The LITFL Review 132

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 132nd edition, brought to you by:

The Most Fair Dinkum Ripper Beaut of the Week

Ripper this week is taken out by  the ongoing debate on do C-spine collars still have a role? Scancrit explains why EMS in Bergen, Norway has made the move to get rid of cervical collars for trauma patients. Minh Le Cong at the PHARM also has some strong words about cervical collars this week. [TRD,MG]

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

The Best of #FOAMPed Paediatrics

  • Cliff Reid on Resus.Me discusses the optimum number of team members to be around for a  paediatric resus – the balance between overload and support. [TRD]
  • Sean Fox covers patellar dislocations for this week’s PED EM morsel. [TRD]
  • Swimming pools, baths, and even buckets can all be potential drowning traps for kids. How do we manage near-drowning? Ben Lawton on Don’t Forget the Bubbles. [TRD]

#FOAMTox Toxicology

  • It looks like Intralipid is going to be my Tox word of the year but what about Intralipid AND HIET (high dose insulin euglycaemic therapy)? Probably not. Leon Gussow of the Poison Review looks at a reported case series where both HIET and intralipid were used but it’s not all it’s cracked up to be [JAR]
  • Do people on anti-coagulants and/or antiplatelets bleed more after snakebite? Complex question but Justin Hensley of EMGoneWild gives his thoughts (via emlitofnote.com) on a recent paper investigating bleeding following rattlesnake envenomation in patients on antiplatelet and anticoagulant drugs [JAR]
  • In another post, Leon Gussow looks at the recent report from the CDC regarding e-cigarettes. This new trend known as ‘vape’ has lead to more and more calls relating to exposure in the US. Check it out…

#MedEd Education and Social Media (including #smaccGOLD)

News from the Fast Lane

  •  Our shiny new author Mat Goebel kicks of with a brilliant ECG case in Winter is Coming… [KG]

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 — 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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Mac Sweeney’s Best of the Rest 2013

Before collapsing in a heap at 3am on a cold Belfast morning, Rob Mac Sweeney (@CritCareReviews) managed to complete the SMACC podcast‘s review of the best critical care literature from 2013, following on from  2013 ‘Top Ten’ randomised control trials in intensive care and the best guidelines, commentaries and reviews of 2013.

Listen to the  30 minute podcast below or download via the direct link or iTunes:

Brief mentions

  • Marik. Does the Central Venous Pressure Predict Fluid Responsiveness? An Updated Meta-Analysis and a Plea for Some Common Sense. Critical Care Medicine 2013;41(7):1774-1781  [Article Link]
  • Wilkman. Association between inotrope treatment and 90-day mortality in patients with septic shock. Acta Anaesthesiologica Scandinavica 2013; epublished January 8th  [Article Link]
  • Vaahersalo. Therapeutic hypothermia after out-of-hospital cardiac arrest in Finnish intensive care units: the FINNRESUSCI study. Intensive Care Med 2013;39(5):826-837  [Article Link]
  • Hagness. Liver Transplantation for Nonresectable Liver Metastases From Colorectal Cancer. Annals of Surgery 2013;257(5):800–806  [Article Link]
  • Loekito. Common laboratory tests predict imminent medical emergency team calls, intensive care unit admission or death in emergency department patients. Emergency Medicine Australasia 2013; epublished January 8th  [Article Link] [Editorial]
  • Schnell. Renal Perfusion Assessment by Renal Doppler During Fluid Challenge in Sepsis. Crit Care Med 2013;41(5):1214-1220  [Article Link]
  • Cooper. Albumin Resuscitation for Traumatic Brain Injury: Is Intracranial Hypertension the Cause of Increased Mortality? J Neurotrauma 2013; epublished March 21st  [Article Link]
  • Casaer. Role of Disease and Macronutrient Dose in the Randomized Controlled EPaNIC Trial. Am J Respir Crit Care Med 2013;187:247-255  [Article Link]

Neurological

  • Shehabi. Sedation depth and long-term mortality in mechanically ventilated critically ill adults: a prospective longitudinal multicentre cohort study (SPICE study). Intensive Care Med 2013;39(5):910-918  [Article Link]
  • Page. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial. Lancet Respiratory Medicine 2013;epublished August 21st  [Article Link]
  • Mourvillier. Induced Hypothermia in Severe Bacterial Meningitis:  A Randomized Clinical Trial. JAMA 2013;epublished October 8th  [Article Link]

Circulatory

  • Annane. Effects of Fluid Resuscitation With Colloids vs Crystalloids on Mortality in Critically Ill Patients Presenting With Hypovolemic Shock. The CRISTAL Randomized Trial. JAMA 2013;epublished October 9th  [Article Link]
  • Mylotte. Primary Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction, Resuscitated Cardiac Arrest, and Cardiogenic ShockThe Role of Primary Multivessel Revascularization. J Am Coll Cardiol Intv 2013;6(2):115-125  [Article Link]
  • Mahjoub. Evaluation of pulse pressure variation validity criteria in critically ill patients: a prospective observational multicentre point-prevalence study. Br J Anaesth 2013;epublished December 29th  [Article Link]

Respiratory

  • Papazian. Effect of Statin Therapy on Mortality in Patients With Ventilator-Associated Pneumonia. A Randomized Clinical Trial.   JAMA 2013;epublished October 9th  [Article Link]
  • Goodacre. Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial. Lancet Respiratory Medicine 2013;epublished May 17th  [Article Link]
  • Hernandez. The effects of increasing effective airway diameter on weaning from mechanical ventilation in tracheostomized patients: a randomized controlled trial. Intensive Care Med 2013;epublished March 8th  [Article Link]
  • Figueroa-Casas. Accuracy of the chest radiograph to identify bilateral pulmonary infiltrates consistent with the diagnosis of acute respiratory distress syndrome using computed tomography as reference standard. J Crit Care 2013; epublished April 5th  [Article Link]
  • Thille. Comparison of the Berlin Definition for Acute Respiratory Distress Syndrome with Autopsy. Am J Respir Crit Care Med 2013;epublished January 31st   [Article Link]

Renal

  • McGuinness. Sodium Bicarbonate Infusion to Reduce Cardiac Surgery-Associated Acute Kidney Injury: A Phase II Multicenter Double-Blind Randomized Controlled Trial. Critical Care Medicine 2013;41(7):1599-1607  [Article Link]

Infection Control

  • Harris. Universal Glove and Gown Use and Acquisition of Antibiotic-Resistant Bacteria in the ICU: A Randomized Trial. JAMA 2013;epublished October 4th  [Article Link]
  • Huang. Targeted versus Universal Decolonization to Prevent ICU Infection. N Eng J Med 2013;epublished May 29th  [Article Link]
  • Climo. Effect of Daily Chlorhexidine Bathing on Hospital-Acquired Infection. N Engl J Med 2013;368:533-542  [Article Link]

Sepsis

  • Bernard. Evaluating the Efficacy and Safety of Two Doses of the Polyclonal Anti-Tumor Necrosis Factor-[alpha] Fragment Antibody AZD9773 in Adult Patients With Severe Sepsis and/or Septic Shock: Randomized, Double-Blind, Placebo-Controlled Phase IIb Study. Crit Care Med 2013;epublished December 11th [Article Link]
  • Opal. Effect of Eritoran, an Antagonist of MD2-TLR4, on Mortality in Patients With Severe Sepsis: The ACCESS Randomized Trial. JAMA 2013;309(11):1154 [Article Link]
  • Annane. Recombinant Human Activated Protein C for Adults with Septic Shock: a Randomized Controlled Trial (APROCCHSS Trial). Am J Respir Crit Care Med 2013; epublished March 22nd [Article Link]
  • Guntupalli. A Phase 2 Randomized, Double-Blind, Placebo–Controlled Study of the Safety and Efficacy of Talactoferrin in Patients With Severe Sepsis. Critical Care Medicine 2013;41(3):706-716 [Article Link]
  • Kruger. A Multicentre Randomised Trial of Atorvastatin Therapy in Intensive Care Patients with Severe Sepsis. Am J Respir Crit Care Med 2013;epublished ahead of print [Article Link]

Miscellaneous (not included in the podcast due to cognitive meltdown!)

  • Jabre. Family Presence during Cardiopulmonary Resuscitation. N Engl J Med 2013;368:1008-1018 [Article Link]

Finally, if you want to stay on top of the critical care literature, be sure to sign up to Rob’s newsletter at Critical Care Reviews — it is FOAM at it’s best.

The post Mac Sweeney’s Best of the Rest 2013 appeared first on LITFL.

Are your airway skills ACE?

The airway or more specifically, the need to secure an airway in a potentially unwell/unstable patient is a phenomenon which unites all doctors who work in critical care. In fact, it’s one of those things that ‘makes us critical care’, to channel the great Weingart. Whether it’s on the field, in a helicopter, in the Emergency Department, the Operating Theatre or the Intensive Care Unit; being comfortable with managing a patient’s airway is a quintessential skill. Having a sound strategy is the key and the opportunity to perfectly practice this makes perfect.

A new course in Melbourne, Australia that started last year encourages and helps participants to achieve both. I had the opportunity to go last year and wanted to share my thoughts on the Airway Course for Critical Care and Emergency or ACE for short. To speak frankly, it’s a pretty slick operation (no pun intended at the time of writing, happy accident) especially for a course just entering its second year. Organised by Western Health anaesthetist, Dr Adriano Cocciante, this one-day workshop features of suite of doctors working in critical care including emergency physicians, intensivists and anaesthetists. One admirable aspect of the course was that it wasn’t an airway course run by anaesthetists for everyone else but rather an airway course run by doctors across the critical care spectrum for all comers. They all use a suggested algorithm based on the DAS difficult airway algorithm, which is great (although note the ‘wake the patient up’ is not usually an option for ED intubators). All the facilitators were friendly, approachable and keen to share their knowledge with the participants. The course involves six modules ranging from the focused airway exam (getting the essentials right) to practical airway skills (lots of toys) to high fidelity simulation (practice drills). With a medical education hat on, the curriculum design is excellent and has been well thought out for the intended participants. The modules all come back to their algorithm meaning there’s plenty of reinforcement of key themes throughout the day. The end result was a group of participants from numerous backgrounds and airway experience walking away with worthwhile experience as well as a greater degree of comfort and respect for the airway. The catering was pretty decent too.

So if you’re around in Melbourne come July and want to learn something new or put your existing airway skills into practice, give the ACE course a go.

The Airway Course for Critical Care and Emergency will be held this year on July 19th. Registration opens soon. Details can be found here. ACE is accredited by ACEM and CICM.

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Winter is Coming…

aka ECG Exigency 015

A 54-year old man presents by private vehicle to the Emergency Department with chest discomfort he described as “heartburn.” The pain is substernal and non-radiating. He is also mildly diaphoretic. There is no history of diabetes, hypertension, high cholesterol, or coronary artery disease. On arrival he is resting comfortably, with the following vitals: heart rate 56, blood pressure 125/82, respirations 18 per minute and unlaboured, oxygen saturation 100% on room air.

His ECG is shown below:

winter is coming

Q1: Describe the ECG.

  • Ectopic atrial rhythm: inverted P waves in II, III, aVF
  • Rate 75 bpm
  • Normal axis: +30 degrees, QRS complexes upright in leads I + II
  • Normal intervals
  • 1mm ST-segment elevation in aVR
  • Upsloping ST-segment depression in V2-V6
  • Tall, prominent, symmetric T waves throughout the precordial leads

Q2: What is the significance of these ECG findings?

These ST and T waves abnormalities are known as de Winter’s T-waves.

de winters t wave

de Winter’s T wave

 

This ECG finding:

  • Is specific for left anterior descending artery (LAD) occlusion.
  • Represents ~2% of LAD occlusions.
  • May persist until the culprit artery is opened (making it a STEMI equivalent) or may evolve into an anterior STEMI.

Q3: How would you manage this patient?

  • This patient needs to be managed as a STEMI with analgesia, nitrates, oxygen, aspirin, heparin and (most importantly) emergent PCI or thrombolysis!

Q4: Can you guess what happened next?

 

The patient was admitted for emergent PCI. Angiography revealed a 100% mid-LAD occlusion, which was successfully stented. His troponin peaked at 197 ng/mL. The patient was eventually discharged with a normal ejection fraction.

Take Home Points

  • The de Winter ECG pattern is a recently-described STEMI equivalent that emergency physicians and paramedics must be aware of.
  • These patients typically have critical stenosis of the LAD requiring emergent PCI or thrombolysis.
  • Lack of familiarity with these ECG findings may lead to reluctance to activate the cath lab and unacceptable delays in reperfusion.
  • Remember that in many cases the de Winter pattern persisted until after the target artery was opened. Don’t wait for serial ECGs to evolve into a more easily-recognisable STEMI pattern (which may never happen): activate the cath lab now!

Learn More About De Winter’s T Waves

  • Read the de Winter page from the LITFL ECG library for more detailed information on this topic, including more fantastic ECG examples, references from the literature and links to high-quality FOAMed resources!

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The LITFL Review 131

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 131th edition, brought to you by:

The Most Fair Dinkum Ripper Beaut of the Week

Ripper this week heads over to EDECMO Episode 6 – On Life & Death with Peter Rosen — a great interview with an EM legend. This is a must listen to, one of the godfathers of EM  talks us through life and death from what it was when he started out in emergency medicine to were we are heading today in cardiac resuscitation! [KG, CN]

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

The Best of #FOAMPed Paediatrics

#FOAMTox Toxicology

  • It was great meeting the man behind the Poison Review, Dr Leon Gussow, at SMACCGold. Here in this latest post, he shares his thoughts on a paper describing opioid prescription from adult US departments from 2001 to 2010 [JAR]
  • The next episode of the Poison Review podcast has arrived with all things that explode! Wax, meth and even poo! Check it out! [JAR]
    The second most talked about white liquid in medicine- Intralipid, Dr Gussow reviews a paper that looks at the complications (for a change!) of intralipid emulsion therapy [JAR]

#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 — 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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