desflurane anesthesia in volunteers. Anesth Analg. 1997 Nov;85(5):1154-63. doi: 10.1097/00000539-199711000-00036. PMID: 9356118. Eger EI 2nd, Koblin DD, Bowland T, Ionescu P, Laster MJ, Fang Z, Gong D, Sonner J, Weiskopf RB. Nephrotoxicity of sevoflurane versus desflurane anesthesia in volunteers. Anesth Analg. 1997 Jan;84(1):160-8. doi: 10.1097/00000539-199701000-00029. PMID: 8989018. Feldman JM, Hendrickx J, Kennedy RR. Carbon Dioxide Absorption During Inhalation Anesthesia: A Modern Practice. Anesth Analg. 2021 Apr 1;132(4):993-1002. doi: 10.1213/ANE.0000000000005137. PMID: 32947290. Fukuda H, Kawamoto M, Yuge O, Fujii K. A comparison of the effects of prolonged (>10 hour) low-flow sevoflurane, high-flow sevoflurane, and low-flow isoflurane anaesthesia on hepatorenal function in orthopaedic patients. Anaesth Intensive Care. 2004 Apr;32(2):210-8. doi: 10.1177/0310057X0403200208. PMID: 15957718. Keijzer C, Perez RS, de Lange JJ. Compound A and carbon monoxide production from sevoflurane and seven different types of carbon dioxide absorbent in a patient model. Acta Anaesthesiol Scand. 2007 Jan;51(1):31-7. doi: 10.1111/j.1399-6576.2006.01187.x. Epub 2006 Nov 10. PMID: 17096668. Kennedy RR, Hendrickx JF, Feldman JM. There are no dragons: Low-flow anaesthesia with sevoflurane is safe. Anaesth Intensive Care. 2019 May;47(3):223-225. doi: 10.1177/0310057X19843304. Epub 2019 May 24. PMID: 31124374. Kharasch ED, Frink EJ Jr, Artru A, Michalowski P, Rooke GA, Nogami W. Long-duration low-flow sevoflurane and isoflurane effects on postoperative renal and hepatic function. Anesth Analg. 2001 Dec;93(6):1511-20, table of contents. doi: 10.1097/00000539-200112000-00036. PMID: 11726433. Mazze RI, Jamison RL. Low-flow (1 l/min) sevoflurane: is it safe? Anesthesiology. 1997 Jun;86(6):1225-7. doi: 10.1097/00000542-199706000-00001. PMID: 9197289. McGain F, Bishop JR, Elliot-Jones LM, Story DA, Imberger GL. A survey of the choice of general anaesthetic agents in Australia and New Zealand. Anaesth Intensive Care. 2019 May;47(3):235-241. doi: 10.1177/0310057X19836104. Epub 2019 May 15. PMID: 31088129.

Could Aspirin 81mg in COVID-19 patients help keep them off of mechanical ventilation, out of the ICU, and decrease mortality? Let's explore! Show Notes: https://eddyjoemd.com/aspirin-covid/ Receive a FREE audiobook (TWO for Amazon Prime members) with your FREE 30-day trial by using my link for Audible: CLICK HERE! You will be reminded when your trial is ending, by the way.

Post-op nausea and vomiting is associated with high levels of patient dissatisfaction, longer admissions and therefore higher costs to the medical system. Screen with the APFEL score + the other risk factors (younger age, type and length of surgery, anesthetic gases or nitrous exposure) 1+ risk factors? 2 prophylactic anti-emetics. 3+ risk factors? 3-4 prophylactic anti-emetics. For rescue therapy within 6 hours post-op, use a different agent. References: 1. Butterworth J, Mackey D, Wasnick J. Morgan & Mikhail's Clinical Anesthesiology. 5th ed. McGraw-Hill Education; 2013. 2. Gan TJ, Belani KG, Bergese S, et al. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg. 2020;131(2):411-448. doi:10.1213/ANE.0000000000004833 3. Barash P, Cullen B, Stoelting R. Clinical Anesthesia. 8th ed. Wolters Kluwer Have questions, comments, corrections, or concerns? Please reach out via email: anesthesiaclerkship@gmail.com All research, scriptwriting and recording was by Blake Birnie, MD 2021 candidate at UBC's Southern Medical School Program

Our guest today is Dr. Daniel Saddawi-Konefka, residency program director at Mass General. In this part II or II series on neuromuscular blockade, we investigate the claim that a train-of-four target of 90% is important to achieve prior to extubation. Connect with us @DepthAnesthesia on Twitter or email us at depthofanesthesia@gmail.com. Thanks for listening! Please rate us on iTunes and share with your colleagues.  Music by Stephen Campbell, MD.  -- References Naguib M, Kopman AF, Lien CA, Hunter JM, Lopez A, Brull SJ. A survey of current management of neuromuscular block in the United States and Europe. Anesth Analg. 2010;111(1):110-119. doi:10.1213/ANE.0b013e3181c07428 Ali HH, Kitz RJ. Evaluation of recovery from nondepolarizing neuromuscular block, using a digital neuromuscular transmission analyzer: preliminary report. Anesth Analg. 1973;52(5):740-745. Ali HH, Wilson RS, Savarese JJ, Kitz RJ. The effect of tubocurarine on indirectly elicited train-of-four muscle response and respiratory measurements in humans. Br J Anaesth. 1975;47(5):570-574. doi:10.1093/bja/47.5.570 Sundman E, Witt H, Olsson R, Ekberg O, Kuylenstierna R, Eriksson LI. The incidence and mechanisms of pharyngeal and upper esophageal dysfunction in partially paralyzed humans: pharyngeal videoradiography and simultaneous manometry after atracurium. Anesthesiology. 2000;92(4):977-984. doi:10.1097/00000542-200004000-00014 Eikermann M, Groeben H, Hüsing J, Peters J. Accelerometry of adductor pollicis muscle predicts recovery of respiratory function from neuromuscular blockade. Anesthesiology. 2003;98(6):1333-1337. doi:10.1097/00000542-200306000-00006 Gopalaiah Venkatesh Kumar, Anita Pramod Nair, Hanuman Srinivasa Murthy, Koppa Ramegowda Jalaja, Karnate Ramachandra, Gundappa Parameshwara; Residual Neuromuscular Blockade Affects Postoperative Pulmonary Function. Anesthesiology 2012; 117:1234–1244 doi: https://doi.org/10.1097/ALN.0b013e3182715b80 Eriksson LI, Lennmarken C, Wyon N, Johnson A. Attenuated ventilatory response to hypoxaemia at vecuronium-induced partial neuromuscular block. Acta Anaesthesiol Scand. 1992;36(7):710-715. doi:10.1111/j.1399-6576.1992.tb03550.x Suzanne J. L. Broens, Martijn Boon, Chris H. Martini, Marieke Niesters, Monique van Velzen, Leon P. H. J. Aarts, Albert Dahan; Reversal of Partial Neuromuscular Block and the Ventilatory Response to Hypoxia: A Randomized Controlled Trial in Healthy Volunteers. Anesthesiology 2019; 131:467–476 doi: https://doi.org/10.1097/ALN.0000000000002711 Kopman AF, Yee PS, Neuman GG. Relationship of the train-of-four fade ratio to clinical signs and symptoms of residual paralysis in awake volunteers. Anesthesiology. 1997;86(4):765-771. doi:10.1097/00000542-199704000-00005 Glenn S. Murphy, Joseph W. Szokol, Jesse H. Marymont, Steven B. Greenberg, Michael J. Avram, Jeffery S. Vender, Margarita Nisman; Intraoperative Acceleromyographic Monitoring Reduces the Risk of Residual Meeting Abstracts and Adverse Respiratory Events in the Postanesthesia Care Unit. Anesthesiology 2008; 109:389–398 doi: https://doi.org/10.1097/ALN.0b013e318182af3b Butterly A, Bittner EA, George E, et al. Postoperative residual curarization from intermediate-acting neuromuscular blocking agents delays recovery room discharge. BJA: British Journal of Anaesthesia. 2010 Sep;105(3):304-309. DOI: 10.1093/bja/aeq157. Section Editor(s): Brull, Sorin J.Murphy, Glenn S. MD; Szokol, Joseph W. MD; Marymont, Jesse H. MD; Greenberg, Steven B. MD; Avram, Michael J. PhD; Vender, Jeffery S. MD Residual Neuromuscular Blockade and Critical Respiratory Events in the Postanesthesia Care Unit, Anesthesia & Analgesia: July 2008 - Volume 107 - Issue 1 - p 130-137 doi: 10.1213/ane.0b013e31816d1268 Kirmeier E, Eriksson LI, Lewald H, et al. Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study [published correction appears in Lancet Respir Med. 2018 Nov 6;:]. Lancet Respir Med. 2019;7(2):129-140. doi:10.1016/S2213-2600(18)30294-7

Our guest today is Dr. Keith Baker, Vice Chair of Education at Massachusetts General Hospital.  We investigate the claim that emergence from sevoflurane is substantially faster than from isoflurane. We explore rationales and discuss cost.  Connect with us @DepthAnesthesia on Twitter or email us at depthofanesthesia@gmail.com. Thanks for listening! Please rate us on iTunes and share with your colleagues.  Music by Stephen Campbell, MD.  -- References Seitsonen ER, Yli-Hankala AM, Korttila KT. Similar recovery from bispectral index-titrated isoflurane and sevoflurane anesthesia after outpatient gynecological surgery. J Clin Anesth. 2006;18(4):272-279. doi:10.1016/j.jclinane.2005.12.005 Gupta A, Stierer T, Zuckerman R, Sakima N, Parker SD, Fleisher LA. Comparison of recovery profile after ambulatory anesthesia with propofol, isoflurane, sevoflurane and desflurane: a systematic review. Anesth Analg. 2004;98(3):. doi:10.1213/01.ane.0000103187.70627.57 Gauthier A, Girard F, Boudreault D, Ruel M, Todorov A. Sevoflurane provides faster recovery and postoperative neurological assessment than isoflurane in long-duration neurosurgical cases. Anesth Analg. 2002;95(5):. doi:10.1097/00000539-200211000-00052 Ries CR, Azmudéh A, Franciosi LG, Schwarz SK, MacLeod BA. Cost comparison of sevoflurane with isoflurane anesthesia in arthroscopic menisectomy surgery. Can J Anaesth. 1999;46(11):1008-1013. doi:10.1007/BF03013193 Maheshwari K, Ahuja S, Mascha EJ, et al. Effect of Sevoflurane Versus Isoflurane on Emergence Time and Postanesthesia Care Unit Length of Stay: An Alternating Intervention Trial. Anesth Analg. 2020;130(2):360-366. doi:10.1213/ANE.0000000000004093 Yasuda N, Targ AG, Eger EI 2nd. Solubility of I-653, sevoflurane, isoflurane, and halothane in human tissues. Anesth Analg. 1989;69(3):370-373.

Our guest today is Dr. Ronald George (@Ron_George), professor and chief of obstetric anesthesia at UCSF. We investigate the following claims related to DPE: 1. Dural puncture epidural (DPE) technique improves analgesic quality versus traditional epidural 2. DPE technique has faster onset of analgesia versus traditional epidural 3. DPE has less adverse effects compared with combined spinal-epidural (CSE) Connect with us @DepthAnesthesia on Twitter or email us at depthofanesthesia@gmail.com Thanks for listening! Please rate us on iTunes and share with your colleagues.  Music by Stephen Campbell, MD.  -- References Heesen M, Rijs K, Rossaint R, Klimek M. Dural puncture epidural versus conventional epidural block for labor analgesia: a systematic review of randomized controlled trials. Int J Obstet Anesth. 2019;40:24-31. doi:10.1016/j.ijoa.2019.05.007 Thomas JA, Pan PH, Harris LC, Owen MD, D'Angelo R. Dural puncture with a 27-gauge Whitacre needle as part of a combined spinal-epidural technique does not improve labor epidural catheter function. Anesthesiology. 2005;103(5):1046-1051. doi:10.1097/00000542-200511000-00019 Wilson SH, Wolf BJ, Bingham K, et al. Labor Analgesia Onset With Dural Puncture Epidural Versus Traditional Epidural Using a 26-Gauge Whitacre Needle and 0.125% Bupivacaine Bolus: A Randomized Clinical Trial. Anesth Analg. 2018;126(2):545-551. doi:10.1213/ANE.0000000000002129 Cappiello E, O'Rourke N, Segal S, Tsen LC. A randomized trial of dural puncture epidural technique compared with the standard epidural technique for labor analgesia. Anesth Analg. 2008;107(5):1646-1651. doi:10.1213/ane.0b013e318184ec14 Chau A, Bibbo C, Huang CC, et al. Dural Puncture Epidural Technique Improves Labor Analgesia Quality With Fewer Side Effects Compared With Epidural and Combined Spinal Epidural Techniques: A Randomized Clinical Trial. Anesth Analg. 2017;124(2):560-569. doi:10.1213/ANE.0000000000001798

For our first episode of 2020, we investigate claims related to the application of cricoid pressure. Claim 1. Cricoid pressure reduces the risk of pulmonary aspiration. Claim 2. Landmark technique is able to accurately identify the cricoid cartilage. Claim 3. Cricoid pressure should be routinely applied in all rapid-sequence intubations. Our guest today is Dr. Jerome Crowley, an adult cardiothoracic anesthesiologist and intensivist at the Massachusetts General Hospital. Connect with us @DepthAnesthesia on Twitter or depthofanesthesia@gmail.com. Thanks for listening! Please rate us on iTunes and share with your colleagues.  Music by Stephen Campbell, MD.  -- References Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Sellick BA. Lancet. 1961;2:404–406. Smith KJ, Dobranowski J, Yip G, Dauphin A, Choi PT. Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging. Anesthesiology. 2003;99:60–64. Rice MJ, Mancuso AA, Gibbs C, Morey TE, Gravenstein N, Deitte LA. Cricoid pressure results in compression of the postcricoid hypopharynx: the esophageal position is irrelevant. Anesth Analg. 2009;109:1546–1552 Lee D, Czech AJ, Elriedy M, Nair A, El-Boghdadly K, Ahmad I. A multicentre prospective cohort study of the accuracy of conventional landmark technique for cricoid localisation using ultrasound scanning. Anaesthesia. 2018;73:1229–1234. Smith CE, Boyer D. Cricoid pressure decreases ease of tracheal intubation using fiberoptic laryngoscopy (WuScope system. Can J Anesth. 2002;49:614–619. The Effectiveness of Cricoid Pressure for Occluding the Esophageal Entrance in Anesthetized and Paralyzed Patients: An Experimental and Observational Glidescope Study. Anesth Analg. 2014 Mar;118(3):580-6. doi: 10.1213/ANE.0000000000000068. Effect of cricoid pressure compared with a sham procedure in the rapid sequence induction of anesthesia: the IRIS randomized clinical trial. Birenbaum A, Hajage D, Roche S, et al; IRIS Investigators Group. JAMA Surg. 2019;154:9–17. Flucker CJ, Hart E, Weisz M, Griffiths R, Ruth M. The 50-millilitre syringe as an inexpensive training aid in the application of cricoid pressure. Eur J Anaesthesiol 2000; 17: 443–447.

We investigate the claim that norepinephrine is not safe for peripheral administration. Our guests today are Dr. Katarina Ruscic and Dr. Jamie Sparling of the Critical Care Division of the Massachusetts General Hospital.  Full show notes available at depthofanesthesia.com.  Connect with us @DepthAnesthesia on Twitter or depthofanesthesia@gmail.com. Thanks for listening! Please rate us on iTunes and share with your colleagues.  Music by Stephen Campbell, MD.  -- References Cardenas‐Garcia J, Schaub KF, Belchikov YG, Narasimhan M, Koenig SJ, Mayo PH, Peripheral Administration of VM. J. Hosp. Med 2015;9;581-585. doi:10.1002/jhm.2394 Hasanin AM, Amin SA, Agiza NA, Elsayed MK, Refaa S, Hussein HA, Rouk TI, Alrahmany M. Elsayad M. Norepinephrine Infusion for Preventing Postspinal Anesthesia Hypotension during Cesarean Delivery Anesthesiology 2019; 130:55–62. Medlej K, Kazzi AA, El Hajj Chehade A. Complications from Administration of Vasopressors Through Peripheral Venous Catheters: An Observational Study. The Journal of emergency medicine. 2018; 54(1):47-53. Ngan Kee, WD A random-allocation graded dose-response study of norepinephrine and phenylephrine for treating hypotension during spinal anesthesia for cesarean delivery. Anesthesiology 2017; 127:934-41 Ngan Kee WD, Lee SWY, Ng FF, Khaw KS. Prophylactic norepinephrine infusion for preventing hypotension during spinal anesthesia for cesarean delivery. Anesth Analg. 2018;126:1989–1994. Permpikul C, Tongyoo S, Viarasilpa T, Trainarongsakul T, Chakorn T, Udompanturak S. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER) : A Randomized Trial. Am J Respir Crit Care Med. 2019 Parienti JJ, Mongardon N, Mégarbane B. Intravascular Complications of Central Venous Catheterization by Insertion Site. The New England journal of medicine. 2015; 373(13):1220-9. Ricard J, Salomon L, Boyer A, et al. Central or peripheral catheters for initial venous access of ICU patients. Crit Care Med 2013;41(9):2108-2115. --

We investigate claims about reversal of neuromuscular blockade.  Claim 1. Location of train-of-four assessment matters Claim 2. Train-of-four is unnecessary with "sufficient" time from the last dose  Claim 3. Fade can be discriminated by tactile assessment Our guest today is Dr. Daniel Saddawi-Konefka of the Massachusetts General Hospital.    Full show notes available at depthofanesthesia.com.  Connect with us @DepthAnesthesia on Twitter or depthofanesthesia@gmail.com. Thanks for listening! Please rate us on iTunes and share with your colleagues.  Music by Stephen Campbell, MD.  -- References Arain Sr, Kern S, Ficke DJ, Ebert TJ. Variability of duration of action of neuromuscular blocking drugs in elderly patients. Acta Anaesthesiol Scand. 2005;49:312–315.  Caldwell JE. Reversal of residual neuromuscular block with neostigmine at one to four hours after a single intubating dose of vecuronium. Anesth Analg 1995;80:1168 –74 JØRGEN VIBY-MOGENSEN, NIELS HENRIK JENSEN, JENS ENGBAEK, HELLE ØRDING, LENE THEIL SKOVGAARD, BENT CHRAEMMER-JØRGENSEN; Tactile and Visual Evaluation of the Response to Train-of-four Nerve Stimulation. Anesthesiology1985;63(4):440-442. Stephan R. Thilen, Bradley E. Hansen, Ramesh Ramaiah, Christopher D. Kent, Miriam M. Treggiari, Sanjay M. Bhananker; Intraoperative Neuromuscular Monitoring Site and Residual Paralysis. Anesthesiology 2012;117(5):964-972. doi: 10.1097/ALN.0b013e31826f8fdd. --

We investigate pro and con positions on preoperative anxiolytics.  Pro claim: Preoperative anxiolytics improve patient satisfaction.  Con claim: Preoperative anxiolytics delay recovery and discharge. My guest is Dr. Matthew Vanneman, an attending cardiothoracic anesthesiologist at the Massachusetts General Hospital. Full show notes available at depthofanesthesia.com.  Recommend a guest or topic at depthofanesthesia@gmail.com or tweet us @DepthAnesthesia.  Rate us on iTunes.  -- References C. Boncyk, A. S. Hess, A. Gaskell, J. Sleigh, R. D. Sanders, on behalf of the ConsCIOUS group, Does benzodiazepine administration affect patient satisfaction: a secondary analysis of the ConCIOUS study, BJA: British Journal of Anaesthesia, Volume 118, Issue 2, February 2017, Pages 266–267, https://doi.org/10.1093/bja/aew456 Kain ZN, Sevarino FB, Rinder C, et al. Preoperative anxiolysis and postoperative recovery in women undergoing abdominal hysterectomy. Anesthesiology 2001;94:415–22. Maurice-Szamburski A, Auquier P, Viarre-Oreal V, et al; for the PremedX Study Investigators. Effect of sedative premedication on patient experience after general anesthesia: a randomized clinical trial. JAMA. doi:10.1001/jama.2015.1108  Richardson MG, Wu CL, Hussain A. Midazolam premedication increases sedation but does not prolong discharge times after brief outpatient general anesthesia for laparoscopic tubal sterilization. Anesth Analg. 1997;85:301–5. van Vlymen JM, Sá Rêgo MM, White PF. Benzodiazepine premedication: can it improve outcome in patients undergoing breast biopsy procedures? Anesthesiology 1999; 90:740. Walker KJ, Smith  AF. Premedication for anxiety in adult day surgery. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD002192. DOI: 10.1002/14651858.CD002192.pub2. --

We investigate the claim that morphine causes more nausea than hydromorphone.  My guest is Dr. Daniel Saddawi-Konefka, program director of the Anesthesia Residency Program at Massachusetts General Hospital. Full show notes available at depthofanesthesia.com.  Connect with us @DepthAnesthesia on Twitter or depthofanesthesia@gmail.com. Thanks for listening! Please rate us on iTunes and share with your colleagues.  Music by Stephen Campbell, MD.  -- References Felden L, Walter C, Harder S, Treede RD, Kayser H, Drover D, Geisslinger G, Lotsch J. Comparative clinical effects of hydromorphone and morphine: a meta-analysis. British Journal of Anaesthesia 2011; 107(3): 319-328 Wirz S,  Wartenberg HC,  Nadstawek J. Less nausea, emesis, and constipation comparing hydromorphone and morphine? A prospective open-labeled investigation on cancer pain, Support Care Cancer , 2008, vol. 16 (pg. 999-1009) Hong D, Flood P, Diaz G. The side effects of morphine and hydromorphone patient-controlled analgesia. Anesth Analg. 2008;107:1384–9 Chang, AK, Bijur, PE, Meyer, RH, Kenny, MK, Solorzano, C, and Gallagher, EJ. Safety and efficacy of hydromorphone as an analgesic alternative to morphine in acute pain: a randomized clinical trial. Ann Emerg Med. 2006; 48: 164–172 Chang, AK, Bijur, PE, Baccelieri, A, and Gallagher, EJ. Efficacy and safety profile of a single dose of hydromorphone compared with morphine in older adults with acute, severe pain: a prospective, randomized, double-blind clinical trial. Am J Geriatr Pharmacother. 2009; 7: 1–10 --

We investigate the claim that mask ventilation should be "checked" or "confirmed" before administering paralytics.  My guest is Dr. Daniel Saddawi-Konefka, program director of the Anesthesia Residency Program at Massachusetts General Hospital.  Full show notes available at depthofanesthesia.com.  Connect with us @DepthAnesthesia on Twitter or depthofanesthesia@gmail.com. Thanks for listening! Please rate us on iTunes and share with your colleagues.  Music by Stephen Campbell, MD.  -- References Chingmuh Lee, Jonathan S. Jahr, Keith A. Candiotti, Brian Warriner, Mark H. Zornow, Mohamed Naguib; Reversal of Profound Neuromuscular Block by Sugammadex Administered Three Minutes after Rocuronium: A Comparison with Spontaneous Recovery from Succinylcholine. Anesthesiology 2009;110(5):1020-1025. doi: 10.1097/ALN.0b013e31819dabb0. Drummond GB, Park GR. Arterial oxygen saturation before intubation of the trachea. An assessment of oxygenation techniques. Br J Anaesth 1984; 56:987. Benjamin J. Dixon, John B. Dixon, Jennifer R. Carden, Anthony J. Burn, Linda M. Schachter, Julie M. Playfair, Cheryl P. Laurie, Paul E. O’Brien; Preoxygenation Is More Effective in the 25° Head-up Position Than in the Supine Position in Severely Obese Patients: A Randomized Controlled Study. Anesthesiology 2005;102(6):1110-1115. Jense HG, Dubin SA, Silverstein PI, O’Leary-Escolas U. Effect of obesity on duration of apnea in anesthetized humans. Anesth Analg 1991; 72: 89–93. Min, Se-Hee & Im, Hyunjae & Rim Kim, Bo & Yoon, Susie & Bahk, Jae-Hyon & Seo, Jeong-Hwa. (2019). Randomized Trial Comparing Early and Late Administration of Rocuronium Before and After Checking Mask Ventilation in Patients With Normal Airways. Anesthesia & Analgesia. 1. 10.1213/ANE.0000000000004060. R. Sirian, Jonathan Wills, Physiology of apnoea and the benefits of preoxygenation, Continuing Education in Anaesthesia Critical Care & Pain, Volume 9, Issue 4, August 2009, Pages 105–108, https://doi.org/10.1093/bjaceaccp/mkp018 Roland Amathieu, Xavier Combes, Widad Abdi, Loutfi El Housseini, Ahmed Rezzoug, Andrei Dinca, Velislav Slavov, Sébastien Bloc, Gilles Dhonneur; An Algorithm for Difficult Airway Management, Modified for Modern Optical Devices (Airtraq Laryngoscope; LMA CTrach  ™): A 2-Year Prospective Validation in Patients for Elective Abdominal, Gynecologic, and Thyroid Surgery. Anesthesiology 2011;114(1):25-33. doi: 10.1097/ALN.0b013e318201c44f. Sachin Kheterpal, Richard Han, Kevin K. Tremper, Amy Shanks, Alan R. Tait, Michael O’Reilly, Thomas A. Ludwig; Incidence and Predictors of Difficult and Impossible Mask Ventilation. Anesthesiology 2006;105(5):885-891. Sachdeva R Kannan TR Mendonca C Patteril M. Evaluation of changes in tidal volume during mask ventilation following administration of neuromuscular blocking drugs. Anaesthesia  2014; 69: 826–31

In this 112th episode I welcome Dr. Christina Miller to the show to discuss Anesthesia for Electroconvulsive Therapy (ECT). References: Ding Z, White PF. Anesthesia for electroconvulsive therapy. Anesth Analg. 2002 May;94(5):1351-64. Sadowksy, Jonathan. Electroconvulsvie Therapy: A History of Controversy, but Also of Help.  The Conversation. Scientific American.  January 13, 2017. Wright, M.D., Bruce A. … Continue reading "Episode 112: Anesthesia for ECT with Christina Miller"

From Essentials of Emergency Medicine NYC 2017, Reuben Strayer explains how the pulse ox might be the most useful bit of tech in the ED.   Pearls: The pulse ox waveform is an excellent indicator of mechanical heart rate and peripheral perfusion.   For patients  breathing room air, pulse oximetry can be used to monitor for hypoventilation.   Nail polish has minimal impact on the accuracy of pulse oximetry. If you are unable to get a good pulse ox waveform by adjusting or repositioning the probe, be concerned that the patient is poorly perfused.       “The respiratory rate is the most vital of the vital signs.”    Experienced doctors look at a patient who seems well, but understands that they’re not truly well, because they subconsciously notice tachypnea. Subconsciously is the only way to notice tachypnea, because respiratory rate is often not measured accurately.  Since we don’t always have access to reliable respiratory rate, Strayer’s go-to vital sign is the oxygen saturation. “Reusable pulse oximeter probes are gross.”  One study found that even when these probes are cleaned by standard procedure, ⅔ had bacteria cultured from them. Strayer recommends using single use probes in your department. Wilkins MC. Residual bacterial contamination on reusable pulse oximetrysensors. Respir Care. 1993 Nov;38(11):1155-60. PubMed PMID: 10145923. Data is conflicting about the effect of nail polish on pulse oximetry readings, but overall it is felt that the impact is minimal.   Earlier data suggested that nail polish decreased sat readings by 2-10%, but more recent studies found minimal effect.   If it seems that the waveform is affected by nail polish, you can remedy the situation by turning the probe 90 degrees, so it goes sideways through the finger. Yamamoto LG, et al. Nail polish does not significantly affect pulse oximetry measurements in mildly hypoxic subjects. Respir Care. 2008 Nov;53(11):1470-4. PubMed PMID: 18957149. As long as a patient is breathing room air, pulse ox can monitor ventilation and function as a hypoventilation alarm.   Significantly hypercapnic patients saturate less than 95% when they’re breathing room air. So if you need to monitor a patient for hypoventilation, such as due to intoxication or procedural sedation, the pulse ox will do a great job of telling you if the patient is still breathing. If you need to give supplemental oxygen, then use capnography to monitor respirations.   The pulse oximeter does so much more than provide oxygen saturation.     It provides the photoplethysmogram (PPG) which is a waveform that tells you the “mechanical” heart rate. While telemetry gives the electrical heart rate, what really matters to your organs is the mechanical rate. This can be especially helpful during transvenous or transcutaneous pacing. When you have reliable tracing, the pulse ox heart rate is more reliable than the telemetry heart rate.   The pulse ox can measure the peripheral perfusion index which is a more sensitive and earlier indicator of hypoperfusion than blood pressure. This is a numerical value which indicates the strength of the pulsations read by the pulse oximeter. It is based on the amplitude of the pulse ox waveform and expressed as a number between 1 (low) and 10 (high).  The perfusion index dips before the stroke volume drops and long before the heart rate rises. Many monitors will report the perfusion index in tiny print after the word PERF. Lima AP, Beelen P, Bakker J. Use of a peripheral perfusion index derived from the pulse oximetry signal as a noninvasive indicator of perfusion. Crit Care Med.2002 Jun;30(6):1210-3. PubMed PMID: 12072670. van Genderen ME, et al. Peripheral perfusion index as an early predictor for central hypovolemia in awake healthy volunteers. Anesth Analg. 2013 Feb;116(2):351-6. PubMed PMID: 23302972. What if you don’t have a reliable pulse ox tracing?   Most of the time this is because the probe is poorly positioned, the patient is moving too much, or there’s a lot of ambient light. If you’ve corrected for these problems and you still don’t have a good tracing, you should be concerned that the patient is poorly perfused. One study of 20,000 anesthesia cases showed that pulse ox failure was directly related to worsening physical status.   Moller JT, et al. Randomized evaluation of pulse oximetry in 20,802 patients: I. Design, demography, pulse oximetry failure rate, and overall complication rate. Anesthesiology. 1993 Mar;78(3):436-44. PubMed PMID: 8457044.   How does the pulse ox measure oxygen saturation and what is the best way to position the oximeter probe on the finger?   One side of the pulse ox puts emits visible (red) light and infrared light. On the other side is the detector. The percent oxygen saturation is calculated based on the different way in which oxyhemoglobin absorbs visible and infrared light compared with deoxyhemoglobin.   The pulse ox measures carboxyhemoglobin as if it were oxyhemoglobin, giving a falsely elevated pulse ox reading for a victim of carbon monoxide poisoning. The best spot for a peripheral pulse ox is a place with a lot of capillaries and arterioles, like the fingertips, earlobes, nose, or forehead. Functionally,  it doesn’t seem to matter whether the emitter is on the dorsum, volar aspect, or even side of the finger.  For convenience sake, most find it ergonomically superior to have the cord and emitter on the dorsum of the finger.   Mannheimer PD. The light-tissue interaction of pulse oximetry. Anesth Analg.2007 Dec;105(6 Suppl):S10-7. Review. PubMed PMID: 18048891 Vegfors M, Lennmarken C. Carboxyhaemoglobinaemia and pulse oximetry. Br JAnaesth. 1991 May;66(5):625-6. PubMed PMID: 2031826   DeMeulenaere, Susan. "Pulse oximetry: uses and limitations." The Journal for Nurse Practitioners 3.5 (2007): 312-317. Link. Chan ED, et al. Pulse oximetry: understanding its basic principles facilitates appreciation of its limitations. Respir Med. 2013 Jun;107(6):789-99. PMID: 23490227

In this 101st episode I welcome back Dr. Stephen Freiberg to the show to discuss how to successfully come off bypass when doing cardiac surgery with cardiopulmonary bypass. References: -Barash Anesthesia for Cardiac Surgery -Barry AE, Chaney MA, London MJ. Anesthetic management during cardiopulmonary bypass: a systematic review. Anesth Analg 2015; 120:749. -Denault AY, Tardif … Continue reading "Episode 101: Coming off Bypass with Stephen Freiberg"

In this episode, episode 51, I welcome back Dr. Jacqueline Galvan to discuss labor analgesia.  We cover opioids including remifentanil, nitrous oxide, neuraxial anesthesia and other nerve blocks. References: Hess PE, et al. An association between severe labor pain and cesarean delivery. Anesth Analg. 2000 Apr;90(4):881-6 Van den Bussche E. Why women prefer epidural analgesia … Continue reading "Episode 51: Labor Analgesia with Jacqueline Galvan"

When you give only after you're asked, you've waited too long. – John Mason First, learn to bag Place a towel roll under the scapulae to align oral, pharyngeal, and tracheal axes: Karsli C. Can J Anesth. 2015. Use airway adjuncts such as the oropharyngeal airway or a nasal trumpet. Use the two-hand ventilation technique whenever possible:   (See Adventures in RSI for more)     Supraglottic Airways: for difficult bag-valve-mask ventilation or a difficult airway (details in audio) LMA Classic Pros: Best studied; sizes for all ages Cons: Cannot intubate through aperture   LMA Supreme Pros: Better ergonomics with updated design; bite bloc; port for decompression Cons: Cannot pass appropriate-sized ETT through tube   King Laryngeal Tube Pros: Little training needed; high success rate; single inflation port Cons: Flexion of tube can impede ventilation or cause leaks; only sized down to 12 kg (not for infants and most toddlers)   Air-Q Pros: Easy to place; can intubate through aperture Cons: Not for neonates less than 4 kg   iGel Pros: Molds more accurately to supraglottis; no need to inflate; good seal pressures Cons: Cannot intubate through (without fiberoscopy)   Summary • If you can bag the patient, you're winning. • If you have difficulty bagging, or anticipate or encounter a difficult airway, then don't forget your friend the supraglottic airway (SGA). • Ego is the enemy of safety: SGAs are simple, fast, and reliable. • Just do it.   References Ahn EJ et al. Comparative Efficacy of the Air-Q Intubating Laryngeal Airway during General Anesthesia in Pediatric Patients: A Systematic Review and Meta-Analysis. Biomed Res Int. 2016;2016:6406391. Black AE, Flynn PE, Smith HL, Thomas ML, Wilkinson KA; Association of Pediatric Anaesthetists of Great Britain and Ireland. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Paediatr Anaesth. 2015 Apr;25(4):346-62. Byars DV et al. Comparison of direct laryngoscopy to Pediatric King LT-D in simulated airways. Pediatr Emerg Care. 2012 Aug;28(8):750-2.  Carlson JN, Mayrose J, Wang HE. How much force is required to dislodge an alternate airway? Prehosp Emerg Care. 2010 Jan-Mar;14(1):31-5. Diggs LA, Yusuf JE, De Leo G. An update on out-of-hospital airway management practices in the United States. Resuscitation. 2014 Jul;85(7):885-92. Ehrlich PF et al. Endotracheal intubations in rural pediatric trauma patients. J Pediatr Surg. 2004 Sep;39(9):1376-80. Hernandez MR, Klock PA Jr, Ovassapian A. Evolution of the extraglottic airway: a review of its history, applications, and practical tips for success. Anesth Analg. 2012 Feb;114(2):349-68.  Huang AS, Hajduk J, Jagannathan N. Advances in supraglottic airway devices for the management of difficult airways in children. Expert Rev Med Devices. 2016;13(2):157-69. Jagannathan N, Wong DT. Successful tracheal intubation through an intubating laryngeal airway in pediatric patients with airway hemorrhage. J Emerg Med. 2011 Oct;41(4):369-73.  Jagannathan N et al. Elective use of supraglottic airway devices for primary airway management in children with difficult airways. Br J Anaesth. 2014 Apr;112(4):742-8. Jagannathan N, Ramsey MA, White MC, Sohn L. An update on newer pediatric supraglottic airways with recommendations for clinical use. Paediatr Anaesth. 2015 Apr;25(4):334-45. Karsli C. Managing the challenging pediatric airway: Continuing Professional Development. Can J Anaesth. 2015 Sep;62(9):1000-16. Luce V et al. Supraglottic Airway Devices vs Tracheal Intubation in Children: A Quantitative Meta-Analysis of Respiratory Complications. Paediatr Anaesth 24 (10), 1088-1098. Nicholson A et al. Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients. Cochrane Database Syst Rev. 2013 Sep 9;(9):CD010105. Ostermayer DG, Gausche-Hill M. Supraglottic airways: the history and current state of prehospital airway adjuncts. Prehosp Emerg Care. 2014 Jan-Mar;18(1):106-15.  Rosenberg MB, Phero JC, Becker DE. Essentials of airway management, oxygenation, and ventilation: part 2: advanced airway devices: supraglottic airways. Anesth Prog. 2014 Fall;61(3):113-8.  Schmölzer GM, Agarwal M, Kamlin CO, Davis PG. Supraglottic airway devices during neonatal resuscitation: an historical perspective, systematic review and meta-analysis of available clinical trials. Resuscitation. 2013 Jun;84(6):722-30. Sinha R, Chandralekha, Ray BR. Evaluation of air-Q™ intubating laryngeal airway as a conduit for tracheal intubation in infants--a pilot study. Paediatr Anaesth. 2012 Feb;22(2):156-60. Timmermann A. Supraglottic airways in difficult airway management: successes, failures, use and misuse. Anaesthesia. 2011 Dec;66 Suppl 2:45-56. Timmermann A, Bergner UA, Russo SG. Laryngeal mask airway indications: new frontiers for second-generation supraglottic airways. Curr Opin Anaesthesiol. 2015 Dec;28(6):717-26.   Supraglottic Airway on WikEM   This post and podcast are dedicated to Tim Leeuwenburg, MBBS FRACGP FACRRM DRANZCOG DipANAES and Rich Levitan, MD, FACEP for keeping our minds and our patients' airways -- open.  You make us better doctors.  Thank you. Powered by #FOAMed — Tim Horeczko, MD, MSCR, FACEP, FAAP Pediatric; Emergency Medicine; Pediatric Emergency Medicine; Podcast; Pediatric Podcast; Emergency Medicine Podcast; Horeczko; Harbor-UCLA; Presentation Skills; #FOAMed #FOAMped #MedEd

N.B.: This month's show notes are a departure from the usual summary.  Below is a reprint (with permission) of a soon-to-be released chapter, Horeczko T. "Acute Pain in Children". In Management of Pain and Procedural Sedation in Acute Care. Strayer R, Motov S, Nelson L (eds). 2017.  Rather than the customary blog post summary, the full chapter (with links) is provided as a virtual reference. INTRODUCTION Pain is multifactorial: it is comprised of physical, psychological, emotional, cultural, and contextual features.  In children often the predominant feature may not be initially apparent.  Although clinicians may focus on the physical component of pain, much time, energy, and suffering can be saved through a holistic approach.  What is the age and developmental stage of the child?  How is the child reacting to his condition?  What are the circumstances?  What is the family or caregiver dynamic? We rely much on how patients and families interact with us to gauge pain.  Assessing and managing children’s pain can be challenging, because they may not exhibit typically recognized signs and symptoms (Srouji 2010).  Further, children participate in and absorb their family’s culture and specific personality from a very young age (Finley 2009).  Knowing the context of the episode may help.  For example, a very anxious caregiver can easily transmit his or her anxiety to the child, which may either inhibit or amplify presentation of symptoms (Bearden 2012). The guiding principles in pediatric pain assessment and management are: know the child; know the family; and know the physiology.  Children have long suffered from an under-treatment of their pain, due both to our incomplete acknowledgement of their pain and our fear of treatment (Howard 2003).  As the pendulum on pain management swings one way or the other, do not let your pediatric patient get knocked by the wayside.  Take a thoughtful approach: know the signs and symptoms, and aggressively treat and reassess. ASSESSMENT Each stage of development offers a unique framework to the child’s signs and symptoms of pain.  In pre-verbal children, use your observational skills in addition to the parent’s report of behavior.  Verbal children can self-report; younger children require pictorial descriptions, while older children and adolescents may use standard adult scales.  In all ages, ask open-ended questions and allow the child to report and speak for himself whenever possible. Neonates Neonates are a unique group in pain assessment.  The neonate (birth to one month of age) has not yet acquired social expression of pain, and his nascent nervous system is only now learning to process it.  Do not expect typical pain behaviors in neonates.  Facial grimacing is a weak indicator of pain in neonates (Liebelt 2000).  When this behavior is present, look for a furrowed brow, eyes squeezed shut, and a vertically open mouth.  Tachycardia, tachypnea, and a change in behavior can be indicators not only to the presence of pain, but possibly to its etiology as well. Neonatal observational scales have been validated in the intensive care and post-operative settings; ED-specific quantitative scales are lacking.  CRIES is a 10-point scale, using a physiologic basis similar to APGAR: Crying; Requires increased oxygen administration (distress and breath-holding); Increased vital signs; Expression; and Sleeplessness (Krechel 1995).  CRIES (Table 1) was validated for post-operative patients; to adapt its use for the ED, the most conservative approach is to substitute “preoperative baseline” with normal range for age.  Although the numerical values of CRIES have not been validated to date in the ED, the clinician may find the domains included in CRIES to be a useful cognitive construct in assessing neonatal pain. Neonatal pain pathways are particularly plastic; prompt assessment of and increased alertness to neonatal pain may help to mitigate long-lived pain sensitivity and hyperalgesia (Taddio 2002).  In other words, treat the neonate’s pain seriously, as you may save him long-term pain sequelae in the future. Infants and Toddlers This group will begin to exhibit more reproducible, reliable signs and symptoms of pain. For infants of less than one year of age, the Neonatal Infant Pain Scale (NIPS) uses observational and physiologic parameters to detect pain (Table 2).  A score of 0-2 indicates no pain present.  A score of 3-4 indicates mild to moderate pain; non-pharmacologic techniques may be tried first.  A score of 5 or greater indicates severe pain; some pharmacologic intervention is indicated (Lawrence 1993). For children greater than one year who are preverbal, a well performing scale is the FLACC score: Face, Legs, Activity, Cry, Consolability (Table 3). Contextual and caregiver features predominate in this group.  Frequent reassessments are helpful, as the initial trepidation and fright in triage may not accurately reflect the child’s overall pain status. Preschool and School-age children Increasing language development offers the hope of more information to the clinician, but be careful not to ask leading questions.  Do not jump directly to “does this hurt?”.  Preschoolers will say ‘yes’ to anything, in an attempt to please you.  School-age children may passively affirm your “statement”, if only to validate their human need for care or attention.  Start with some ice-breaking banter, lay down the foundations for rapport, and then ask open-ended questions.  Be careful not to allow the caregiver to “instruct” the child to tell you where it hurts, how much, how often, etc.  Rather, engage the parents by asking them what behavior they have noticed.  Eliciting history from both the child and the parent will go a long way in constructing a richer picture of the etiology and severity of the pain, and will help to build rapport and trust. The Baker-Wong FACES Pain Rating scale (Figure 1) was developed with feedback from children and has been validated for use in those 3 years of age and older (Keck 1996, Tomlinson 2010). Adolescents Adolescents vary in their development, maturity, and coping mechanisms.  You may see a mixture of childhood and adult behaviors in the same patient; e.g. he may be initially stoic or evades questioning, then later exhibits pseudo-inconsolability.  Do what you can to see the visit from the adolescent’s perspective, and actively transmit your concern and intention to help – many will respond to a warm, open, non-judgemental, and helpful attitude.  The overly “tough” adolescent is likely secretly fearful, and the “dramatic” adolescent may simply be very anxious.  Take a moment to gauge the background behind the presentation. You may use the typical adult scale of 0 (no pain) to 10 (worst pain), or the Faces Pain Scale–Revised (FPS-R).  The FPS-R uses more neutral and realistic faces and, unlike the Wong Baker scale, does not use smiling or crying faces to anchor the extremes of pain (Tsze 2013). PAIN PHYSIOLOGY Pain includes two major components: generation and perception.  Generation of pain involves the actual propagation of painful stimuli, either through nociceptive pain or neuropathic pain.  Nociceptive pain arises from free nerve endings responding to tissue damage or inflammation. Nociceptive pain follows a specific sequence: transduction (an action potential triggered by chemical mediators in the tissue, such as prostaglandins, histamine, bradykinin, and substance P); transmission (the movement of the action potential signal along the nerve fibers to the spinal cord); perception (the impulse travels up the spinothalamic tract to the thalamus and midbrain, where input is splayed out to the limbic system, somatosensory cortex, and parietal and frontal lobes); and modulation (the midbrain enlists endorphins, enkephalins, dynorphin, and serotonin to mitigate pain) (Pasero 2011).  As clinicians we can target specific “stations” along the pain route to target the signal more effectively. Simple actions such as ice, elevation, local anesthetics, or splinting help in pain transduction.  Various standard oral, intranasal, or IV analgesics may help with pain’s transmission. Non-pharmacologic techniques such as distraction, re-framing, and others can help with pain perception.  The sum of these efforts encourage pain modulation. A phenomenon separate from nociceptive pain is neuropathic pain, the abnormal processing of pain stimuli.  It is a dysregulated, chaotic process that is difficult to manage in any setting.  Separating nociceptive from neuropathic symptoms may help to select specific pain treatments and to clarify treatment goals and expectations. Neonates Neonates are exquisitely sensitive to many analgesics.  Hepatic enzymes are immature and exhibit decreased clearance and prolonged circulating levels of the drug administered.  Once the pain is controlled, less frequent administration of medications, with frequent reassessments, are indicated. The neonate’s vital organs (brain, heart, viscera) make up a larger proportion of his body mass than do muscle and fat.  That is to say, the volume of distribution is unique in a neonate.  Water-soluble drugs (e.g. morphine) reach these highly perfused vital organs quickly; relatively small overdosing will have rapid and exaggerated central nervous system and cardiac effects.  The neonate’s small fat stores and muscle mass limit the volume of distribution of lipophilic medications (e.g. fentanyl, meperidine), also making them more available to the central nervous system, and therefore more potent.  Other factors that predispose neonates to accidental analgesic overdose are their decreased concentrations of albumin and other plasma proteins, causing a higher proportion of unbound drug.  Renal clearance is also decreased in the first few months of life. Clinical note: in the ED, neonates often require analgesia for procedures more than for injury.  Non-pharmacologic techniques predominate (see below).  Make liberal use of local anesthetics such as eutectic mixture of local anesthetics (EMLA; for intact skin, e.g. IV access, lumbar puncture) and lidocaine-epinephrine-tetracaine gel (LET; for superficial open skin and soft tissue application).  Oral sucrose (30%) solutions (administered either with a small-volume syringe or pacifier frequently dipped in solution) are effective for minor procedures (Harrison 2010, Stevens 2013) via the release of dopamine and through distraction by mechanical means.  Neonates with severe pain may be managed with parenteral analgesics, on a monitor, and with caution. Infants and Toddlers With increasing body mass comprised of fat stores in conjunction with an increase in metabolism, this group will require a different approach than the neonate.  For many medications, these children will have a greater weight-normalized clearance than adults (Berde 2002).  They will often require more frequent dosing.  Infants and toddlers have a larger functioning liver mass per kilogram of body weight, with implications for medications cleared by cytochrome p-450. Clinical note: some drugs, such as benzodiazepines, will have both a per-kilogram dosing as well as an age-specific modification.  When giving analgesics or anxiolytics to young children, always consult a reference for proper dosing and frequency. School-age children and Adolescents This group retains some hyper-metabolic features of younger children, but the dose-effect relationship is more linear and transparent.  Physiologic clearance is improved, and from a physical standpoint, these are typically lower-risk children.  From a psychological standpoint, this group may need more non-pharmacologic consideration and support to modulate pain optimally. NON-PHARMACOLOGIC TREATMENT The first line of treatment in all pain management is non-pharmacopeia (Horeczko 2016).  Not only is this the safest of all techniques, but often the most effective.  Some are simple comfort measures such as splinting (fracture or sprain), applying cold (acute soft tissue injury) or heat (non-traumatic, non-specific pain), or other targeted non-pharmacology. Many a pain control regimen is sabotaged without consideration of non-pharmacologic techniques, which may augment, or at times replace, analgesics.  Think of non-pharmacopoeia as your “base coat” or “primer” before applying additional coats of analgesic treatment.  With the right base coat foundation, you have a better chance of painting a patient’s symptoms a more tolerable and long-lasting new color. A tailored approach based on age will allow the practitioner to employ a child’s developmental strengths and avoid the frustration that results in asking the child to do what he is not capable of doing.  A brief review of Piaget’s stages of development will help to meet the child at his developmental stage for best effect (Piaget 1928, Sheppard 1977) during acute painful presentations and minor procedures. Sensorimotor stage (from birth to age 2): Children use the five senses and movement to explore the world.  They are egocentric: they cannot see the world from another’s viewpoint.   At 6 to 9 months, object permanence is established: understanding that objects (or people) exist even without seeing them. Preoperational stage (from ages 2 to 7):  Children learn to use language.  Magical thinking predominates. They do not understand rational or logical thinking. Concrete operational stage (from age 7 to early adolescence): Children can use logic, but in a very straightforward, concrete manner (they do well with simple examples).  By this stage, they move from egocentrism to understanding another point of view.  N.B. Some children (and adults) never completely clear this stage. Formal operational stage (early adolescence to adult): children are capable of abstract thinking, rationalizing, and logical thinking. It is important to assess the child’s general level of development when preparing and guiding him through the minor procedure or distracting him until his pain is controlled.  It is not uncommon for acutely ill or injured to regress temporarily in their behavior (not their development) as a coping mechanism. Neonate and Infant (0-12 months) Involve the parent, and have the parent visible to the child at all times if possible.  Make advances slowly, in a non-threatening manner; limit the number of staff in the room.  Use soothing sensory measures: speak softly, offer a pacifier, and stroke the skin softly.  Swaddle the infant and encourage the parent to comfort him during and after the procedure.  Engage their developing sensorimotor skills to distract them. Toddler to Preschooler (1-5 years) Use the same techniques as for the infant, and add descriptions of what he will see, hear, and feel; you can use a doll or toy to demonstrate the procedure.  Use simple, direct language, and give calm, firm directions, one at a time.  Explain what you are doing just before doing it (do not allow too much time for fear or anxiety to take root).  Offer choices when appropriate; ignore temper tantrums.  Distraction techniques include storytelling, bright and flashy toys, blowing bubbles, pinwheels, or having another staff member play peek-a-boo across the room.  The ubiquitous smart phone with videos or games can be mesmerizing at this age. School age (6-12 years) Explain procedures using simple language and (briefly) the reason (understanding of bodily functions is vague in this age group).  Allow the child to ask questions, and involve him when possible or appropriate.  Distraction techniques may include electronic games, videos, guided imagery, and participation in the minor procedure as appropriate. Adolescent (13 and up) Use the same techniques for the school age child, but can add detail.  Encourage questioning.  Impose as few restrictions as possible – be flexible.  Expect more regression to childish coping mechanisms in this age group.  Distraction techniques include electronic games, video, guided imagery, muscle relaxation-meditation, and music (especially the adolescent’s own music, if available). APPLIED PHARMACOLOGY No amount of knowledge of the above physiology, pharmacology, or developmental theory will help your little patient in pain without a well constructed and enacted plan.  Aggressively search out and treat your pediatric patient’s presence and source of pain.  Frequent reassessments are important to ensure that breakthrough pain treatment is achieved, when re-administration is indicated, or when a change of plan is necessary.  This is the time to involve the parents or caregivers to let them know what the next steps are, and what to expect. Start with the least invasive modality and progress as needed.  After non-pharmacologic treatments such as splinting, ice, elevation, distraction, and guided imagery, have an escalation of care in mind (Figure 2). From a pharmacologic perspective, various options are available.  Your pain management plan will differ depending on whether a painful procedure is performed in the ED (Table 4).  Once pain is addressed, create a plan to keep it managed.  Consider the trajectory of illness and the expected time frame of the painful episode.  Include practicalities such as how well the pain may be controlled as an outpatient.  Poorly controlled pediatric pain is more often managed as an inpatient than the same condition in an adult.  Speak frankly with the parents about what drug is indicated for what type of pain and that treatment goals typically do not include absence of all pain, but function in face of the pain, in anticipation for clinical improvement. A special note on codeine: Tylenol with codeine (“T3”) has never been a very effective pain medication, as up to 10% of patients lack enzymatic activity to metabolize it into morphine, its active form (Crews 2014).  New evidence is emerging on the erratic and unpredictable individual metabolism of codeine.  Some children are ultra-rapid-metabolizers of codeine to morphine, causing a rapid “bolus” of the available drug, with respiratory depression and death in some cases (Ciszkowski 2009, Racoosin 2013).  Author’s advice: take codeine off your formulary. COMMON SCENARIOS Head and neck pain Most common non-traumatic head and neck complaints can be managed non-pharmacologically (e.g. headache: improved hydration, sleep, stress, nutrition) or with PO medications, such as NSAIDs.  The anti-inflammatory nature of ibuprofen (10 mg/kg PO q 4-6 h prn, up to adult dose) for example, will treat the cause as well as the symptoms of ear pain, sore throat, and muscular pain.  Ibuprofen may be more effective than acetaminophen (paracetamol) for odontogenic pain (Bailey 2013).  For most applications, acetaminophen may be as effective; however, the combination of both NSAIDs is not likely to be more effective than either agent individually (Merry 2013). True migraine headache may be treated with all of the above, and rescue therapy may include prochlorperamide (0.15 mg/kg IV, up to 10 mg ) (Brousseau 2004), often given with diphenhydramine (1 mg/kg PO or IV, up to 50 mg) and IV fluids.  Ketoralac (0.5 mg/kg IV, up to 10 mg) may be substituted for ibuprofen (Paniyot 2016).  Other specific therapies may be considered, although evidence for them varies. Chest pain After ruling out important pulmonary (e.g. the under-recognized spontaneous pneumothorax) and cardiac (e.g. pericarditis, myocarditis) etiologies, many chest complaints are amenable to NSAIDs.  There is often a large component of anxiety in the child and/or parents in chest pain; no amount of medication will assuage them without addressing their concerns as well. Abdominal pain Abdominal pain in children is challenging, as it is common, often benign, but may be disastrous if the etiology is missed.  For mild pain, consider acetaminophen as indicated (15 mg/kg/dose q 4-6 h prn, up to 650 mg).  The oral route is preferred, but intravenous acetaminophen is an option for patients unable to tolerate PO, or for those in whom the per rectum (PR) route is contraindicated (e.g. neutropenia) (Babl 2011, Dokko 2014).  For children with moderate to severe abdominal pain in whom a nil per os (NPO) status is ideal, consider rehydration/volume repletion, and small, frequent aliquots of a narcotic agent.  Surgical pain is not “erased” by opioids (Thomas 2003, Poonai 2014); treating pain improves specificity to certain surgical emergencies with retained diagnostic accuracy (Manterola 2007).  If there is inter-departmental concern about prolonged effects, sedation, limitation in the physical exam, or there is a need to “see if the pain will come back”, you may opt to use fentanyl initially for its shorter half-life.  More frequent re-assessments may help the surgical team in its deliberations.  Transition quickly to a longer-acting opioid as soon as possible. Long-bone injuries Fracture pain should be addressed immediately with splinting and analgesia.  Oral, intranasal, and intravenous routes are all acceptable, depending on the severity of the injury and symptoms. Intranasal (IN) medications offer the advantage of a fast onset for moderate-to-severe pain (Graudins 2015), either as monotherapy or as a bridge to parenteral treatment (Table 4).  The ideal volume of IN medication is 0.25 mL/naris, with a maximum of 1 mL/naris.  Common concentrations of fentanyl limit its mg/kg use to the school-aged child; intranasal ketamine may be used for pain (i.e. sub-dissociative dose) up to adult weight. Long-bone injuries are a good opportunity to employ a speedy modality that requires little technical skill in administration: nebulized fentanyl.  Clinically significant improvement in pain scales are achieved with 3 mcg/kg/dose of fentanyl administered via standard nebulizer in children 3 years of age or older (Miner 2007, Furyk 2009).  Nebulized fentanyl is a rapid, non-invasive alternative to the IN route for older children, adolescents, or adults, in whom the volume of IN medication would exceed the recommended per naris volume (Deaton 2015). Consider an aggressive, multi-modal approach to control symptom up front.  For example, for a simple forearm fracture, you may opt to give an oral opioid, perform a hematoma block, and offer inhaled nitrous oxide for reduction, rather than a formal intravenous procedural sedation (Luhmann 2006). Ultrasound-guided peripheral nerve blocks are a good pain control adjunct, after initial treatment, and in communication with referring consultants (Ganesh 2009, Suresh 2014). Skin and Soft tissue Skin and soft tissue injuries or abscesses often require solid non-pharmacopoeia in addition to local anesthetics.  For IV cannulation, consider EMLA if the patient is stable and a minor delay is acceptable. Topical ethyl chloride vapo-coolant offers transient pain relief due to rapid cooling and may be used just prior to an IV start (Farion 2008).  Try this: engage your young child’s imagination to distract him and say, “have you ever held a snow ball? You are in luck – it’s just like that – here, do you feel it?”. Vibratory adjuncts such as the “BUZZY” bee can be placed near the IV cannulation site to provide mechanical and cognitive distraction (Moadad 2016). Needleless lidocaine injectors may facilitate IV placement without obscuring the target vein (Spanos 2008, Lunoe 2015).  The medication is propelled into the dermis by a CO2 cartridge that makes a loud popping sound; try this to alleviate anxiety, just before using it: “your skin looks thirsty – it needs a drink – there you are!”. As with any minor procedure, when you tell the child what you are doing, be sure to do it right away.  Do not delay or build suspense. Lidocaine-epinephrine-tetracaine gel (LET) is used for open or mucosal wounds.  Apply as soon as possible in the visit.  The goal of LET is to pretreat the wound to allow for a painless administration of injectable anesthetic.  A common practice to apply LET two or three times at 15-minute intervals for deeper anesthesia, in an attempt to avoid injection altogether.  Researchers are currently working to offer an evidence base to this anecdotal practice. Pediatric burns should be assessed carefully and treated aggressively.  Submersion of the affected extremity in room-temperature water (if possible) or applying room-temperature saline-soaked gauze will both thwart ongoing thermal damage, soothe the wound, and provide foundational first-aid.  Minor burns can be treated topically and with oral medications.  Major burns require IN, IM, or IV analgesics with morphine.  Treatment may escalate to ketamine (Gandhi 2010), in analgesic or dissociative dosing, depending on the context.  Post-traumatic disorders are common in burns; effective pain management is ever-more important in these cases. SPECIFIC SCENARIOS The child with chronic medical problems Children with acute exacerbations of their chronic pain or episodic painful crises require special attention.  Some examples of children with recurring pain are those suffering from sickle cell disease, juvenile idiopathic arthritis, complex regional pain syndrome, and cancer.  Find out whether these symptoms and circumstances are typical for them, and what regimen has helped in the past.  Previous unpleasant experiences may prime these children with amplified anxiety and perception of pain (Cornelissen 2014).  Target the disease process and do your best to show the patient and his family you understand his condition and needs. An equally challenging scenario is the child with chronic pain.  Treat the entire patient with a multimodal approach.  Limit opioids as possible.  As an opioid-sparing strategy or as rescue therapy, consider sub-dissociative ketamine, especially for conditions such as sickle cell crisis, complex regional pain syndrome, autoimmune disorders, or chronic pain due to sub-acute trauma (Sheehy 2015). Intranasal ketamine may be used for sub-dissociative pain control at 0.5 – 1 mg/kg (Andolfatto 2013, Yeaman 2013).  Intravenous infusions of ketamine at 0.1 – 0.3 mg/kg/h may be initiated in the ED and continued 4 – 8 h/d, up to a maximum of 16 h total in 3 consecutive days (Sheehy 2015).  In vaso-occlusive episodes, dexmedetomidine has been shown to be an effective adjunct for severe pain poorly responsive to opioids and/or ketamine (Sheehy 2015b). The child with cognitive impairment Children with cognitive impairment such as those with various genetic or metabolic syndromes, or primary neurologic conditions such as some with cerebral palsy are a challenge to assess and treat properly.  These children not only cannot explain their symptoms, but they also have atypical expressions of pain.  Pain responses in severely intellectually disabled children include a full-blown smile (which may or may not accompany inappropriate laughter), stiffening, and non-cooperation (Hadden 2002).  Other observed behaviors include the freezing phenomenon, in which the child acutely feels the pain, and he abruptly pauses without moving his face for several seconds.  Look also for episodes of unexplained pallor, diaphoresis, breath-holding, and shrill vocalizations. The FLACC has been revised (r-FLACC) for children with cognitive impairment and appears to be reliable for acute care (Malviya 2006). The most distressing and perplexing presentation is the parent who brings his or her child with cognitive impairment for “fussiness”, “irritability”, or “I think he’s in pain”.  Often, this is after significant investigations have been performed, sometimes repeatedly.  Poorly controlled spasticity is an often under-appreciated cause of unexplained pain; treat not with opioids, but with GABA-receptor agonists, such as baclofen or benzodiazepines. Take special precautions in the administration of opioids or benzodiazepines in children with metabolic disorders (e.g. mitochondrial disease) or various syndromes (e.g. Trisomy 21).  They may have a disproportionate reaction to the medication.  Start with a low dose in these children and reassess frequently, titrating in small aliquots as needed. After careful, meticulous investigation in the ED to rule out occult infection, trauma, electrolyte imbalance, or surgical causes, the child with cognitive impairment who continues to be symptomatic despite ED treatment may be admitted for observation.  However, in some cases, the addition of gabapentin to the typical regimen has been shown to manage unexplained irritability in these children (Hauer 2007) by treating visceral hyperalgesia. Multi-trauma The child with multi-trauma is in need of meticulous critical care.  Frequent assessments of pain analgesic response (typically via the intravenous route) are necessary to gauge the child’s trajectory.  Unexplained tachycardia may be the early signs of shock.  Without controlling the child’s pain, it is difficult to distinguish the extreme tachycardia from pain or from blood loss.  If intubated, control the pain first with a fentanyl drip, then use a sedative in addition as needed to keep him comfortable. The child under palliative care Children undergoing palliative care require a multidisciplinary approach.  This includes engaging the patient’s car team as well as “treating” members of the patient’s family.  Examples include the natural course of devastating chromosomal, neurologic, and other congenital conditions; terminal cancer; and trauma, among others (Michelson 2007).  Family dynamics and family members’ needs are often overlooked; the family as a whole must be considered.  Focus on the productive and beneficial treatments that can be offered.  Treat pain promptly, but speak with the parents about end-of-life goals as early as possible, as any analgesic or sedative may have an untoward effect.  You do not want to be caught in the position of potentially precipitously providing cardiopulmonary resuscitation in a child undergoing palliative care, because of a lack of understanding of how increasingly large doses of pain medications can affect breathing and circulation (AAP 2000). Children with ongoing opioid requirements may present not so much with an exacerbation of their chronic pain, but a complication of its treatment.  Identify, assess and aggressively treat constipation, nausea and vomiting, pruritus, and urinary retention (Friedrichsdorf 2007); treating side-effects of pain management may be just as important for quality of life as treating the pain itself. PEARLS AND PITFALLS IN PEDIATRIC PAIN Allow the child to speak for himself whenever possible.  After acknowledging the parent’s input, perhaps try “I want to make sure I understand how the pain is for you.  Tell me more.” Engage parents and communicate the plan to them.  Elicit their expectations, and give them of preview of what to expect in the ED. Opioids are meant for pain caused by acute tissue injury, for the briefest period of time feasible.  Older school-aged children and adolescents are increasingly at risk for opioid dependence and addiction. Premature infants present a challenge in pain control.  Their pain is under-recognized, as they often display atypical responses to painful stimuli.  Treatment is equally difficult, as they are particularly sensitive to analgesia-sedation.  This is important, as this group is even more likely to undergo painful procedures due to their higher-risk status. Give detailed advice on how to manage pain at home.  Set expectations.  Let them know you understand and will help them through your good advice that will carry them through this difficult time.  Patients and families often just need a plan.  Map it out clearly. SUMMARY In pediatric acute pain, know the child; know the family; and know the physiology. Use your observational skills enhanced with collateral information to assess and reassess for pain in children. Treat pediatric pain well and often. Failure to address the child’s pain has long-lasting consequences. Non-pharmacologic treatments for all, pharmacologic treatments for many. A multi-modal approach is the most effective. Neonates, infants and toddlers, and school-aged children and adolescents exhibit specific physiology in expression of pain and in response to treatment. Tailor your regimen to your young patient’s physiologic pitfalls and needs. References American Academy of Pediatrics. Committee on Bioethics and Committee on Hospital Care. Palliative care for children. Pediatrics. 2000 Aug;106(2 Pt 1):351-7. Andolfatto G, Willman E, Joo D, Miller P, Wong WB, Koehn M, Dobson R, Angus E, Moadebi S. Intranasal ketamine for analgesia in the emergency department: a prospective observational series. Acad Emerg Med. 2013 Oct;20(10):1050-4. Babl FE, Theophilos T, Palmer GM. Is there a role for intravenous acetaminophen in pediatric emergency departments? Pediatr Emerg Care. 2011 Jun;27(6):496-9. Bailey E, Worthington HV, van Wijk A, Yates JM, Coulthard P, Afzal Z. Ibuprofen and/or paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth.Cochrane Database Syst Rev. 2013 Dec 12;(12):CD004624. Bearden DJ, Feinstein A, Cohen LL. The influence of parent preprocedural anxiety on child procedural pain: mediation by child procedural anxiety. J Pediatr Psychol. 2012 Jul;37(6):680-6. Berde CB, Sethna NF. Analgesics for the treatment of pain in children. N Engl J Med. 2002 Oct 3;347(14):1094-103. Brousseau DC, Duffy SJ, Anderson AC, Linakis JG. Treatment of pediatric migraine headaches: a randomized, double-blind trial of prochlorperazine versus ketorolac. Ann Emerg Med. 2004 Feb;43(2):256-62. Ciszkowski C, Madadi P, Phillips MS, Lauwers AE, Koren G. Codeine, ultrarapid-metabolism genotype, and postoperative death. N Engl J Med. 2009 Aug 20;361(8):827-8. Cornelissen L, Donado C, Kim J, Chiel L, Zurakowski D, Logan DE, Meier P, Sethna NF, Blankenburg M, Zernikow B, Sundel RP, Berde CB. Pain hypersensitivity in juvenile idiopathic arthritis: a quantitative sensory testing study. Pediatr Rheumatol Online J. 2014 Sep 6;12:39. Crews KR, Gaedigk A, Dunnenberger HM, Leeder JS, Klein TE, Caudle KE, Haidar CE, Shen DD, Callaghan JT, Sadhasivam S, Prows CA, Kharasch ED, Skaar TC; Clinical Pharmacogenetics Implementation Consortium. Clinical Pharmacogenetics Implementation Consortium guidelines for cytochrome P450 2D6 genotype and codeine therapy: 2014 update. Clin Pharmacol Ther. 2014 Apr;95(4):376-82. Deaton T, Auten JD, Darracq MA. Nebulized fentanyl vs intravenous morphine for ED patients with acute abdominal pain: a randomized double-blinded, placebo-controlled clinical trial. Am J Emerg Med. 2015 Jun;33(6):791-5. Dokko D. Best practice for fever management with intravenous acetaminophen in pediatric oncology. J Pediatr Oncol Nurs. 2015 Mar-Apr;32(2):120-5. Farion KJ, Splinter KL, Newhook K, Gaboury I, Splinter WM. The effect of vapocoolant spray on pain due to intravenous cannulation in children: a randomized controlled trial. CMAJ. 2008 Jul 1;179(1):31-6. Finley GA, Kristjánsdóttir O, Forgeron PA. Cultural influences on the assessment of children's pain. Pain Res Manag. 2009 Jan-Feb;14(1):33-7. Friedrichsdorf SJ, Kang TI. The management of pain in children with life-limiting illnesses. Pediatr Clin North Am. 2007 Oct;54(5):645-72. Furyk JS, Grabowski WJ, Black LH. Nebulized fentanyl versus intravenous morphine in children with suspected limb fractures in the emergency department: a randomized controlled trial. Emerg Med Australas. 2009 Jun;21(3):203-9. Gandhi M, Thomson C, Lord D, Enoch S.  Management of Pain in Children with Burns. Int J Pediatr. 2010; 2010: 825657. Ganesh A, Gurnaney HG. Ultrasound guidance for pediatric peripheral nerve blockade. Anesthesiol Clin. 2009 Jun;27(2):197-212. Graudins A, Meek R, Egerton-Warburton D, Oakley E, Seith R. The PICHFORK (Pain in Children Fentanyl or Ketamine) trial: a randomized controlled trial comparing intranasal ketamine and fentanyl for the relief of moderate to severe pain in children with limb injuries. Ann Emerg Med. 2015 Mar;65(3):248-254.e1. Hadden KL, von Baeyer CL. Pain in children with cerebral palsy: common triggers and expressive behaviors. Pain. 2002 Sep;99(1-2):281-8. Harrison D, Bueno M, Yamada J, Adams-Webber T, Stevens B. Analgesic effects of sweet-tasting solutions for infants: current state of equipoise. Pediatrics. 2010 Nov;126(5):894-902. Hauer JM, Wical BS, Charnas L. Gabapentin successfully manages chronic unexplained irritability in children with severe neurologic impairment. Pediatrics. 2007 Feb;119(2):e519-22. Horeczko T, Mahmoud MA. The sedation mindset: philosophy, science, and practice. Curr Opin Anaesthesiol. 2016 Feb;29 Suppl 1:S48-55. Howard RF. Current status of pain management in children. JAMA. 2003 Nov 12;290(18):2464-9. Keck JF, Gerkensmeyer JE, Joyce BA, Schade JG. Reliability and validity of the Faces and Word Descriptor Scales to measure procedural pain. J Pediatr Nurs. 1996 Dec;11(6):368-74. Krechel SW, Bildner J. CRIES: a new neonatal postoperative pain measurement score. Initial testing of validity and reliability. Paediatr Anaesth. 1995;5(1):53. Lawrence J, Alcock D, McGrath P, Kay J, MacMurray SB, Dulberg C. The development of a tool to assess neonatal pain. Neonatal Netw. 1993;12(6):59–66. Liebelt EL. Assessing children's pain in the emergency department. Clin Pediatr Emerg Med. 2000; 1(4):260-269. Luhmann JD, Schootman M, Luhmann SJ, Kennedy RM. A randomized comparison of nitrous oxide plus hematoma block versus ketamine plus midazolam for emergency department forearm fracture reduction in children. Pediatrics. 2006 Oct;118(4):e1078-86. Lunoe MM, Drendel AL, Levas MN, Weisman SJ, Dasgupta M, Hoffmann RG, Brousseau DC. A Randomized Clinical Trial of Jet-Injected Lidocaine to Reduce Venipuncture Pain for Young Children. Ann Emerg Med. 2015 Nov;66(5):466-74. Malviya S, Voepel-Lewis T, Burke C, Merkel S, Tait AR. The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment. Paediatr Anaesth. 2006 Mar;16(3):258-65. Manterola C, Astudillo P, Losada H, Pineda V, Sanhueza A, Vial M. Analgesia in patients with acute abdominal pain. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005660. Maxwell LG, Malavolta CP, Fraga MV. Assessment of pain in the neonate. Clin Perinatol. 2013 Sep;40(3):457-69. Merry AF, Edwards KE, Ahmad Z, Barber C, Mahadevan M, Frampton C. Randomized comparison between the combination of acetaminophen and ibuprofen and each constituent alone for analgesia following tonsillectomy in children. Can J Anaesth. 2013 Dec;60(12):1180-9. Michelson KN, Steinhorn DM. Pediatric End-of-Life Issues and Palliative Care. Clin Pediatr Emerg Med. 2007 Sep; 8(3): 212–219. Miner JR, Kletti C, Herold M, Hubbard D, Biros MH. Randomized clinical trial of nebulized fentanyl citrate versus i.v. fentanyl citrate in children presenting to the emergency department with acute pain. Acad Emerg Med. 2007 Oct;14(10):895-8. Moadad N, Kozman K1, Shahine R, Ohanian S, Badr LK. Distraction Using the BUZZY for Children During an IV Insertion. J Pediatr Nurs. 2016 Jan-Feb;31(1):64-72. Patniyot IR, Gelfand AA. Acute Treatment Therapies for Pediatric Migraine: A Qualitative Systematic Review. Headache. 2016 Jan;56(1):49-70. Pasero C, McCaffery M. Pain Assessment and Pharmacologic Management. St. Louis, Mo: Mosby; 2011. Piaget J. Judgment and reasoning in the child. Harcourt & Brace. Oxford, England. 1928. Poonai N, Paskar D, Konrad SL, Rieder M, Joubert G, Lim R, Golozar A, Uledi S, Worster A, Ali S. Opioid analgesia for acute abdominal pain in children: A systematic review and meta-analysis. Acad Emerg Med. 2014 Nov;21(11):1183-92. Racoosin JA, Roberson DW, Pacanowski MA, Nielsen DR. New evidence about an old drug--risk with codeine after adenotonsillectomy. N Engl J Med. 2013 Jun 6;368(23):2155-7. Sheehy KA, Muller EA, Lippold C, Nouraie M, Finkel JC, Quezado ZM. Subanesthetic ketamine infusions for the treatment of children and adolescents with chronic pain: a longitudinal study. BMC Pediatr. 2015 Dec 1;15:198. Sheehy KA, Finkel JC, Darbari DS, Guerrera MF, Quezado ZM. Dexmedetomidine as an Adjuvant to Analgesic Strategy During Vaso-Occlusive Episodes in Adolescents with Sickle-Cell Disease. Pain Pract. 2015 Nov;15(8):E90-7. Sheppard JL. The application of Piaget's theory to physiotherapy. Aust J Physiother. 1977 Dec;23(4):133-40. Spanos S, Booth R, Koenig H, Sikes K, Gracely E, Kim IK. Jet Injection of 1% buffered lidocaine versus topical ELA-Max for anesthesia before peripheral intravenous catheterization in children: a randomized controlled trial. Pediatr Emerg Care. 2008 Aug;24(8):511-5. Srouji R, Ratnapalan S, Schneeweiss S. Pain in children: assessment and nonpharmacological management. Int J Pediatr. 2010;2010. Stevens B, Yamada J, Lee GY, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD001069. Suresh S, Sawardekar A, Shah R. Ultrasound for regional anesthesia in children. Anesthesiol Clin. 2014 Mar;32(1):263-79. Taddio A, Shah V, Gilbert-MacLeod C, Katz J. Conditioning and hyperalgesia in newborns exposed to repeated heel lances. JAMA. 2002;288(7):857. Thomas SH, Silen W. Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain. Br J Surg. 2003 Jan;90(1):5-9. Tomlinson D, von Baeyer CL, Stinson JN, Sung L. A systematic review of faces scales for the self-report of pain intensity in children. Pediatrics. 2010 Nov;126(5):e1168-98. Tsze DS, von Baeyer CL, Bulloch B, Dayan PS. Validation of Self-Report Pain Scales in Children. Pediatrics. 2013 Oct; 132(4): e971–e979. Voepel-Lewis T, Merkel S, Tait AR, Trzcinka A, Malviya S. The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in children with cognitive impairment. Anesth Analg. 2002 Nov;95(5):1224-9. Yeaman F, Oakley E, Meek R, Graudins A. Sub-dissociative dose intranasal ketamine for limb injury pain in children in the emergency department: a pilot study. Emerg Med Australas. 2013 Apr;25(2):161-7   This post and podcast are dedicated to Sergey M. Motov, MD, FAAEM, for his integrity, hard-won expertise, humility, and innovation.  Thank you for making us better doctors, Sergey, and for getting us ever closer to a pain-free ED. Pediatric Pain Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP

Ep #21 Ketamine Induced Rapid Sequence Intubation with Faizan H. Arshad, MD @emscritcare Happy #EMSWeek #EMSStrong #EMSNation   SKEPTIC = Safety & Efficacy of Ketamine in Emergent Prehospital Tracheal Intubation – a Case Series   Brand new paper from Sydney HEMS on Ketamine and Shock Index in Annals of EM! http://www.annemergmed.com/article/S0196-0644(16)30002-6/abstract   Additional References: Carlson JN, Karns C, Mann NC, et al. Procedures performed by emergency medical services in the united states.Prehosp Emerg Care. 2015. Jacobs PE, Grabinsky A. Advances in prehospital airway management.International Journal of Critical Illness & Injury Science. 2014;4:57-64. Prekker ME, Kwok H, Shin J, Carlbom D, Grabinsky A, Rea TD. The process of prehospital airway management: Challenges and solutions during paramedic endotracheal intubation.Crit Care Med. 2014;42:1372-1378. Wang HE, Kupas DF, Greenwood MJ, et al. An algorithmic approach to prehospital airway management.Prehospital Emergency Care. 2005;9:145-155. Mace SE. Challenges and advances in intubation: Airway evaluation and controversies with intubation.Emerg Med Clin North Am. 2008;26:977-1000. Combes X, Jabre P, Jbeili C, et al. Prehospital standardization of medical airway management: Incidence and risk factors of difficult airway.Acad Emerg Med. 2006;13:828-834. Drummond GB. Comparison of sedation with midazolam and ketamine: effects on airway muscle activity. Br J Anaesth. 1996;76:663-667. Jackson APF, Dhadphale PR, callaghan ML, Alseri S. Haemodynamic studies during induction of anaesthesia for open-heart surgery using diazepam and ketamine. Br J Anaesth. 1978;50:375-378. Price B, Arthur AO, Brunko M, et al. Hemodynamic consequences of ketamine vs etomidate for endotracheal intubation in the air medical setting. Am J Emerg Med. 2013;31:1124-1132. Scherzer D, Leder M, Tobias JD. Pro-Con Debate: Etomidate or Ketamine for Rapid Sequence Intubation in Pediatric Patients. J Pediatr Pharmacol Ther. 2012;17:142-149. Bruder Eric A, Ball Ian M, Ridi S, Pickett W, Hohl C. Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients.Cochrane Database of Systematic Reviews. 2015 Thompson Bastin ML, Baker SN, Weant KA. Effects of Etomidate on Adrenal Suppression: A Review of Intubated Septic Patients.Hospital Pharmacy. 2014;49:177-183. Arnold C. The promise and perils of ketamine research Ketamine began its life as an anaesthetic , but has enjoyed a recent renaissance as a potential. Lancet Neurol. 2013;12:940-941. Craven R. Ketamine. Anaesthesia. 2007;62:48-53. Perkins ZB, Gunning M, Crilly J, Lockey D, O’Brien B. The haemodynamic response to pre-hospital RSI in injured patients. Injury. 2013;44:618-623. Aroni F, Iacovidou N, Dontas I, Pourzitaki C, Xanthos T. Pharmacological Aspects and Potential New Clinical Applications of Ketamine: Reevaluation of an Old Drug. J Clin Pharmacol. 2009;49:957-964. Manthous CA. Avoiding circulatory complications during endotracheal intubation and initiation of positive pressure ventilation.J Emerg Med. 2010;38:622-631. Kohrs R, Durieux ME. Ketamine. Anesth Analg. 1998;87:1186-1193. Moy RJ, Clerc S Le. Trends in Anaesthesia and Critical Care Ketamine in prehospital analgesia and anaesthesia. Trends Anaesth Crit Care. 2011;1:243-245. Reich DL, Silvay G. Ketamine: an update on the first twenty-five years of clinical experience. Can J Anaesth. 1989;36(2):186-197. Porter K. Ketamine in prehospital care. Emerg Med J. 2004;21:351-354. Svenson JE, Abernathy MK. Ketamine for prehospital use: new look at an old drug. Am J Emerg Med. 2007;25:977-980. Johansson J, Sjöberg J, Nordgren M, Sandström E, Sjöberg F, Zetterström H. Prehospital analgesia using nasal administration of S-ketamine--a case series. Scand J Trauma Resusc Emerg Med. 2013;21:38. Filanovsky Y, Miller P, Kao J. Myth: Ketamine should not be used as an induction agent for intubation in patients with head injury. Can J Emerg Med. 2010;12:154-201. Himmelseher S, Durieux ME. Revising a Dogma: Ketamine for Patients with Neurological Injury? Anesth Analg. 2005;101:524-534. Kropf J a., Grossman MD, Genzlinger M a., Stoltzfus J, Stehly CD. 328 Ketamine versus Etomidate for Rapid Sequence Intubation in Traumatically Injured Patients: An Exploratory Study. Ann Emerg Med. 2012;60:S117. Angus DC, van dP. Severe sepsis and septic shock.N Engl J Med. 2013;369:840-851. Jabre P, Avenel A, Combes X, et al. Morbidity related to emergency endotracheal intubation-A substudy of the KETAmine SEDation trial. Resuscitation. 2011;82:517-522. Shafi S, Gentilello L. Pre-Hospital Endotracheal Intubation and Positive Pressure Ventilation Is Associated with Hypotension and Decreased Survival in Hypovolemic Trauma Patients: An Analysis of the National Trauma Data Bank. The Journal of Trauma: Injury, Infection, and Critical Care. 2005;59:1140–1147. Seymour CW, Band RA, Cooke CR, et al. Out-of-hospital characteristics and care of patients with severe sepsis: A cohort study.J Crit Care. 2010;25:553-562. Williams E, Arthur a., Price B, Banister NJ, Goodloe JM, Thomas SH. 175 Ketamine versus Etomidate for Use in Helicopter Emergency Medical Services Endotracheal Intubation. Ann Emerg Med. 2012;60:S63-S64 Bruns, B, Gentilello, L, Elliott, A, Shafi, S. Prehospital Hypotension Redefined. The Journal of Trauma: Injury, Infection, and Critical Care. 2008;65:1217–1221. Seymour, CW, Cooke, CR, Heckbert, SR, et al. Prehospital Systolic Blood Pressure Thresholds: A Community-based Outcomes Study. Acad Emerg Med Academic Emergency Medicine. 2013;20:597–604. Kristensen AKB, Holler JG, Mikkelsen S, Hallas J, Lassen A. Systolic blood pressure and short-term mortality in the emergency department and prehospital setting: a hospital-based cohort study.Critical Care. 2015;1:158. Heffner AC, Swords DS, Neale MN, Jones AE. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation. 2013;84:1500-1504. Salt PJ, Baranes PK, Beswick FJ. Inhibition of neuronal and extraneuronal uptake of noradrenaline by ketamine in the isolated perfused rat heart. Br J Anaesth. 1979;51:835-838. Sprung J, Schuetz SM, Stewart RW, Moravec CS. Effects of Ketamine on the Contractility of Failing and Nonfailing Human Heart Muscles in Vitro. Surv Anesthesiol. 1999;43:230-231. Kunst G, Martin E, Graf BM, Hagl S, Vahl CF. Actions of Ketamine and Its Isomers on Contractility and Calcium Transients in Human Myocardium. Anesthesiology. 1999;90:1363-1371. Lundy PM, Lockwood PA, Thompson G, Frew R. Differential Effects of Ketamine Isomers on Neuronal and Extraneuronal Catecholamine Uptake Mechanisms. Anesthesiology. 1986;64:359-363. Selde W. Push dose epinephrine. A temporizing measure for drugs that have the side-effect of hypotension.JEMS. 2014;39:62-63.   Sponsored by @PerfectCPR Apple Watch App with Audio and Haptic Feedback to Optimize Cardiac Arrest Training and Improve Quality of CPR Delivery PerfectCPR.com     Query us on Twitter: www.twitter.com/EMS_Nation Like us on Facebook: www.facebook.com/prehospitalnation   Wishing Everyone a safe tour! ~Faizan H. Arshad, MD @emscritcare www.emsnation.org  

Ep #17 A Primer on Intrathoracic Pressure Regulation & The Physiology of CPR with Dr. Keith Lurie Happy #EMSWeek #EMSStrong #EMSNation   Sponsored by @PerfectCPR Apple Watch App with Audio and Haptic Feedback to Optimize Cardiac Arrest Training and Improve Quality of CPR PerfectCPR.com   Dr. Keith Lurie is a practicing cardiac electrophysiologist and resuscitation scientist who, over the past 25 years, has devoted himself to study novel ways to resuscitate patients experiencing sudden cardiac arrest.  Dr. Lurie earned his bachelors degree at Yale University and his medical degree at Stanford University. He studied cardiovascular medicine at the University of California in San Francisco and later joined the faculty there.  He has been on the faculty at the University of Minnesota since 1991. As one of the leading innovators in the field, he has helped to develop new devices and methods that optimize cardio-pulmonary resuscitation (CPR) and, in turn, improve survival chances following cardiac arrest. In addition, he has become a respected thought leader in developing and implementing a systems-based approach to managing and treating sudden cardiac death events. Some of his most notable contributions include the development and assessment of various resuscitative techniques such as the impedance threshold device (ITD), active compression-decompression (ACD) CPR and the use of intra-thoracic pressure regulation to modulate cerebral and systemic circulation in states of severe hypotension and head injury. He has also helped to develop devices to treat heart failure and abnormal heart rhythms. He has mentored scores of research and clinical fellows over the past 30 years and he actively collaborates with multiple scientist colleagues worldwide. A professor of Emergency Medicine and Internal Medicine at the University of Minnesota, Dr. Lurie also directs an NIH-funded research laboratory at Hennepin County Medical Center in Minneapolis and he is a consultant for Zoll Medical.   Selected Peer-Reviewed Publications (Selected from over 200 publications):   Lurie KG, Nemergut EC, Yannopoulos D, Sweeney M. The physiology of cardiopulmonary resuscitation. Anesth Analg. 11/2015 Kwon Y, Debaty G, Puertas L, Metzger A, Rees J, McKnite S, Yannopoulos D, Lurie K. Effect of regulating airway pressure on intrathoracic pressure and vital organ perfusion pressure during cardiopulmonary resuscitation: A non-randomized interventional cross-over study. Scandinavian journal of trauma, resuscitation and emergency medicine. 2015;23:83 Debaty G, Metzger A, Lurie K. Evaluation of zoll medical's resqcpr system for cardiopulmonary resuscitation. Expert review of medical devices. 2015;12:505-516 Smith G, Dwork N, O'Connor D, Sikora U, Lurie K, Pauly J, Ellerbee A. Automated, depth resolved estimation of the attenuation coefficient from optical coherence tomography data. IEEE transactions on medical imaging. 2015 Lurie KL, Gurjarpadhye AA, Seibel EJ, Ellerbee AK. Rapid scanning catheterscope for expanded forward-view volumetric imaging with optical coherence tomography. Optics letters. 2015;40:3165-3168 Debaty G, Metzger A, Rees J, McKnite S, Puertas L, Yannopoulos D, Lurie K. Enhanced perfusion during advanced life support improves survival with favorable neurologic function in a porcine model of refractory cardiac arrest. Crit Care Med. 2015;43:1087-1095 Salzman JG, Frascone RJ, Burkhart N, Holcomb R, Wewerka SS, Swor RA, Mahoney BD, Wayne MA, Domeier RM, Olinger ML, Aufderheide TP, Lurie KG. The association of health status and providing consent to continued participation in an out-of-hospital cardiac arrest trial performed under exception from informed consent. Acad Emerg Med. 2015;22:347-353 Metzger A, Rees J, Kwon Y, Matsuura T, McKnite S, Lurie KG. Intrathoracic pressure regulation improves cerebral perfusion and cerebral blood flow in a porcine model of brain injury. Shock. 2015;44 Suppl 1:96-102 Debaty G, Shin SD, Metzger A, Kim T, Ryu HH, Rees J, McKnite S, Matsuura T, Lick M, Yannopoulos D, Lurie K. Tilting for perfusion: Head-up position during cardiopulmonary resuscitation improves brain flow in a porcine model of cardiac arrest. Resuscitation. 2015;87:38-43 Bartos JA, Matsuura TR, Sarraf M, Youngquist ST, McKnite SH, Rees JN, Sloper DT, Bates FS, Segal N, Debaty G, Lurie KG, Neumar RW, Metzger JM, Riess ML, Yannopoulos D. Bundled postconditioning therapies improve hemodynamics and neurologic recovery after 17 min of untreated cardiac arrest. Resuscitation. 2015;87:7-13 Gold B, Puertas L, Davis SP, et al. Awakening after cardiac arrest and post resuscitation hypothermia: are we pulling the plug too early? Resuscitation. Feb 2014;85(2):211-214. Metzger A, Rees J, Segal N, et al. "Fluidless" resuscitation with permissive hypotension via impedance threshold device therapy compared with normal saline resuscitation in a porcine model of severe hemorrhage. The journal of trauma and acute care surgery. Aug 2013;75(2 Suppl 2):S203-209. Frascone RJ, Wayne MA, Swor RA, et al. Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device. Sep 2013;84(9):1214-1222. Yannopoulos D, Segal N, Matsuura T, et al. Ischemic post-conditioning and vasodilator therapy during standard cardiopulmonary resuscitation to reduce cardiac and brain injury after prolonged untreated ventricular fibrillation. Aug 2013;84(8):1143-1149. Sarraf M, Sharma A, Caldwell E, McKnite S, Aufderheide T, Lurie K, Neumar R, Riess M, Yannopoulos D. Postconditioning with inhaled sevoflurane at the initiation of cpr improves hemodynamics and mitigates post-cardiac arrest myocardial injury after 15 min of untreated ventricular fibrillation. Crit Care Med. 2012;40:1-328 Yannopoulos D, Segal N, McKnite S, Aufderheide TP, Lurie KG. Controlled pauses at the initiation of sodium nitroprusside-enhanced cardiopulmonary resuscitation facilitate neurological and cardiac recovery after 15 mins of untreated ventricular fibrillation. Crit Care Med. 2012;40:1562-1569 Segal N, Matsuura T, Caldwell E, Sarraf M, McKnite S, Zviman M, Aufderheide TP, Halperin HR, Lurie KG, Yannopoulos D. Ischemic postconditioning at the initiation of cardiopulmonary resuscitation facilitates functional cardiac and cerebral recovery after prolonged untreated ventricular fibrillation. Resuscitation. 2012;83:1397-1403 Convertino VA, Parquette B, Zeihr J, Traynor K, Baia D, Baumblatt M, Vartanian L, Suresh M, Metzger A, Gerhardt RT, Lurie KG, Lindstrom D. Use of respiratory impedance in prehospital care of hypotensive patients associated with hemorrhage and trauma: A case series. The journal of trauma and acute care surgery. 2012;73:S54-59 Yannopoulos D, Matsuura T, Schultz J, et al. Sodium nitroprusside enhanced cardiopulmonary resuscitation improves survival with good neurological function in a porcine model of prolonged cardiac arrest. Crit Care Med. Jun 2011;39(6):1269-1274. Yannopoulos D, Kotsifas K, Lurie KG. Advances in cardiopulmonary resuscitation. Heart Fail Clin. Apr 2011;7(2):251-268, ix. Lurie KG, Coffeen P, Shultz J, McKnite S, Detloff B, Mulligan K. Improving active compression-decompression cardiopulmonary resuscitation with an inspiratory impedance valve. Circulation 1995;91(6):1629-32. Plaisance P, Lurie KG, Vicaut E, Adnet F, Petit JL, Epain D, Ecollan P, Gruat R, Cavagna P, Biens J and others. A comparison of standard cardiopulmonary resuscitation and active compression-decompression resuscitation for out-of-hospital cardiac arrest. French Active Compression-Decompression Cardiopulmonary Resuscitation Study Group. N Engl J Med 1999;341(8):569-75. Lurie KG, Voelckel WG, Zielinski T, McKnite S, Lindstrom P, Peterson C, Wenzel V, Lindner KH, Samniah N, Benditt D. Improving standard cardiopulmonary resuscitation with an inspiratory impedance threshold valve in a porcine model of cardiac arrest. Anesth Analg 2001;93(3):649-55. Lurie KG, Zielinski T, McKnite S, Aufderheide T, Voelckel W. Use of an inspiratory impedance valve improves neurologically intact survival in a porcine model of ventricular fibrillation. Circulation 2002;105(1):124-9. Aufderheide TA, Sigurdsson G, Pirrallo RG, Yannopoulos D, McKnite S, van Briesen C, Sparks C, Conrad CJ, Provo CA, Lurie KG. Hyperventilation-induced hypotension during CPR. 2004;109:1960-65. Aufderheide TP, Pirrallo RG, Provo TA, Lurie KG. Clinical evaluation of an inspiratory impedance threshold device during standard cardiopulmonary resuscitation in patients with out-of-hospital cardiac arrest. Critical Care Medicine. 2005, Apr;33(4):734-40. Pirrallo RG, Aufderheide TP, Provo TA, Lurie KG. Effect of an inspiratory impedance threshold device on hemodynamics during conventional manual cardiopulmonary resuscitation. 2005 Jul;66(1):13-20. Aufderheide T, Alexander C, Lick C, Myers B, Romig L, Vartanian L, Stothert J, S. M, Matsuura T, Yannopoulos D and others. From laboratory science to six emergency medical services systems: New understanding of the physiology of cardiopulmonary resuscitation increases survival rates after cardiac arrest. Crit Care Med 2008;36(Suppl):S397-S404. Lurie KG, Yannopoulos D, McKnite SH, Herman ML, Idris AH, Nadkarni VM, Tang W, Gabrielli A, Barnes TA, Metzger AK. Comparison of a 10-breaths-per-minute versus a 2-breaths-per-minute strategy during cardiopulmonary resuscitation in a porcine model of cardiac arrest. Respir Care 2008;53(7):862-70. Metzger A, Yannopoulos D, Lurie KG. Instrumental Management of CPR. Severe Acute Heart Failure Syndromes:  A Practical Approach for Physicians. Mebazaa, A., Gheorghiade, M., Zannad, F., Parrillo, J.E. (eds.). Springer-Verlag, London Ltd. 2008, pp. 43-51. Metzger A, Lurie K. Harnessing Cardiopulmonary Interactions to Improve Circulation and Outcomes After Cardiac Arrest and Other States of Low Blood Pressure. In: Iaizzo PA, editor. Handbook of Cardiac Anatomy, Physiology, and Devices: Springer Science; 2009. p 583-604. Nichol G, Aufderheide TP, Eigel B, Neumar RW, Lurie KG, Bufalino VJ, Callaway CW, Menon V, Bass RR, Abella BS and others. Regional systems of care for out-of-hospital cardiac arrest: A policy statement from the American Heart Association. Circulation;121(5):709-29. Yannopoulos D, Matsuura T, McKnite S, Goodman N, Idris A, Tang W, Aufderheide TP, Lurie KG. No assisted ventilation cardiopulmonary resuscitation and 24-hour neurological outcomes in a porcine model of cardiac arrest. Crit Care Med;38(1):254-60.     Query us on Twitter: www.twitter.com/EMS_Nation Like us on Facebook: www.facebook.com/prehospitalnation   Wishing Everyone a safe tour! ~Faizan H. Arshad, MD @emscritcare www.emsnation.org  

Tim Platts-Mills shares his pearls about pain management for older adults in the ED. See here to leave a comment: https://gempodcast.com/2016/05/02/pearls-and-pitfalls-of-pain-management-in-older-adults/ Pain is the number one reason why people seek care in the Emergency Department (ED). One major goal of acute care is diagnosing the cause of the pain, but another is helping relieve the suffering associated with pain. In older adults, some of the risks of pain management with opioids are amplified, such as the risk of sedation and falls. With NSAIDs, there is a higher risk of acute renal insufficiency and electrolyte abnormalities, as well as cardiovascular risks with longer treatment. How should we approach acute pain management in the ED, and on discharge in older patients? In this podcast episode, Tim Platts-Mills, an expert and researcher on pain in older adults talks us through some ideas for non-opiates, opiates, and other adjuncts. We discuss some of the risks of over-treatment and under-treatment, and introduce the idea of the allostatic load created by chronic pain. Selected References 1. Hwang U, Platts-Mills TF. Acute pain management in older adults in the emergency department. Clin Geriatr Med. 2013;29(1):151-164. http://www.ncbi.nlm.nih.gov/pubmed/23177605 2. Platts-Mills TF, Esserman DA, Brown DL, Bortsov AV, Sloane PD, McLean SA. Older US emergency department patients are less likely to receive pain medication than younger patients: Results from a national survey. Ann Emerg Med. 2012;60(2):199-206. http://www.ncbi.nlm.nih.gov/pubmed/22032803 3. Hwang U, Richardson LD, Harris B, Morrison RS. The quality of emergency department pain care for older adult patients. J Am Geriatr Soc. 2010;58(11):2122-2128. http://www.ncbi.nlm.nih.gov/pubmed/21054293 4. Terrell KM, Hui SL, Castelluccio P, Kroenke K, McGrath RB, Miller DK. Analgesic prescribing for patients who are discharged from an emergency department. Pain Med. 2010;11(7):1072-1077. http://www.ncbi.nlm.nih.gov/pubmed/20642733 5. Gilron I, Bailey JM, Tu D, Holden RR, Weaver DF, Houlden RL. Morphine, gabapentin, or their combination for neuropathic pain. N Engl J Med. 2005;352(13):1324-1334. http://www.ncbi.nlm.nih.gov/pubmed/15800228 6. Siddall PJ, Cousins MJ. Persistent pain as a disease entity: Implications for clinical management. Anesth Analg. 2004;99(2):510-20, table of contents. http://www.ncbi.nlm.nih.gov/pubmed/15271732 7. Jakobsson U, Klevsgard R, Westergren A, Hallberg IR. Old people in pain: A comparative study. J Pain Symptom Manage. 2003;26(1):625-636. http://www.ncbi.nlm.nih.gov/pubmed/12850645 8. Elliott AM, Smith BH, Penny KI, Smith WC, Chambers WA. The epidemiology of chronic pain in the community. Lancet. 1999;354(9186):1248-1252. http://www.ncbi.nlm.nih.gov/pubmed/10520633 9. Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly patients with cancer. SAGE study group. systematic assessment of geriatric drug use via epidemiology. JAMA. 1998;279(23):1877-1882. http://www.ncbi.nlm.nih.gov/pubmed/9634258 This podcast uses sounds from freesound.org by Jobro and HerbertBoland Image credit: https://pixabay.com/en/heart-3d-stone-white-pain-old-1463424/