The LITFL Review 134

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 134th edition, brought to you by:

The Most Fair Dinkum Ripper Beaut of the Week

Learn from EM Nerd this week about the foibles of thrombolytics for anything but STEMI. A follow-up on his previous post, The Adventure of the Greek Interpreter, this week he revisits the lytic for submassive PE debate to discuss the new TOPCOAT trial relative to MOPETT and PEITHO. [MG, BT, CN]

Just in time for this week’s edition is Reuben Strayer’s overview of intubation options in the ED, with emphasis on ketamine-supported intubation among other options like traditional RSI, DSI, and awake intubation. When RSI isn’t the Right SI is a superb synthesis. [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

LITFL Review EM/CC Educational Social Media Round Up

Emergency Medicine and Critical Care Blogroll — Emergency Medicine and Critical Care Podcasts — 123Sonography.com — 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 — empem.org — 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 — HQmeded.com — 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 — PulmCCM.org — Radiology Signs — Radiopaedia — REBEL EM - Resus.com.au — 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 — underneathEM.com  — ToxTalk — tjdogma — Twin Cities Toxicology — Ultrarounds — UMEM Educational Pearls —Ultrasound Podcast

LITFL Review

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Should I Stay or Should I Go?

Should I Stay or Should I Go?- an Irish Doctor’s conundrum: Dr John Iliff

“Top’o the morning to ya”- a phrase which is perhaps echoing more frequently in the Emergency Departments of many hospitals across Australia and New Zealand; said in that distinctive and charming brogue is which is unmistakably that of yet another Paddy Irishman fresh off the boat, stethoscope at the ready.

It can be hard not to miss these twenty and thirty something’s who arrive through the Triage door, at what seems a rate similar to emigrants to the United States during Irish Potato Famine in the 1800’s, and like those famine survivors, they are seeking a better life

So why Australia do you ask? It is not simply sun, sand and the Sydney Harbour Bridge. Australia is quite the package for budding junior doctors. To work in Australia affords many opportunities which are simply too good to say no to, especially for a young aspiring Emergency Physician.

As a junior, a large focus has to be on what you gain in experience in each place you work, what you take forward and learn from each posting throughout your medical career. What has impressed this newly immigrated Irishman is the focus on teaching by consultants. Not only with scheduled teaching sessions through the week, but also bed-side learning opportunities, be it explaining a clinical sign/symptom worth taking note of, or the monitoring of a nervous RMO putting in their first central line. Each day at work is an opportunity for learning in a safely monitored environment, with consultants who have the time to teach as they go. With their healthy mix of clinical and non-clinical shifts, they provide an excellent service to the people of Australia, monitoring their junior staff whilst ensuring the i’s are dotted and t’s are crossed in the office.

Let us then look at the typical working week, a week which has the ideal mix of work, rest and play. At a typical 40 hours work per week, the newly arrived Irish find it a stark difference to what they were previously accustomed. Doctors are given the opportunity to work hard during their shifts AND have the down time to recover and relax. It is indisputable that the well rested doctor is not only a happier doctor but also a safer doctor.

What perhaps makes this a more poignant factor for the Irish doctors is the hours many worked as interns or residents back in the Emerald Isle, where this element of practising safely is tested to breaking point at times. On a standard day, the typical surgical intern starts at 7.30am and works through until 8.00pm, this of course before doing call at night. 24-hour shifts are the norm with the hope of perhaps a 3 hour break for a snooze, however many have been asked to go beyond the call of duty and work more. Indeed this Irish-trained Registrar, whilst as an intern, one night worked 30 hours non-stop (including treating an unstable upper GI bleed and an 87 year old lady who was saturating at 83%) with no sleep, whilst the surg reg was in theatre. It has to be no surprise to the reader that I did not get home scot free after a reluctant snoozing spell on the drive home. Thankfully the only cost of this incident was a Renault Clio, a hiked insurance cost, a matter of pride and not waking up back in ICU being tended to by my boss. However to add insult to a slightly stiff neck for a week, the overtime payment due was simply laughed at by the a paper pusher in the Finance Department who was more interested in what buns Norma in Human Resources had baked than my problems.

I wish to say that my own experiences were unique, there are, however, worse ones. I will however not delve into those stories, but when this becomes the norm, why would Irish doctors stay? People are being driven away by the strain of the working life. The allure of leisure and labour co-existing harmoniously is a sweet one, and with the Australian College of Emergency Medicine Programme, it does appear that the Emergency Trainee has a very structured but also manageable opportunity to further their training.

Now I don’t wish to completely disregard the Irish Health System. Although it does face problems, there are rays of sunshine for Emergency Trainees. 2011 saw the introduction of the membership programme affiliated to the College of Emergency Medicine. A 3 year programme encompassing Emergency, Orthopaedic, Internal, Paediatric Medicine and Anaesthesiology. A well rounded programme encompassing core elements required for competent Emergency Physician. After completion of this programme, one then applies to the Specialist Registrar Scheme of 5 years training. Now that this is finally set in stone, junior doctors now have a pathway to become a fully trained Emergency Doctor without having to leave the country. This will hopefully increase the number of much needed Emergency Physicians. Now bear in mind that St. James’s Hospital in Dublin has only 5 full-time Emergency Consultants.

Emergency Physicians in Ireland are keen to teach, as much as the typical Australian consultant and to bring on the next generation of specialist trainees. However when busy departments are staffed by very few consultants, a huge proportion of time is spent in the office doing the mandatory paperwork and not on the shop-floor where most would prefer to be. The simple answer is to hire more consultants and thankfully the programme is giving this opportunity to train new residents and registrars coming through. But is the Irish Healthcare system going to hire more consultants? Will funding for new positions become available? If positions do pop up, a new question fresh on lips at present is will people take them? Only recently have the new public consultant contracts been revealed with a dramatic slash in their annual wage. Why stay when more can be earned elsewhere? Not that money is the be all and end all, it does however factor when mortgages are to be paid and mouths to be fed and educated.

The future for the Irish Emergency trainee is very uncertain. Steps have been taken in the right direction, the question now is, will the Irish Healthcare System decision makers realise the importance of a well consultant staffed Emergency Department? With the drive to convert to an Australasian-like Emergency model, consultants are trying to reel back the junior doctors they are losing to foreign shores. With resident numbers tightening, Ireland is not only looking at a problem in regards to consultants, but a very real problem of limited junior doctors to staff busy departments. More and more find themselves getting on a flight bound for the southern hemisphere with the promise of money for the hours they work, safe working environment and the bonus of sunshine most of the year (this is certainly something that can not be guaranteed in Ireland). In the past Irish doctors came for a year or two before returning to Ireland to ride the back of the Celtic Tiger when financially Ireland was much more affluent. Now the reality is these travellers are now packing their bags for good.

‘The best preparation for tomorrow is to do today’s work superbly well’- Sir William Osler

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The Confrontation

Another classic Emergency Musical Interlude from the Legend of Medical Musical Parody - ZDoggMD

Relive “The Confrontation“,  a “Les Misérables” parody: where an ED doc and a Hospitalist lock horns in counterpoint juxtaposition…

http://www.youtube.com/watch?v=G78CDQFcw5o

An epic, age-old saga of good versus just OK, starring:

  • ZDoggMD as The Hospitalist
  • Dr. Harry as Dr. Javert, ED physician (stereotypically wearing appropriate hat…)
  • And Dr. Diego as The Psych Intern on Call

Original music from Les Misérables, The Confrontation

 

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Toxicology Antidote Hyperbaric Oxygen

Jawad_KassemIn this flashcard I drew my friend and colleague Dr Jawad Kassem, a Board Certified Hyperbaric Medicine doctor.

Hyperbaric Oxygen has a role for the treatment of carbon monoxide (CO) Poisoning and may have some potential benefit in the treatment of cyanide and hydrogen sulfide poisoning.

As a child I learned that hyperbaric oxygen is the treatment of “the bends” and “the chokes” as taught to me on ‘Raise the Flagg’ – Season 2 Episode 20 of the GI Joe Cartoon Series. In this episode members of the GI Joe team and the Dreadnaughts attempted to salvage an anti-matter pod from a sunken USS Flagg. However, their ascent was too quick and everyone experienced decompression sickness and required treatment in hyperbaric oxygen chambers. [Ascent begins around 17:30 and they are at sea level at 18:30 and show signs of the bends at 19:05 treatment initiated at 20:30]

Stuck in Phone Booth HyperbaricsI also turned to Bill and Ted’s Excellent Adventure for inspiration on how I wanted myself and Travis to appear while trapped in the hyperbaric chamber…

Incidentally, I also learned in “The Germ” Season 1 of GI Joe – that apple seeds contain a small amount of poison (cyanide in the form of amygdalin). Cobra invented a super bacteria that morphed into a giant blob that GI Joe killed by diverting it to an apple orchard and bombing it with apples…

Print

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Cricoid pressure… time to change?

Revised 22 April 2014

Cliff Reid recently wrote a post on cricoid pressure in response to a long online discussion (since deleted) featuring the usual logical fallacies, circular arguments and dogmatic claims of negligence against enlightened practitioners who have discarded this unproven technique.

He originally invited the ‘tongue-in-cheek’ renaming of the procedure to highlight its drawbacks.  However, due to the unnecessary offence caused, Cliff has wisely decided to withdraw the parody with its misfiring acronym. His perspective on why he thinks cricoid pressure lacks value, and on the storm that raged following his original post, is worth reading.

I think these comments left on the original post remain valid. The first by Cliff himself, explaining his original post and where he was coming from:

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. [Editor note: the original parody of cricoid pressure and its acronym have since been removed]

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

Cliff

… and this was my reaction to Cliff’s post:

It is clear that (this) is:

“..an 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 unproven 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:
http://lifeinthefastlane.com/education/ccc/cricoid-pressure/

Cheers and thanks
Chris

Look out for John Hinds’ destruction of cricoid pressure in the ‘Cricoid… to press, or not to press?’ debate from smaccGOLD  (likely packed with logical fallacies on both sides for edutainment purposes) when released on the SMACC podcast…

Ultimately, 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 allowed to call a doctor negligent for performing or not performing cricoid pressure given the (lack of) evidence. Logical fallacies and wrong-headed thinking should always be challenged when deployed in a sincere debate  — indeed, I expect others to do the same when I am the perpetrator.

Like Cliff, I apologise for any unnecessary offence caused by promoting the original parody-gone-wrong. We are humans and we make mistakes. In future we will try to remain hard on the issues, but softer on the people that matter as we try to defend what we think is right.

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.

Questions

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…

Resuscitation

  • 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

Investigations

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

Decontamination

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

Antidotes

  • None available

Enhanced elimination

  • Not useful

Disposition

  • 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

References

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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