Cricoid pressure or manual RETARD?

Cliff Reid has just written a MUST READ post on cricoid pressure in response to a long discussion on the FOAMcc Google Plus Community featuring the usual logical fallacies, circular arguments and dogmatic claims of negligence against enlightened practitioners who have discarded this unproven technique.

Read Time to change thinking on ‘cricoid pressure’ NOW!

In one of the concluding paragraphs he advocates the renaming of this procedure as manual Routine Esophageal Transposition with Airway Restriction and Distortion (aka manual RETARD). I invite you to use this new terminology when describing this procedure.

Also note the comment that Cliff left below the post:

Please note I have had some feedback that this post has caused offence to person(s) I have the utmost respect for, for which I sincerely and publicly apologise. I am grateful for their honest feedback which has resulted in some subtle rewording to avoid the impression of ad hominem attack.

I consider cricoid pressure to be potentially harmful to patients, and feel duty bound to challenge it most assertively. Through social media we have immense influence and here I have attempted to offset its continued promotion by other influential figures who add credence to those who wield the power to punish a provider legally or professionally for not following a non-evidence based guideline.

I respect these colleagues immensely, and I respect ABSOLUTELY their right to hold and express different views to myself, but I do NOT respect all of their views, and I do not believe any view held by a ‘public figure’ (including me) should be protected from critique, criticism or even ridicule if the latter promotes detailed consideration and skepticism of the topic in question. I promise it is NEVER personal.

Please read the post in the spirit it is intended – as a cheeky poke in the ribs to those who actively put themselves in a position of influence, forfeiting any entitlement to protection from criticism. If you think this is ‘anti-anaesthetist’, read the paragraph beginning ‘An unsurprising but at the same time very reassuring observation…‘. I am continually in awe of the anaesthetists I work with who are so much smarter than me and who have taught me so much.

Finally to the individual practitioner torn over this issue. Please follow your institutional policy, and always do what you think is best for the patient in the moment. If the guideline doesn’t fit with what you think is right, work on changing the guideline.

Keep lysing the dogma


This is the comment I left on Cliff’s post:

Fantastic post Cliff

It is clear that manualRETARD is:

“ example of an intervention introduced with little evidence, handed down from teacher to student over the years as a pseudoaxiom. Pseudoaxioms need to be criticised, studied and discarded where appropriate.”

To me it is clear that:
(1) there is little to no evidence for it’s benefit
(2) there is low level evidence that it can cause harm
(3) the weight of evidence is for harm over benefit, especially in the critically ill due to distraction, unnecessary added complexity, and delay to first pass intubation.

It is obscene to think that there are health professionals who would claim that those who do not perform this worthless procedure are negligent. We need to eradicate this procedure being deemed mandatory from any guideline or recommendations (such as NAP4) on RSI. We also need to name and shame the logical fallacies used by proponents of this technique to justify its use.

I have amended the LITFL CCC entry on cricoid pressure appropriately:

Cheers and thanks

Look out for John Hinds’ destruction of cricoid pressure when released on the smaccGOLD podcast.

Finally, I agree with Cliff – it is up to the individual to make up his or her own mind, and importantly to follow local policy. But I am adamant that no claims can be made about cricoid pressure, or not performing cricoid pressure, being a standard of care. Any guidelines or protocols that suggest otherwise should be challenged. No one should be able to call a doctor negligent for performing or not performing cricoid pressure given the (lack of) evidence.

Down with dogma!

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Seizures, Sedation and Saliva

aka Toxicology Conundrum 052

A 21-year-old male with a background of schizophrenia and previous intentional overdose, weighing 70kg, was brought to the ED via ambulance after having a witnessed seizure at home. Prior to this, he was witnessed to be drowsy and salivating excessively by his family but was able to admit to taking 2000mg (20 x 100mg) of his own clozapine an hour prior to his witnessed seizure. His family reported that he did not have access to any other medications as he was ‘closely supervised’ at home. After initially found to be drowsy, he subsequently had a generalised tonic-clonic seizure lasting five minutes. On arrival, paramedics found him to be unresponsive but protecting his airway and sitting up intermittently but non-purposefully. He was tachycardic (130 beats/min) and hypotensive (80mmHg systolic), the latter of which responded to an intravenous fluid bolus of 0.9% saline (1000mL). He had a subsequent seizure en route but this resolved spontaneously. ECG demonstrated a sinus tachycardia with a manually measured QRS and QT durations of 80 ms and 320 ms respectively.


Q1. What type of drug is clozapine and what receptors does it act on?

Clozapine is an atypical anti-psychotic agent.

Clozapine is commonly prescribed for treatment-refractory schizophrenia. Given this indication, it is not often used and is usually administered under supervision so overdose with this drug is rare.

Clozapine is a tricyclic dibenzodiazepine atypical antipsychotic that acts at multiple receptors with antagonism of D1 and D2 as well as serotonin (5HT2), muscarinic (M1), histaminic (H1), peripheral alpha-adrenoreceptors and gamma-aminobutryic acid (GABA) receptors.

Like other anti-psychotics, the observed action of clozapine at multiple receptors also accounts for the clinical presentation seen in overdose.

Clozapine is available as 25, 50, 100 and 200mg tablets in either packets of 28 or 100 tablets.


IMage by Fuse809 - click image for source

IMage by Fuse809 – click image for source

Q2. Describe the toxicokinetics of clozapine

Toxicokinetics of clozapine:

  • Absorption: Rapidly absorbed following oral administration. Intoxication occurs within 4 hours of ingestion.
  • Distribution: Moderate volume of distribution (0.5-3L/kg). Highly protein-bound.
  • Metabolism: Metabolised in the lliver by oxidation (cytochrome P450 1A2, 2D6) to its metabolites with significant first pass effect.
  • Excretion: Mainly in the urine and faces as metabolites

Q3. What are the clinical features of clozapine overdose?

Clozapine, like many other anti-psychotics, has multiple potential toxicological properties owing to its actions at multiple receptors. Toxicity usually resolves within 24 hours.

Effects include:

CNS effects

  • Lethargy, confusion, sedation, coma (the latter requiring intubation is rare)
  • Seizures occur in ~5-10% of patients
  • Extra-pyramidal side-effects are more common in children

Cardiovascular effects

  • Sinus tachycardia, hypotension (due to alpha2-adrenoreceptor blockade)
  • QT prolongation is rare

Anti-muscarinic effects

  • Agitation, restlessness, delirium, mydriasis (big pupils) but often have miosis (small pupils due to alpha-bloackade), dry, warm skin, tachycardia, ileus, urinary retention (don’t forget an IDC with an agitated patient post overdose with an anticholinergic!)

Hypersalivation is a characteristic and seemingly paradoxical effect of clozapine toxicity. The mechanism is poorly understood and likely multifactorial

Q4. The patient’s family are adamant he could have not taken anything else. The medical student shadowing you asks if that means you don’t need to order a paracetamol level?  What is your response?

There are two tests that are incredibly useful in Toxicology (not only my opinion but that of many smarter people too):

  1. ECG
  2. paracetamol level

Whilst some patients present to the Emergency Department whilst conscious and clearly volunteer how much and what they have taken, many do not (as in this case). Paracetamol poisoning is often clinically silent initially and, if not treated, can lead to serious morbidity or even mortality. However, it is easily detected via a simple blood test, and has a safe and effective antidote that is widely available. Similarly, the ECG is a cheap, useful non-invasive test useful for identifying otherwise occult cardiotoxicity.

On arrival to the ED, the patient is taken into a resuscitation cubicle. The patient has another episode of hypotension (80/40mmHg) and is given another litre of 0.9% saline. The assist button is pressed thirty minutes later. You race in to find the patient seizing. The seizure is terminated with some midazolam but you notice that the patient is still hypotensive with a blood pressure of 75/40mmHg. What are you going to do?

Q4. What is the risk assessment for this patient?

Whilst clozapine overdose is usually considered to be benign and any accompanying hypotension can be resolved with intravenous fluids alone, this patient has significant hypotension despite adequate filling.

As clozapine is known to act as a peripheral alpha-adrenoreceptor antagonist, commencing an inotrope is suggested. Noradrenaline, an alpha-agonist, is the preferred choice. Alternatives could include other alpha-adrenergic agents such as metaraminol or phenylephrine. In refractory cases, vasopressin has been used with good effect in a previous published case report.

Q5. Whilst the noradrenaline is being hung, your super keen medical student suggests getting an ‘Echo’ because ‘this might be clozapine myocarditis….I read about this once!’. Is it?

Both agranulocytosis and myocarditis are known complications of chronic therapeutic clozapine use, however they are not features of acute overdose.

An echocardiogram may be appropriate if there were concerns about response to inotropes in the setting of hypotension.

Q6. In general, what is the management of clozapine overdose?

Using the Resus-RSI-DEAD approach as all good toxicologists do…


  • Attention to airway, breathing and circulation always takes precedent. Basic resuscitative measures ensure a good outcome in the vast majority of patients.
  • Treat seizures with benzodiazepines
  • If intravenous fluid does not improve hypotension, consider the use of an inotrope (noradrenaline is generally preferred)

Supportive care and monitoring

  • Supportive care will suffice for most cases so ensure it is done well!
  • Secure appropriate IV access
  • Ensure adequate hydration with IV fluids
  • Remember FASTHUGS IN BED Please especially pressure care, bladder care and DVT prophylaxis
  • Cardiac monitoring should continue until toxicity is reversed if ECG changes are present


  • ECG, paracetamol and blood glucose levels should be performed as recommended for all intentional overdoses
  • Consider possible co-ingestants


  • Clozapine is rapidly absorbed and usually benign. Activated charcoal is therefore not indicated on these grounds.


  • None available

Enhanced elimination

  • Not useful


  • Haemodynamically stable patients that are symptomatic (i.e. drowsy) can be managed as inpatients in an appropriate ward (e.g. observation unit) until medically cleared (awake, able to walk, has passed urine independently and has tolerated oral intake)
  • Patients requiring inotropic support require HDU/ICU but this is likely to be for a short period of time (~24 hours)
  • Psychiatric review and possible inpatient management


Journal articles and Textbooks

  • Burns MJ. The pharmacology and toxicology of atypical antipsychotic agents. J Toxicol Clin Toxicol. 2001;39(1):1-14. Review. PubMed PMID: 11327216.
  • Murray L, Daly FFS, Little M and Cadogan M. Toxicology Handbook (2nd Edition), Elsevier Australia 2011 <Google books preview>
  • Rotella JA, Zarei F, Frauman AG, Greene SL. Refractory hypotension treated with vasopressin after intentional clozapine overdose. European Journal of Emergency Medicine March 17th 2014 (published ahead of print)

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The LITFL Review 133

The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle to find the most fantastic EM/CC FOAM (Free Open Access Meducation) around.

Welcome to the 133rd edition, brought to you by:

The Most Fair Dinkum Ripper Beaut of the Week

Tim Leewenburg (KI Docs) doesn’t hold back on his views on homeopathy. I won’t spoil the punchline but it’s fair to say he’s not a fan. [TRD]
That’s how I (was) roll(ed) is a personal account of being a trauma patient with a pelvic and being log rolled. Not nice. [CN]

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

The Best of #FOAMPed Paediatrics

#FOAMTox Toxicology

#MedEd Education and Social Media (including #smaccGOLD)

News from the Fast Lane

  •  Another bumper issue of EMA April 2014 is out for your reading pleasure. [KG]

LITFL Review EM/CC Educational Social Media Round Up

Emergency Medicine and Critical Care Blogroll — Emergency Medicine and Critical Care Podcasts — — Academic Life in Emergency Medicine — A Life at Risk — Bedside Ultrasound - Boring EM — Broome Docs — CCM-L — Critical Care Perspectives in EM — Dave on Airways — Dont Forget the Bubbles — Dr Smith’s ECG Blog — ECG Academy — ECG Guru — ECG of the Week — ED ECMO — ED Exam — ED-Nurse — EDTCC — EKG Videos — EM Basic — EMCrit — EM CapeTown — EMCases — EMDocs — EMDutch — EMin5  Emergency Medical Abstracts — EM Journey — EmergencyLondon — Emergency Medicine Cases — Emergency Medicine Education — Emergency Medicine News — Emergency Medicine Ireland — Emergency Medicine Tutorials — Emergency Medicine Updates — EM on the Edge — Emergucate  — EM Journey —  EM IM Doc — EM Literature of Note — — EMpills — Emergency Physicians Monthly — EM Lyceum —EM nerd— EMProcedures — EMRAP — EMRAP: Educators’ Edition — EMRAP.TV — EM REMS — ER CAST — EXPENSIVECARE — Free Emergency Medicine Talks — Gmergency! — Got Resuscitation— Greater Sydney Area HEMS — — Impactednurse —Injectable Orange  — Intensive Care Network — iTeachEM — IVLine — KeeWeeDoc — KI Docs— ER Mentor — MDaware — MD+ CALC — MedEDMasters — Medical Education Videos — Medical Evidence Blog — MedEmIt — Micrognome — Movin’ Meat — Paediatric Emergency Medicine — Pediatric EM Morsels — PEM ED — PEMLit — PEM Cincinnati — PHARM — Practical Evidence — Priceless Electrical Activity — Procedurettes — — Radiology Signs — Radiopaedia — REBEL EM - — Resus.ME — Resus Review — RESUS Room — Resus Room Management — Richard Winters’ Physician Leadership — ruralflyingdoc — SCANCRIT — SCCM Blogs — SEMEP — SinaiEM — SinaiEM Ultrasound — SMART EM — SOCMOB — SonoSpot — StEmylns — Takeokun — thebluntdissection — The Central Line — The Ember Project —The Emergency Medicine Resident Blog — The Flipped EM Classroom — thenursepath — The NNT — The Poison Review — The Sharp End — The Short Coat — The Skeptics Guide to Emergency Medicine — The Sono Cave - The Trauma Professional’s Blog —  — ToxTalk — tjdogma — Twin Cities Toxicology — Ultrarounds — UMEM Educational Pearls —Ultrasound Podcast

LITFL Review

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Caustic Ingestion Acid

Toilet bowl cleaners in the United States tend to be acidic in nature so I chose the ‘Ty-D-Bol Man’ as our victim for this Caustic Ingestion flashcard.

The Ty-D-Bol Man was a little guy in a motor boat that would drive around in your toilet and keep it clean. As a kid I always hoped to see him when I lifted my toilet lid, but never did. As it turns out, Tidy Bowl man was also an inspiration for Dave Chappelle who immortalised East Coas Rapper Redman in the NSFW “Redman’s Potty Fresh” skit.


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TechTool Techno Review SensiMat

This week I’m taking a break from reviewing apps that educate us as doctors, and instead have decided to look at how our smartphones, and technology in general, can be used to help our patients.

A sensor for wheelchair users caught my eye this week.

SensiMat, designed by a team at the University of Toronto, aims to use tech to reduce the frequency of pressure ulcers in wheelchair users. It’s specifically aimed at wheelchairs users with impaired sensation, who might not be aware of pressure sores developing or who may not notice when they have been positioned too long in one place.

The sensor part is a small device that slides under any wheelchair cushion and it supplies data to smartphones.

This can be used in 3 ways:

  1. It can be set to alert the user when they haven’t changed position for a while.
  2. It displays patterns of pressure distribution so can help give users an idea of where they tend to put most pressure on their bodies, thus increasing awareness of positioning
  3. It produces some lovely diagrammatic data showing sitting positions and weight distribution that could be accessed by physios/patients/rehab teams to better manage and prevent ulcers.

It is not going to be cheap, however, at an expected cost of $599 as well as an ongoing monthly fee for access to the web data it collects.

The developers are crowd-sourcing their funding for this, a tactic that has become increasingly popular with medical projects. They are funding this via Indiegogo, but if you’re interested in seeing more crowd-sourced medical projects then MedStartr may be a good place to begin browsing.

And it looks like they have almost achieved their goal – at over $13k at the time of writing. So it seems as though other people out there think this could be a great idea too.

They haven’t produced proof of its efficacy as yet, but they hint at having the data and being in the process of analysing it. And they have a smart team of science geeks behind it so I don’t doubt it will be long before we see some hard evidence.


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EMA April 2014

Issue 2 (Vol. 26) of Emergency Medicine Australasia for 2014 was published online on 8 April. Editorial overview by Andrew Gosbell & Geoff Hughes

New look for EMA   (#FOAMed)

This issue of EMA introduces a brand new cover format and page layout for the journal. IN this editorial, new Editor-in-Chief, Prof Geoff Hughes outlines his vision for encouraging good quality scientific contributions, as well as expanding the magazine content, in EMA

Dispatches from the Free Open Access Meducation frontier  (#FOAMed)

In the new Social Media section of EMA, Spiegel (@EMNerd_), Johnston (@Eleytherius), Ercleve (@Ercleve) and Nickson (@precordialthump), transport us through a window-in-time to a future where FOAM is the norm. We meet Sienna Adjoin, Professor of Astro-Archaeology, in a rollicking tale, as she seeks out FOAM artefacts to look back in time to try to understand how FOAM helped to change the way medical education was delivered and encouraged debate and challenging of traditional approaches emergency medicine practice, such as the diagnosis and management of ACS

What makes a good healthcare quality indicator?  (Abstract)

Inappropriate indicators can result in unintended consequences in terms of implementation of healthcare reforms, resource allocation and quality of service provided to patients. Jones et al present a systematic review and validation of the attributes that should be considered in selecting healthcare quality indicators. This led them to develop a quality indicator critical appraisal (QICA) tool to enable all important attributes to be considered when assessing health service performance measures in order to improve decision-making on indicator selection. This is particularly relevant for emergency medicine to assist with selection of appropriate indicators for healthcare improvement initiatives that are being driven by the current time-based access targets

Elevated troponin: Diagnostic gold or fool’s gold? (#FOAMed)

Troponin is a widely used, highly sensitive biomarker for the diagnosis of acute myocardial infarction (AMI) and for risk stratification of patients presenting to ED with acute coronary syndrome (ACS). However, this review from Rahman and Broadley considers the broad range of non-ischemic causes and mechanisms for troponin elevation. It is a salient reminder that elevated troponin in the absence of AMI is common and careful attention is needed with regards to the reasons for testing troponin levels and the subsequent interpretation of abnormal findings

Acute coronary syndrome diagnosis at hospital discharge  (Abstract)

Most research into acute coronary syndrome (ACS) in ED has focused on preventing errors or missed diagnosis. This retrospective case series from Handrinos and colleagues, considers the hospital discharge diagnosis for patients admitted from the ED with a provisional diagnosis. Approximately one-third of these patients did not have an ACS on discharge. Further prospective research is required to analyse the effects of non-concordant diagnosis of ACS, including in-patient investigations used and decision steps along with patient outcomes, in order to determine if steps can be taken in ED to improve concordance.

Parental satisfaction with paediatric care (Abstract)

An understanding of parental/guardian’s perceptions of their child’s journey through an ED has the potential to increase treatment compliance, minimise complications and reduce subsequent visits to other health practitioners. Fitzpatrick and colleagues surveyed parent perceptions of waiting time, environment/facilities, professionalism and communication skills of staff and overall satisfaction of care at a metropolitan ED. Time waiting for, or receiving, care did not primarily influence parental perceptions of, or satisfaction with, their child’s care; however the need for ED professionals to ensure adequate communication and respect for patients was reinforced by the survey responses

Further reading:

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