Saturday with SMACC: Scott Weingart on Cutting Edge Intra-Arrest Care

The main theme of this extremely thought-provoking talk by Scott Weingart (@emcrit) is that CPR should not be limited to the cookbook algorithms taught in the American Heart Association’s ACLS course. Scott argues that ACLS teaches what can be done easily, not necessarily what’s needed to achieve an optimal outcome. He covers everything from the laryngeal mask airway to intra-arrest extracorporeal membrane oxygenation (ECMO.) You may not agree with all of Scott’s points, but this is a must-listen lecture.

This talk was given at the 2014 SMACC Gold conference in Australia last March. I was there, and it was by far the most exciting and inspirational medical conference I’ve ever attended. This was not only because of the core content, but also because the meeting was a gathering of 1300 people passionately interested in FOAMed  (Free Open Access Medical education) and the use of social media as a means both of disseminating clinical information and opinion and also creating bonds and relationships across continents.

The 2015 SMACC conference (SMACC US) will take place June 23-26 in my kind of town (Chicago) and is shaping up to be the biggest and best ever. The line-up includes:

  • Critical Care Ultrasound: Vicki Noble, Mike Stone, Matt Dawson and Mike Mallin from the Ultrasound Podcast, John Bailitz, Laleh Gharabaghian, James Rippey and Adrian Goudie from Ultrasound Village, and more!
  • Critical Care and Resuscitation: Scott Weingart, Cliff Reid, Chris Nickson, Paul Marik, Rich Levitan, John Hinds, Minh Le Cong, Haney Mallemat, Roger Harris, Oli Flower, and much more!
  • Emergency Medicine: Joe Lex, Rob Rogers, David Newman, Paul Auerbach, Jeremy Faust, Rob Orman, Natalie May and Simon Carley and Iain Beardsell and Rick Body (the entire St. Emlyn’s blog team!), Steve Smith, Brent Thoma, Ashley Shreves . . . and that’s just for starters.
  • Medical Toxicology: David Juurlink, Bryan Hayes, Steve Aks, Reuben Strayer, and Leon Gussow.

Never before in the history of the universe have all these people been in the same place at the same time. Registration is open, and some of the workshops are filling up fast. (The Toxicology session is nearing capacity.) For more information, go to the SMACC Chicago website.

Sorin Memo3d ReChord Mitral Valve Annuloplasty Ring FDA Cleared

memo 3d rechord Sorin Memo3d ReChord Mitral Valve Annuloplasty Ring FDA ClearedSorin Group received FDA clearance for its Memo 3D ReChord annuloplasty ring designed for mitral valve repair procedures. The semi-rigid device is an upgrade to the existing Memo 3D ring, now featuring a new chordal guidance system that helps with implantation, particularly when performing artificial Gore-Tex chordae replacement.

The ring is covered with Sorin’s unique Carbofilm coating that, according to the company, improves the hemo-compatibility of the ring and its flexible shape, as the “3D” in the name implies, allows it to bend along with the heart’s motion while staying put within the annulus.

Some more details about the Memo 3D ReChord according to its product page:

The exclusive alloy core cell design is a laser-cut one-piece structure that allows truly physiological annular dynamics. The precision laser-cutting technology is also used to obtain Sorin’s innovative Perceval sutureless aortic prosthesis.

Ease of implant with superior visualization, placement and attachment while ensuring a perfect annular fit. The oval silicone sheath provides easy suturability with conformable needle penetration.

Truly physiological three-dimensional motion of the mitral annulus with a natural anterior/posterior to lateral/lateral relationship to maximize blood flow, even after more than five years from implantation.

The bio/hemocompatible properties of the unique CarbofilmTM coating allows complete endothelialization, prevents inflammatory reaction and scar tissue formation. Designed to maintain physiological dynamics in the long term.

Product page: Memo 3D ReChord…

Press release: FDA CLEARANCE AND FIRST IMPLANT OF MEMO 3D RECHORD ANNULOPLASTY RING…

Senior Report 8.8

seniorreport

Case Presentation by Sarah Michael, DO

 

Chief Complaint: “My chest has been bothering me.”

History of Present Illness:

A 67-year-old female patient presents to the ED complaining of chest discomfort slowly worsening over the past 10-12 hours. It has been relatively mild but constant since the time of onset. The patient reports a left substernal nonradiating pressure sensation. She has never experienced anything similar in the past and has not taken anything for pain. She is not short of breath, diaphoretic, dizzy, or lightheaded. When questioned further, the patient reports she thinks her symptoms are “due to stress” as she has been hosting several extended family members at her home over the past few days. She drove herself to the ED.

 

Past Medical History: hypothyroidism, hyperlipidemia

Past Surgical History: none

Medications: simvastatin, levothyroxine

Allergies: NKDA

Social: Lives alone. Drinks alcohol infrequently (none recently). No tobacco or drug use.

Family History: Denies significant family history. No family history of early myocardial infarction.

Physical Exam:

BP 138/86

HR 82

RR18

T 37.5

Oxygen saturation 100% RA

General: Alert, oriented, well-appearing Caucasian female, sitting in a chair without distress. She speaks in complete sentences.
Cardiovascular: Regular rate & rhythm. No murmurs. No chest wall tenderness or exacerbation of pain with palpation.
Respiratory: Clear to auscultation bilaterally
GI: Abdomen soft, non-tender, non-distended
Neuro: Alert, oriented, appropriate. Strength 5/5 in all extremities.
Psychiatric: No acute psychiatric decompensation is noted. She is appropriate, lucid and able to formulate and articulate complex thought processes without delusions. No evident anxiety.

A cardiac workup was initiated and the following EKG was obtained.

 

Web Case EKG

1. Where does the pathology demonstrated in the EKG localize?

A. right coronary artery
B. left circumflex artery
C. left anterior descending artery
D. pericardium

The following bedside echocardiogram was obtained in the ED.

 

echo

2. On the basis of the echocardiogram, where does the patient’s pathology localize?

A. right ventricle
B. left ventricle
C. mitral valve
D. pericardium

3. What is the underlying pathologic mechanism resulting in this clinical picture?

A. catecholamine surge
B. plaque rupture
C. inflammation with PMN infiltration
D. infection of a pletelet-fibrin nidus with circulating bacteria


Filed under: Senior Report, Uncategorized

Pittfalls in Dvt Management

You’re on your last patient of the day, starting to thinking about which type of sushi you’re going to order later, when the ultrasound comes back. Positive study, you were sure of it, after all, the patient had a hx of cancer and 3 days of progressive leg swelling and pain. He looked like this:

Red Leg Small

You start them on lovenox, admit and run off for sushi.

The next day, you get a call from the chairman, he says “remember that patient you admitted….” Oh Oh…

In this case, the patient has something called Phlegmasia Cerulea Dolens. Along with Phlegmasia Alba Dolens, this is caused by clots in the proximal deep veins. It presents with the triad of edema, pain out of proportion and Cyanosis (for Cerulea) or paleness (for Alba).

Cerulea is more severe than Alba. In addition to proximal venous clots, it also involves the collateral veins and can lead to venous gangrene.

Management: In either case, you should call an urgent vascular consult in addition to the standard DVT treatments. Patients with Cerulea will generally go to the OR for thrombectomy or intravenous thrombolytics while patients with Alba usually undergo conservative treatment with close observation, for progression to Cerulea.

Sub-Pearl: Also, Remember the superficial femoral vein is a deep vein. So a clot there IS a DVT.

Further Reading/Listening: 

https://www.emrap.org/episode/2014/may/hipporeviews

Mumoli, Nicola, et al. “Phlegmasia cerulea dolens.” Circulation 125.8 (2012): 1056-1057.

Beck, Josh, and Timothy B. Jang. “Short answer question case series: evaluation of the swollen, blue extremity.” Emergency Medicine Journal 29.7 (2012): 604-605.

 

Lactate Level in Kids

Lactate

Patients’ families often present to us requesting “bloodwork” to make sure that the child is not “sick” or to tell them “what’s wrong.”  While we all know that no lab can be used to proclaim complete certainty of a patient’s health or to make a definitive diagnosis on its own, often we perpetuate the myth by ordering labs that do not necessarily direct our actions.  By now, most of you know of my disdain for the ubiquitous WBC count (The Last Bastion of the Intellectually Destitute – Amal Mattu), but there is another often ordered test that may also fall into that category — the Lactate Level.

The Lactate Level has grown in popularity over the past decade, particularly in the Adult EDs.  Certainly, there is literature that supports its utility with respect to evaluation of SEPSIS and trauma, but this often becomes extrapolated to all patients who “may be sick” as a means to find the covertly ill.  This  approach (often in a “shotgun” fashion) has steadily crept into the Pediatric EDs as well.  What is the known utility of Lactate Level in children? [Thank you @ErnestoAlarco12 for inspiring the question].

 

Lactate Level – Basic BioChem

  • Just in case you don’t recall BioChem class as well as you used to…
  • During Glycolysis glucose is converted into Pyruvate.
    • Through AEROBIC metabolism, pyruvate is used to generate 2 Acetyl-CoA and eventually many ATPs, H2O, and CO2 (remember the Krebs cycle?).
    • When there is not enough Oxygen around (ANAEROBIC metabolism), then pyruvate is converted into Lactate.
    • Lactate can be converted back to pyruvate once the oxygen deficit has been corrected.
    • Well that was a fun walk down memory lane.
  • With this in mind, elevated lactate levels would potentially reflect tissue oxygen deficit.
  • Under normal conditions, lactate is rapidly cleared by the liver, with some assistance from the kidneys. (Anderson, 2013)
  • There is no standardized levels:
    • Most studies use cutoff values of 2.0 to 2.5 mmol/L.
    • Many define “High” as a Lactate level > 4.0 mmol/L. (Anderson, 2013)

 

Lactate Level – Some Causes of Lactate Elevation

Most often elevated Lactate Levels conjure thoughts of tissue hypoperfusion with diminished access to oxygen (SHOCK), but there are others causes to consider. (Anderson, 2013)

  • Global ischemia (SHOCK)
  • Regional ischemia (ex, mesenteric ischemia, burns, trauma, compartment syndrome)
  • High Metabolic States (ex, seizures, heavy exercise, increased work of breathing)
  • Drugs (ex, Metformin, epinephrine, propofol, acetominophen, beta-2-agonists)
  • Toxins (ex, Cocaine, Cyanide, Carbon monoxide, alcohols)
  • Malignancies
  • Liver Disease (can’t clear the lactate)
  • Diabetic Ketoacidosis
  • Thiamine Deficiency (w/o thiamine, anaerobic metabolism predominates)
  • Inborn Errors of Metabolism and Mitochondrial Diseases

 

Lactate Level – Elevation in Kids

  • In the PICU:
    • Studies of SEPSIS have shown increased mortality in the setting of elevated lactate levels. (Jat, 2011)
    • Monitoring serial lactate levels in patients following surgery for congenital heart disease can help discriminate patients at high risk. (Schumacher, 2014; Agrawal, 2012)
    • Poor lactate clearance (< 30% at 6 hours) has been associated with increased risk of mortality. (Munde, 2012)
    • High lactate level upon admission to the PICU is associated with in-hospital mortality. (Bai, 2014)
  • In the ED:
    • High lactate levels can be useful to help “rule-in” severe bacterial infection in children in the ED. (Vorwek, 2011)
    • High lactate levels identify a population at higher risk for severe outcomes amongst the kids with SIRS in the Peds ED. (Scott, 2012)
    • After Return of Spontaneous Circulation following a resuscitation, higher lactate levels are associated with higher likelihood of death, although don’t predict outcomes. (Topjian, 2013)
    • Elevated lactate levels obtained in pediatric trauma patients during prehospital transport are associated with increased need for critical care. (Shah, 2013)

 

Lactate Level – Did it Help You?

  • Thus far, we see that, like in adults, an elevated lactate can help identify those patients who are potentially sicker than others, although not perfectly.
  • One issue is that, often, an astute clinician would generate a similar assessment of clinical severity. (Scott, 2012)
  • Another issue is that, when obtained in the “shotgun” approach of obtaining labs, often the confounders (see above) are not taken into account.
  • It is only helpful if it alerts you to severe illness presenting subtly or helps direct your resuscitation efforts… which, again, require the astute clinician to determine.

 

References

Munde A1, Kumar N, Beri RS, Puliyel JM. Lactate clearance as a marker of mortality in pediatric intensive care unit. Indian Pediatr. 2014 Jul;51(7):565-7. PMID: 25031136. [PubMed] [Read by QxMD]

Bai Z, Zhu X, Li M, Hua J, Li Y, Pan J, Wang J, Li Y1. Effectiveness of predicting in-hospital mortality in critically ill children by assessing blood lactate levels at admission. BMC Pediatr. 2014 Mar 28;14:83. PMID: 24673817. [PubMed] [Read by QxMD]

Schumacher KR1, Reichel RA2, Vlasic JR2, Yu S2, Donohue J2, Gajarski RJ2, Charpie JR2. Rate of increase in serum lactate level risk-stratifies infants after surgery for congenital heart disease. J Thorac Cardiovasc Surg. 2014 Aug;148(2):589-95. PMID: 24138790. [PubMed] [Read by QxMD]

Shah A1, Guyette F, Suffoletto B, Schultz B, Quintero J, Predis E, King C. Diagnostic accuracy of a single point-of-care prehospital serum lactate for predicting outcomes in pediatric trauma patients. Pediatr Emerg Care. 2013 Jun;29(6):715-9. PMID: 23714761. [PubMed] [Read by QxMD]

Topjian AA1, Clark AE, Casper TC, Berger JT, Schleien CL, Dean JM, Moler FW; Pediatric Emergency Care Applied Research Network. Early lactate elevations following resuscitation from pediatric cardiac arrest are associated with increased mortality*. Pediatr Crit Care Med. 2013 Oct;14(8):e380-7. PMID: 23925146. [PubMed] [Read by QxMD]

Andersen LW1, Mackenhauer J, Roberts JC, Berg KM, Cocchi MN, Donnino MW. Etiology and therapeutic approach to elevated lactate levels. Mayo Clin Proc. 2013 Oct;88(10):1127-40. PMID: 24079682. [PubMed] [Read by QxMD]

Agrawal A1, Agrawal N, Das J, Varma A. Point of care serum lactate levels as a prognostic marker of outcome in complex pediatric cardiac surgery patients: Can we utilize it? Indian J Crit Care Med. 2012 Oct;16(4):193-7. PMID: 23559725. [PubMed] [Read by QxMD]

Vorwerk C1, Manias K, Davies F, Coats TJ. Prediction of severe bacterial infection in children with an emergency department diagnosis of infection. Emerg Med J. 2011 Nov;28(11):948-51. PMID: 20971726. [PubMed] [Read by QxMD]

Jat KR1, Jhamb U, Gupta VK. Serum lactate levels as the predictor of outcome in pediatric septic shock. Indian J Crit Care Med. 2011 Apr;15(2):102-7. PMID: 21814374. [PubMed] [Read by QxMD]

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Portable Lens-Free Hollographic Microscopy Brings Pathology Lab Anywhere

lens free imaging Portable Lens Free Hollographic Microscopy Brings Pathology Lab Anywhere

Tissue sample image created by a new lens-free microscope developed in the UCLA lab of Aydogan Ozcan.

The lab of Dr. Aydogan Ozcan at UCLA seems like an ever-flowing wellspring of new optical gadgets that can be used in biomedical applications. Yesterday we reported on a new fluorescence imaging smartphone attachment developed by Ozcan et. al. that can be used to spot and measure DNA strands, and in the past we’ve covered other technologies the team developed to count cells, holographic processing to analyze them, and high-res 3D imaging of samples on a tiny chip.

Today we learn of a new study published by the researchers in Science Translational Medicine describing a new lens-free microscopy technique that allows for wide-field viewing of pathology slides using a small, cheap, and portable device. The device creates a holographically reconstructed image the objects within which can be brought into focus at any depth following the image capture. Unlike normal optical microscopes, this does not require any mechanical components to move the lens, making image capture nearly automatic.

From the study abstract in Science Translational Medicine:

Using this lens-free on-chip microscope, we successfully imaged invasive carcinoma cells within human breast sections, Papanicolaou smears revealing a high-grade squamous intraepithelial lesion, and sickle cell anemia blood smears over a FOV of 20.5 mm2. The resulting wide-field lens-free images had sufficient image resolution and contrast for clinical evaluation, as demonstrated by a pathologist’s blinded diagnosis of breast cancer tissue samples, achieving an overall accuracy of ~99%. By providing high-resolution images of large-area pathology samples with 3D digital focus adjustment, lens-free on-chip microscopy can be useful in resource-limited and point-of-care settings.

Study abstract in Science Translational Medicine: Wide-field computational imaging of pathology slides using lens-free on-chip microscopy…

Press release: Lens-free microscope can detect cancer at the cellular level…